Maintaining the conversation about diversity throughout plastic surgery

When ASPS member David Watts, MD, looks back on his time more than 30 years ago as the only African- American in residency at Johns Hopkins University, he recalls, perhaps unsurprisingly, a rather lonely existence.

"It's tough if you're isolated to hang-in there for eight years," he says. "It's tough."

In the decades since graduating and building a successful private practice in Vineland, N.J., Dr. Watts says that although progress has been made, more needs to be accomplished. The question of diversity – or lack thereof – as in so many other facets of society, continues to hang over the plastic surgery specialty.

According to a 2015-16 report from the Association of American Medical Colleges, Caucasians represent 57.1 percent of medical school graduates, while Asian-American follow at 21.1 percent, trailed by African-Americans and Latinos, which constituted just 5.5 percent and 5 percent, respectively, of medical school graduates.

A 2009 PRS study titled "Ethnic Diversity Remains Scarce in Academic Plastic and Reconstructive Surgery" reported that Asian-Americans constituted 10.9 percent of plastic surgery faculty, while African-Americans accounted for just 1.4 percent and Latinos represented 3.6 percent.

ASPS member Paris Butler, MD, Philadelphia, who authored the PRS study, says those numbers have increased in the past eight years, but "they're still low." A 2017 PRS article notes that "plastic surgeons comprise a racially disproportionate workforce when compared with other medical specialties."

In addition to the ethnic divides throughout the practice, there also remains a gender discrepancy. Although the AAMC report put the rate of women graduating from medical school in 2015-16 at 46.4 percent, plastic surgery numbers reveal that women comprise only 14 percent of the specialty and 32 percent of female plastic surgery residents.

Diversity within the specialty and Society has become a front-of-mind topic for many members, including ASPS President Jeffrey Janis, MD.

"If you take a look at the composition of the executive level of the Society over the last three or four years, it's a lot more diverse than it used to be," he says. "I'm not suggesting we're there yet, but we're definitely a lot better than we used to be, and we're looking forward to increasing that in the future."

Ash Patel, MD, Albany, N.Y., chair of the YPS Steering Committee, notes concerns expressed by members of YPS about a lack of visibility of minorities in leadership positions throughout the specialty – whether within societies or institutions.

Without exact numbers, it's difficult to say whether the Society has a diversity problem, says ASPS Membership Chair Steven Williams, MD, Dublin, Calif. Nevertheless, he says discussion needs to take place.

"We're physicians," he says. "We like data. I think we need to find out if diversity is a problem. How widespread is the problem? Are we making improvements? How quickly? At some level, at least, those answers are knowable. But we have to start asking the questions."

Assuming things are fine by doing a quick scan of committee makeup would be a mistake, adds Dr. Watts, who is president of the American Association for Accreditation of Ambulatory Surgical Facilities.

"The majority group might think that everything is fine," he says. "But from a minority perspective, I would say it's not."

Dr.Butler agrees.

"In some respects, plastic surgery is probably the most homogenous out of all medical specialties," he says. "I don't think it's malicious. Those who have read my manuscripts or heard me talk on this subject have been receptive. They don't question the fact that [a lack of diversity] exists. I just hear that they are unaware that it's this large of a deficit of minority representation in our field.

"It doesn't affect them, and they don't live in that realm, so they may not find it as important," he adds. "I do a lot of health-care disparity work and I'm a minority plastic surgeon, so it's something I eat, sleep and breathe."

Finding the audience

ASPS member Kia Washington, MD, Pittsburgh, says she has received positive feedback from her "Improving Ethnic and Gender Diversity in Academic Plastic Surgery" presentation during Plastic Surgery The Meeting in October in Orlando. She adds that some attendees conceded they never thought about implicit bias, privilege or institutional discrimination.

"I think a light bulb went off for some people, and those are the people I wanted to reach," Dr. Washington says. "That acknowledgement creates awareness."

The fact that the Society is willing to have the discussion is a positive thing, Dr. Washington adds, suggesting that just a decade ago, there might not have even been a request for her to provide such a presentation.

Nevertheless, the presentation might not be reaching the most appropriate audience, says ASPS member Liza Wu, MD, who has participated on diversity and cultural competence panels with Drs. Washington and Butler. Dr. Wu says she's astonished that some of her peers don't view diversity as a problem in their specialty.

"The people who showed up to attend the two panels we put on during the last two years wanted to be there and know there's a problem, but unfortunately, those are not the people who need to be there," she notes. "There have been multiple times when one of my colleagues will turn to me and say that there is no longer an issue of gender discrimination in plastic surgery. I will look around the room to see one or two women in a room full of men who are sitting at the table. We have come far but still have a long way to go for equality."

The patient effect

Each of the doctors we spoke to for this piece said the main problem regarding the lack of diversity throughout the specialty is what it means to patients.

Dr. Washington says many of her patients are women who feel more comfortable talking to women physicians about their respective issues or concerns. As far as disparities among racial and ethnic lines, she says, it can be more comforting for the patient if the workforce reflects his or her community.

Dr. Butler says research supports that claim by showing minority physicians are more likely to treat underserved communities than majority doctors, and although there's no evidence that minority doctors provide better patient outcomes, the difference is that minority physicians are generally more willing to go into these communities to serve them. The patients, after being surveyed, reported that they felt they received better treatment.

"At Penn, we are in one of the poorest areas in Philadelphia," he says. "If the only people minority patients see caring for them are those making their beds and changing their linens – and not participating in their traditional medical care – the optics for that are bad. They may think, 'Why are the only people I see who look like me are serving in this capacity?'"

Dr. Watts notes that many patients travel to his New Jersey practice from throughout the United States because he's one of the few African-American plastic surgeons in the country. He says plastic surgery is not and should not be insulated from the racial issues that affect patients on a daily basis. Increasing diversity will continue to lead to better patient care, he maintains.

"Healing and taking care of patients are more than what we do with knives and sutures," Dr. Watts says. "It's really the psychological interaction that has so much to do with bedside manner.

"Let's call a spade a spade – we're really getting into the browning of America," he adds. "By 2025, the majority of the population in the United States will be brown. To not have that representation in the plastic surgery arena is a fallacy and mistake. How are you going to deal with a population base going in that direction when you don't have any kind of representation, or a lesser representation that isn't addressed in the Society?"

The need to bring more women into the specialty is also pronounced. ASPS member Heather Furnas, MD, Santa Rosa, Calif., recently co-authored a study with her husband, Francisco Canales, MD, to determine the impact of a plastic surgeon's gender on patient choice. Drs. Furnas and Canales surveyed 200 female plastic surgery patients, and their findings revealed that the preference for a female surgeon was significantly higher than a preference for a male surgeon.

"Among the 27 percent of patients requesting a physician by gender, 26 percent wanted a female doctor and only 1 percent wanted a male doctor," she tells PSN. "All of our patients were female, reflecting the specialty's high proportion of female patients. With women comprising only 16 percent of ASPS active membership, female patients seeking female plastic surgeons will welcome the increasing number of women entering plastic surgery. Creating greater public visibility of women plastic surgeons' faces and voices may help potential patients, particularly women, find a connection with the specialty."

Dr. Wu says she isn't surprised that female patients with a physician gender preference sought female surgeons for their cosmetic procedures, especially since women accounted for 92 percent of the total cosmetic procedures performed in 2016.

"There is patient-doctor concordance where patients relate to doctors who are more like them," Dr. Wu states. "When you're talking about plastic surgery, the majority of patients are women. You can expect women to be more comfortable with female surgeons."

Starting young

While Dr. Janis points out that the Society is continually working to ensure that more of its committees better-represent the broad spectrum of members, others add that the key to working one's way up to a committee or executive board level must begin early.

"I think it begins at the student level," Dr. Watts says. "It would behoove the Society to make programs and students aware of these opportunities or even programs where minority students can be exposed to this kind of thing."

More specifically, each of the doctors we spoke to advocated for a mentorship program for minority residents. Dr. Butler notes that he was so eager to speak with another African-American plastic surgeon early in his career that he cold-emailed five he located online. He eventually discovered one African-American female surgeon who provided him with perspective on the private sector. As Dr. Watts alluded to in his own experience, a residency that can stretch up to eight years can lead to intense feelings of isolation.

The lack of mentorship is an issue for minority medical students, Dr. Washington says.

"As a female or underrepresented minority, it's easier to feel like you fit in an environment and can excel when there are people who look like you in leadership positions," she explains. "Getting access to mentors may seem intimidating at first, if they don't look like you. As a medical student, I didn't feel like I had someone who understood my experience as a black woman, so now I make sure I'm accessible to minority students and I help them navigate their environment."

Dr. Patel says he often hears from minority residents reflecting on a distinct lack of visibility when it comes to minorities as presidents, vice presidents or chairs of various committees. It's natural, he says, for some residents to question whether it's worth the effort to push through a residency itself, let alone the apparent visible barriers of getting into leadership positions.

A 2016 study in PRS Global Open noted that with residency programs in particular, the number of African-Americans, Hispanics and Asians has increased in the past 20 years, Hispanics and African-Americans in particular remain underrepresented in plastic surgery – and "interventions are needed to attract minorities to plastic surgery residency."

The immediate feelings of isolation and racism notwithstanding, the prolonged effect of a homogeneous specialty is that those students who look for examples now of minority plastic surgeons who have made it – whether in an academic, hospital or private practice – remain few and far between.

"I can recount stories of being a resident, walking around in scrubs with my ID and people asking me to empty the garbage, assuming I was the janitor," Dr. Williams recalls. "I don't think those people necessarily meant anything negative – it was just their expectation when they saw a black man on a hospital floor, he was the janitor, not a fourth-year surgical resident."

Dr. Watts says he believes that a Society-sponsored mentoring program could have further-reaching impacts on Society activity and committee membership.

"If you see people who have finished, you have role models and something to aspire to," he says. "To be able to have someone to talk to or get advice or suggestions from would be very helpful. For kids at the medical school level, perhaps if they're brought to Society meetings and meet these people, they could begin to see plastic surgery as a friendly, engaging environment. Perhaps they'll see it as a place where they're being encouraged and where diversity is important."

At the PSN Presidents Forum in Orlando, The PSF President Arun Gosain, MD, said he wants to put that kind of program in place to spur both diversity and membership in the organization, and to broaden the pool of candidates for committee positions.

"Then we have to identify those who are interested in serving as role models and leaders, bring them into committees and leadership positions and let them help demonstrate to others that we are representing that culture," he added.

Seeking progress

Although less than 20 percent of practicing plastic surgeons are women, Dr. Wu says gender diversity in the specialty is improving. She also hopes that leadership opportunities for women and underrepresented minorities increase.

"It becomes an issue of the glass ceiling," she says. "There are still some disparities regarding leadership and advancement in women's and underrepresented minorities' careers. If you look at the leadership, it's not equal regarding female, and it's certainly not equal regarding ethnic or racial diversity."

Since ASPS formed in 1931, only two women – Roxanne Guy, MD, and Debra Johnson, MD – have served as president of the organization. David Song, MD, MBA, became the Society's first minority president in 2016, proving there has been progress, but there's still work to be done.

"Diversity is the strength of our country and what makes the United States great," Dr. Song says. "So, too, is fostering diversity in our Society. I'm honored to have been the first minority president of ASPS. I hope our Society's leadership continues to mirror what our membership looks like."

Dr. Johnson says that having an organization's leadership represent its membership is critical.

"For ASPS, that means paying close attention to gender, ethnicity, geographic location and practice type," she says. "We want to be a voice for all of our constituents and responsive to all of their needs."

Dr. Butler says it's going to be the responsibility of the current and more seasoned leaders to appoint surgeons who look different than them to various committees in order to improve the optics of the specialty. He urges ASPS leadership and academic leadership to give more thought on providing more opportunities to surgeons from underrepresented backgrounds.

"The position that there aren't that many qualified candidates out there and that's why we don't have them – that's a false narrative I hear frequently, and we must change that," he says. "There are many qualified candidates. They just haven't been granted the opportunity. Recruitment efforts are going to be extremely important – not just into our field but also leadership positions in ASPS. If this is going to ever become a priority, it's going to happen because someone in leadership decides we need to do better with this. I'm going to continue to push."

During his year as ASPS president-elect, Dr. Janis says he analyzed the diversity among ASPS leadership and asked two questions: "Are we as diverse as we could be, and what can we do to improve it?"

"One of the opportunities afforded to the president is to realize the critical issues in the Society and appoint task forces to dive deep and focus-in on some of these issues," Dr. Janis says. "I wanted to know if we should implement a diversity task force that essentially analyzes diversity of all types across the organization and ensures we have policies and infrastructures in place to promote it by taking a proactive approach. I'm talking about encouraging people to either apply for positions or to be promoted to positions of responsibility so that we can create an environment where diversity is supported."

Drs. Washington, Butler and Wu are all in favor of Dr. Janis' idea to start a task force solely focused on ethnic and gender diversity. Dr. Washington hopes the Society takes a direct approach in addressing the issue by making a concerted effort to consider women and minority candidates for upcoming elections and committee positions. The first step, she says, is acknowledging that improvement is needed.

"There won't be any kind of change unless there's acknowledgment and some kind of action," she says. "Forming a task force on diversity and inclusion can help us address the issues. I hope to see improvement in the upcoming decade."

Both Dr. Patel and Dr. Williams, however, note that while continuing dialogue is good, trying to rush to a prescriptive fix – for instance, establishing a certain quota of minority members in leadership positions – isn't the answer.

"You have to let peoples' skills shine through naturally, without implicit bias," Dr. Patel says.

The fact that so many members of the Society are willing to discuss the subject is a good start, Dr. Watts says.

"I've been in practice in 25 years and in residency another eight years before that, and this is the first time ever a discussion about diversity has been mentioned to me," he says. "Most of the time it's just swept under the rug and not really spoken about."

In the interest of helping better serve patients and provide equal access to care, it's a discussion that simply can't go away.

"We're supposed to be taking care of people and helping advance society," Dr. Williams says. "We have an obligation to stand up for this stuff."