Diversity within the neurosurgical oncology workforce in the United States: A cross-sectional study with proposed strategies to pave the path forward

Zerubabbel Ketema Asfaw; Analiz Rodriguez; Tiffany Renee Hodges; Madhu Mazumdar; Serena Zhan; Michael Lim; Isabelle Margherita Germano

doi:10.1093/neuonc/noac150

. 2022 Jun 15;25(1):177–184. doi: 10.1093/neuonc/noac150

Diversity within the neurosurgical oncology workforce in the United States: A cross-sectional study with proposed strategies to pave the path forward

Zerubabbel Ketema Asfaw ¹, Analiz Rodriguez ², Tiffany Renee Hodges ³, Madhu Mazumdar ⁴, Serena Zhan ⁵, Michael Lim ⁶, Isabelle Margherita Germano ^7,^✉

PMCID: PMC9825340 PMID: 35705107

Abstract

Background

Improving and fostering diversity within the neurosurgical workforce has become a high priority. This cross-sectional study aims to provide data on the diversity of neurosurgical oncology faculty (NSOF) in the US.

Methods

All 115 neurosurgery (NS) Accreditation Council for Graduate Medical Education (ACGME) accredited programs were included in this study. The academic rank, academic and clinical title(s), gender, race, and hiring date of neurosurgical faculty with a primary focus on neurosurgical oncology (NSOF) were recorded. Geographical distribution and “top 10” programs were tabulated according to published data. Underrepresented minorities in medicine (URiM) faculty were identified according to the AAMC definition.

Results

The NSOF workforce constitutes 21% of the total NS faculty. Of these, 10.1% are women and 9.9% are URiM (P < .001). Currently, 58% of neurosurgery programs (NSP) do not have URiM and/or women NSOF. The top 10 ranked NSP, according to Blue Ridge Institute for Medical Research, had a significantly less URiM NSOF (P = .019) than nontop 10 ranked programs. There was a decreasing trend in the proportion of URiM at higher academic ranks (P = .019). All of the URiM department chairs (3/113)—all men—and 1/3 women department chairs nationwide subspecialized in neurosurgical oncology.

Conclusions

Neurosurgical oncology is a sought-after subspecialty attracting a fifth of neurosurgeons practicing in ACGME-accredited training programs. Changing demographics and the benefits of workforce diversity represent a great opportunity for our field to continue leading inclusion efforts and attracting the best and brightest.

Keywords: diversity, neurosurgical oncology workforce, URiM neurosurgeons, women neurosurgeons

Key Points.

The proportion of women NSOF and URiM NSOF is significantly lower than the proportion of women and URiM in the US population.
The higher number of URiM NSOF with an assistant professor rank indicates that the field is attracting more minorities.

Importance of the Study.

Enhancing the diversity of the physician workforce has been linked to improving the medical care provided to all patients. However, the necessary changes required to foster diversity have been sluggish due to multiple factors, including the lack of research on the current state of diversity among certain specialties and subspecialties. This cross-sectional study is the first report on the racial and gender diversity within the US neurosurgical oncology faculty (NSOF) workforce. After comparing the proportion of women and underrepresented minorities in medicine (URiM) within the workforce and the general US population, the study analyses how several salient factors, such as institutional rank, faculty size, geographic distribution, and academic rank are related to diversity. Moreover, the study investigates whether the department chairpersons subspecializing in neurosurgical oncology lead more diverse departments relative to their peers in other subspecialties. The report culminates by highlighting strategies to enhance diversity in the NSOF workforce.

Diversifying the workforce within the medical field has been identified as a vital component of addressing health disparities in the United States (US). The non-White inhabitants of the US comprise nearly 40% of the population, with expected growth to over 50% by 2045.¹ The increasing diversity of our nation’s population has served as an impetus for promoting a diverse workforce in different institutions and sectors of the economy ranging from the military to academia.² Previous reports have demonstrated that institutions that brought together different perspectives and experiences in the form of a diverse workforce were more innovative, profitable, and retained a higher proportion of their employees than peer institutions with a relatively homogenous workforce.^3–5

As the issue of diversity in medicine gained traction within the field, the American Association of Medical Colleges (AAMC) coined the term underrepresented minorities in medicine (URiM) to describe individuals who belong to the following groups—Blacks, Latinx, and Natives (Americans Indians, Alaska Natives, and Native Hawaiians).⁶ According to the US Census Bureau, Blacks, Latinx, and Natives constitute 13.4%, 18.3%, and 0.9% of the US population, respectively.¹ Yet, Black physicians make up 5% of the workforce, and Latinx doctors account for 5.8%.⁷ Regarding gender, women remain underrepresented within the physician workforce as only 35.2% of active physicians and less than 25% of most surgical specialists are women.^8–11 In light of reports that indicate continued growth in the proportion of URiM and the majority of women in the population, the racial and gender underrepresentation may worsen in the coming decades.

Women comprise 10% of the faculty workforce in academic neurosurgery, and 22% (25/115) of Accreditation Council for Graduate Medical Education (ACGME)-accredited neurosurgery programs (NSP) did not have women neurosurgery faculty.¹¹ In terms of racial diversity, we recently reported that Black and Latinx neurosurgery residents made up 4.8% and 5.8% of the resident workforce, while Black and Latinx faculty accounted for 8% of the faculty workforce.¹² Neurosurgical oncology was the third most common subspecialty for women and URiM, preceded by pediatrics and spine, respectively.¹² With the growing trend in subspecialization, neurosurgical oncology has emerged as a leading subspecialty, as demonstrated by the American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Joint Section on Tumors being one of the largest Joint Sections—preceded only by the Joint Section on Spine.¹³ In light of the increasing interest in neurosurgical oncology among the broad neurosurgical workforce as well as URiM and women neurosurgeons, this cross-sectional study aims to present the current state of racial and gender diversity in the neurosurgical oncology field. We also characterize the diversity, rankings, and geographic distribution of neurosurgery departments led by neurosurgical oncology faculty (NSOF).

Methods

NSOF at Academic Programs: Data Collection and Data Mining

All 115 neurosurgery programs with a residency program recognized by the ACGME were identified using ACGME Data Resource books.¹⁴ Using a Google search, between August 3 and September 28, 2021, demographic data on neurosurgery faculty in each program was compiled into a database. The definition of URiM was based on the AAMC description⁶ to include individuals who belong to the following groups: Blacks, Latinx, and Natives (American Indians, Alaska Natives, and Native Hawaiians). The institutional websites of nine departments did not provide faculty members’ clinical profiles and/or academic ranks. Inclusion criteria: All three of the following criteria had to be fulfilled by each faculty to be included in the study cohort: (1) completed a neurosurgery residency; (2) currently practicing neurosurgery full-time; (3) neurosurgical oncology as primary practice focus. Completion of brain tumors, skull base, and radiosurgery training was also recorded. Exclusion criteria: (1) Adjunct and affiliated faculty were excluded from the study cohort; (2) neurosurgeons with a primary clinical interest in other subspecialties such as cerebrovascular, spine, and pediatrics were not included in the study cohort, albeit tumors were listed among their multiple clinical interests. The exclusion criteria were applied only to faculty-level analyses rather than analyses with a program or multi-institutional scale. Exclusion/inclusion criteria were formulated by consensus among the Authors, a group representing geographical/ethnic/gender diversity.

Data on the racial and gender diversity of neurosurgeons is not currently nationwide and/or on a departmental basis. Data was collated using a Google search, as reported by others.^15,16 Two authors independently screened all faculty members. Any disagreements were resolved by a consensus with the input of a third investigator (I.M.G.).

Institutional ranking was based on three different sources: (1) Top 40 NIH-funded institutions 2020,¹⁷ (2) Blue Ridge Institute for Medical Research (BRIMR) ranking of neurosurgery departments based on total annual NIH funding 2020,¹⁸ (3) Doximity neurosurgery program ranking 2021.¹⁹ All academic programs were categorized into four geographic quadrants according to the US Census Bureau.²⁰ The research reported in this article conforms to the ethical principles and norms established by the Declaration of Helsinki.

Statistical Analysis

Data analysis was completed using SAS software Version 8 (Cary, NC). Where possible, both parametric and nonparametric methods were performed for each hypothesis test. The binary proportion test was used to compare the proportion of URiM NSOF and women NSOF with the corresponding proportions within the US population.²¹ The binary proportion test was also used to compare the proportion of programs headed by NSOF amongst the most diverse programs in terms of proportion of URiM NSOF or proportion of women NSOF.

Kendall’s correlation coefficients are calculated and tested to understand the relationship between the total number of URiM NSOF or women NSOF with respect to total NSOF.²² Kendall’s correlation coefficients are also calculated and tested to understand the relationship between hire year and proportion of URiM NSOF or women NSOF assistant professors hired. Cochran–Armitage test for trend was used to analyze the association between professor rank and total NSOF hired, the proportion of URiM NSOF hired, and women NSOF hired.²³ Both ANOVA and Kruskal–Wallis tests were conducted to study the relationship between the distribution of NSOF across the US geographic quadrants.²⁴ Both two-sample independent t-test and Wilcoxon two-sample test were conducted to understand the proportion of URiM NSOF or women NSOF and the three institution ranking systems (NIH, Doximity, and Blue Ridge).²⁴ All tests were two-sided with statistical significance defined as P < .05.

Results

NSOF Workforce: Gender and URiM Distribution Across US Programs

Neurosurgery Oncology faculty (NSOF) comprise 21% of all NS faculty, calculated as 345/1648 (NSOF/total NSF), identified in the 102/115 programs reporting subspecialty focus. Whereas women are 51%, and URiM are 33% of the US population, women and URiM comprise a significantly smaller proportion of the NSOF workforce, 10.1% and 9.9%, respectively (P < .0001) (Figure 1). Among URiM NSOF, 18% are women. Currently, 58% of NSP do not have URiM and/or women NSOF. 28% (29/102) of programs included at least one woman NSOF and 27% (28/102) of programs had at least one URiM NSOF.

Fig. 1 — Gender and URiM proportions in the US population and neurosurgical oncology faculty (NSOF) workforce. The proportion of women NSOF and URiM NSOF was significantly lower than the proportion of women and URiM in the US population (P < .0001).

In addition to the above 345 NSOF, 40 pediatric neurosurgeons and 76 spine neurosurgeons were identified with primary clinical interest/practice in neurosurgical oncology. In a Kendall correlation analysis assessing the relationship between faculty size and URiM NSOF representation in neurosurgery programs, there was no statistically significant correlation (τb = 0.24, P = .14). A similar analysis examining the relationship between faculty size and women NSOF representation in neurosurgery programs demonstrated no statistically significant correlation (τb = 0.28, P = .08).

Women NSOF and URiM NSOF in Top 10-ranked Institutions

Neurosurgery programs listed among the top 10 according to Blue Ridge ranking had a statistically significant lower proportion of URiM NSOF compared to the rest of the programs (Figure 2, P = .019). Such difference was not found when comparing the other two top 10 cohorts and/or combining all top 10 ranked programs. There was no statistically significant difference in the proportion of women NSOF in top 10 ranked programs versus nontop 10 ranked programs—regardless of ranking sources.

Fig. 2 — Top 10-ranked programs based on Blue Ridge Institute for medical research had a lower proportion of URiM NSOF (P = .019).

NSOF Diversity Across Academic Ranks

The distribution of URiM NSOF across academic ranks demonstrated a decreasing trend in the proportion of URiM at higher academic ranks (Figure 3, P = .019). Out of the 345 adults NSOF, 319 faculty had academic rank information with the following distribution—112 assistant professors, 62 associate professors, and 145 professors.

Fig. 3 — Distribution across academic ranks showed a significantly higher number of URiM NSOF at the assistant professor rank (P = .019).

Diversity in Departments Chaired by NSOF

NSOF department chairs account for 35% (40/113) of programs nationwide. Chairperson subspecialty of two programs was not available on institutional websites. Neurosurgical oncology was the most popular subspecialty among chairpersons, followed by vascular (28%), functional (10%), spine (9%), general neurosurgery (8%), pediatrics (5%), and trauma (4%). All URiM department chairs (3/113)—all men—subspecialized in neurosurgical oncology. Out of the three women department chairs nationwide, one subspecialized in neurosurgical oncology. Nearly 33% (13/40) of NSOF-led programs are located in the Northeast US quadrant, albeit there were no significant differences between NSOF-led programs in terms of geographic distribution. There were no statistically significant differences between NSOF-led departments and the rest of the study cohort regarding racial and gender diversity.

Discussion

Racial and gender diversity are prominent features of diverse societies like the US. On the population scale, diversity is a product of converging natural and artificial factors such as birth, immigration, and social constructs. In contrast, the racial and gender diversity of organizations is a valued asset that comes through actionable efforts rather than natural factors. As a result, studies indicate that organizations committed to diversifying their workforce benefited from heterogeneous perspectives, superior problem-solving, and decisive decision-making.^25–28 Moreover, the advantages of racial and gender diversity are not limited to the sociocultural and workplace spheres but also include higher financial returns relative to more homogenous organizations.^25,28 Within medicine, racial and gender diversity of physicians has been associated with a lower incidence of implicit bias, better patient satisfaction, higher enrollment of minority patients in research studies, and compliance with physician’s recommendations.^12,29–31

Our study showed that the representation of women and URiM within the NSOF is similar to that of the overall neurosurgery workforce, as recently published.¹² The study also demonstrated that 58% of NSP did not have URiM and/or women NSOF. This data highlights that substantial efforts are needed to provide more support for women and URiM trainees to ensure their increased representation within the NSOF workforce. Different strategies can be used toward this goal. They can be grouped into three main categories: creating pipelines, decreasing entry barriers, and building retention of women and URiM within the NSO workforce. The true inflection point to increasing diversity is when our minority and women recruits become successful.

Creating pipelines to neurosurgical oncology involves exposure during medical school, active recruitment efforts, and mentorship. Pipelines created by providing access to learn about our profession to younger students can further contribute to accomplishing this goal. In orthopedics surgery, the Perry Initiative, which established programs for high school and medical students, was started to address gender disparities and led to a significant increase in women applicants.³² Recent data from orthopedic surgery demonstrates that 3/5 of medical schools that produce the highest amount of successfully matched Black applicants are from historically Black medical schools.³³ In neurosurgery, we have also shown the positive impact of creating pipelines for URiM high-school students (I.M.G., unpublished observations, presented at 2021 AANS meeting).

Decreasing entry barriers to our field can create new leaders and mentors who will inspire minorities to join the workforce. On a national level, neurosurgical organizations have started efforts to ensure that gender and racial representation adequately reflect present-day US demographic trends, provide diversity programming and educational offerings, and remove barriers for women and URiM neurosurgeons to give presentations at national meetings. Both neurosurgical organizations have taken steps toward this goal. The Congress of Neurological Surgeons, for example, has implemented the Pathways to Neurosurgery and the Community Engagement Programs to lower these barriers.³⁴ The AANS has formed a Diversity Task Force to promote ethnic, racial, and gender inclusion. Similarly, the Society of Neuro-oncology (SNO) has formed the women and minority committee. The recent creation of the American Society of Black Neurosurgeons (ASBN) reflects the active mission of the recruitment and retention of Black neurosurgery residents and faculty. Neurosurgical societies in other countries, such as the European Association of Neurological Societies (EANS), have established a scholarship program that supports minority candidates who enroll in a leadership course that equips them with the skills required to succeed beyond academic neurosurgery.³⁵ Concerted and collaborative efforts between national organizations to address diversity within neurosurgery will ensure sustainable changes. Such efforts are relevant to all clinical settings, not just academics.

Recent initiatives have demonstrated that social media can be another method to recruit and mentor students.³⁶ In neurosurgery, social media has already shown great promise in addressing the gender gap.³⁷ The AANS Diversity Task Force uses social media to highlight diversity initiatives.³⁸ Similarly, the EANS has also launched a Twitter handle that complements the feeds of other branches of the organization while increasing the visibility of minority leaders in neurosurgery.³⁹

Our study showed a significantly higher proportion of URiM and women at the lowest academic rank, assistant professor. While these results are encouraging as they could signify that the efforts in building pipelines and decreasing barriers are successful, it raises questions about retention and promotion efforts. While attracting a diverse workforce to our profession is desirable, ensuring its retention and promotion should be an equally important goal. The retention of women and URiM faculty provides identifiable preceptors for students, which in turn can lead to increased recruitment of women and URiM in neurosurgery.⁴⁰ Furthermore, providing an equitable distribution of division/departmental resources may maximize the chances of building a diverse department in which women and URiM faculty do not experience career stagnation and lack of promotion.

The complexity of the upward trajectory in achieving diversity in the NSOF workforce does not seem to be influenced by the geographical location of the training program or the size of the program’s faculty, as these variables were shown not to be significant in our study. On the other hand, the top 10 ranking seems to influence diversity growth negatively. Our study showed a significantly lower proportion of URiM NSOF was found in Blue Ridge’s top 10 ranked NSP. The lower proportion of women and URiM at top-ranked programs was a surprising result of this study, considering that such institutions would have the best infrastructure and means to attract diversity. That said, multiple factors, including NIH funds, determine ranking. Previous studies indicate that women and URiM receive a smaller percentage of NIH funds.^41–43 Therefore, implicit and explicit bias might hinder women and URiM from being hired by top-ranked programs. In other words, until recent changes in the NIH award structure, hiring a woman and/or URiM faculty could be a deterrent while aspiring to maintain or improve national ranking. Our study was not powered to analyze the causes at the base of this observation. We hope that these results inspire others to look into possible explanations further.

The importance of continuing to build a diverse workforce to serve our patients with brain and spine tumors is supported by studies showing better clinical outcome when gender or racial congruence exists.^30,31 Additionally, due to the unmet need to find new therapies for brain and spine tumors, strategies to optimize enrollment of a diverse population are sought. The role of gender and race concordance has been highlighted in recent literature.^31,44 A recent study showed that women patients are more likely to suffer from adverse postoperative outcomes if operated on by a male surgeon, while male patients did not experience postoperative outcomes disparity based on their surgeon’s gender.⁴⁴ While the role of neurosurgical oncologist–patient gender concordance on postoperative outcomes remains to be investigated, a report on brain tumor statistics revealed that Black pediatric patients had lower survival rates than White patients with diffuse astrocytomas and embryonal tumors. Non-Hispanic Black women and non-Hispanic White men had the highest incidence of malignant brain tumors.⁴⁵

There are many barriers on the systemic and individual level that have impacted the clinical trial enrollment of racial and ethnic minorities in cancer clinical trials. These barriers include but are not limited to lack of community engagement, attitude/bias by patients and providers, eligibility criteria, and access.⁴⁶ To ameliorate these barriers, multilevel systemic approaches are needed, and workforce diversity may be one of such avenues. In a study that analyzed central nervous system (CNS) tumor clinical trial accrual from 2000 to 2019, it was demonstrated that women and minorities remain underrepresented in therapeutic neurosurgical oncology trials relative to incidence and mortality. Another study on clinical trials for brain tumors reported a significant lack of diversity in patients enrolled in clinical trials—even if the trial is conducted in multicultural hubs.⁴⁷ Neurosurgical oncology clinical trials that reported higher levels of racial diversity were correlated to having more diverse authorship, indicating that increasing workforce diversity will likely lead to increased enrollment of underserved patients.⁴⁸

There are limitations of our study worth highlighting. These include the definition and the methodology used to define minorities. Although our study used the AAMC definition of URiM, it is crucial to consider that other minorities are now identified as an overlooked population in leadership positions in other fields. According to an article by Gee et al.,⁴⁸ Asian women are often placed into a category that does not distinguish race, and Asian men are not considered a minority population in many demographic reports from companies. Furthermore, reports based on data from the national Equal Employment Opportunity Commission (EEOC) point out that Asians were the least likely to be promoted to management roles of all races.⁴⁹ Hence, we must be cognizant of including Asians along with other minority groups in demographic data for leadership positions in our field to understand how we as a field compared to other disciplines in medicine and other professions.

Perhaps an important point of this study, and yet one of its significant weaknesses, is that there is no organized database that includes the race and gender of the NSF workforce in the US. In light of the absence of such data, the collection of gender and racial data based on publicly available websites may be susceptible to inaccuracies. We minimized bias by having two authors of different racial and gender backgrounds collect the data independently and build a consensus with another author when there was a discrepancy, in line with previous reports.^15,16 We hope the lack of self-reported race, gender, and other demographic data for NSF will prompt leaders of academic departments and organized neurosurgery to establish a comprehensive database that can be utilized in future research. Another limitation is that the study did not account for individuals who may not fall under a binary gender category or NSF with a heterogeneous racial background. Additionally, the different time frames for institutional website updates may have led to minor inaccuracies that may not reflect changes in a given neurosurgeon’s institutional affiliation. Finally, we recognize that although our study is limited to ACGME-accredited programs to facilitate comparison with previous reports, there are other prominent neurosurgical oncology groups whose faculty should be considered in future studies.

Acknowledgments

The authors would like to thank Elizabeth Soto for contributing to the data collection process in the early stages of the study.

Contributor Information

Zerubabbel Ketema Asfaw, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Analiz Rodriguez, Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arizona, USA.

Tiffany Renee Hodges, Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.

Madhu Mazumdar, Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Serena Zhan, Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Michael Lim, Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA.

Isabelle Margherita Germano, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Funding

No funding was received to support this study.

Conflict of interest statement. All authors do not have any conflicts of interest pertinent to the work presented in this report.

Authorship statement. Conception and design: I.M.G., Z.K.A., S.Z. Acquisition and analysis of data: I.M.G., Z.K.A., E.S., S.Z., M.M. Drafting the article: I.M.G., Z.K.A., M.L., A.R., T.R.H. Manuscript editing: I.M.G., Z.K.A., M.L., A.R., T.R.H., S.Z., M.M.

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PERMALINK

Diversity within the neurosurgical oncology workforce in the United States: A cross-sectional study with proposed strategies to pave the path forward

Zerubabbel Ketema Asfaw

Analiz Rodriguez

Tiffany Renee Hodges

Madhu Mazumdar

Serena Zhan

Michael Lim

Isabelle Margherita Germano