More than a moment: Why surgical societies must continuously strive for diversification and creating a culture of equity and inclusivity in academic surgery

The year 2020 arrived with a bang as a pandemic of epic proportions rattled our healthcare system to its core. We all tuned in to news broadcasts and radio shows to keep us updated on emerging details about COVID-19. That, along with the fact that our usual distractors: sports, movies, travel and even schools, were all paused, resulted in a captive audience that most desperately clung to the media for any bit of news regarding the path forward. With so few distractors, the entire country was also forced to bear witness to some ugly truths. A pandemic killing brown and black Americans disproportionately, the murders of George Floyd and others, the rise in Anti-Asian violence, and the mistreatment of Hispanic immigrants at the border were all on display. The combination created an awakening in many Americans who were previously either unaware or unbothered by ongoing racial and ethnic prejudices that exist within our society.

Academic surgery was not a stranger to this awakening. More than ever, institutions and societies acknowledged the impact of bias and microaggressions on diversity and inclusivity in our profession. Many quickly pivoted to at least acknowledge, and at times address, these shortcomings with statements and pledges to address inequities. Perhaps for the first time, we as a profession were unified in the desire to make necessary change as we strive to achieve true diversity, justice, equity and inclusion in academic surgery and surgical leadership. But these efforts must extend far beyond the moment. Two years into the pandemic, not much has changed in academia, and the necessary work to diversify our surgeon workforce is just beginning.

The representation of ethnic and racial minority groups in the United States population is increasing at a pace much faster than earlier predicted; by 2045, it is anticipated that White Americans will no longer be a majority.¹ As the demographic shifts in our population continue, the potential for widening the already concerning health disparities by race, ethnicity, sex, gender identity and socioeconomic status is of major concern and has been identified as a top public health priority.² Racial and ethnic minorities are more likely to provide care for medically underserved communities, and patients of color are more likely to seek out physicians of color to provide their care.3, 4, 5 Concordance in physician race and gender has been found to positively influence preventative services and patient satisfaction.^{6 , 7} As such, efforts to eliminate health disparities must focus on creating a physician workforce that reflects our patient population.

In 2019, 60.1% of the US population identified as White, 18.5% Hispanic, 12.5% Black, 5.8% Asian, 2.2% other, and 0.7% American Indian/Alaska Native.¹ During the same year, the AAMC US Physician Workforce Data demonstrated that Hispanics, Blacks and Native Americans remained grossly underrepresented in medicine, accounting for only 5.8%, 5.0% and 0.3% of practicing physicians respectively.⁸ Surgery in particular faces a steep challenge in attaining the necessary physician diversity to meet our patient needs. Low racial and ethnic diversity in surgery is persistent; only 13.6% of students matriculating into medical school are underrepresented in medicine (URM), with Blacks accounting for only 7.1%, and Hispanics accounting for 6.2% of matriculating medical students in 2018.⁸ More disappointingly, there has been no significant change in these numbers over the past 30 years, despite efforts to increase the pipeline for URMs into medicine and other STEM careers. Even fewer URMs enter general surgery residencies. In 2020, only 5.3% of surgical trainees identified as Black, 8.1% as Hispanic/Latino, 0.8% as American Indian and 0.3% as Pacific Islander.⁹

The number of individuals who identify as members of the lesbian, gay, bisexual, transgender, queer, and others community (LGBTQ+) continues to increase with 5.4% of US adults identifying as LGBTQ+.¹⁰ Approximately 5–11% of surgical residents identify as LGBTQ+, but a significant proportion report harassment and mistreatment throughout their training—likely impacting retention in academia after residency completion.^{11 , 12} The paucity of data on the LGBTQ + surgical workforce highlights the lag in coordinated efforts to specifically address the needs of our LGBTQ + patients and colleagues.

Lack of diversity within surgery, however, cannot be not simply attributed to problems in the pipeline. While almost half of students matriculating into medical school are women, fewer women in general are entering surgical residencies. After completing surgical training, women and minorities are less likely to enter academic practices, and those that do are faced with limited opportunities for advancement and promotion when compared to their white male colleagues.^{13 , 14} There has been an approximately 3-fold increase in the number of female surgical faculty over the last three decades. Still, women only account for a quarter of assistant professors, 20% of associate professors, 10% of full professors and 15% of surgical chairs despite embodying 40% of surgical trainees.^{13 , 15 , 16} When controlled for rank, female surgical faculty were often compensated significantly less than male counterparts.17, 18, 19 The gender gap in leadership of surgical societies persists despite increased female representation in the field. A recent analysis of gender parity in general surgical societies noted 83% male representation amongst society leaders when compared to only 17% female.²⁰ Other studies show that these disparities are most pronounced at the highest echelons of leadership, with the largest gender gap seen at the level of society president.²¹

Asian Americans in medicine are a heterogenous racial and ethnic group largely consisting of individuals who identify as being of Indian, Chinese or Korean heritage. Asian Americans constitute 21% of medical students but only 12% of surgical trainees.²² While well represented in surgery, Asian Americans are underrepresented in surgical leadership, accounting for 12% surgical chairs of departments and only 2.3% of governing boards of surgical societies.^{16 , 22}

So how do we combat these barriers to diversity and inclusivity in surgery? Academic institutions and surgical societies carry the brunt of the responsibility in working to correct these issues. After all, we construct the systems that shape the experiences and careers of minoritized students, trainees and junior faculty, often serving as the gate keepers that decide who gets the ‘privilege’ of entry into medical school, residencies, and fellowships. If we are to really address the issues of lack of diversity and inclusivity in surgery, we must start here first.

Fortunately, organizations such as the Association of Women Surgeons (AWS), the Latino Surgical Society (LSS), the Society of Asian Academic Surgeons (SAAS), the Society of Black Academic Surgeons (SBAS) and the Society of Out Surgeons and Allies (SOSA) exist in part to support the professional development of their respective members. They may serve as a significant source of mentorship and sponsorship for those who may not be able to identify mentors and sponsors at their home institutions. The Association for Academic Surgery (AAS) and the Society of University Surgeons (SUS) are committed to improving diversity, equity and inclusion in academic surgery by supporting our sister societies and championing the diversity of our members through targeted courses, programs and antiracist educational content. These efforts require intentionality and financial investment, and they must continue for the long term—a succession of moments—to achieve to true equity and justice. In this focused issue of the American Journal of Surgery, we will discuss the needs of minoritized populations in academic surgery and targeted efforts to address them based on the “Together We Rise” sessions from the Academic Surgical Congress 2021 Virtual Meeting.

Declaration of competing interest

The authors report no relationships that could be construed as a conflict of interest.