Where do we go from here?

Camille Cash, MD, Houston, comes from a family of physicians who made history in medicine – her great-uncle was the first African-American surgeon in southern Georgia, and her grandfather became the first African-American doctor in Brunswick, Ga.

"Their career paths didn't directly influence my decision to pursue medicine, but the idea that I could be a doctor wasn't foreign to me," she says. "I knew I could do it because they had."

In 2002, Dr. Cash started her own private practice right out of residency, and like her grandfather and great-uncle before her, the decision proved historic. She became the first African-American female plastic surgeon in the state of Texas – although she says the move was one of necessity rather than choice.

"There weren't any opportunities or offers for me to join a local practice – few plastic surgeons showed any interest in hiring a Black female, mother of two," Dr. Cash recalls. "I've worked really hard to build my practice. It hasn't been easy or given to me. There hasn't been a mentor or roadmap. Every single Black female plastic surgeon I knew at that time was all on her own. We didn't have a big connection. At times, it's been lonely."

Even with more than 20 years of experience under her belt and a successful private practice, Dr. Cash says she's still mistaken for an industry partner or sales rep by her peers at national meetings. The shock on their faces isn't lost on her when they learn she's a plastic surgeon.

"I'm the only Black plastic surgeon in the room, and you still can't see me," she says. "They don't see me as a peer when I walk into the room or through the exhibit hall."

Dr. Cash says she's encountered racial microaggressions from former employees and peers (e.g., "You're so articulate") and adds she's cognizant that she has little room for error.

"It's a constant balancing act between not being taken advantage of and not being viewed as a stereotype," Dr. Cash says. "It's a double-edge sword for women, but especially for Black women. We don't have the luxury of being flippant or cavalier. We work hard, and we're aware that our decisions and outcomes have to be just as good or better than our white colleagues to compete. We can't sit back and get too comfortable. While that applies to all plastic surgeons, it's heightened for African-Americans because we are judged by a different standard and represent a very different group."

In 2017, PSN published an article that dove into the topic of racial and gender diversity within the specialty and highlighted the perspectives of underrepresented plastic surgeons. In the months after the publication of that piece, the Society launched the Diversity and Inclusion Task Force, which has since become a standing committee. However, the discussion about promoting greater diversity throughout the specialty continues to this day, and several ASPS members note that there's also a need for amplifying the voices of African-American members and sustaining dialogue on structural racism – not only for the good of membership, but of patients as well.

The tragic murders of George Floyd, Ahmaud Arbery and Breonna Taylor amid COVID-19 – a pandemic disproportionately impacting African-American communities – shone a glaring spotlight on racial inequality and forced America to confront its longstanding history of systemic racism and racial disparities in every domain. In the wake of worldwide protests over repeated instances of police brutality against unarmed Black men and women, ASPS members with whom PSN spoke say fostering these conversations is a step in the right direction. However, real change will also require anti-racist actions and a concerted effort by plastic surgeons to dismantle racism in healthcare, improve access to medical care and health outcomes for underserved patients, and create equal opportunities for the future generation of African-American plastic surgeons.

The time for all of this is now, says Paris Butler, MD, MPH, assistant professor of surgery at the University of Pennsylvania, and a member of the Society's Diversity and Inclusion Committee.

"We have some of the most challenging statistics when it comes to racial and ethnic diversity," he says. "I'm unaware of any subspecialty within the house of surgery  that struggles with minority representation quite as much as our field. Black and Brown surgeons will not be able to fix this challenge by ourselves. The majority community will have to make significant contributions to end systematic racism. It's time to have those uncomfortable conversations to become more comfortable. We have now reached a point where simply being a bystander is perceived by many as being complicit in the problem."

Erika Sears, MD, MS, assistant professor at the University of Michigan, urges all plastic surgeons to actively educate themselves on racial bias, disparities and systemic racism. Be open to listen and learn – and never assume that racism doesn't exist because you don't see it happening. Being an ally starts with a willingness to speak up about inappropriate things – even when it doesn't affect you, and particularly when it's uncomfortable.

"There's an art of bringing up issues that allows the other person to listen and learn rather than feeling attacked, which is important in the workplace where we have ongoing relationships and we have to continue working with one another," she says. "It requires practice, attention and diligence, and it starts with all of us being willing to speak up and learn from another perspective."

Different perspective

Aisha Baron, MD, Atlanta, still remembers the first time she heard her older, white male attending utter a racial microaggression in the O.R. during her residency. The nurses and anesthesiologists fell silent, and as the only resident and African-American present, Dr. Baron says she felt isolated.

"I didn't think a comeback would do anything, and I wasn't going to debate someone who held the grade of that rotation in his hands," she says. "That can be disempowering because you don't want to get poor reviews or do badly on a rotation, so you find yourself scared to stand up. You can't scrub out, so you just put your head down, continue to work and try not to scrub additional cases with that person."

Although Dr. Baron says she never experienced blatant racism during her training, she notes she frequently encountered microaggressions due to her age, race and gender. Nurses, for example, sometimes challenged her orders and then label her difficult to work with when corrected.

"Microaggressions can be just as bad because it's not out in the open," she says. "No one is calling you a racial slur or blatantly saying they don't like you because you're Black, but they'll smile to your face and then write you a poor evaluation, or they'll display nasty attitudes only toward you."

Dr. Baron says she tried to avoid the "angry Black woman" trope whenever she advocated for her minority patients, but it wasn't always possible. After watching another young African-American attending and mentor, Jamal Bullocks, MD, gracefully handle microaggressions from staff during residency, Dr. Baron says she learned how to remain calm and respond with stern kindness. She also learned some incidents didn't deserve her time or energy.

"You just have to know when to speak up and challenge those microaggressions," she says. "As Black surgeons, we're not automatically granted the same level of respect that we deserve from our peers, and it's a hurdle we have to overcome. Being in control of the majority of my working environment is one of the reasons I opened my own practice."

It's not uncommon for underrepresented, minority plastic surgeons to experience feelings of isolation, alienation or loneliness – particularly in academic plastic surgery. Dr. Sears says the feeling of isolation increased as she advanced in her career due to the lack of racial diversity.

"I can count the number of Black academic plastic surgeons on two hands, which isn't great," she says. "When I attend our national meetings, I typically don't see anyone who looks like me. I've become used to being the only one in the room, but it's still a lot to take on when you feel you have to be everything to everyone. You're representing your race, and sometimes you're very careful about what you say and how you say it. I didn't feel this way in undergrad or medical school because there was more representation among my colleagues, but the further up I go, that representation is essentially nonexistent."

Dr. Sears coaches underrepresented minority trainees through their struggles to help foster a sense of belonging that she says she's lacked at various points in her career.

"That's a real problem – particularly for Black women in our field," she says. "I hope that if I'm present, visible and available to be a role model to trainees inspiring for academic careers, then they feel there's a place for them."

Nevertheless, Dr. Sears says there's pressure in being the face of representation.

"Because there are so few Black people in academic medicine nationwide, a lot more is asked of you in terms of perspective, representation and to be that role model for people of color," she says. "We often get asked to do collectively more while still doing what's expected of us, like research, writing papers, teaching.

"Mentoring and coaching are often not valued as much as writing papers and serving on high-profile committees when it comes to promotion," she adds. "That part is the burden. But I feel pressure and a responsibility to be successful in this space because I see very few people doing it who look like me."

Dr. Butler encourages African-American plastic surgeons to expand their network and find social support outside the specialty.

"I was the first African-American to be hired on the plastic surgery faculty here at the University of Pennsylvania, but I refused to view it as working in isolation," he tells PSN. "I viewed it as an opportunity to collaborate with my majority colleagues, and open their eyes to a different perspective and background. It has also served as fertile ground for me to collaborate with my Black and Brown contemporaries from other specialties when racially centric challenges arose. That has actually served as a healthy mechanism to overcome isolation. The Society of Black Academic Surgeons has also been a wonderful resource for me."

Rose Lewis, MD, San Francisco, who holds the distinction of being the first African-American female plastic surgeon in the world, says there were hardly any African-American doctors when she started her plastic surgery residency in 1978.

"But I didn't let that stop me," she says. "You don't have to only communicate with doctors who look like you. When I started practicing, I connected with another woman and we were surgery residents together. Once we finished, we both went into plastic surgery and then we started practicing together. That made it less isolating to some extent."

Racial health disparities

Structural racism in the U.S. healthcare system continues to drive racial health disparities in communities of color, and the harmful effects of discrimination and implicit bias span across medical specialties, from OB/GYN (where African-American women historically have the highest maternal mortality) to plastic surgery (where African-American women receive breast reconstruction at half the rate of the majority population and are less likely to receive referrals to a plastic surgeon).

American history exposes the inequities and systemic racism that have long existed in the U.S. healthcare system and affected health outcomes for African Americans. In the horrific Tuskegee Syphilis Experiment, a 40-year government study that began in 1932, 600 Black men were promised free healthcare to treat their "bad blood." However, doctors never informed the 399 men who had syphilis of their diagnosis and deliberately denied them treatment to document the natural progression of the disease. Dr. Baron notes the history of racism in medical research is also evident in the case of Henrietta Lacks, a 31-year-old Black woman whose cancer cells (HeLa Cells) were used for research and financial gain without her consent or her family's knowledge and permission after her death.

"People might think plastic surgery is exempt because it's mainly elective, but the issue reaches into the realm of our specialty – particularly with breast reconstruction," Dr. Baron explains. "My white breast cancer patients are almost always referred and know their options, but my Black patients are less likely to receive a referral to a plastic surgeon at the time of mastectomy. They learn about me through a family member or the Internet."

Dr. Baron challenges plastic surgeons to check their own biases to ensure all patients are treated equally.

"Racial implications in plastic surgery will definitely affect the patient's quality of life if they're denied or not made aware of the same plan of action as another patient," she says. "That could alter how a patient feels about their body, what they're able to do and their recovery."

Dr. Butler authored numerous studies on racial disparities in breast cancer care and hosted outreach events in Philadelphia's underserved communities to educate women of color on breast reconstruction and to improve health literacy. He notes Black and Brown faculty are needed to serve patients in these often overlooked areas – and fewer Black plastic surgeons available in those areas only amplifies the challenge.

"I have to apply for my own funding to do it, but it's very important to me," Dr. Butler says. "I feel beholden to that community because it raised me, so I need to respect and educate my community on what their options are when it comes to breast reconstruction."

To that end, Dr. Butler helped establish an understanding at Pennsylvania Hospital where all women undergoing a mastectomy receive a documented referral to a plastic surgeon regardless of age, race or ethnicity.

"It's not a failure of the system if a woman doesn't have breast reconstruction," he says. "It's a failure of our system if a woman isn't informed of her options. Let them choose."

Dr. Lewis says improving health literacy will reduce some of the disparities in underserved communities.

"I used to perform a lot of breast reductions on mostly Black women, and the majority of them didn't know breast reduction is considered a reconstructive procedure," she says. "They think it's cosmetic and continue to suffer with discomfort because they can't afford plastic surgery, and they don't realize it's covered by insurance."

Beyond improving health literacy, Nicholas Jones, MD, Atlanta, says increasing racial and ethnic representation in every field of medicine will also dispel dangerous myths and stereotypes (e.g., African-American patients feel less pain due to "thicker skin").

"Even though Black women have a higher maternal death rate, literature shows doctors are less likely to give them pain medicine than their white counterparts," he says. "If they have the same operation, why would they not have the same pain? There's a misconception that Black women are not in pain because they are strong, which contributes to health disparities.

"If you have a diverse group of physicians, you're able to provide better care because there are cultural differences that affect the way patients are treated," he adds. "A Black woman with breast cancer is probably more likely to undergo breast reconstruction if she can go to a plastic surgeon who looks like her, because she can relate to them better and feels understood."

Improving cultural competence

When Ferdinand Ofodile, MD, clinical professor emeritus and special lecturer in surgery at Columbia University, became the chief of plastic surgery at Harlem Hospital in 1982, he noted African-American features – particularly noses – were regarded as "negroid" features in the specialty. This often resulted in plastic surgeons giving African-American patients white, Anglo-Saxon noses. Dr. Ofodile set out to meet the needs of minority patients and designed the Ofodile Nasal Implant in 1994 to fit African-American and Hispanic features. Regarded as a pioneer of Black rhinoplasty, Dr. Ofodile created three categories of African-American noses – the African, Afro-Caucasian and the Afro-Indian – as a model for surgeons and taught fellow surgeons how to preserve patients' ethnic identity while performing rhinoplasty.

"When you look at a lot of Black females and men, you'll find people with the so-called 'negroid' features are very beautiful, but they do not conform to the Eurocentric notion of beauty," Dr. Ofodile says. "Inserting a Caucasian nasal implant into a Black nose makes it incongruous with the face because the bridge is very narrow. We started working on the design of our implant to widen it, so that it brought the nose into harmony and reduced the dichotomy between the tip and bridge."

During his 33-year-career as the program director and chief of plastic surgery, Dr. Ofodile trained and mentored young minority plastic surgeons and educated fellow surgeons on the increased risk of scarring on African-American skin – particularly after reconstructive procedures of the hands, face or breasts. When a facelift is performed on a Caucasian patient, he notes, the scar heals flat and you can hide the scar, but on African-American skin, it can form a keloid.

"We concentrated on teaching surgeons how to minimize keloid formation after surgery," he says. "That was one of the factors that kept African-Americans from embracing plastic surgery to the same extent as Caucasians, so we created an opportunity for them to have the same type of procedures without running the risk of keloids and a deformative.

"When you minimize scarring, the surgery becomes more acceptable to the patient," he adds. "With Black patients, you also risk the skin becoming hyperpigmented after surgery. Plastic surgeons have to understand all of these things – and they must talk to the patient and take measures to reduce the appearance."

According to the latest ASPS Plastic Surgery Statistics report, African-Americans comprised 9 percent of the patients who received cosmetic procedures in 2019, a 60 percent increase since 2010. Dr. Baron says a continued understanding of cultural differences will provide better results for the growing number of African-American female cosmetic patients.

"There's been more of a push recently to understand and accept different ethnic forms of beauty," Dr. Baron says. "A lot of the beauty ideals that we as African-Americans have been ridiculed, taunted and objectified for years – such as fuller lips and curvier figures – are now being sought-out by the majority population.

"I want us to define our standards of beauty instead of following the European standard of beauty handed down by the pioneers of plastic surgery," she adds. "As plastic surgeons, it's important to provide culturally competent care to guide our patients toward the best results. We need surgeons who will listen to patients' wants and preserve their ethnicity. Let them define what that beauty standard is for them."

Real-life example

Dr. Baron starred in Lifetime's docuseries "Atlanta Plastic," which followed three African-American board-certified plastic surgeons and their work with patients. Dr. Baron says the series showed positive representation of Black medical professionals on reality TV, challenging a common stereotype.

"The most important part of that experience was the young Black men and women who reached out to me to say they didn't know plastic surgery existed as a career and surgical option for them," she says. "Just seeing Black surgeons like myself and my colleagues on the show made an impact. It showed people they can be successful."

Dr. Sears says she receives similar feedback treating underserved patients through the VA system.

"Most of my practice is hand surgery, and when I treat people of color – particularly women – they tell me they're excited to see me and they are proud of me," she says. "They have taken pictures with me to show their families. It's a double-edge sword. I feel proud but also sad to realize it isn't common for them to see a Black plastic surgeon, and they don't expect someone like me to be their doctor."

Dr. Cash says African-American women specifically seek her out because they want a plastic surgeon who looks like them and understands their skin.

"I've never shied away from the fact that I'm an African-American female plastic surgeon," she says. "I'm a plastic surgeon for everybody, but I do make that distinction. I'm very proud of my background and heritage. It's important for people to feel like there's someone out there for them."

To that end, Dr. Cash says she unapologetically incorporates diversity in her marketing, including her stock images, website and presentations. She's also challenged industry companies to feature African-American women on their marketing materials.

"I told them their brochures don't connect with my brand or my audience, and they've done a better job of coming around because there's a lot more diversity," she says. "I've made a concerted effort to make sure my stock images represent all sorts of women. I've woven that into my practice and all of marketing before there was an emphasis on Blacks getting plastic surgery."

Fixing leaky pipelines

Despite an increasingly diverse patient population, the current racial composition of the plastic surgeon workforce is less so. In 2009, Dr. Butler published a study in PRS that reported African-Americans accounted for just 1.4 percent of plastic surgery faculty. Although the specialty continues to make strides in female representation, progress remains stagnant for African-Americans in academic plastic surgery.

In fact, Dr. Butler notes that research shows a decline of African-Americans in plastic surgery training programs and says the AAMC recently combined African-American, American Indian, Alaskan Native and Native Hawaiian into one group due to the low numbers in plastic surgery.

"We often discuss limitations in the pipeline and how we can get more African-American medical students into plastic surgery to increase the cohort," he says. "That indeed will be necessary, but I argue that, in parallel, it's going to require our health system leadership to hire and promote more Black and Brown faculty. I'm a proponent of looking at middle schools and high schools, but it has to come from both ends.

"There's still a fair number of qualified and capable Black and Brown plastic surgeons currently in practice that we need to put in leadership positions, so they can continue to be successful," he adds. "Not only to carry out the business of being an academic plastic surgeon, but also to serve as mentors for the junior people in the pipeline. Many would love the opportunity to get promoted within."

ASPS/PSF Board Vice President of Membership Steven Williams, MD, who made history as the first African-American elected to the ASPS/PSF Board of Directors, says putting more Black plastic surgeons into leadership positions is important – but it is one component of a lot of work yet to do.

"It is easy to retell terrible stories or to assume that the small steps we've made are enough," says Dr. Williams, who is also chair of Society's D&I Committee. "I think it is more important to remember that the history of formal segregation and of laws enshrining the devaluation of people based on their skin color are only in the very recent past and that the systemic preconceptions that exist still greatly disenfranchise the very vast majority of men and women of color who would otherwise contribute so much to our profession and to our society. I'm cognizant of the past and hopeful for the future but it is clear that our work, together, has only just begun."

Dr. Lewis recommends exposing students to the specialty before medical school.

"Teachers, particularly in high school and elementary school, don't always encourage minority students to do much, so they're uninformed about different careers," she says. "I once attended career day as a guest for at-risk minority youth, and they guessed I was a secretary. They were surprised to see a Black woman doctor. They don't have exposure to it, and they need a lot more exposure at an early age."

Quality educational opportunities need to be provided as early as elementary school to improve minority representation in the future, Dr. Cash says.

"We aren't going to get more minorities in plastic surgery if we don't support our kids getting into and finishing medical school," she says. "You must have a strategic pipeline and vested interest to get African-American students into medical school and surgical fields."

Despite the troubling statistics and lack of racial diversity in academic plastic surgery, Kerri Woodberry, MD, MBA, chief of plastic and reconstructive surgery at West Virginia University School of Medicine, says she remains hopeful things will change.

"There's an emphasis and push now to focus more on diversity and inclusion at many institutions across the country," Dr. Woodberry says. "I serve on the D&I Committee at our institution, and everyone wants to make changes. I've noticed more minority medical students and residents who are interested in plastic surgery when I travel around the country. It's exciting to see the increase."

Dr. Woodberry, the first African-American woman to serve as chief of an academic division of plastic surgery, says she's glad to be a face for African-American medical students and residents aspiring for leadership positions in academic surgery.

"It's hard to imagine being a plastic surgeon if you don't see anyone who looks like you," she says. "I was able to collaborate with Black plastic surgeons through the National Medical Association during my residency. Seeing other Black plastic surgeons let me

The power of mentorship

ASPS members who spoke to PSN emphasized the positive impact mentorship had on their careers and acknowledged the need for mentoring programs for underrepresented minorities in plastic surgery.

"Without those mentors available, many of these promising young people we're trying to put into the field struggle without proper guidance," Dr. Butler says. "We all need mentors to help us navigate these very turbulent waters. There's no recipe to become an academic surgeon. You need people to help guide you through the process."

Dr. Butler also encourages African-American plastic surgeons to be open to seeking mentorship outside their race.

"Because our numbers are so small, I would be remiss if I didn't say I've been mentored and sponsored by many surgeons who don't look like me," he says. "Don't be afraid to ask for that kind of mentorship or sponsorship. You'd be surprised at how many are happy to do it.

"The vast majority of Black and Brown surgeons who have attained levels of leadership in academic surgery can attribute some of that to majority physicians who mentored them and helped sponsor them to obtain those opportunities," he adds. "It doesn't happen without it. It's an all-hands-on-deck situation."

Dr. Jones mentors students from historically Black colleges and universities and provides shadowing opportunities to attract qualified students into the specialty. He also visits schools in underserved areas to educate minority youth on medical careers. Even in 2020, he notes, some students have never seen an African-American doctor before.

"My assistant basketball coach in high school laughed at me when I told him I wanted to become a surgeon, as if becoming a Black doctor was unattainable," recalls Dr. Jones, who recently transitioned to a solo private practice. "I go into the schools to encourage them and let them know they can be whatever they want. I want them to know they can actually achieve great things."

Dr. Woodberry says that without mentorship, the future of Black plastic surgeons could be nonexistent.

"Whether you're in private practice or academic settings, we have to be there to give residents guidance," she says. "Sometimes they don't know how to get involved in the organization, publish papers or make those connections. A lot of people don't know what's needed to become successful or even to find opportunities. Having that network is important."

Dr. Woodberry encourages African-American plastic surgeons to get involved with the Arthur L. Garnes Society, which was formed in 2019 to foster mentorship, collaboration and fellowship among African-Americans and other underrepresented minorities in plastic surgery.

"Our goal is to be a face for residents and students, collaborate and network with each other," she says. "It starts with bringing people together, so we can have a sense of community and not feel isolated."

Looking ahead

Dr. Cash commends the Society for addressing the lack of racial diversity in plastic surgery, but she hopes to see future mentoring programs for members – as well as events specifically designed for plastic surgeons of color at annual meetings.

"We certainly are able to embrace the idea of women in plastic surgery and host happy hours and meetings, which is great – but there's another need," she says. "Until we make it a priority to change the narrative and open it up to younger voices and more minority voices, we're never going to break through."

Dr. Cash says it's critical to acknowledge the strong disconnect between African-Americans in the physician workforce (4 percent) and the African-American U.S. population (13 percent), and its impact on racial health disparities. She appreciates that more people acknowledge the disparity, but even after all these years of her family members pioneering African-American representation in medicine throughout the South, Dr. Cash says true change remains elusive.

"It doesn't matter if it's cosmetic surgery, management of diabetes or mental-health conditions," Dr. Cash says. "Until we recognize unconscious bias and increase representation, we aren't going to adequately address the needs of a significant number of African-American patients.

"Helping people is at the core of every plastic surgeon's heart," Dr. Cash adds. "If we don't address these issues and improve our racial diversity, we're not going to provide quality healthcare across the board. I want my people to have access to all of the same medical options as white patients. There should be no compromise."