Professional societies play an important role in creating and maintaining a surgical workforce that reflects the populations they serve. To that end, surgical societies must create diverse and inclusive environments that encourage surgeons to achieve their maximum potential. Diversity is defined as the recognition and acceptance of individuals and their different backgrounds, including race, ethnicity, gender, work experience, socioeconomic status, sexual orientation and identity, and other qualities leading to diversity of thought.1 The concept of inclusion was introduced to the world of education in the 1990s as a means to create a space for students with disabilities, where they are respected and valued for their unique characteristics.2 The definition of inclusion now extends beyond special needs education and includes the norms and behaviors within an institution that ensure all individuals feel welcome and respected.
The U.S. population is increasingly diverse. In their responses to the 2010 census, nearly 30 percent of the population described themselves as nonwhite, and 50 percent of the respondents were women.3 Although more women are matriculating into medical school and residency programs, few women hold faculty and leadership positions.4 As of 2019, less than 4 percent of medical school faculty identified as Hispanic/Latino and only 3.6 percent as African American, a stark example of underrepresentation given that Hispanic/Latino make up 18 percent and African Americans 13 percent of the U.S. general population.4
In surgery, the discrepancy in representation is no different. In 2008, Butler and colleagues reported that only 3.6 percent of academic surgery faculty positions were held by Hispanic/Latino surgeons, and only 2.9 percent were held by African Americans.5 This disparity extends into participation and leadership positions in professional organizations. For example, as of 2016 the Society for Surgery of the Alimentary Tract (SSAT) has had only seven women and eight men of racial and ethnic minority heritage hold officer positions since its establishment in 1960.1 In addition, a recent study by Kuo and colleagues that evaluated the diversity of the American Association of Endocrine Surgeons (AAES) revealed that, as of 2017, women comprised only 35 percent of the AAES membership, less than 25 percent of its membership identified as nonwhite, and only 11 percent of past-presidents were women or identified as nonwhite.6
Underrepresentation is more notable in subspecialty surgical societies, where only 10 percent of the membership and 4 percent of named lecture speakers are women, and an even smaller percentage are underrepresented in medicine (URiM), a term used to describe populations less visible in the medical professions than in the general population.7 This article highlights some of the disparities faced by URiMs, specifically in surgery, and offers solutions to increase diversity and inclusion within surgical societies.
The argument for diverse and inclusive professional societies
Promoting diversity and inclusion in the surgical profession is important for a range of reasons both moral and practical in nature. First, there is the question of justice. Ample evidence suggests that the underrepresentation of racial and ethnic minorities, and of women, in the various echelons of the surgical profession have not resulted by mere chance, nor because these minorities are less fit for the profession than their majority counterparts, but rather because of longstanding institutional biases that have systematically excluded minorities from the same opportunities afforded to others.8,9 The profession has a moral obligation to examine and dismantle these biases, such that underrepresented minorities are accepted into and promoted within the profession in a way that is truly equitable.10,11
From a legal standpoint, precedent has been established for promoting greater diversity within training institutions. In the landmark case of Grutter v. Bollinger et al., the U.S. Supreme Court ruled that the consideration of race and ethnicity as a factor in the admissions process by the University of Michigan Law School, Ann Arbor, was lawful, upholding the university’s position that “achieving a ‘critical mass’ of racial and ethnic diversity in its law school was a compelling interest of the law school and the nation.”12
Beyond the moral argument for promoting diversity and inclusion are a number of compelling practical arguments. As Smedley and colleagues argued in a groundbreaking Institute of Medicine report, “Greater diversity among health professionals is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, better patient–provider communication, and better educational experiences for all students while in training.”12 A diverse workforce is essential to effectively care for a diverse population.13 Underrepresented minority physicians are more likely than their non-minority counterparts to treat patients of color, patients who are economically disadvantaged, and patients in poorer health.14-16 In general, ethnic and racial minority patients are more satisfied with the care they receive from minority health care professionals than care from non-minority professionals.17 Greater diversity among faculty and trainees improves the health care educational experience by exposing trainees to a range of perspectives and encounters that may enhance empathy, foster unbiased inquiry, and increase tolerance and appreciation for persons from various backgrounds.18 Finally, diversity fosters innovation.19 An inclusive work culture fosters job satisfaction, institutional loyalty, employee retention, and long-term progress.20
Increasing diversity through membership in professional organizations
Participation in professional societies can serve as a means of attracting and supporting diversity within medical professions. Professional societies that are committed to diversity and inclusion have been shown to correlate with increases in recruitment and retention of more diverse members of their respective professions.21,22 As an example, gastroenterology has experienced recruitment of women since the late 1990s, when the American Society of Gastrointestinal Endoscopy and the American Gastroenterological Association embarked on a structured plan to develop resources for recruiting and retaining women gastroenterologists. The strategic plan included mentoring programs, women-focused leadership training and conferences, grant funding for diversity and minority programs, and concerted efforts to increase the number of women in leadership positions within the organizations.22 In 1996, approximately 16 percent of all first-year gastroenterology fellows were women; over the next 10 years, this number doubled, while other medical subspecialties, such as cardiology, experienced limited growth in the number of female fellows.22 The success of the gastroenterology specialty in recruiting and retaining diverse candidates into the field likely stems from the support, mentorship, and sponsorship that membership in professional societies afforded them.
Surgical organizations have implemented several initiatives to attract diverse membership. The American Surgical Association (ASA), Eastern Association for the Surgery of Trauma (EAST), the Association of Women Surgeons (AWS), the American Otological Society, the American Neurotology Society, and the SSAT have recognized the value of having a diverse membership and have added statements of inclusion and diversity to their bylaws and values. Some societies take this work to promote inclusion a step further, and mandate unconscious bias training for their leadership.
In addition, many of these societies have worked to form collaborations with other URiM organizations through liaison positions designed to increase the participation and representation of URiMs within the organization. Furthermore, many have created diversity and inclusion committees to ensure that sessions at their conferences are diverse, inclusive, and culturally competent. These subcommittees often are responsible for overseeing the diversity of the moderators and panelists, as well as ensuring that the topics of discussion cover gender, race, and health care disparities.1
Other efforts to diversify membership and create equity include creation of open, accessible membership criteria. For example, SSAT has increased accessibility to its membership by supporting resident, fellow, and student memberships with affordable dues. For individuals interested in applying for membership in the SSAT without a member sponsor, the application now includes a feature that indicates if the applicant needs assistance identifying a member sponsor.1 Furthermore, societies like the Association for Academic Surgery, the American Society for Clinical Oncology, and the Society for Vascular Surgery offer training grants and awards specifically aimed at supporting URiM members in an effort to encourage membership and conference attendance. Beyond offering accessible membership and training grants, outreach to community and international members has been a focus of many societies, including the American College of Surgeons, as a way to diversify membership.
How can we foster inclusion within surgical subspecialties?
Contemporary assessments of gender, racial, and ethnic diversity in surgical subspecialty training programs have demonstrated a significant discrepancy between the composition of these disciplines compared with demographics of U.S. medical schools and the population at large.23-27 More than 50 percent of current medical school matriculants are women, but they are underrepresented in multiple surgical subspecialty residencies.23,25,26,28 The notable exception is obstetrics and gynecology, which has approximately 85 percent of residents self-identifying as women, and some have advocated for efforts to increase recruitment and retention of men in this specialty.23 Nevertheless, other surgical specialties, such as urology and orthopaedic surgery, have more male-dominated workforces, with women accounting for only 26 percent of anticipated urology residency graduates in 2020. Moreover, the proportion of women trainees in U.S. orthopaedic programs only increased to 14.4 percent in 2015 from 10.9 percent in 2006.28 Vascular surgery also has remained relatively stagnant in terms of increasing ethnic, racial, and gender diversity.24
The dearth of URiM trainees in the surgical subspecialties also is well described. A survey of residency program directors in otolaryngology demonstrated that over the previous 15 years, more than one-third of programs had matriculated one or fewer residents from a URiM group.25 A 2018 report derived from the American Urological Association Annual Census demonstrated that only 4.1 percent and 3.6 percent of trainees self-identify as either black/African American or Hispanic, respectively.28
Clearly, much progress remains to be made to address the lack of diversity within surgical residencies. Resolving this diversity crisis in surgical subspecialties must begin well before the final years of medical school. In their review of diversity trends in vascular surgery training programs in the U.S., Kane and colleagues conclude that proactive steps, such as targeted recruitment of underrepresented medical students, increased leadership roles for surgical subspecialists in minority medical student groups, and sustained scholarships for underrepresented students to attend regional and national surgical subspecialty meetings, all are actionable improvements.24 With respect to orthopaedic surgery, Poon and colleagues highlight the strong influence of role models in medical student specialty choice and cite a 2016 survey of U.S. medical students, which showed that mentors played a significant role in specialty choice for 81 percent of students.26,29 To this end, they highlight the potential impact of appointing women and underrepresented minorities to preclinical instructor positions, such as musculoskeletal anatomy or physiology, as a means of increasing recruitment for orthopaedic residencies.26
Furthermore, the authors also recommend greater representation of minority and women residents, fellows, and orthopaedic diplomates in pipeline programs targeting URiMs to provide visible role models to these groups.26
Likewise, in a recent report Dai and colleagues reviewed strategies to increase women and underrepresented minorities in urology and attributed the gap in representation to myriad factors, including a lack of mentorship, differences in compensation between genders, as well as implicit and explicit bias.30 The study authors recommend focused mentorship programs aimed at women and URiM groups, alternative compensation models, and deliberate recruitment programs as potential methods to mitigate the shortfall in representation of diversity and inclusion within urology.30
Tackling the lack of diversity endemic to many surgical subspecialties will require pragmatic and comprehensive implementation of local and national policies aimed at improving the status quo. These policies should include efforts to promote and highlight URiM mentors and leaders within the surgical subspecialties, which is perhaps the highest-yield intervention at our disposal.
Summary
Diversity among surgeons and surgeons in training in terms of race, ethnicity, gender, sexual orientation/identity, socioeconomic background, and other factors is increasing. But in spite of the fact that surgeons come from increasingly diverse backgrounds, membership and leadership composition of professional surgical societies has lagged behind representation in the current and incoming surgical workforce. This lack of diversity and inclusion within subspecialty societies propagates the existing disparities in medicine and surgery, and must be addressed. Fostering diversity and inclusion within surgical societies not only will support URiM surgeons and trainees, but will allow these surgeons to better serve their patients and improve surgical care in the U.S. and beyond. By promoting diversity and inclusion through actionable best practices (see Figure 1), we will truly represent the patients we serve.
