Glass ceilings and sticky floors: Examining diversity and inclusion in the surgical workforce

Diversity has been defined as a condition of having or being composed of differing elements. In several sectors of the modern workforce, diversity is recognized as a fundamental factor for success and innovation.^1,2 However, the health care industry lags in diverse representation, which precludes the delivery of culturally competent and sensitive care. Specifically, surgical specialties have a significantly lower demonstration of diversity in the workforce than nonsurgical specialties in terms of gender, prior work experience, political identity, and sexual identity.²

Recognizing these deficiencies, the Institute of Medicine (IOM, now known as the National Academy of Medicine) charged the medical community with diversifying as a compelling interest of the nation.³ In 2004, the IOM suggested that a more diverse health care workforce would improve access to care for minority populations, facilitate communication, and promote greater shared decision making between patients and clinicians.¹ Furthermore, diverse representation could lead to more comprehensive surgical education, as well as innovations in translational research.^1,4

Although recruiting from and promoting inclusion of different demographic pools seems simple, it can be challenging because of what is known as the Dunning-Kruger Effect.⁵ This cognitive bias is a type of anosognosia that leads an individual to make an illusory, superior self-assessment.⁶ For example, a white, heteronormative male who lacks an appreciation or awareness of the importance of diversity fails to acknowledge this deficit, then incorrectly claims to be culturally dexterous. Such a cognitive bias ultimately risks perpetuation of the lack of diversity in the surgical workforce.

French and colleagues examined the surgeon’s perception of diversity in the workplace, and four common themes emerged: personal experiences based on religion, marital status, political identity, number of children, geographic origin, race, and so on; professional experiences, such as undergraduate major, employment history, military service, age, and so on; personal health; and gender or sexual identity.² These categories highlight the extensive metrics of diversity, but only a few of these topics have been researched with respect to surgery.

This article, written by members of the American College of Surgeons Resident and Associate Society (RAS-ACS), examines the literature on diversity and inclusion in surgery as it relates to trainees and leadership. It also offers recommendations and strategies to promote a more inclusive and diverse surgical workforce.

The complicated path to achieving gender equality

In 1849, Elizabeth Blackwell, MD, was the first woman to receive a medical degree in the U.S., ostensibly shattering the glass ceiling. However, women still are significantly underrepresented in academic medicine.⁷ More than a century later, in 1981, only 25 percent of medical school graduates were women. It was not until 2017 that the number of enrolled women eclipsed men.⁸ Nonetheless, gender parity in medical school graduation rates does not translate to the surgical workforce.⁹ This disconnect is likely multifactorial and potentially attributable to a lack of women in leadership positions and mentorship roles, overt gender discrimination, and the fallacy that women are somehow technically distinct from men.^8,10

For the women who do matriculate into surgical residency, inclusion and equality are far from guaranteed. For example, women residents are granted significantly less operative autonomy when rated by residents and attending surgeons.⁵ In a survey of 24 male and 18 female general surgery residents, fewer women trainees self-identified as surgeons (11.1 percent versus 37.5 percent, p < .001).¹¹ Women cardiothoracic surgery residents similarly reported feeling less prepared technically (77 percent versus 90 percent, p = 0.01) and less equipped to perform independently (71 percent versus 87 percent, p = 0.01), despite equal competence displayed.¹² Consequently, female sex has been cited as a risk factor for contemplating quitting surgical residency and for actual attrition.^13-16

In contrast to the epidemiology of gender in the U.S. and prioritization of female inclusion in corporate business leadership, women comprise only a small proportion of all research investigators and health care providers.¹ This disparity is more pronounced in academic medicine and undeniably so in the surgical specialties.⁸ Evidence from the Association of American Medical Colleges (AAMC) and Accreditation Council for Graduate Medical Education demonstrates that women have fewer opportunities to enter academic surgery than their male, white counterparts.¹ To further widen the gender rift, women in surgery earn significantly less money than men and reportedly endure more microaggressions.^8,17-19 These microaggressions are described as discrete affronts, slights, or insults directed toward women, minority groups, and stigmatized populations to subtly convey hostility.⁵

Fortunately, female representation in surgical leadership is on the rise. In fact, 20 of the 25 women chairs of academic surgical departments were appointed in the last 10 years, and nearly half of women leaders of national organizations were elected in the last five years.^20,21 Notably, four women have served as President of the ACS (all MD, FACS): Kathryn D. Anderson (2005–2006); Patricia J. Numann (2011–2012); Barbara L. Bass, FRCS(Hon), FRCSI(Hon), FCOSECSA(Hon), (2017–2018); and Valerie W. Rusch (2019–2020). More women also are leading academic conferences as speakers, panelists, and moderators; however, equal representation has yet to be realized.^22-24 For instance, despite calls to abolish all-male panels in biomedicine, approximately one in five panels at recent ACS Clinical Congresses were composed exclusively of men.²⁴

Similarly, female surgical leadership is low among U.S. medical schools and surgical education programs. A staggering 18 percent of general surgery program directors and 30 percent of assistant program directors are women.²⁵ Of the 11,549 surgical faculty members in 2014, only 14.7 percent were women, and they comprised 19.4 percent of assistant professors, 13.8 percent of associate professors, and 7 percent of full professors.¹ As a result of these “sticky floors,” the number of women in surgery at the full professor level is not expected to match that of men until 2136.²⁶

The underrepresented in medicine and a “hidden curriculum”

In 2003, the AAMC coined the term “underrepresented in medicine” (URiM) to indicate racial and ethnic populations that lack representation in the medical profession relative to their numbers in the general population.¹ African Americans, Hispanics, and Native Americans are examples of URiMs with appointments as full-time faculty at 3.6 percent, 3.2 percent, and 0.16 percent, respectively.⁹ Likewise, African Americans represented 5.7 percent of graduating medical students in 2015, and Hispanics comprised only 4.5 percent—numbers discordant with national epidemiology.^9,27

Parmeshwar and colleagues have suggested that unconscious racial biases perpetuate fewer opportunities for minority groups during medical school.¹⁰ Ross and colleagues examined 6,000 medical student performance evaluations and found that white students were more likely to be described as “exceptional” and “outstanding,” whereas black students were more likely to be described as “competent.”²⁸ The inequality endures well into surgical residency.

For example, despite a paucity of objective reasons to explain this phenomena, nonwhite general surgery residents are less likely to pass the general surgery board exam on the first attempt in comparison with white residents.²⁹ To address this inconsistency, the American Board of Surgery is investigating the potential for unconscious bias among board examiners, increasing the diversity of examiners, and adding implicit bias training.²⁹

Wong and colleagues have even shown that racial minority residents admit to being afraid to ask attendings and peers for help.³⁰ Bucholz and colleagues add that black surgery residents also are more likely than their white counterparts to worry about competence after training.³¹ This disparate experience is augmented by reports that patients and staff mistake many URiM surgeons for nonmedical personnel in the hospital, which further undercuts confidence and undermines feelings of inclusion.⁵

The deleterious effects of being a marginalized minority in surgical residency is fraught with challenges and demands. This additional stress has been associated with increased incidences of depression, mental illness, substance abuse, and suicide.³² Upon completion of residency, the plight of URiMs does not evanesce. According to Fallin-Bennett, the institutional climate, ingrained behaviors, and an amalgam of implicit and explicit biases shape an academic health center’s “hidden curriculum.” This term refers to what health care trainees learn from observation and experience, rather than what is objectively taught.³³ Sadly, this hidden curriculum is indoctrinated, propagated, and recycled back into the next generation of trainees, leading to a culture of uniformity and exclusion.³³

Even with similar qualifying factors, URiM surgeons struggle to enter into academic surgery, let alone obtain a leadership position.^1,34,35 A 2018 study by Abelson and associates demonstrated that black assistant professors have the lowest rates of promotion and that URiM surgeons are less likely than whites to remain in academia.³⁶ Accordingly, representation for both black men and women has remained stagnant in surgical societies, and the number of black associate professors in academic surgery has declined in recent years.^26,27 Yu and colleagues have theorized that at the current rate, it would take nearly 1,000 years for the proportion of black physicians to catch up to the percentage of African Americans in the general U.S. population.³⁷

LGBTQ+ surgeons: Transitioning from marginalized to mainstream

Despite the repeal of Don’t Ask, Don’t Tell policies in 2010 and the upending of the Defense of Marriage Act by the U.S. Supreme Court in 2013, the U.S. has substantial room for growth in terms of inclusion of individuals who are lesbian, gay, bisexual, transgender, queer, and have other sexual identities (LGBTQ+). This cultural reality permeates the field of medicine and the surgical workforce. After all, it was not until 1973 that homosexuality was no longer categorized as a pathologic disorder in the Diagnostic and Statistical Manual of Mental Disorders.³² Although reported rates of homophobia in physicians have declined since then, in 1999, Klamen and colleagues revealed that 25 percent of medical students believed that homosexuality was immoral, and 9 percent still believed it to be a mental illness.³⁹ In a 2009 survey of 182 trainees and attending physicians from varying specialties, 23 percent said they felt that homosexual relationships were wrong.⁴⁰ To make matters worse, a national survey of U.S. citizens found that 30 percent of respondents would change their health care provider if they found out the provider was LGBTQ+.⁴⁰

In another landmark study published in 1994, Schatz and O’Hanlan surveyed lesbian, gay, and bisexual physicians, revealing abhorrent findings.⁴¹ Of the 711 respondents, 17 percent reported being denied promotion or employment because of their sexuality, 34 percent were verbally harassed, 52 percent had directly observed medical colleagues deliver substandard care to LGBTQ+ patients, and 88 percent heard their colleagues disparage LGBTQ+ patients.⁴²

In 2011, after recognizing the importance of LGBTQ+ health care needs, the IOM released a report calling for a comprehensive research training program aimed at raising awareness of LGBTQ+ health issues.³² The IOM’s efforts were laudable; however, few studies examining issues affecting LGBTQ+ physicians, residents, and patients have come to fruition.^32,43

Nevertheless, Lee and colleagues conducted a cross-sectional survey of general surgery residents to understand the attitudes and perceptions of sexual orientation on the training experience. Of the 388 respondents, 10 identified as lesbian (2.6 percent), 24 as gay (6.3 percent), and 9 as bisexual (2.4 percent).³² Among the LGBTQ+ residents, 30 percent did not reveal their sexual orientation when applying to residency for fear of rejection, 57 percent reported actively concealing their sexual orientation from fellow residents owing to fear of rejection, and 21 percent experienced targeted homophobic remarks from other residents (12 percent from surgical attending physicians).³² None of these LGBTQ+ residents reported the discrimination for fear of reprisal or the belief that no disciplinary action would be taken.³²

Traditionally, the surgical working environment is less accepting of LGBTQ+ individuals than other disciplines, such as psychiatry or family medicine.³² Mathews and colleagues demonstrated that the overall rate of homophobia in medicine was 22.9 percent, whereas the surgical specialties significantly exceeded the average with rates of 32 percent in orthopaedic surgery, 31.4 percent in obstetrics-gynecology, and 30.5 percent in general surgery.⁴⁴

Consequently, it is unsurprising that LGBTQ+ surgery residents fear disclosure and instead pretend to be heterosexual to avoid potential problems. This approach not only is unhealthy, but also decreases the opportunity for those surgeons with ingenuous views to have meaningful interactions with LGBTQ+ people, which could help challenge biases.^33,42 As a result, there is little impetus to overcome existing hetero-centric policies and culture, thereby propagating an undeveloped work environment.³³ Furthermore, investigation has revealed that LGBTQ+ patients delay or avoid seeking care because of fear of discrimination;⁴³ however, as the LGBTQ+ community garners momentous attention and integration into society, some surgeons are being forced to confront their prejudice.

Looking to the future

Addressing problems associated with diversity and inclusion in surgery requires active participation and insight. Many societies have called for universal implicit bias training to help departmental members understand their implicit biases.⁴⁵ This education would undoubtedly require a longitudinal curriculum for both residents and faculty and should start early in the professional development process.

Trainee selection processes tend to favor majority applicants despite academic performance, and interviewers are noted to subconsciously favor applicants similar to themselves.⁴⁶ Therefore, greater minority representation among medical student and resident selection committees is necessary to help overcome these biases. A recent study by Geary and colleagues suggests that by increasing the number of URiM interviewees, programs will retain more URiM residents.⁴⁷ In addition, inherent to the selection processes is the use of standardized test scores as a cutoff for decision to interview. Studies have shown URiM applicants tend to perform worse on standardized tests despite equal job performance. Given these concerns, the U.S. Medical Licensing Examination Step 1 is now pass/fail.⁴⁸

Despite commendable efforts directed at gender parity, recognizing that glass ceilings and sticky floors exist is crucial to fostering inclusion.⁸ However, unless exposed to positive role models and experiences in medical education and training, data suggest women are unlikely to consider a surgical career.⁷

Similarly, increased LGBTQ+ visibility and acceptance in the surgical setting is essential to eradicate stigmas and promote a supportive environment for trainees and patients.³² Furthermore, racial and ethnic underrepresentation is related to structural inequalities in education, intergenerational poverty, and opportunity.⁴⁹ Therefore, groups such as the Society for Black Academic Surgery have created outreach programs for high school students to provide mentorship and skills for long-term academic success.⁴⁹

Liang and colleagues explain that while most surgeons struggle with long hours, strained family relationships, and unpredictable patient complications, minority groups seem to have additional preoccupations,⁵⁰ such as a lack of visible mentors for LGBTQ+ trainees, pregnancy leave for women, and a dearth of safe pathways for people of color to report verbal discrimination without fear of repercussion. These researchers suggest that rather than developing interventions that highlight these minority-specific issues,⁵⁰ the focus should be on changing societal norms, challenging institutional biases, or providing insight training to all employees. We believe this approach may be more equitable and effective as the work toward enhancing diversity and inclusion becomes shared across the surgical workforce and leadership.

Conclusion

Diversity and inclusion in surgery have been increasing, particularly within the last few decades. We have seen a rise in the proportion of women, URiMs, and LGBTQ+ providers in the field, as well as in leadership positions. However, there is still much room for improvement. Not only do minority surgeons need mentors, but they also deserve a path devoid of microaggressions and discrimination, which historically have prevented these individuals from ever reaching surgical residency.

Surgical societies should address the lack of opportunity for many young adults to attain the education necessary to pursue a career in medicine. Faculty and deans must confront biases in the medical school selection processes by using more holistic criteria and standardizing the interview experience.

Ideally, working to create a more diverse representation among surgical leadership can help to encourage a more diverse group of trainees. Current leaders also should encourage seasoned minority surgeons to serve as mentors for the surgical workforce’s younger, underrepresented members. Although a community-wide response is essential, surgeons must tackle their individual biases to create a more inclusive surgical workforce for the betterment of our colleagues and the diverse patients we serve.

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