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EDITORIAL
Year : 2022 | Volume
: 8
| Issue : 4 | Page : 189-192
What's new in academic international medicine? Improving the state of representation in the neurosurgical workforce
Christian N Schill1, Frank J Cedeño2, Doron Rabin3
1 Department of Research and Innovation, St. Luke's University Health Network, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
2 Center for Urban Bioethics, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
3 Department of Neurological Surgery, St. Luke's University Health Network, Philadelphia, Pennsylvania, USA
Correspondence Address:
Dr. Christian N Schill
Department of Research and Innovation, St. Luke's University Health Network, Lewis Katz School of Medicine at Temple University, Philadelphia
USA
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijam.ijam_106_22
Neurological surgery is a specialty defined by technological innovation and progressive understanding of the nervous system. However, despite a nationwide focus on the importance of representation of minority groups in the physician workforce, neurosurgery remains among the least diverse specialties in medicine, with almost no progress made on this front in the last decade.[1],[2] Some of the most recent surveys published in 2021 and 2022 revealed that only 6%–8.4% of board-certified neurosurgeons are women, only 4%–4.8% are people who identify as Black, and only 5%–5.8% are people who identify as Latinx.[2],[3],[4] Intersectionality also compounds this issue. Intersectionality describes the compounded social effects of people existing within multiple social categories such as race, ethnicity, gender, and social class which creates overlapping systems of disadvantage. For example, people who are both women and Latinx experience discrimination due to society's view of women and of people who are Latinx. In 2020, there were only 33 attending neurosurgeons in the United States who identified as both women and Black, making up 0.6% of neurosurgery faculty.[5],[6] This suggests that while this specialty has been breaking scientific barriers and improving patient care, the field has remained largely homogenous, with men who are White (64.5%) and Asian (21%) making up the vast majority of practicing neurosurgeons.[2] In addition, the research on this topic is insufficient. The authors could identify no published work that has assessed what percentage of neurosurgeons in the United States identify as lesbian, gay, bisexual, transgender (LGBT+), or nonbinary. This leaves many questions regarding the state of diversity and representation in the neurosurgical workforce and what neurosurgical departments can do to help.
Patients who are Black are twice as likely to die from traumatic brain injury (TBI) than their White counterparts, are less likely to undergo necessary surgical intervention for their injuries, and are less likely to have access to physical therapy after surgery to aid in their long-term recovery.[1] Despite these stark inequities, 92.6% of the first authors on NIH-funded clinical trials focused on TBI are White, nearly 70% of such studies do not even report demographic data, and 65% had failed to recruit any patients who are Black.[1] Even more of these studies had failed to recruit any Latinx or Native American patients.[1] Clearly, the research guiding our clinical practice largely excludes both investigators and patients who are people of color. As a result, the subjective tools devised from these studies to assess metrics such as the extent of brain injury after trauma and when a patient is indicated for surgery will fail to account for cultural differences between patients and thereby bolster systemic health-care inequities. For example, the same study assessed outcomes of using such subjective TBI assessment tools and found that White neurosurgeons were more likely to attribute decreased attentiveness to intoxication in Black patients than in White patients and were less likely to work the patient up for TBI.[1]
Distrust for the medical establishment is highly prevalent in minority groups, particularly in Black Americans, due to a long history of abuses and atrocities inflicted on Black communities by the American Healthcare System.[7] The importance of trust in the medicine has never been more evident than during the recent COVID-19 pandemic. In November 2020, surveys conducted by the National Association for the Advancement of Colored People found that only 14% of people who are Black trusted the COVID-19 vaccines on the market and only 18% were definitely getting the vaccine.[7] Research conducted by the Association of American Medical Colleges (AAMC) found that when the life experience of a physician aligns with that of their patient, patient satisfaction is significantly higher, and they are more likely to follow the directions of their physician.[8] For example, Black patients reported to subjectively trust physicians who are Black to better understand their concerns and were more likely to trust their care instructions.[9] This highlights the importance of a diverse physician workforce to serve the US's diverse population in all specialties, including neurosurgery.
Perhaps more alarming than the currently small percentage of neurosurgeons who come from groups who are underrepresented in medicine (URiM) is the lack of change in the racial, ethnic, and gender makeup of incoming residents over the last decade. Multiple studies reported that from 2009 to 2018, there was no significant change in the number of neurosurgical applicants who self-identified on their Electronic Residency Application Service as female, Black, or Latinx.[2],[3][Figure 1] shows such trends as reported by Gabriel et al.[2] This indicates that appreciation of the impact of representation in medicine has not significantly altered diversity within the neurosurgical workforce.
Figure 1: Neurosurgery residency cohort racial makeup from 2009 to 2018. Here shows the data collected by the AAMC regarding the racial identity of matched neurosurgical residents from 2009 to 2018 showing no significant changes in the makeup of neurosurgery trainees in the last decade.[2] White residents remain the majority of incoming residents and there have been no significant increases in the number of black or Latinx incoming residents. AAMC = Association of American Medical CollegeNeurosurgery residency programs are notoriously difficult to match into and require outstanding scores on the USMLE or COMLEX board examinations, an extensive and impactful research profile, excellent clinical grades during medical school clerkships, and outstanding letters of recommendation from multiple neurosurgery departments. These stringent requirements may be particularly challenging to meet for medical students of color who often have less access to the financial resources of their White counterparts.[10] This includes access to paid review resources, board preparation courses, and question banks. One study found an average USMLE score among Black and Latinx US MD seniors from 2014 to 2015 of 216, while their White peers scored an average of 223 which was statistically significant.[11] Medical students of color also experience stressors such as discrimination and racial biases not faced by White students which is important to consider as clinical clerkship grades and letters of recommendation are largely subjective. The University of Washington School of Medicine reported that over the course of 5 years of data collection, grading disparities favoring White students were found in 4 of 6 of their required clinical clerkships.[12] Surveys done by the AAMC have confirmed that these findings are not just an isolated phenomenon, but medical schools across the country consistently awarded lower clerkship grades to URiM students as compared to their White peers when multiple confounders were controlled for.[13] This may largely be due to cultural differences in perceptions of professionalism, difficulty in cross-cultural communication, and biases held by predominantly White faculty. All these barriers can lead to additional difficulty in meeting the stringent entry requirements for neurosurgical residency and dissuades URiM applicants from seriously pursuing a career in neurosurgery. Few solutions have been offered by US medical schools, likely contributing to the largely unchanged number of incoming URiM neurosurgery residents since 2009.
What can be done to ameliorate this issue? Some programs exist through the American Association of Neurological Surgeons to encourage high school students who come from underrepresented backgrounds to enter neurosurgery. A similar pipeline program could be established for 1st- and 2nd-year medical students. Such programs could include free access to examination review resources, access to neurosurgery faculty and residents who are willing to act as mentors and connecting URiM students with ongoing research projects. Models for such pipelines have developed for undergraduate students to encourage URiM students to enter medical school and even been for entering other surgical specialties.[14] For example, the Nth dimension program published data from 118 medical students from 29 medical schools who went through their URiM surgical pipeline which included an 8-week long summer program with clinical training in general surgery, longitudinal mentoring by attending specialty surgeons, access to research projects, and opportunities to present at national research meetings.[14] They reported that 72% of participants would go on to match in surgical subspecialties.[14]
Offering mentorship is supported in the literature as a key way to recruit medical student interest in specialties such as neurosurgery and otolaryngology.[15],[16] While mentoring from a background that is concordant with a URiM student's identity offers enormous benefits, it should be also made clear that URiM physicians should not shoulder the responsibility of mentoring alone. Having only URiM mentors increases what has been referred to in the literature as a “minority tax” which is placed by institutions on minority physicians.[17] This includes the extra work and responsibility of advancing diversity and inclusion initiatives without additional pay or work benefits. Such responsibility is often expected of URiM faculty, but not of their White peers. Studies have shown that mentorship programs that include a mixture of URiM and non-URiM mentors did not decrease student satisfaction in these programs.[17] While URiM physicians offer their trainees something vital that cannot be found elsewhere, academic guidance, research opportunities, hands-on experience, and specialized training can still be imparted by physicians of every racial background.[17] Of note, to have URiM physicians available to mentor means ensuring such physicians are on the faculty at an institution and that they are retained. Studies of retention of surgeons who are Black at academic medical centers found that Black junior faculty were far less likely to be promoted than White junior faculty and far less likely to feel supported and secure in their respective departments.[18] Neurosurgical departments should ensure access to the timely promotion of their Black faculty and establish a culture that is supportive and that adequately protects Black faculty and residents from microaggressions and racial bias by both patients and colleagues alike.[18] Luckily, surveys in surgical subspecialties such as general and craniofacial surgery have found faculty members who acted as mentees to medical student trainees reported higher levels of job satisfaction and professional fulfillment.[19],[20]
While the research into the racial and gender gaps is somewhat scarce, even scarcer is any data on the representation of LGBT+ neurosurgeons. To date, these authors are unaware of a single publication which examines this dimension of representation in the neurosurgical workforce. The life experiences of LGBT+ people are a unique one which may also affect a patient's trust in the health-care system.[21]
The current state of the neurosurgical workforce remains almost entirely composed of White and Asian men, and the number of entering URiM residents has remained unchanged over the last 10 years. This pattern is seen in most surgical subspecialties, which all lag behind the progress that has been made in primary care specialties.[21],[22] This has contributed to stark disparities in the clinical outcomes of people of color. The lack of progress and the disparities in neurosurgery should be a major concern of departments across the United States. Development of pipeline programs which provide resources to address barriers entering neurosurgery, supporting the hiring and retention of Black faculty, providing adequate student mentorship, and expanding research efforts to monitor the state of diversity are some of the steps neurosurgery departments can take to advance equity and diversity within the neurosurgical workforce. Brilliance is equally distributed among medical students of all racial and ethnic backgrounds, but we must continue to push for the equitable opportunity for such students to enter every specialty medicine has to offer.
Acknowledgements
The authors would like to sincerely thank the following individuals for their independent review of this publication: Ikemefuna Akusoba, MD, Clara Woods, BS, and Jeanette Nicosia, BS.
Financial support and sponsorship
The Department of Research and Innovation at St. Luke's Universtiy Health Network.
Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
This article does not contain any studies involving human participants performed by any of the authors. The authors declare this editorial does not require Institutional Review Board/Ethics Statement.
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