Moving the Needle: Program Directors’ Views on the Recruitment of Diverse Trainees to Plastic Surgery Residency

Abstract

Background:

The plastic surgery workforce lacks racial and ethnic diversity. Traditionally, United States Medical Licensing Examination scores have been used as the initial screening tool for most residency programs; however, this can lead to interview selection bias against underrepresented in medicine (URiM) applicants. Understanding the barriers and facilitators to diversifying the specialty from the perspectives of program directors (PDs) may reveal strategies for improvement.

Methods:

In this mixed methods study, we invited integrated plastic surgery PDs to participate in an online survey and one-on-one semistructured interviews to understand their perspectives on the application process, interview day, and strategies to improve recruitment and retention of URiM trainees. Descriptive statistics were used to analyze the survey data. Interviews were deidentified, transcribed, and analyzed inductively to generate themes based on patterns observed across narratives.

Results:

Of 108 PDs and assistant PDs, 29 (26.9%) responded to the survey and 8 participated in semistructured interviews. We identified 3 broad themes: (1) resident diversity is important for patient care and education, (2) lack of exposure and longitudinal mentorship are barriers to matriculation, and (3) program culture change can shift trends in the recruitment of URiM trainees.

Conclusions:

PDs value the racial and ethnic diversity of trainees and are in favor of efforts to increase representation in the field. Improving mentorship and reducing bias in the application process are necessary strategies to increase representation in plastic surgery.

Takeaways

Question: What are residency program directors’ perspectives on barriers and facilitators to diversity in plastic surgery?

Findings: In this mixed methods study, we identified 3 key themes: (1) resident diversity is important for patient care and education, (2) lack of exposure and longitudinal mentorship are barriers to matriculation of underrepresented in medicine trainees, and (3) program culture change can shift trends in recruitment of underrepresented in medicine trainees.

Meaning: Improving mentorship and reducing bias in the application process are necessary strategies to increase racial and ethnic representation in plastic surgery.

INTRODUCTION

There is a paucity of plastic surgeons who are racially and ethnically underrepresented in medicine (URiM).^1–3 Workforce diversity is essential to address health disparities, as URiM physicians are more likely to care for underserved populations.⁴ In addition, patient-provider racial concordance is associated with higher patient satisfaction and lower healthcare expenditures.^5,6 Diversifying the plastic surgery workforce requires an increase in representation among trainees; however, the proportion of Black and Hispanic plastic surgery residents has remained stagnant since at least 2010.^3,7,8

URiM medical students are 60% less likely to match into plastic surgery, even when controlling for step scores, school rank, and affiliation with a home plastic surgery program.⁹ Several initiatives have been established to address this, including visiting clerkship programs for URiM students.¹⁰ Institutions have also adopted holistic review, an approach that evaluates the unique attributes and experiences of applicants in addition to traditional metrics including test scores and publications.¹⁰ Holistic review has been associated with success in some programs; for instance, the transition to holistic review in general surgery led to an increase in matched URiM candidates between 2013 and 2020 (from 14% to 21%) without a difference in in-service examination scores and quality of applicants.^11,12 Program directors (PDs), who have substantial influence over resident selection, have unique insights into the application process. However, their perspectives on the lack of diversity among residents and possible solutions remain unclear.

To better understand plastic surgery PDs’ views, we conducted a convergent mixed methods study to evaluate their perspectives regarding URiM trainees. We collected data via an online survey and one-on-one qualitative interviews. Our primary outcome included the identification of facilitators to the recruitment of URiM candidates into plastic surgery residency. We hypothesized that URiM applicants face barriers to matching into plastic surgery, including lack of mentorship and biases in the application process. We also hypothesized that programs are changing their application review and interview practices to promote equity.

METHODS

Study Sample

We received institutional review board approval (HUM00227741), permitting us to contact PDs and assistant PDs with publicly available emails. We identified emails through program webpages, PubMed, and Google searches. We sent an electronic link to the anonymous Qualtrics survey and instructions to sign up for qualitative interviews in September 2023, with follow-up 1 month later.

Survey Instrument and Interview Guide

We created the survey and interview guide using concepts from previously published studies detailing applicant characteristics that promote matching into plastic surgery, such as letters of recommendation, mentorship, and research experience.¹³ (See table, Supplemental Digital Content 1, which displays the joint display of mixed methods results, https://links.lww.com/PRSGO/E150.) The survey and interview guide were created in parallel and organized to evaluate (1) approaches to applicant selection for interview, (2) components of the interview day, and (3) strategies to improve recruitment and retention of URiM residents. (See table, Supplemental Digital Content 2, which displays the survey questions, https://links.lww.com/PRSGO/E151.) Survey questions were answered using a Likert scale with opportunities for free text responses. We pilot tested the interview guide and made iterative changes to improve comprehension and clarity (N.B.B., R.C.H., T.C.G., M.L.B.).

After obtaining consent, M.L.B. pilot tested the interview guide via 1 interview, then N.B.B. conducted subsequent interviews using video conference (Zoom). We revised the guide after the initial interview (N.B.B., R.C.H., M.L.B.), then modified the order of questions after 2 subsequent interviews to prioritize discussion of the topics most relevant to our research questions (N.B.B., R.C.H., T.C.G.). We used Fireflies.ai software for automatic transcription. Transcriptions were exported to Microsoft Word to correct inaccuracies and redact identifying information. Interview data were subsequently deleted from Fireflies.ai.

Analysis

Survey data were analyzed using descriptive statistics (Qualtrics software and Microsoft Excel Version 2403). Corresponding free-text responses were also used in the analysis. We conducted a nonresponder analysis by comparing responders’ characteristics to publicly available data describing PD demographics.¹⁴

We analyzed interviews using interpretive description.¹⁵ Briefly, we uploaded transcribed interviews to MaxQDA for analysis. We (N.B.B., R.C.H., T.C.G.) independently created codebooks based on the first 3 interviews and discussed divergent codes until we reached agreement. We coded the subsequent interviews in MaxQDA using the master codebook. We used inductive reasoning to identify patterns and generate themes related to barriers and facilitators to the recruitment of URiM trainees. We repeated transcript review to ensure that themes and codes were supported by the data. We then used the principles of convergent mixed methods, integrating qualitative (interviews) and quantitative (surveys) results to draw more meaningful conclusions.^16,17

RESULTS

Participant Demographics

We identified 108 PDs and assistant PDs; 29 (26.9%) responded to the survey and 8 participated in semistructured interviews. Demographics are shown in Table 1. Participants were from the West (n = 2), Midwest (n = 2), and Northeast (n = 4) regions. The average interview duration was 40 minutes (range 30:08–56:47, SD 8:56). Survey results are displayed in Tables 2 and 3.

Table 1.

Program Director Demographics

Demographics	n (%)
Age, y
<35	0 (0.0)
36–45	5 (17.2)
46–50	4 (13.8)
51–60	7 (24.1)
>60	10 (34.5)
Gender
Man	15 (51.7)
Woman	5 (17.2)
Nonbinary	0 (0.0)
Prefer not to say or no response	9 (31.0)
Race
White	19 (65.5)
Other	1 (3.4)
African American or Black	0 (0.0)
Asian or Asian American	0 (0.0)
Middle Eastern	0 (0.0)
Native American, Alaska Native, Native Hawaiian, or other Pacific Islander	0 (0.0)
Prefer not to say or no response	9 (31.0)
Ethnicity
Non-Hispanic	21 (72.4)
Hispanic	0 (0.0)
No response	8 (27.6)
Tenure as program director
1–3 y	5 (17.2)
4–6 y	10 (34.5)
7+ y	11 (37.9)
No response	3 (10.3)

Table 2.

Survey Responses Related to the Recruitment of URiM Trainees

Question and Response	n (%)
How important is it to have a plastic surgery workforce that is racially and ethnically representative of the population it serves?
Important	25 (86.2)
Neutral	2 (6.9)
Unimportant	1 (3.4)
No response	1 (3.4)
How important is it for plastic surgery residency programs to make deliberate efforts to recruit URiM students into the field?
Important	24 (82.8)
Neutral	4 (13.8)
Unimportant	0 (0.0)
No response	1 (3.4)
How important is the recruitment of URiM trainees to resident education?
Important	25 (86.2)
Neutral	1 (3.4)
Unimportant	2 (6.9)
No response	1 (3.4)
How important is the recruitment of URiM trainees to providing culturally sensitive care for minority patients at your institution?
Important	24 (82.8)
Neutral	3 (10.3)
Unimportant	1 (3.4)
No response	1 (3.4)
Does your institution provide financial assistance for URiM candidates during away rotations? (ie, housing stipends)
Yes	13 (44.8)
No	15 (51.7)
No response	1 (3.4)
How supportive are you of establishing a program to provide financial support to URiM candidates during away rotations? (ie, to offset the cost of travel/housing)
Supportive	21 (72.4)
Neutral	4 (13.8)
Unsupportive	3 (10.3)
No response	1 (3.4)
How supportive are you of establishing a longitudinal program to provide URiM students at your institution with research and clinical opportunities in plastic surgery? (ie, shadowing and research exposure)
Supportive	26 (89.7)
Neutral	1 (3.4)
Unsupportive	1 (3.4)
No response	1 (3.4)

Table 3.

Survey Responses Related to the Application Process and Interview Day

Question and Response	n (%)
How supportive are you of a holistic application process?
Supportive	24 (82.8)
Neutral	4 (13.8)
Unsupportive	1 (3.4)
How important are interactions outside of the formal interview?
Important	25 (86.2)
Neutral	2 (6.9)
Unimportant	1 (3.4)
No response	1 (3.4)
How are applicants interviewed? (select all that apply)
Individual interviewers	12 (41.4)
Small group (1–2) interviewers	16 (55.2)
Medium group (3–5) interviewers	4 (13.8)
Large group (>5) interviewers	0 (0.0)
What aspects of the interview day are supported financially? (select all that apply)
Flight	0 (0.0)
Taxi/ground transport	2 (6.9)
Hotel	2 (6.9)
Meals	20 (70.0)
None	8 (27.6)

Overview of Themes

We identified 3 themes: (1) resident diversity is important for patient care and education; (2) lack of exposure and longitudinal mentorship are barriers to matriculation; and (3) program culture change can shift trends in the recruitment of URiM trainees. The data supporting these themes are displayed in the supplemental digital content (Supplemental Digital Content 1, https://links.lww.com/PRSGO/E150).

Resident Diversity Is Important for Patient Care and Education

Patient Care

Most PDs (86.2%) responded that it is important to have a workforce that is racially and ethnically representative of the population that it serves (Table 3). PD1 shared, “It’s important for our patients … to see that there are people out there like them to help take care of them.” This PD explained that seeing a provider who looks like them helps patients feel cared for. Overall, PDs felt that trainees from diverse backgrounds are an asset to plastic surgery training programs, but emphasized how diversity should not come at the cost of other qualifications. PD7 stated, “I don’t think it can or should be done at the expense of real expertise.” Ideally, there is a pool of diverse candidates who are well prepared for residency from an academic standpoint.

Resident Education

The majority (86.2%) of PDs agreed that URiM trainees enhance education. PDs described how trainees with diverse backgrounds contribute to a richer learning environment: “We need to learn from others … it’s important to make sure that you have a mix of people that grew up in different ways, trained in different ways” (PD8). Another PD added, “a more diverse group of individuals … is going to make us a better place, and those individuals that are selected … are going to have a better experience” (PD2). In summary, PDs emphasized how the different lived experiences of trainees bring unique perspectives that enhance learning.

Lack of Exposure and Longitudinal Mentorship Are Barriers to Matriculation

URiM Students Lack Exposure

PDs highlighted the need for early exposure to the specialty. One PD explained, “The pipeline problem for us probably starts in high school” (PD6). This PD also shared that URiM students often have, “a lot less professional exposure … because of other things that have happened in their life that did not allow them those same kind of resources,” compared with their majority White counterparts, suggesting that early experiences in plastic surgery can change the trajectory of URiM students. Ninety percent of PDs were supportive of establishing longitudinal programs to provide URiM students with opportunities for research in plastic surgery, as this is one of the most sought-after qualifications and helps students build a competitive resume.

Mentorship Can Bridge the Gap

PDs described how the shortcomings of existing mentorship efforts render URiM students underprepared: “it’s still difficult if you’ve spent two weeks with a plastic surgeon to go to a Sub-I for a month and perform well … and that’s a month-long interview” (PD8). Several PDs described their experiences working with students from Historically Black Colleges and Universities (HBCUs), who do not have a home residency program. PDs described how HBCU students often excel in their home environment but are unprepared when compared with peers from top-ranked medical schools, likening it to, “swimming in a high school pool and then going to a D1 championship” (PD4). Inequities in URiM student exposure to plastic surgery and medical school curricula suggest that more deliberate efforts be made so that these students can succeed.

Program Culture Change Can Shift Trends in Recruitment

Achieving Equity in the Application Process

PDs discussed biases in the application process, including access to away rotations. PDs ranked away rotations as the second most important attribute behind letters of recommendation (Fig. 1), indicating their importance. However, PDs noted how this introduces, “disadvantages for people who can’t necessarily afford to pay extra rent for a month” (PD1). Subsidized away rotations may increase the applicant pool by supporting students who do not have the financial means to travel. PDs in our study were in favor of providing financial assistance to URiM candidates during away rotations (89.7%), though less than half (44.8%) of the respondents’ programs currently do. During the interviews, PDs questioned the fairness of scholarships for URiM candidates: “I personally do not think in our program that it’s a good idea to have scholarships … because that is inherently favoring certain people” (PD7). These perspectives highlight the need for balance between promoting equity and avoiding perceptions of favoritism.

Fig. 1.

Application attributes ranked in order of importance (a higher number indicates a greater value).

PDs described how institution and government policies influence diversity efforts. In light of affirmative action bans, PDs expressed concern that people who were already hesitant to support diversity would say, “It’s not worth the administrative burden … to ensure that the language of this program is going to meet the muster of a potential lawsuit” (PD2). Regardless, several PDs described how their institutions’ graduate medical education offices attract URiM applicants and educate PDs on the importance of diversity. One PD described how graduate medical education representatives try, “to make it not feel forced, which I think is an important part … it’s too easy to turn it into a reductionism of, oh, we must have people who meet these criteria” (PD5). On the other hand, another PD felt that institution efforts to enforce diversity often involved uninformed criticism: “I don’t like having someone who knows nothing about our program, nothing about our applicants, say things without even knowing our data” (PD7). These views portray the tension between fostering an inclusive culture through meaningful, internal leadership and pressure from external policies.

Shifts in Culture

PDs described the challenge of transforming a homogeneous program: “The first few people with different backgrounds are going to say, ‘why would I want to come to this place?’” (PD7). To address this, PDs highlighted the importance of demonstrating a commitment to an inclusive culture, particularly through resident involvement. As 1 PD put it, “diverse trainees … serve as ambassadors for future people applying to say, ‘look, the program is welcoming to us’” (PD7). Another PD emphasized the broader role of the institution, noting, “There’s a bigger role for … the institution as a whole … reaching out to historically black colleges and university med schools, and having programs dedicated for DEI” (PD5). In summary, PDs indicated that financial barriers, issues with holistic review and interview practices, as well as existing culture dynamics interfere with the fairness of the application process.

Overcoming Bias

PDs described preconceived notions about URiM candidates. One PD discussed fears that URiM trainees are perceived as liabilities if they do not perform well, recounting a discussion where a chairman was hesitant to interview a candidate because it would be, “that much harder to fire them,” if necessary, owing to their underrepresented status (PD6). PDs also expressed a perception that there are very few URiM students applying to residency and that they “probably have a lot of options,” because their underrepresented status makes them desirable (PD3). These views suggest that PDs find it difficult to achieve racial and ethnic representation across residencies because there is a small pipeline of URiM students and competition to draw the top applicants.

PDs also discussed biases inherent to the application process. Most (82.8%) surveyed PDs were supportive of holistic review (Supplemental Digital Content 1, https://links.lww.com/PRSGO/E150), though the interviews revealed a more complex picture. PDs described how the large volume of applications makes holistic review a challenge. PDs often rely on cutoff systems even though “standardized scores for high-stakes exams have been biased” (PD2). To address the burden of application review, 1 PD suggested that faculty “be compensated in some way,” for the extra time it takes to thoroughly review applications (PD5). PDs also pointed out the inconsistent use of standardized interview questions. One PD mentioned that they ask a standardized question at the beginning of each interview to ensure applicants are evaluated on at least 1 similar data point (PD6). Others, “don’t routinely use standardized questions” (PD3), suggesting an opportunity for improvement.

DISCUSSION

We performed a convergent mixed methods study to understand the perspectives of integrated plastic surgery PDs regarding strategies to improve diversity in the specialty. We found that PDs value the racial and ethnic diversity of trainees and identified several themes: resident diversity is important for patient care and education, lack of exposure and longitudinal mentorship are barriers to matriculation, and program culture change can shift recruitment trends.

PDs believed that the unique perspectives and experiences of URiM trainees are important for patient care and resident education; this view is supported in the literature. For instance, 1 study found that patient-provider racial concordance may influence treatment recommendations for carpal tunnel syndrome.¹⁸ Another study found that racial concordance between breast cancer patients and their surgeons was associated with higher quality-of-life scores after mastectomy and reconstruction, suggesting that patients trust and communicate more effectively with surgeons of similar backgrounds.¹⁹ Studies also indicate that URiM physicians are more likely to work in underserved communities that struggle with access, underscoring the value of diversity in plastic surgery.¹

PDs identified late exposure as a barrier to increasing URiM representation in plastic surgery, emphasizing the importance of early, consistent experiences and mentorship in the field.²⁰ In orthopedic surgery, programs such as the Perry Initiative have exposed students to the field as early as high school.^21,22 Nth Dimension, a program for medical students, was associated with a 45-fold increase in the likelihood of applying to orthopedic surgery for women and a 15-fold increase for URiM students.²³ Evidence on pipeline programs in plastic surgery is sparse across levels of education, though several initiatives have shown success at the medical school level. For example, the University of Pennsylvania was one of the first institutions to establish a multipronged initiative that included URiM-focused visiting clerkship programs, holistic review, and a formal URiM professional network for students interested in multiple specialties, including plastic surgery.¹⁰ The institution subsequently observed an increase in the number of URiM interviewees and residents. As of 2023, 53% of plastic surgery programs provide monetary support to URiM students during away rotations.²⁴ The long-term impact of these investments on URiM match rates remains to be determined.

PDs also expressed concern that URiM students who already intend to enter the field are unprepared; however, this has not been substantiated in the literature. One study found that even when controlling for measures of academic caliber, URiM applicants were 60% less likely to match into plastic surgery when compared with non-URiM applicants.⁹ Several PDs shared their perceptions that students at HBCUs, which do not have plastic surgery residencies, perform poorly during away rotations. There is minimal research comparing the academic success of medical students at HBCUs versus predominantly White institutions, so it is unclear if HBCU students are consistently less prepared. It is possible that the unique attributes of these students are undervalued in the existing application process. HBCUs graduate 10% of all Black medical graduates in the United States, and URiM students report a stronger sense of belonging and confidence at HBCUs.^25,26 Accordingly, 1 strategy to improve the recruitment of URiM students into plastic surgery is through the establishment of partnerships between residencies, HBCUs, and other schools without home programs. Ensuring the success of such partnerships will require investment from all involved institutions.

PDs were generally supportive of holistic review as a strategy to ensure that applicants’ qualities are appropriately valued, though they lamented the time needed to evaluate hundreds of applications. Some general surgery programs have addressed this by expanding their interview selection committees to include larger cohorts of faculty and staff.^11,27 For instance, Nehemiah et al¹¹ established a holistic review protocol that excluded grades, test scores, ethnicity, and photographs, instead focusing on a predefined set of desired attributes. This led to a significant increase in the proportion of women and URiM residents at their program, demonstrating that holistic review can enhance diversity without relying on specific demographic identifiers. By prioritizing attributes aligned with a program’s values, it is possible to foster diversity in an equitable manner, avoiding ambiguity related to affirmative action bans. The Plastic Surgery Common Application, introduced in 2020, further supports holistic review by deemphasizing the number of research activities and experiences.²⁸ It also substantially reduced the cost of applying to plastic surgery residency.^29,30 Yet, it does not address the burden of reviewing a high volume of applications. Preference signaling was recently introduced to help applicants express genuine interest in a program.³¹ Although this may assist PDs in filtering applications, its impact on equity remains to be seen.³²

This study is not without limitations. Our results were influenced by nonresponder bias and a small sample size, limiting generalizability. This is not surprising considering that surgery faculty are the least likely to respond to electronic surveys, likely due to survey fatigue.³³ Although nonresponder analysis demonstrated that the demographics of both the survey and interview cohorts are similar to those of the greater population of PDs, we could not compare their personal experiences and perspectives on diversity in medicine. All interviewees indicated that they support diversity efforts on some level, and it is possible that nonresponders had opposing views. This study is also focused more on individuals’ perceptions than structural and systemic barriers, which are key drivers of disparities. Furthermore, we did not capture the viewpoints of other stakeholders in the recruitment process, such as residents.

We demonstrated that PDs from integrated plastic surgery programs value racial and ethnic diversity and support efforts to increase representation in the field. Increasing exposure and mentorship, establishing formal partnerships between academic institutions and schools without plastic surgery training, and decreasing bias in the application process represent tangible strategies to increase the proportion of URiM individuals in plastic surgery.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.