The chronic underrepresentation of Black physicians at every stage of surgical training persists across the United States, especially among Black men, who are particularly affected, a nationwide, multicenter study concludes.
“The decline in the training of Black male surgeons and the low and unchanged rate in the training of Black female surgeons is deeply concerning,” senior author Cherisse Berry, MD, of the New York University Grossman School of Medicine, told Medscape Medical News in an email.
“Representation within the surgical workforce is critical to achieving health equity among patients and delivering high quality patient care,” she added, explaining that the more surgeons reflect the diversity of a community, the more patients will feel represented. And that, in turn, will ultimately lead to greater trust, increased compliance, and improved outcomes.
In addition, “Having a more diverse and inclusive surgical workforce drives innovation in that diverse perspectives lead to diverse and more inclusive research questions and more inclusive clinical trials, which can result in new techniques, new treatments, and updated clinical practice management guidelines applicable for all patients,” she said.
However, Berry predicted that until the US dismantles structural racism, “The health inequities within our communities and the disparities in representation within our field will persist.”
The study was published online February 9 in JAMA Surgery.
Applications Reviewed
For the study, investigators reviewed the Association of American Medical Colleges’ roster of Electronic Residency Application Service general surgery residency applications between 2005 and 2018. “Over the study period, there were 71,687 applicants, 26,237 first-year matriculants, and 24,493 graduates,” the investigators note. Among all applicants, slightly over one third were women, roughly 23% were Asian, 8.3% were Black, and 3.4% were Latino.
Not unexpectedly, a plurality of applicants (43.5%) were White. Stratified by race and ethnicity, some 8.5% of female applicants were Asian, 3.3% were Black, 1.1% were Latina, and 14.1% were White. Evaluated across the study interval, there were small but significant yearly increases of 0.10% among Black female applicants (P < .001), 0.18% among Latina women, (P < .001), and 0.27% among Asian women, at 0.27% a year (P < .001).
In contrast, the percentage of White female applicants remained unchanged across the study interval at between 14% and 15%. When male applicants were stratified by race and ethnicity, the pattern was similar to that seen among women, with 14.6% of applicants being Asian, 5% being Black, 2.2% being Latino, and 29.4% being White. Again when evaluated over time, yearly applications increased the most among Latino men, at 0.37% (P < .001), and decreased the most (at 0.36% a year) among White men, the investigators note.
In contrast, no change in applications across the years was seen among Black or Asian men.
First-Year Matriculants
When first-year female matriculants were stratified by race and ethnicity, 6.7% were Asian, 2.4% were Black, and 1.1% were Latina. By comparison, almost 21% of female matriculants were White. Over time, first-year matriculation rates increased significantly each year among Latina women (P < .001), Asian women (P = .01), and White women (P = .006) but not among Black women, where the matriculation rate remained unchanged at approximately 2.3% to 2.4% over the study interval.
Among first-year male matriculants, lower rates were seen among Black men, at 3.1%, compared with Asian men, at 11.5%, and White men, at 41.7%, but representation for Black male matriculants was still higher than it was for Latino men, at 2.2% (P < .001). In contrast to Latino men, who had a significant yearly increases in first-year matriculation rates, both Black and White men had a significant yearly decreases in first-year matriculation rates, at 0.01% (P = .04) and 0.41% (P = .002), respectively.
First-year matriculation rates for Asian men remained unchanged. Among graduates from general surgery residency, almost 20% were Asian, 6.3% were Black, and 3.4% were Latino. This compared to over 61% of male graduates who were White, the authors report. “Black women represented a smaller percentage of graduates (2.5%) compared with Asian graduates (6.2%) and White graduates (17.4%) but higher compared with Latina women (0.9%; P < .001),” Keshinro and colleagues point out.
Moreover, the graduation rate among Black women over time remained low and unchanged at between 1.7% and 2.2% over time. This was not the case for either Asian or White female residents, among whom the yearly rate of graduates increased at 0.2% per year (P = .004) and 0.4% a year (P = .002), respectively.
The percentage of Latina women who graduated also increased but at a much lower rate of 0.06% per year (P < .001). Analysis of male graduates revealed that 13.1% were Asian, 3.8% were Black, and 2.5% were Latino. Again, a plurality of male graduates, at 43.8%, were White. “A trend analysis of male graduates over time also revealed a significant decline in Asian male graduates (P < .001); Black male graduates (P = .03), and White male graduates (P < .001); the number of Latino male gradates remaining unchanged over the same study interval,” the authors report.
The attrition rate for general surgery residency also remained significantly higher for Black trainees compared with either Asian trainees (P = .001), Latino trainees (P < .001), or White trainees (P < .001), although all groups showed a significant decline in over time.
Changing Demographics
As the authors point out, demographics are changing rapidly in the US, and based on these changes, a 41% increase in growth in full-time physicians will be needed for the rising Hispanic population by the year 2032 as well as a 23% increase in growth in full-time physicians for the rising Black community. “However, over the past 120 years, there has been an underwhelming 4% increase in Black physicians in the US,” Keshinro and colleagues point out.
Alarmingly, fewer Black men matriculated at US medical schools in 2014 than in 1978 — “a staggering finding when one considers the vast expansion of medical schools in the US,” they add. Berry suggested that strategies to get more Black students to apply to medical school should include a multipronged approach. These strategies might include an active effort to create an inclusive environment for trainees, one that is free from discrimination and bias and in which strong mentorship and sponsorship are celebrated.
“I also think we need to include advancing and promoting Black faculty to leadership positions,” Berry emphasized. In point of fact, this does seem to be happening now; for the first time ever, a total of four Black women were appointed to the position of the Chair of Surgery in 2021 and 2022. Patricia L. Turner, MD, MBA, FACS, a Black woman, was also recently named executive director of the American College of Surgeons.
Recent data have shown that of some 22,000 students who started medical school last fall, those who identified as Black or African American increased to 21% from 2020 to 2021. “Real change happens at the top and in the C-Suite,” Berry said.
“Representation at the leadership table is absolutely critical to achieve representation along the surgical workforce pathway,” she stressed.
Asked to comment on the findings, Andre Campbell, MD, professor of surgery and vice chair for diversity, equity, and inclusion at the University of California, San Francisco, said that he agreed with Berry that US medical schools have a serious problem with respect to training underrepresented residents such as Black students.
“Having a paper like this is very helpful in getting us to better understand what’s really happening, because you have to understand what’s really happening before you can make a difference in the numbers,” Campbell told Medscape Medical News. Campbell is also optimistic that the number of underrepresented students who are now considering a career in medicine has been going up over the past few years.
“Assuming we can attract students to our specialty, the numbers are getting there, and hopefully, students will see surgery as a specialty where they can have a fulfilling career with excitement, academic interest, great patient interaction, and the ability to really make a difference in peoples’ lives,” Campbell elaborated. “And this is what we have to do as educators — try to turn this around and make these numbers different.”
Asked if he thought that being a role model as a Black surgeon himself might help attract more Black students to the specialty, Campbell said he hoped so, although he didn’t want to put too much faith in that. However, “if you do see someone who looks like you, it is encouraging for others that you can do that yourself,” he said.
“So I always try to talk to medical students whenever I can about pursuing a career in medicine, because it’s a great career, and they really need to think about it and look into any options that might be available to them [to do so],” Campbell emphasized.
Berry and Campbell have disclosed no relevant financial relationships.
JAMA Surg. Published online February 9, 2022. Abstract
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