Mirror, mirror: How current societal issues reflect changes arising in surgery

At one time, # meant “number” or was called the pound sign. Since the advent of social media, this symbol now is referred to as a “hashtag” and has come to represent societal trends and movements. In fact, hashtags such as #MeToo and #BlackLivesMatter have transcended social media movements and now are used to support victims of sexual harassment and assault and racial profiling. These movements are slowly affecting professional settings, with an increased awareness and calls to action for diversity and inclusion in the workforce.

A search of recent news with the terms “diversity, equity, and inclusion” results in numerous articles published on a daily basis about the new appointments of diversity officers, sensitivity training programs, awards, and other initiatives in the business sector, academia, sports, and medicine. Unfortunately, the search also results in multiple articles citing a recent national survey of U.S. general surgery residents reporting a prevalent experience of racial, ethnic, and gender discrimination.¹

Furthermore, the effects of national diversity movements are just beginning to be realized in academic surgery. A review of the most recent Association of American Medical Colleges (AAMC) demographic data shows that a gender and racial gap persists in the numbers of active surgical academic faculty across the U.S.² Of the 16,221 total academic surgical faculty as of December 31, 2018, 23 percent were women, and only 7 percent were underrepresented minorities (URM). Additional breakdowns of gender and race are summarized in Table 1.

Change is inevitable, and medicine and surgery are lagging behind other sectors of society. This article delves into the parallels between ongoing public battles for equity and inclusion to struggles facing various professionals with lesbian, gay, bisexual, transgender, queer, and other sexual identities (LGBTQ+); minorities; and women.³

#BornThisWay

In 2011, Lady Gaga, a pop music artist, released the song “Born This Way.” The lyrics evoke feelings of freedom, empowerment, and love of oneself. The song quickly became the latest anthem for the LGBTQ+ community.⁴ #BornThisWay continues to represent individuals who are trying to break free of the stereotypes and stigma of their sexual and gender identities.

The implications of bias and gender-based harassment cannot be overstated. For example, overt discrimination as well as microaggressions against LGBTQ+ individuals in the sports world are associated with significant influences on athletes’ educational and athletic outcomes, depressive symptoms, substance use and abuse, and suicidal ideation.⁵ In the same light, negative experiences in the workplace and in health care are associated with lower self-esteem, increased stress and anxiety, feelings of isolation, headaches, poor appetite, and eating disorders.^6,7 Residents who experience discrimination reported higher rates of burnout (51.6 versus 40 percent, p <0.001), thoughts of attrition (16.2 versus 10.1 percent, p <0.001), and suicidal thoughts (6.5 versus 3.8 percent, p <0.001).¹

An evaluation of the factors abetting discrimination reveals ignorance as the most basic cause. Lack of knowledge of the various gender and sexual identities, and the implications of bias against them, forms the basis of harassment and microaggression. In the setting of a surgical training program, the source of discrimination is not just fellow health care workers, but patients and their families as well.¹ Part of the problem lies in how the health care environment is portrayed to the public; until recently, the public misrepresentation of the medical workforce has been cisgender (gender identity aligns with sex assigned at birth), white, and male. This image directly correlates with the negativity that minority health care professionals often experience.⁸ Thankfully, change is afoot.

The past two decades have seen several prominent personalities come out openly about their gender and sexuality and begin to advocate for LGBTQ+ rights. Nowhere is this more apparent than in the athletic arena. This includes the work done by soccer World Cup winner Megan Rapinoe, major league baseball player Billy Bean, and the first openly transgender triathlete Chris Mosier.⁹ Led by these vocal role models, the sporting industry has been at the forefront of societal changes—inclusion and empowerment, acceptance, and compassion. Table 2 highlights several of the practices that the National Collegiate Athletic Association (NCAA) has adopted to promote a positive campus climate for LGBTQ+ athletes.¹⁰

One crucial NCAA practice involves creating a visible and supportive presence for the LGBTQ+ community. Acceptance of LGBTQ+ individuals by both their families and their teams leads to greater self-esteem, improved health, and prevention of depression, suicide, and other self-harming behaviors.¹¹ Another important step is enhancing the cultural awareness of educators, making an effort to extend language beyond traditional binaries, and integrating LGBTQ+ issues into existing educational programs.¹² Guidance and mentorship are key to surviving in an environment of bias and microaggression. The medical and surgical communities could learn a lot from this approach, by incorporating gender sensitivity training, by providing visible support and mentorship to LGBTQ+ members, and taking steps to eradicate discrimination based on gender identity.

#OscarsSoWhite

#OscarsSoWhite is a social justice campaign that was started in January 2015 in response to the fact that all 20 acting nominations of the Academy of Motion Pictures Arts and Sciences were awarded to white actors. The movement gained even more momentum when, a year later in 2016, all 20 acting nominees again were white actors.¹³ The movement eventually expanded to call out the underrepresentation in the motion picture industry, both on and off screen, of multiple marginalized groups. A large part of the problem was that, as of 2012, of almost 6,000 voting members of the Academy of Motion Pictures Arts and Sciences, only 6 percent were people of color and 23 percent were women.¹⁴ In 2019, these numbers improved; today, the academy has almost 8,000 voting members, 16 percent of which are people of color, and 31 percent are women.

Furthermore, despite the fact that in 2019, when four of the acting nominations and three of the eventual winners were people of color, 2020 again was notable for its lack of diversity. The question then becomes, how do we not only promote change, but also sustain it?

The issue of diversity extends beyond who is celebrated in the movie business to who is portrayed in the movies. According to a 2016 report released by the Annenberg Foundation and the University of Southern California (USC) Annenberg School for Communication and Journalism, in the top 100 top-grossing films of 2015, 73.7 percent of the characters were Caucasian, 12.2 percent African American, 5.3 percent Latino, and 3.9 percent Asian. These percentages had remained unchanged since at least 2007. The issue also encompasses who holds one of the most coveted positions on the movie set; in 2015, only four of the 107 directors were of African descent (3.7 percent), and six were of Asian descent (5.6 percent). Across 886 directors from 2007 to 2015 (excluding 2011), only 5.5 percent were black and 2.8 percent were Asian.¹⁵

Many of these same disparities are mirrored in American surgery (see Figures 1 and 2). Based on 2019 U.S. census data, 13.4 percent of the population is black, 18.3 percent is Hispanic or Latino, and 5.9 percent is Asian.¹⁶ However, only 3.6 percent of the U.S. medical school faculty members are black and 5.5 percent are Latino.²

These disparities also are reflected in the surgical resident population. Of the 4,339 (71 percent of the eligible cohort) surgery residents who completed a 2008 survey, 61.9 percent identified as white, 18.5 percent as Asian, 8.5 percent as Hispanic, 5.3 percent as black, and 5.8 percent as other. Compared with white residents, black and Asian residents were less likely to report being able to turn to faculty when struggling (95.3 percent versus 91.2 percent and 93.1 percent, respectively; p = 0.016) and were more likely to report that attendings would think less of them if they asked for help (13.5 percent versus 20.4 percent and 18.4 percent, respectively; p = 0.002).¹⁷ Unsurprisingly, people of color also are markedly underrepresented as surgical department chairs as of December 31, 2018; only 3.7 percent are black, 5.3 percent are Latino, and 11.2 percent are Asian.²

It is well established that “you can’t be what you can’t see.” Thus, the lack of URMs at the highest levels leads to a lack of diversity throughout all levels of surgical education—from medical students through full professors.¹⁸

Professional societies such as the Society of Black Academic Surgeons and the Society of Asian Academic Surgeons were established to address these inequities. By promoting both mentorship and academic excellence, these societies aim to increase the representation of URM surgeons in leadership positions within academic medical centers and surgical societies.

#ILookLikeaSurgeon

In recent years, we have seen many strides toward achieving gender equality in medicine. For example, #ILookLikeaSurgeon was sparked by two surgical residents in 2015 who wanted the world to see that many surgeons are women or URMs.¹⁹ A new movement was born and later expanded in 2017 when The New Yorker published cover art featuring four women peering over a patient in an operating theater, all garbed in surgical gear.^20,21 Women surgeons on social media created the #NYerORCoverChallenge, and Facebook, Instagram, and Twitter were filled with images from hospitals around the world in which women and diverse members of surgical departments stood in groups, replicating The New Yorker cover.²²

#ILookLikeaSurgeon has been influential beyond expanding visual impressions of surgeons. In July 2017, Annals of Surgery published the presidential address from a European surgical society in which the male pronoun was the only pronoun used to refer to surgeons.²³ After an outcry for correction, the article was retracted until revisions were made to be more representative of present-day surgeons.

Similarly, there has been an ongoing exposition of “manels,” wherein societies posting images of expert panels composed exclusively of men are called out and asked to address the lack of diversity. In response to the wider awareness of this issue, the director of the National Institutes of Health (NIH) released a statement in 2019 that he no longer would participate in panels lacking fair representation.^16,24

According to AAMC data on medical student enrollment, in the last decade, women medical students have expanded to being the majority, increasing to 50.5 percent in 2019–2020 from 47.4 percent of medical school classes in the 2010–2011 academic year.²⁵ Furthermore, the number of newly board-certified, women general surgeons increased to 440 in 2019 from 186 in 2000.²⁶ However, of the 31,376 certified general surgeons, only 7,193 (22.9 percent) are women. As a comparison, the latest available U.S. Census data indicate that women comprise 50.8 percent of the population, with 58.2 percent of the civilian workforce ages 16 and older being female.¹⁶ The etiology and manifestations of the disparity between female representation in surgery and women in the general population are beyond the scope of this article; suffice it to say that women face an uphill battle when it comes to explicit and implicit gender bias.^27,28 Nonetheless, there is great optimism as a result of the slow progress made over the last five years. More women are being promoted to leadership positions at academic institutions, with 21 women chairs of surgery departments as of 2019.²⁹

We cannot brag about these achievements, however, until the issue of pay equity has been adequately addressed.³⁰ In 2018, the mean salary for a woman chair of surgery was $892,100—10 percent less than the $983,700 earned by male chairs. More strikingly, women holding instructor titles earned only 68 percent of their male counterparts, with assistant professors, associate professors, and professors earning 25 percent less.³¹

The gender pay gap is not unique to surgery departments, with women earning 81 cents for every dollar a man earns.³² After their 2019 World Cup victory—their fourth consecutive win—the U.S. Women’s Soccer Team forced the public to reconcile why they were paid significantly less than the U.S. Men’s Soccer Team, which had never won a World Cup. The prize money afforded by the Fédération Internationale de Football Association (FIFA) was $30 million, versus $400 million offered to the men’s World Cup winner.³³ The team filed multiple lawsuits against U.S. Soccer for an unequal collective bargaining agreement that resulted in the women athletes earning a maximum of 38 percent of the maximum a men’s soccer player could earn in a contractually mandated match.

Women athletes in other sports face a similar discrepancy.³⁴ The average salary of a Women’s National Basketball Association (WNBA) player is $116,000, whereas the average National Basketball Association (NBA) player earns $7.5 million. Arguments have been posed about the higher revenue brought in by NBA players, but the pay gap has forced WNBA players to join teams overseas to continue playing in the off-season, which has resulted in injuries to several star players.³⁵ Fortunately, a new agreement was made this year, with increased base salaries and more bonus opportunities for players.³⁶

Just as these athletes have made strides in achieving equal compensation, women physicians are uniquely positioned to fight for pay equity. For example, a Harvard study published in JAMA Internal Medicine demonstrated that elderly patients had better outcomes when treated by women internists.³⁷ Commentary ensued that women were not being rewarded for better outcomes despite working within a system that was outcomes based.³⁸ This argument was strengthened by the study published in the Proceedings of the National Academy of Sciences in 2018, in which women patients seen in emergency departments for acute coronary symptoms had worse outcomes when receiving care from male physicians, and increasingly so if the male physicians did not have many women colleagues.³⁹ The New York Times reported this study as part of the article “Should you choose a female doctor?”⁴⁰

So, how can we move forward and do better? In 2014, actress Emma Watson gave a speech at the United Nations calling upon men to stand up for gender equality, inspiring many to join in the #HeForShe campaign.⁴¹ The Association of Women Surgeons has a #HeForShe Task Force to educate male surgical leaders to mentor and sponsor women more effectively, which empowers women to ask for equitable salaries.⁴²

We also must look at industries that are having success in diversifying the workforce, namely the business sector.⁴³ Significant increases in recruitment and promotion of women have occurred over a relatively short period of five years; such changes can occur when leadership is engaged in addressing the issue, exposed to diverse individuals, and held accountable (see Figure 3). Finally, nations such as Finland and Iceland have set an example by creating a pipeline to advance women through the ranks of government, such that young boys questioned how a male president could be possible.⁴⁴ Physicians need to engage in advocacy efforts to further systemic change in the direction of greater diversity and equity.

Discussion

The common theme among the three diverse groups discussed in this article is the need for increased representation, and, further, a need to normalize the presence of LGBTQ+, URMs, and women within our surgical communities. In describing the issues facing these groups as individual categories, the authors of this article admittedly have limited the complexity of diversity.

It is at the intersection of these different groups where efforts tend to be the weakest. The concept of intersectionality came to light by the violence black women faced in the wake of feminist and antiracist movements. This was a prime example of how some groups can be left devoid of a support network even in a system meant to protect minorities.⁴⁵ Since Kimberlé Crenshaw, a law professor at Columbia and the University of California-Los Angeles, defined the concept of intersectionality in 1989, a great deal of work has gone into analyzing and minimizing the problems facing individuals at the intersections between various groups.⁴⁶ This attention must be translated into the medical profession to remove gender and sexual identity as a predictor of success and to achieve equity.

It is important to note that other minority members of society often are overlooked but face similar challenges. Until recently, aging has had a negative connotation in the U.S.⁴⁷ In fact, surgeon retirement age has been questioned because of concerns related to declining motor skills.^48,49

Native Americans have known health care disparities. While the U.S. population of Native Americans approaches 1 percent, Native Americans comprise 0.1 percent or less of academic surgical faculty (see Table 1). Although Asians are the second largest race represented in medicine and surgery, discrimination against these individuals, as well as subgroups from the numerous individual cultures, remains an issue that receives more attention during national disasters, such as after 9/11 and during the coronavirus 2019 pandemic.⁵⁰

While the state of diversity in surgery is suboptimal, we are making progress. We should never be satisfied with the status quo and must continue to improve as our society evolves. Lessons from any industries that are doing this work well should be heeded and applied to surgical departments as appropriate. We hope to see a day when “surgeon” is the only term needed to describe a surgeon of any color, gender, and identity.

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