If not now, when? Why diversity is important in plastic surgery – and why it's time for action

This is has been a year unlike any other. An unprecedented global pandemic has laid bare unaddressed disparities across minority groups, disproportionately affecting Black and LatinX communities. Asian-Americans – including Asian physicians – experienced racist verbal abuse and violent attacks, exacerbated by political rhetoric. Videotaped hate-killings of Black people renewed Black Lives Matter and Black Trans Lives Matter activism. Most recently, #MedBikini demonstrated the persistence of sexist tropes within professional roles – a pointed statement on the importance of including diverse perspectives to avoid embarrassing, outdated gaffes.

That this pandemic started during Black History month, built steam through Asian Pacific American Heritage month and then barreled on through Pride month seemed to highlight the urgency of an intersectional reckoning with systemic inequality.

The ensuing, global response proves that pervasive structural, institutional and individual racism remain urgent barriers that must be dismantled, particularly by those in medicine and healthcare.

Other professions have already completed organized, well-financed strides to understand and fully utilize the benefits of diversity. Diversity has been proven to augment collective intelligence, creativity, innovation and problem-solving. Even though diversity is expected to positively impact the U.S. healthcare system, multiple papers have concluded that continued under-representation of non-Caucasian/non-Asian (NC/NA) groups will have a profoundly negative public health effect.

So where do we stand in plastic surgery?

Female plastic surgeons

Recent literature demonstrates the preference for female plastic surgeons by female patients, with data supporting better healthcare outcomes by female physicians. However, since its initiation in 1993, the Godina Fellowship microsurgery grant was awarded to a female recipient for the first time only three years ago. The American Association of Plastic Surgery Honorary Citation has never been given to a woman – in fact, since its founding in 1921, the organization has counted just two female presidents, in 2008 and 2018. Since its founding in 1931, only three women have served as ASPS president, with the first woman of color (Lynn Jeffers, MD, MBA) serving this year. Carr, et al., put forth the notion that "increased number of women in medicine will eventually bring gender equality" – but it's a sentiment held by men and not shared by women.

Within general surgery, Schroen et al., found female faculty do not succeed at the same rate as men and must overcome a "cumulative career disadvantage," due to a constellation of variables that include the sense of isolation; harassment; inadequate mentoring; and inadequate career advancement. Data from 2016 show that women in medicine continue to earn less than men, with an increasing gap even after adjusting for covariates. Women also receive less institutional support than their male counterparts.

In addition, women have a higher rate of attrition in faculty positions. At the assistant professor level, women are almost six times more likely than their male colleagues to leave academia within two years. From 1994-2015, female general surgery faculty saw an annual increase of just 0.3-0.6 percent. Based on the demonstrated rates of increase, the study postulated that it would take 49, 57 and 121 years for women to comprise 50 percent of, respectively, all assistant, associate and full professors. The field of plastic surgery demonstrates a similarly slow growth rate of female faculty, at less than 1 percent per year.

Female trainees report feeling excluded from networking and career advancement, and their gendered experiences diminish their career goals and ambitions. As this disconcerting perception amplifies with age, the confidence to challenge this culture of inequity dwindles. In addition, when screened for anxiety, depression and post-traumatic stress disorder (PTSD), female trainees are more likely to experience multiple symptoms – including changes in mental health, social behaviors and the desire for or commitment of personal or professional harm. Unsurprisingly, women experience more symptoms of burnout. Given the physician suicide epidemic, this is a serious concern.

Furthermore, sexual misconduct persists in training. In a 2018 survey, Chen et al., found that one-third of current female trainees experience sexual comments about their bodies, 9 percent experience unwanted touching or sexual exposure and 4 percent experience sexual assault or coercion in offer for advancement. More than two-thirds of perpetrators are colleagues, attending physicians or other residents, while one-third are nurses, patients, staff and medical students. Victims are more likely to be minorities, and those minorities are less likely to feel prepared to address the misconduct.

Ethnic underrepresentation

In terms of racial minority representation and advancement among plastic surgery faculty, Smith et al., noted a total +0.3 percent and +1.7 percent representation of Black and LatinX Americans over the course of 12 years, representing, alarmingly, no change. To put this in perspective, it would take more than 8,013 and 863 years for Black and LatinX Americans, respectively, to attain parity in academic plastic surgery.

Neither the ASPS or The PSF presidential positions have never been held by a Black or LatinX surgeon, nor has there ever been a Black or LatinX recipient of the Godina Fellowship or ASPS Honorary Citation. A review of all board members of national plastic surgery societies revealed only two NC/NA board members from a sample of 136. Of the 375 past presidents of these national societies, 96 percent have been Caucasian, 3.7 percent Asian, 0.3 percent LatinX – and none of other races. In terms of journal editorial boards, NC/NA members average 2.6 percent, and Black/LatinX members are represented in less than half (n=5) of the journals.

Studies repeatedly show that relative to their majority counterparts, Black and LatinX Americans have poorer baseline health, inadequate health insurance and limited access to care. These disparities are recapitulated in plastic surgery, breast reconstruction, burn care, cleft care, craniosynostosis, pediatric breast reduction and brachial plexus reconstruction. The lack of minority representation in healthcare can compound these inequalities. Conversely, an underrepresented in medicine physician is an active member of their care team, minority patients have higher patient-reported outcome measures (PROMs), better compliance and an increased likelihood of participating in clinical studies. This finding is recapitulated in plastic surgery patients.

LGBTQ plastic surgeons

Have you ever worried whether you might face physical harm in public based on your physical appearance or with whom you're holding hands? Have you ever thought twice about talking about the love of your life in the O.R. or bringing him or her to the department holiday party?

In a survey presented at ASPS in 2018, 10.9 percent of plastic surgery trainees and 4.5 percent of plastic surgeons identified as LGB. Ninety-five percent of LGB trainees disclosed their sexual orientation to some/all residents, whereas only 88 percent of LGB trainees did so with some/all attendings. In the survey, 36 percent of LGB trainees reported purposely concealing their sexual orientation from either residents or attendings for fear of reprisal. At the time of interviewing in plastic surgery, 24 percent had been concerned that disclosure would risk acceptance, as 13 percent of LGB trainees reported being advised by faculty mentors to not disclose their LGB status during interviews.

Most (93 percent) felt comfortable bringing their significant other (SO) to events with residents, though less feel comfortable bringing their SO to events with attendings (86 percent) or to formal events (79 percent). Among the respondents, 13 percent of LGB faculty feel uncomfortable bringing their SO to department events regardless of attendees.

Why, in 2020, might this be? Eighteen percent of this cohort reported personally experiencing a direct homophobic remark from a resident, while 27 percent reported experiencing a direct homophobic mark from an attending. Five percent and 11 percent of LGB respondents reported differential treatment by residents and attendings, respectively. LGB respondents also reported hearing general homophobic remarks from nurses, residents and attendings at 62 percent, 38 percent and 34 percent, respectively (compared with rates of 25 percent, 18 percent and 17 percent by heterosexual peers). Nineteen percent of LGB respondents reported witnessing discriminatory care of LGB patients or their partners, in contrast to just 6 percent of their heterosexual peers.

What can we do?

Plastic surgeons are competitive, creative, innovative and constantly evolving. It leaves us to wonder why these disparities persist – and why clear data has not translated to more diversity, equity and inclusion (DEI). We can do better. If, as Martin Luther King Jr., so eloquently and timelessly reminds us, "The arc of the moral universe is long, but it bends toward justice," what are some actionable ways to keep us bending in the right direction?

1. Know that you are a leader
Culture is defined by the members of that community. In choosing to become a physician and a surgeon, you have chosen to be a leader in your community. Who are you leading? Maybe it's the medical student passing through the rotation or on your research team. Maybe it's the junior residents on your service team or with you in the O.R. As a chief resident or junior faculty, you can speak up at grand rounds, at journal club, in the surgeon's lounge, in the resident lounge or out with friends. Remember: The burden to point out inequalities, to make change and to make space at the table for others lies with those who yield positions of power and privilege.

If you have a platform, use your privilege and opportunities to further those of others. Point out injustice and inequality. Your omissions are perceived as permissions, and the boundaries you set for professional, respectful behavior do not go unnoticed. Just because you aren't a program director or department head doesn't mean you're not a leader.

2. Start having difficult conversations
Radically accept that your colleagues have had – and continue to have – different experiences than you. Have you ever been mistaken for the nurse? The custodian? Have you ever had your shoulders massaged while insetting a pec flap? Have you watched your attending prance and exaggerate hand gestures to mimic gay people? Have you ever worried that driving in from home call, with your white coat on, you might still get pulled over and have a potentially fatal encounter with law enforcement? Have you ever experienced workplace bullying? Start by simply asking someone different from you what their experience has been. You'll be surprised by what you learn. Ask. Listen.

3. Remember that no one's perfect
Everyone has implicit bias. Identify them and understand them (Harvard University Project Implicit), map your privilege and recognize microaggressions when they occur. Hold each other accountable in the moment. Ask, "What did you mean by that?" Role-model respectful discussion. Commit to candor. We're all on a journey with different starting points, and it's OK to ask for help.

4. Educate yourself
The last few years have seen greater interest in DEI publications. Not only can you look to medical education literature; there are numerous reading lists to understand the experience of your peers. Social media is a ready source of education and activism (@TimesUpPRS, @WOCPRS). Your local university has dedicated offices to offer structured training and education (Title IX, Office of Diversity and Inclusion, etc). Remember, the burden to educate yourself and affect change doesn't lie with your minority colleagues. Do some homework.

The time is now

According to the U.S. Census, the nation is becoming increasingly diverse; 2030 is the first expected inflection point and the white population is expected to reach minority status by 2045. The observant plastic surgeon understands that a new era is imminent. According to a 2019 Pew Survey, the collective awareness of American businesses perceives this cultural shift, and most American people are similarly aware. The time for plastic surgery to evolve and lead is now. The argument for change and the need for evolution is undeniable.

Some individuals may explain away the lack of DEI by questioning the qualifications or interest of underrepresented minorities, but keep in mind this is a long-refuted and archaic argument – and it's been disproven in plastic surgery. If you question the qualifications of minorities, chances are that you're in a position of privilege. If you don't understand the need to level the playing field to increase representation, it's likely you don't understand the historical context of opportunities (or lack thereof) for women, minorities and queer colleagues.

Instead of blaming maternity as a reason for gender disparity, let's talk about incorporating and supporting parental leave and family planning. Instead of blaming Black applicants for less publications, let's talk about increasing sponsorship, inclusion and scholarships.

Plastic surgeons are innovators. We need only to look at our history: the first kidney transplant, the first free flap, the first wound VAC. Like any need that incites innovation and evolution, the current times call for our historically unyielding resolve, bravery, investment and persistence. Just as we apply the scientific method to our work, we must be systematic and relentless about our commitment to DEI. There's no shortcut.

If not you, then who? If not now, then when? In this short article, we've presented data and some starting points you can implement today. As Maya Angelou says: "Do the best you can until you know better. Then when you know better, do better."

It's time to do better.

For more information, or to become involved in activism or research, please contact Dr. Chen at wendychenmdms@gmail.com; Dr. Pang at john.henry.pang@gmail.com; or Dr. Butler at paris.butler@pennmedicine.upenn.edu.

A full list of the sources cited in this article can be found in the online version of Plastic Surgery Resident.