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. Author manuscript; available in PMC: 2022 Oct 1.
Published in final edited form as: Curr Opin Organ Transplant. 2021 Oct 1;26(5):560–566. doi: 10.1097/MOT.0000000000000915

Gender and Racial Disparities in the Transplant Surgery Workforce

Valeria S M Valbuena 1,2, Joy E Obayemi 1, Tanjala S Purnell 3, Velma P Scantlebury 4, Kim M Olthoff 5, Paulo N Martins 6, Robert S Higgins 3, Daryle M Blackstock 7, André A S Dick 8, Anthony C Watkins 9, Michael J Englesbe 1, Dinee C Simpson 10
PMCID: PMC8524746  NIHMSID: NIHMS1728863  PMID: 34524181

Abstract

Purpose of Review:

This review explores trends in the United States (US) transplant surgery workforce with a focus on historical demographics, post-fellowship job market, and quality of life reported by transplant surgeons. Ongoing efforts to improve women and racial/ethnic representation in transplant surgery are highlighted. Future directions to create a transplant workforce that reflects the diversity of the US population are discussed.

Recent Findings:

Representation of women and racial and ethnic minorities among transplant surgeons is minimal. Although recent data shows an improvement in the number of Black transplant surgeons from 2% to 5.5% and an increase in women to 12%, the White to Non-White transplant workforce ratio has increased 35% from 2000 to 2013. Transplant surgeons report an average of 4.3 call nights per week and less than five leisure days a month. Transplant ranks 1st among surgical sub-specialties in the prevalence of three well-studied facets of burnout. Concerns about lifestyle may contribute to the decreasing demand for advanced training in abdominal transplantation by US graduates.

Summary:

Minimal improvements have been made in transplant surgery workforce diversity. Sustained and intentional recruitment and promotion efforts are needed to improve the representation of women and minority physicians and advanced practice providers in the field.

Keywords: diversity, transplant surgery, gender parity, burnout, lifestyle, job market

Introduction

Organ transplantation is a young discipline marked by a number of technical and scientific discoveries;(1) yet it is also a field in which stark disparities in the burden of organ failure and access to transplantation persist.(2) Improvement in immunosuppression therapy, advances in living donation, and an overall rise in the prevalence of end-stage organ disease in the United States (US) have increased the demand for transplant services,(3) but national efforts are still needed to achieve transplant equity.

The workforce for transplant surgery is small, but it has had the largest relative growth of any surgical subspecialty over the past thirteen years.(4) Despite this growth, the demographic composition of the workforce has experienced minimal change in stark comparison to the constant reinvention of the field. Lack of diversity in the transplant workforce has key implications, including those related to cultural congruency and trustworthiness in patient education and communication, implicit bias, community engagement, surgical concerns and fears, and decisions around organ donation, all major factors driving disparities in transplant access and outcomes.(5–8)

There has been increasing attention to the importance and clinical implications of workforce diversity issues in medicine and surgery in response to the worsening healthcare crisis of our country. The transplant field can learn from the plethora of evidence from other fields indicating that a diverse workforce benefits patients, processes, and innovation.(9, 10) There has been widespread support from the major surgical governing bodies to (1) set goals to create a workforce that reflects our society; (2) develop programs that actively support the recruitment and retention of women and individuals from backgrounds underrepresented in medicine (URiM) at all levels of medical and surgical training; and (3) take an active anti-racist stand to promote equity and social justice in surgery.(11–13) In transplant surgery, the American Society of Transplant Surgeons (ASTS) Boldly Against Racism (BAR) Taskforce, Pipeline Taskforce, and Diversity, Equity and Inclusion (DEI) Committee have identified workforce diversity as a priority area of improvement for transplant surgery.(14)

The demographic makeup of the transplant workforce at its beginnings reflected the trends in medical and surgical education of that era, where male students who identified as White represented >70% of medical school matriculants and >90% of surgical residents.(15, 16) As medicine and surgery became more inclusive, these numbers changed as well. In 2019 and 2017 respectively, 50.5% of medical school matriculants and 40.1% of general surgery residents identified as female.(15, 17) These changes have hardly reflected on the transplant surgery workforce, and applications to the field by US medical graduates are declining every year.(18) Among the suspected reasons behind these trends are training demands, the lifestyle historically associated with the specialty, and a unique post-fellowship hiring landscape. As we refocus as a specialty on the importance of providing equal and just service to a growingly diverse patient population, we must place special attention to how the multidimensional diversity of the workforce (or lack thereof) will affect the field and our patients for decades to come.

In this review, we will (1) explore the historical trends of the transplant surgery workforce, (2) highlight the unique aspects of the transplant surgery training paradigm and current day practice that might drive inequities in recruitment and retention trends, and (3) demonstrate the ongoing disparities in the transplant workforce as it pertains to gender and racial/ethnic diversity.

Overview of the US surgical workforce and transplant surgery workforce

The US surgical workforce has changed dramatically over the past 30 years. Currently, 20.6% of general surgeons identify as women.(17) These statistics somewhat reflect the current medical school matriculation figures where ~50% matriculants identify as women.(15) In contrast, only 12.8% of practicing surgeons and 14.3% of surgery residents identify as URiM, and that number has not changed in the past ten years.(19) There are approximately 1,200 practicing transplant surgeons in the US distributed across more than 235 transplant centers.(20)

There have been at least three major US transplant workforce surveys sponsored and published by the ASTS over the past decade. In their 2011 ASTS Workforce Committee Survey, Florence et al. described the demographics, education, training, practice, and lifestyle of 171 transplant surgeons.(21) This study had a predominantly male (90%) and White (72%) sample of respondents with a diverse clinical practice (multiorgan transplantation, HPB, and vascular access). They reported a younger age of prospective retirement for women compared to men. The sample had minimal representation of African American (2%) and Hispanic (8%) surgeons with no women in either of these response groups. Transplant surgeons self-identifying as Asian represented 17% of the sample, with 25% of them identifying as female. No other demographic data for the sample was reported. Recent unpublished membership data by the ASTS reported that as of 2020, 12% of member surgeons identified as female, 3% as African American, and 5% as Hispanic (22) indicating there has been only marginal improvement in gender parity, and racial and ethnic disparities have not changed significantly.

Historical trends in the Transplant Surgery Workforce

Strategizing supply and demand trends for the transplant surgery workforce is challenging. The increase in demand for transplant services and prevalence of end stage organ dysfunction in the US, as well as long waitlists for organs increased concerns about transplant surgeon scarcity in the early 2000’s.(23) However, in their 2011 publication on transplant workforce projections, Reich et al. forecasted that there would not be any transplant surgeon shortage until the year 2020.(24) A similar study projected an increase in liver transplantation from 3.15% to 4.76% per year and a decrease in the number of liver transplants performed by a single transplant surgeon from 13.4 to 12.9 on average per year from 2006 to 2020.(25) These data led authors to conclude that the transplant workforce needs would remain stable through 2020, though further analysis is needed to determine how well these projections correspond to true current numbers.

Between years 2000 – 2013, transplant surgery had the largest increase in workforce size (215%; 66–208 surgeons) of any surgical subspecialty.(4) Overall, White surgeons are overrepresented in all specialties at three times the rate than non-White surgeons. When we look closely at all surgical sub-specialties, transplant surgery has 4.84 times the number of White surgeons compared to non-White surgeons. This trend has been increasing over time, with the White-to non-White workforce ratio in transplant surgery increasing by 35% between 2000–2013.(4) At this time, all other surgical specialties decreased their White to non-white surgeon ratio.

The male to female ratio in the specialty has also increased as the specialty grows. One of the most recent studies illustrating this is the 2019 ASTS Membership and Workforce Committee Survey, which was designed to describe the current practice characteristics of transplant centers in order to estimate changes in the workforce. In this study, transplant centers were the unit of analysis and transplant fellowship directors were the target of the survey. 235 centers were identified, and 71 centers responded (84 directors, 30% response rate). 242 responses had enough data for analysis. The study found there was a 3-year positive inflow of transplant surgery trained surgeons, with twice as many surgeons entering the field than leaving. Women in the workforce increased from 3.7% in 1980 to 18.4% in 2010. The current practicing workforce for transplant is ~12% female.(20)

Transplant Surgery Recruitment

There are currently 77 transplant surgery fellowship positions available in 67 ASTS-accredited centers in the US and Canada. From 2006 to 2018, 404 of the matched applicants in transplant surgery (58.6%) were international medical graduates and 285 (41.4%) were US-trained residents.(18) While there has been a steady increase in the number of accredited fellowships and available positions since 1980, the job prospects of these fellowship graduates remain a source of concern for trainees interested in transplantation.(26)

Transplant surgery remains among the least competitive surgical subspecialties in the United States. Roughly 25% of fellowship positions remain unfilled each year, and US-trained applicants currently make up only 27% of the transplant surgery applicant pool.(18, 24) While concerns about job security may be partially to blame, past survey data indicate that minimal resident operative experience on transplant rotations, poor integration of residents into the transplant team, lack of teaching by attendings, and poor interactions with attendings are additional reasons why 60% of general surgery residents rotating on transplant responded negatively when asked whether they were considering a career in transplant surgery.(27)

Job Prospects

Vigorous fellowship recruitment efforts are limited by the ability to secure post-fellowship employment. While past analyses projected a stable demand for transplant surgeons, the reality is that “in the small field of transplantation, the job market can be at times limited, and the scope or location of available opportunities can be finite… thus placing a premium on the best training and preparation of fellows.”(28) As part of their 2019 survey, Kaldas et al also investigated transplant center staffing projections. 62% of centers (n=44) described their current transplant surgery staffing as “just right”, 25% of centers (n=18) described themselves as understaffed, and 3% (n=2) described themselves as overstaffed. However, the centers that self-identified their surgeon staffing as “just right” were still planning to recruit an average of 0.90+/−0.63 surgeons within the next three years and were more likely to hire junior level faculty. In the 2011 ASTS Fellowship Training Committee survey, Reich et al. reported that almost 90% of graduated transplant fellows obtained positions as transplant surgeons immediately after completing training, with 80% of fellows finding a position involving transplantation of their organ of choice. However, over one-quarter of respondents had left their first job by the time they answered the survey indicating a high degree of turnover.(24) More up to date data is needed to continuously assess the current state of the transplant surgery job market.

Work-Life Integration

Recruitment into transplant surgery has also been limited by concerns regarding work-life integration in the field. A previous study compared transplant surgeons to 13 other surgical specialties and found that transplant surgeons reported a high workload, with a mean workweek of 68.8 h/week and an average of 4.3 nights on call per week (rank 1st).(29) This data is consistent with survey data from Kaldas et al reporting that transplant surgeons were on-call an average of 4.3 nights/week and 11.6 +/− 5.8 days per month with 48.8% of surgeons working >70 hours per week.(20) In a meta-analysis of 16 cross-sectional studies on surgeon burnout across seven different surgical specialties, the authors found increased rates of burnout across the three different dimensions – emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA) – in transplant surgery.(30) These findings were an extension of the seminal work on transplant surgery burnout published by Yost et al in 2005.(31) This study showed that 38% of surgeons had high amounts of EE, 27% had high levels of DP, and 16% had low levels of PA.(31) The strongest predictors of emotional exhaustion were found to be a decreased amount of leisure time per month and fewer years of medical practice. Of note, the transplant surgeons in this study reported an average if 4.5 leisure days/month, which closely resembles the 4 days/month mandated by the ACGME at the residency level. Interestingly, 99% of transplant surgeons surveyed still found transplantation rewarding. A follow up cross-sectional study of both US and EU transplant surgeons by the same group revealed that lack of accessible childcare contributed significantly to feelings of burnout, even though 88.5% of those surveyed were male.(32)

Diversity in the Transplant Surgery Workforce

Women in transplant surgery:

Currently, approximately 12% of ASTS member surgeons, and ~20% current fellows and fellowship applicants (candidate members) identify as female.(22) Kaldas et al reported similar figures in 2019, stating female representation in transplant surgery was higher than many other surgical specialties including orthopedic surgery (5.0%), urology (8.0%), thoracic surgery (6.0%), vascular surgery (11.3%), and neurosurgery (7.8%) according to the 2015 Association of American Medical Colleges workforce study. However, the authors did not comment on the size of the workforce in these other specialties, which is many folds larger than the one for transplant surgery. The quoted 12% female representation in transplant corresponds to less than 150 women in the field. These demographics are similar to those in other recent international workforce diversity surveys in transplantation.(33) Of other reported surgical subspecialties, only obstetrics and gynecology (54.5%), ophthalmology (23.9%), general surgery (19.2%), otolaryngology (15.8%), and plastic surgery (15.0%) had a higher percentage of female surgeons. This is in contrast to the 34.0% female representation of the entire physician workforce and > 50% female representation in medical school matriculants. (34) In 2017, 40% of US general surgery residents were women (compared to 14% in 2001).(17) Gender parity trends in medicine and general surgery are not yet fully reflected in the transplant surgery workforce.

Racial and Ethnic Diversity in the Transplant Surgery Workforce:

There are no recent publications reporting detailed demographics for transplant faculty or fellows. In the 2019 ASTS Transplant Program Directors Meeting, Purnell et al. presented the results from the ASTS DEI Committee sanctioned survey conducted in 2013.(35) This survey was completed by n=613 transplant surgeons and n=699 transplant nephrologists. Non-Hispanic White transplant surgeons represented 57.7% (n=354) of the respondents, and 42.2% (n=259) of respondents self-identified with a racial or ethnic minority groups. There were 15.2%(N=93) Asian, 8.0%(n=49) Hispanic, and 5.5% (n=34) African American surgeons represented in this survey. These results indicate modest improvement in African American representation in the transplant surgery workforce when compared the results of the 2011 ASTS sponsored workforce survey which reported minimal representation of African American (2%) and Hispanic (8%) surgeons in the transplant workforce.(21)

Advanced Practice Providers:

Transplant surgery relies heavily on a multidisciplinary team approach. Advanced Practice Providers (APPs)- Nurse Practitioners (NPs) and Physician Assistants (PAs)- are playing in increasing role in the field.(36) Establishing a pipeline to ensure multiethnic representation amongst APPs in transplant surgery is important. According to the US Bureau of Labor Statistics, in 2020 only 6.3% of PAs and 9.1% of NPs were Black/African American. Nationwide, only 7.9% of PAs and 6.3% of NPs identify as Hispanic/Latinx.(37–39)

Discussion

The topic of workforce disparities in any field is one that is difficult to bridge because of the many tacit assumptions made about worth, access, and achievement when focus is placed on specific groups of the population requiring increased access to educational and professional opportunities. Achievement has long been the currency of medicine and academia, but there is a growing body of evidence showing students from less privileged backgrounds face significant barriers to educational achievement, and these disparities start very early and are far reaching.(40–44) The communities these students represent bear the burden of lack of representation in medicine, surgery, and by default the sub-specialty field of transplantation.

Hispanic and Black communities have a higher incidence and prevalence of end stage organ disease compared to their White counterparts (5) but are poorly represented in the transplant workforce. Scarcity of diverse providers affect patient outcomes, and it has been demonstrated that racially-concordant physicians play a significant role in addressing the pressing health inequities in these populations.(5, 45–47) Since disparities and systemic racism in transplantation care have and continue to be one of the largest issues faced by the discipline,(5, 48) there is a pressing need to reevaluate the recruitment and retention paradigm for transplantation to benefit patients.

As it pertains to gender parity, women continue to be underrepresented in transplant surgery fellowship and faculty. The last five years have brought encouraging advances to the field, with more women fellows being trained than ever before.(22) However, promotion and inclusion are lagging behind, with fewer women advancing to the positions of transplant center directors, division heads, and presidents of the ASTS. When we evaluate intersectionality in the transplant surgery workforce, the currents prospects are even bleaker, with very few minority women gaining entry and remaining in the field. At the time of publication of this review, there are only eight Black women practicing transplant surgery in the US.(22)

Workforce disparities are not an issue exclusive to transplant surgery. Other surgical disciplines such as thoracic and vascular surgery report similar representation figures but have taken an active stance to strengthening and diversifying their training pipelines. The Society of Thoracic Surgeons (STS) embarked on a decade-long journey to recruit, retain, and promote diverse applicants into their field.(49, 50) As a result of a number of internal initiatives, one that included a formal sponsored mentorship program, the STS reports improvement in their workforce diversity and specialty culture.(51) Specialties like vascular surgery are following suit.(52)

Workforce planning issues, as it pertains to whether the field is training the correct number of fellows for the available positions is another factor for consideration. As the field seeks to expand and diversify, there are limitations to how bold these changes can be given the limited number of post-fellowship opportunities. As more women enter the field, a culture shift that addresses the wage gap and clears paths for leadership in the specialty, and a greater focus on integration of personal and professional goals will be necessary.(53, 54)

Conclusions and future directions

There has never been a better time to invest in the early recruitment of promising trainees into transplant surgery. However, disparities in medical school matriculation are profound, and the ‘wells’ from which many surgical programs are drawing from, especially when it pertains to racial and ethnic diversity are drying up. Considering this, a more upstream approach where surgical specialties actively contribute to K-12 initiatives geared toward supporting children and adolescents through the educational continuum is a direction that has yet to be explored. With the current stable enrollment of URiM students in medical school, all specialties and subspecialties are facing a zero-sum game where the same limited number of applicants are subject to recruitment from all directions, and the gain of one specialty is the loss of another.(34)

A diverse workforce for transplantation is a goal that will require commitment from the educational and regulatory bodies of the specialty, but most importantly, from each transplant surgeon who desires the continued success of the field and best outcomes for patients. By supporting and promoting women transplant surgeons already in the field, recruiting a diverse cohort of fellows, investing in trainees of all levels, and contributing to the larger efforts of workforce diversity for medicine, transplant surgery is in the unique position to continue to be a leader not only in innovation and patient care, but also in justice and equity.

Key Points.

  • While transplant surgery is the most rapidly growing surgical subspecialty, only ~12% of its workforce identify as women.

  • Transplant remains the least competitive surgical fellowship with only 41% of matched applicants having completed their surgical training in the US and approximately 25% of positions remaining unfilled each year.

  • Recruitment into transplant surgery is often limited by poor resident experiences on rotations and concerns about the documented high levels of burnout, limited leisure time, and high call-shift burden experienced by attendings.

  • Black physicians represent only 5.5% of transplant surgeons, a modest increase from 2% in 2011 but far from proportional to the number of Black patients in need of transplantation in the country.

  • Intentional efforts for targeted recruitment, promotion, and retention are needed to diversify the field.

Acknowledgements

Guarantor Statement: VV and DS had full access to all the reviewed literature and take responsibility for the integrity of the presentation of evidence and the accuracy of all statements

Financial Disclosures: VV is supported by the Institute for Healthcare Policy and Innovation Clinician Scholars Program and the National Institutes of Health (5T32HS000053–29). JO has no relevant disclosures. TP is supported, in part, by grant K01HS024600 from the Agency for Healthcare Research and Quality (AHRQ). The AHRQ had no role in the preparation, review, or approval of the manuscript or the decision to submit for publication. TP is the Chair of the American Society of Transplant Surgeons (ASTS) Diversity, Equity, and Inclusion Committee. PM is the chair for UNOS/OPTN Minority Affairs Committee and co-chairs the ASTS Diversity, Equity and Inclusion Committee. DS is the Diversity, Equity, and Inclusion Advisor to the Executive Council of the ASTS, and the chair of the ASTS Boldly Against Racism Task Force.

Footnotes

All the authors of this manuscript are members of the ASTS Boldly Against Racism Task Force. The ASTS played no role in the preparation, review, or approval of the manuscript or the decision to submit for publication. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Veterans Affairs, Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. No funder or sponsor had any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Conflicts of Interest: None

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