ORIGINAL ARTICLE

Is There Color or Sex Behind the Mask and Sterile Blue? Examining
Sex and Racial Demographics Within Academic Surgery
Adeeti Aggarwal, BA,  Claire B. Rosen, MD,y Ariel Nehemiah, MD, MS,y Ivy Maina, MD,y
Rachel R. Kelz, MD, MSCE, MBA,y Cary B. Aarons, MD, MSEd,y and Sanford E. Roberts, MDyY
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studies for URM patients.5 In addition, minority healthcare profes-

Background: The lack of underrepresented minorities has been a persistent
issue within the surgical workforce. Equal sex representation has also been a
problem in surgery. Underrepresented minorities females face the unique
challenge of being a minority in both race and sex.
Objective: The objective of this retrospective cross-sectional study is to
determine the racial and sex demographics of medical trainees and faculty and
determine the degree to which minority women are underrepresented at higher
ranks and leadership.
Methods: Race and sex demographic data for all medical students, surgical
residents and faculty was extracted from the AAMC data files. This data was
compared to the US population using chi squared tests. Race and sex
breakdowns of the different surgical subspecialties was also analyzed using
chi squared tests. Demographics of surgical faculty at various ranks are also
reported.
Results: White men made up 37% of all surgical residents. Black men made
up only 1.9% of all surgical residents whereas Black women made up 2.6%.
The subspecialty with the smallest percentage of Black women was Ortho-
pedic Surgery with 0.6%. The specialty with the highest representation of
Black women was Ob/Gyn with 6.2%. There was a decrease in representation
of Black women with each increase in professional rank, with 2.8%, 1.6%, and
0.7% for assistant, associate, and full professor, respectively, as compared to
Black men, who as a percentage, remained stable at the various ranks with
2.1%, 2.4%, and 2.1% for assistant, associate, and full professor, respectively.
Conclusions: There is a striking lack of minority women in surgery. This
trend is amplified as surgeons progress from student, to resident, to attending,
and then to leadership positions.
Keywords: disparities, equity, sex, pipeline, race, representation, surgery,
workforce
(Ann Surg 2021;273:21–27)
A cademic surgery has a noted deficiency in the number of
underrepresented minority (URM) residents, junior faculty,
and tenured professors.1,2 Underrepresented minorities comprise
a small percentage of medical school graduates, and with each
successive step along the academic surgical career pathway, their
representation dwindles.3
This lack of diverse representation in the surgical workforce is
concerning for several reasons. There are well-described advantages
to having a diverse physician workforce, including higher patient
satisfaction scores, superior patient compliance with physician rec-
ommendations,4 and increased participation in clinical research
From the Department of Neuroscience, Perelman School of Medicine, University
of Pennsylvania, Philadelphia, Pennsylvania; and yDepartment of Surgery,
Perelman School of Medicine, University of Pennsylvania, Philadelphia,
Pennsylvania.
Sanford.Roberts@pennmedicine.upenn.edu.
The authors report no conflicts of interest.
Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0003-4932/20/27301-0021
DOI: 10.1097/SLA.0000000000004461
sionals are more likely than their White peers to treat patients of
color, and to practice in medically underserved communities.6
Unfortunately, the demographics of the surgical workforce are
lacking in multiple areas. Sex representation has been a persistent
issue in the surgical fields.7 Women are now entering medical school
at higher rates than men8; however, they are less likely to pursue
surgical disciplines, advance in rank or achieve leadership roles.9,10
In 2017, only 16% of all medical school deans and department chairs
across all medical specialties were women.
To date there have been 31 female chairs of Departments of
Surgery nationally. At this time, there has never been a Black female
chair of a Department of Surgery in the United States.11,12 Black
females face the unique challenge of being a minority in both race
and sex. However, there has been scant literature looking directly at
the status of Black females in surgery.
We believe that delineating the demographics of the US
surgical workforce and trainee pipeline could provide substantial
information and insight into the reasons behind the underrepresen-
tation of certain groups. As authors, we predict that the number of
minority (namely Hispanic and Black) medical students, residents
and faculty will be underrepresented and that these deficits will likely
be even more prominent for female URM trainees and faculty.
METHODS
The AAMC data files were used to collect demographic infor-
mation on all medical school applicants, accepted students, matricu-
lants, and medical school faculty in US allopathic medical schools.
Combined data on race and sex for active residents is not publicly
available and had to be requested specifically from the AAMC.
Race/ethnicity, defined by the AAMC as American Indian or
Alaskan Native, Asian, Black/African American, Hispanic/Latino or
of Spanish origin, Native Hawaiian or other Pacific Islander, White,
Other, multiple race or unknown, were extracted from the data base.
To simplify the analysis the very small Native and Hawaiian Amer-
icans’ groups were combined with the Other group. The small
unknown racial group was excluded from analysis.
Data from the AAMC on medical students was broken down
into several categories: applicants to medical school, students
accepted to a US medical school, and matriculated students. Surgical
specialties included in our analysis were Obstetrics and Gynecology,
Otorhinolaryngology, Ophthalmology, Orthopedic Surgery, and Gen-
eral Surgery. The category ‘‘General Surgery’’ includes Neurosur-
gery, Cardiothoracic Surgery, Vascular Surgery, Urologic Surgery,
Plastic Surgery, General Surgery, and General Surgery subspecial-
ties. AAMC data from 2017 to 2018 was used for our analysis.13
In effort to determine whether medical students, residents, and
surgical faculty were reflective of the US population, information
was collected from the 2018 US Census Bureau population projec-
tions.14 The US Census data was broken down into the following
racial groups: Hispanic, White, Black, Asian, American Indian/
Alaskan Native and Other/Mixed Race. The AAMC data was

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Aggarwal et al
FIGURE 1. Demographics of medical trainees and faculty compared to the US population.
grouped using the same categories to allow for comparison to the
census in Figure 1. For the remainder of the analysis, the mixed-race
group was separated from the Other group.
Data was analyzed for medical students, surgical residents and
faculty in comparison with the overall US population using chi
squared tests. Race and sex breakdowns of the different surgical
subspecialties was also analyzed using chi squared tests assuming
mutual independence of the variables sex, race, and subspecialty.
Statistical significance was noted if the P value was <0.01
RESULTS
Racial Demographics of Medical Students, Surgical
Residents, and Surgical Faculty
The racial demographics of medical school applicants,
accepted students and matriculated students are broken down by
percentage in Figure 1. Information from the AAMC revealed a
significant difference in the demographics of the medical student
applicants, medical school matriculants, surgical residents and US
surgical faculty when compared to the overall US population (P <
0.01). Whites were overrepresented, comprising 69.8% of the surgi-
cal faculty but only 60.4% of the US population. Asians were also
overrepresented making up 17.7% of surgical faculty, but only 5.7%
of the US population. Both Blacks and Hispanics were underrepre-
sented; Blacks made up 12.5% of the US population and only 4.2% of
US surgical faculty, Hispanics comprised 18.3% of the US popula-
tion and only 3.4% of the surgical faculty.
Matriculated medical students were then compared to surgical
faculty and found to be significantly different in their racial/ethnic
composition (P < 0.01). Black medical students made up 7.4% of the
matriculated student population, meanwhile Black faculty only com-
prised 4.2% of surgical faculty. Whites comprised 51.5% of matricu-
lated medical students and 69.8% of surgical faculty. Asians made up
22.8% of the matriculated medical student population and 17.7% of the
surgical faculty. Hispanic students were 6.4% of matriculated students
with only 3.4% represented in the surgical faculty.
Racial and Sex Demographics of Medical Students,
Surgical Residents, and Surgical Faculty
Women overall made up a higher percentage of accepted and
matriculated medical students than men (51.7% and 51.6%,
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Annals of Surgery  Volume 273, Number 1, January 2021
respectively). When broken down into race and sex subgroups, we
found that White men were the largest individual of both accepted
and matriculated students, at 25.9%. Black women were 4.7% of both
accepted and matriculated students. Black men represented 2.8% of
accepted and matriculated students. Hispanic men and women each
equally comprised 3.2% of accepted and matriculated students
(Table 1).
Women made up 43.8% of all surgery residents. Broken into
subgroups, White males were again the largest group at 37.6%. Of
note, Hispanic females were only 2.1% and Hispanic males 2.4%.
Men made up a higher percentage in every racial category, as
compared to women, except for the Black group. Black men made
up only 1.9% of all surgical residents whereas Black women made up
2.6%.
Even though women made up the majority of matriculated
medical students, only 34.3% of surgical faculty were female. As
seen in the demographics of surgical residents, women comprised a
smaller percentage than men in almost every racial category for
faculty. White men were the largest group at 46.9%, whereas White
women, the second largest group, comprised 22.9% of surgical
faculty. Hispanic women made up the smallest subgroup with only
1.1% represented. Hispanic men were 2.3%. The only racial group
where women outnumbered men was Blacks with men comprising
2.1% and women comprising 2.2%.
Surgical Faculty Demographics Broken Down by
Surgical Subspecialty
The racial and sex demographics of the surgical faculty was
then broken down by individual subspecialties (Obstetrics and
Gynecology, Otorhinolaryngology, Ophthalmology, Orthopedic Sur-
gery, and General Surgery). Obstetrics and Gynecology (Ob/Gyn)
was found to have significantly different demographics than the other
subspecialties, as seen in Figure 2 (P < 0.01). Ob/Gyn had the
highest representation of Black women of any surgical subspecialty
where they made up 6.2% of faculty. Hispanic women comprised
2.6% of Ob/Gyn and White women 43.1%.
Black women made up only 1.3% of the General Surgery
faculty. Hispanic women were the least represented group in General
Surgery with just 0.7%. White men made up the largest group in the
General Surgery group with 52.6%. The second largest group was
White women with 16.9%, followed by Asian men at 13.3%.
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Annals of Surgery  Volume 273, Number 1, January 2021 Is There Color or Sex Behind the Mask?

TABLE 1. Demographics of Accepted Medical Students, Matriculated Medical Students, Active Residents/Fellows and Surgical
Faculty Broken Down by Race/Ethnicity and Sex
Black or Hispanic, Multiple
African Latino, or of Race/
Asian American Spanish Origin White Other Ethnicity
Male Female Male Female Male Female Male Female Male Female Male Female Total
Applicants 5345 5871 1558 2872 1595 1701 12,904 11,776 690 638 2315 2537 49,802
(10.7%) (11.8%) (3.1%) (5.8%) (3.2%) (3.4%) (25.9%) (23.6%) (1.4%) (1.3%) (4.6%) (5.1%)
Accepted students 2273 2674 626 970 705 696 5622 5573 241 219 1017 1097 21,713
(10.5%) (12.3%) (2.9%) (4.5%) (3.2%) (3.2%) (25.9%) (25.7%) (1.1%) (1.0%) (4.7%) (5.1%)
Matriculants 2191 2595 604 936 680 669 5442 5338 232 210 979 1065 20,941
(10.5%) (12.4%) (2.9%) (4.5%) (3.2%) (3.2%) (26.0%) (25.5%) (1.1%) (1.0%) (4.7%) (5.1%)
Active surgical 2435 2023 509 679 624 539 9819 7101 330 202 980 908 26,149
Residents/fellows (9.3%) (7.7%) (1.9%) (2.6%) (2.4%) (2.1%) (37.6%) (27.2%) (1.3%) (0.8%) (3.7%) (3.5%)
US surgical faculty 3511 1980 640 671 710 334 14,576 7112 196 108 770 472 31,080
(11.3%) (6.4%) (2.1%) (2.2%) (2.3%) (1.1%) (46.9%) (22.9%) (0.6%) (0.3%) (2.5%) (1.5%)

The specialty with the smallest percentage of Black women
was Orthopedic Surgery with only 0.6%. The smallest representation
of any subspecialty was Hispanic women in Orthopedic Surgery,
making up only 0.4% of faculty.
The specialty with the highest representation of Black men
was General Surgery with 2.4%. Ophthalmology had the lowest
percentage of Black men at 0.8%. White men were the largest group
of every specialty except Ob/Gyn where White women were the
largest group. White men had the highest representation in Orthope-
dic Surgery with 62.8% and the lowest in Ob/Gyn with 25.3%.
Demographics of Surgical Faculty at Different
Academic Ranks
Faculty data was then broken down by academic rank. Cate-
gories included: instructor, assistant professor, associate professor,
full professor, and other. The racial and sex demographics of each of
these rank groups were then analyzed. Overall, there was a clear
underrepresentation of Black and Hispanic faculty at the higher ranks
of associate professor and professor.
With each increase in professional rank, the percentage of
Black women fell. Black women made up 2.8% of assistant
professors, but only 1.6% of associate professors and 0.7% of full
professors. Black men were underrepresented, however there was
less attrition in representation at the higher ranks. Black men made
up 2.1% of assistant professors, 2.4% of associate professors and
2.1% of full professors.
Hispanic women had the least representation of any individual
group, comprising 1.1% of assistant professors, 0.9% of associate
professors and 0.6% of full professors. Similar to Black women,
Hispanic women also had attrition in percentage with each increase
in rank. White men were by far the largest group in each category;
with each successive increase in rank, White male representation
increased. White men made up the majority of professors (65.4%).
As seen in Table 2, Ob/Gyn had significantly higher represen-
tation of Black women as compared to other specialties. Given the
fact that Ob/Gyn was significantly different, subsequent analysis was
performed both including Ob/Gyn in the grouped data, and excluding
it as an outlier as shown in Table 3.
With the Ob/Gyn data removed, we see that Black women
make up only 1.6% of assistant professors, 0.9% of associate
professors and 0.4% of full professors. Similarly, the same trend
was noted with regards to Hispanic women. Without Ob/Gyn,

FIGURE 2. Surgical subspecialties broken down by race and sex.

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Aggarwal et al Annals of Surgery  Volume 273, Number 1, January 2021

TABLE 2. Different Surgical Subspecialties Broken Down by Race/Ethnicity and Sex

Black or Hispanic, Multiple
African Latino, or of Race/
Asian American Spanish Origin White Other Ethnicity
Department Male Female Male Female Male Female Male Female Male Female Male Female Total
OB/GYN 267 550 142 386 138 160 1584 2707 21 47 92 179 6273
(4.3%) (8.8%) (2.3%) (6.2%) (2.2%) (2.6%) (25.3%) (43.2%) (0.3%) (0.7%) (1.5%) (2.9%)
Ophthalmology 440 414 24 46 46 23 1225 643 12 12 64 61 3010
(14.6%) (13.8%) (0.8%) (1.5%) (1.5%) (0.8%) (40.7%) (21.4%) (0.4%) (0.4%) (2.1%) (2.0%)
Orthopedic surgery 457 104 77 25 67 15 2521 591 36 7 96 20 4016
(11.4%) (2.6%) (1.9%) (0.6%) (1.7%) (0.4%) (62.8%) (14.7%) (0.9%) (0.2%) (2.4%) (0.5%)
Otorhinolaryngology 267 140 28 16 43 23 1040 527 10 9 48 32 2183
(12.2%) (6.4%) (1.3%) (0.7%) (2.0%) (1.1%) (47.6%) (24.1%) (0.5%) (0.4%) (2.2%) (1.5%)
Surgery 2080 772 369 198 416 113 8206 2644 117 33 470 180 15598
(13.3%) (4.9%) (2.4%) (1.3%) (2.7%) (0.7%) (52.6%) (17.0%) (0.8%) (0.2%) (3.0%) (1.2%)

Hispanic women made up 0.8% of assistant professors, 0.6% of
associate professors and 0.3% of professors. White male representa-
tion increased to 68.5% at the level of full professor. Black male
representation remained stable.
DISCUSSION
This is the first national cross-sectional survey of medical
students, surgical residents, and academic surgical faculty that
examines the combination of both race and sex demographics in
the full surgical workforce. Moreover, we feel that these results are
robust because we have included the full population of medical
trainees from medical students through academic faculty. Our results
highlight the dramatic underrepresentation of certain groups and
offer a compelling call to action.
Figure 1 highlights that the racial breakdown of applicants and
matriculants to medical school do not mirror that of the US popula-
tion. Black and Hispanics are significantly underrepresented as
compared to the general US population, and Whites and Asians
are conversely overrepresented. These disparities are further ampli-
fied within surgery, as we see the numbers of Black and Hispanic
surgical residents decrease when compared to medical school
matriculants.
Although it is well known that Blacks are underrepresented in
the surgical workforce,15 the authors find it striking to see the
difference between Black men and women in regards to academic
rank. Black men, as a percentage, remained stable at the various
ranks with 2.1%, 2.4%, and 2.1% for assistant, associate, and full
professor, respectively. However, Black women had a dramatic
decrease in representation with increase in rank, sometimes by more
than half, with 2.8%, 1.6%, and 0.7% for assistant, associate, and full
professor, respectively. This trend was exacerbated when Ob/Gyn
was excluded. Again, Black men remained stable with 2.1%, 2.2%,
and 2.0% at each escalating rank, whereas Black women fell with
each step, 1.6%, 0.9%, and 0.4% (Fig. 3).

TABLE 3. Demographics of Surgical Faculty by Rank

Black or Hispanic, Multiple
African Latino, or of Race/
Asian American Spanish Origin White Other Ethnicity
Male Female Male Female Male Female Male Female Male Female Male Female Total
Rank
(including OB/Gyn)
Assistant professor 1615 1114 297 400 313 160 5707 3555 112 60 403 317 14,053
(11.5%) (7.9%) (2.1%) (2.8%) (2.2%) (1.1%) (40.6%) (25.3%) (0.8%) (0.4%) (2.9%) (%)
Associate professor 878 361 155 105 166 58 3229 1323 35 20 152 53 6535
(13.4%) (5.5%) (2.4%) (1.6%) (2.5%) (0.9%) (49.4%) (20.2%) (0.5%) (0.3%) (2.3%) (%)
Professor 742 193 153 49 170 42 4785 959 26 1 167 26 7313
(10.1%) (2.6%) (2.1%) (0.7%) (2.3%) (0.6%) (65.4%) (13.1%) (0.4%) (0.0%) (2.3%) (%)
Instructor 199 240 32 87 47 58 626 969 19 25 37 62 2401
(8.3%) (10.0%) (1.3%) (3.6%) (2.0%) (2.4%) (26.1%) (40.4%) (0.8%) (1.0%) (1.5%) (%)
Other 77 72 3 30 14 16 229 306 4 2 11 14 778
(9.9%) (9.3%) (0.4%) (3.9%) (1.8%) (2.1%) (29.4%) (39.3%) (0.5%) (0.3%) (1.4%) (%)
Rank
(excluding OB/Gyn)
Assistant professor 1499 789 230 172 257 90 5117 2100 101 34 351 193 10,933
(13.7%) (7.2%) (2.1%) (1.6%) (2.4%) (0.8%) (46.8%) (19.2%) (0.9%) (0.3%) (3.2%) (1.8%)
Associate professor 823 259 120 50 132 34 2860 838 33 9 142 41 5341
(15.4%) (4.8%) (2.2%) (0.9%) (2.5%) (0.6%) (53.5%) (15.7%) (0.6%) (0.2%) (2.7%) (0.8%)
Professor 670 148 121 23 146 19 4240 644 20 0 143 20 6194
(10.8%) (2.4%) (2.0%) (0.4%) (2.4%) (0.3%) (68.5%) (10.4%) (0.3%) (0.0%) (2.3%) (0.3%)
Instructor 185 177 24 29 23 28 560 621 17 17 31 30 1742
(10.6%) (10.2%) (1.4%) (1.7%) (1.3%) (1.6%) (32.1%) (35.6%) (1.0%) (1.0%) (1.8%) (1.7%)
Other 67 57 3 11 14 3 215 202 4 1 11 9 597
(11.2%) (9.5%) (0.5%) (1.8%) (2.3%) (0.5%) (36.0%) (33.8%) (0.7%) (0.2%) (1.8%) (1.5%)

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Annals of Surgery  Volume 273, Number 1, January 2021
FIGURE 3. Demographics of surgical faculty
by rank.
Black women outnumber Black men in medical school and
surgical residency; however, Black women account for less than half
of the representation of Black males at the level of full professor. If
Ob/Gyn is excluded, Black women comprise less than a quarter of
their male counterparts. These findings are corroborated by the
recent work by Berry et al which similarly found a dearth of Black
female representation at the highest levels of surgical leadership.11
Additionally, the degree to which Hispanics were underrepre-
sented was striking. At the faculty level, Hispanic women comprised
only 0.4% of full professors (0.3% without Ob/Gyn), making them
the least represented subgroup at the highest levels of leadership. The
Hispanic population in the US is the fastest growing ethnic or racial
group in the country.16 This demonstrated lack of diversity highlights
how the US surgical workforce is not representative of US demo-
graphics, and likely not optimally equipped to handle the needs of our
increasingly diverse patient population.
Differences Between Subspecialties
Black women were significantly over represented in Ob/Gyn
when compared to the other surgical fields at 6.2%. As a percentage,
this was more than three times higher than any other surgical field.
One possible explanation for this observation is that Ob/Gyn has the
highest representation of women of any surgical specialty. Given that
there are more female Black medical students (female 4.5% and
2.9% male), if all else is held equal, there will be more Black female
surgeons in Ob/Gyn than in any other surgical specialty. Another
hypothesis is that there are more diverse and female mentors to serve
as role models to incoming medical students.17 However, overall,
there is scant literature examining why Ob/Gyn in particular has
higher female URM representation when compared to the other
surgical fields and is an area that warrants future research.
As a trend, both Blacks and Hispanics were very poorly
represented within Ophthalmology, Orthopedic surgery, and Otorhi-
nolaryngology. One possible explanation is that minority students
have traditionally scored lower on the United States Medical Licens-
ing Examination (USMLE).18 It is also worth noting that the cause of
lower USMLE scores among Black and Hispanic students is likely
multifactorial, but beyond the scope of this current project.
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Is There Color or Sex Behind the Mask?
Competitive subspecialties such as Ophthalmology, Orthopedic sur-
gery and Otorhinolaryngology often use USMLEs to screen appli-
cants during the residency application process.19 Thus, the use of
rigid screening criteria can create barriers for minority students.
Alternatively, the use of more holistic screening criteria may yield
more diverse resident populations. The AAMC defines holistic
review as a flexible and individualized way of assessing an appli-
cant’s capabilities. Traditional approaches have relied heavily on
standardized testing, grades and class ranking.20 Holistic review has
already been implemented in many medical schools and has demon-
strated a significant increase in racial diversity of accepted and
matriculated medical students.21 This approach is especially appeal-
ing given the recent announcement that the USMLE Step 1 exam is
shifting to pass/fail grading. This change gives program directors an
opportunity to reevaluate their selection criteria. Opponents to
holistic review often state that the elimination of objective metrics
may compromise acceptance standards; however, this may not be
valid. The USMLE may not be an accurate predictor of later
success22; for example, surgical residents with lower than average
USMLE scores often go on to be successful residents and pass their
surgical boards.23
Why the Lack of Diversity at the Top?
Our analysis shows that there is attrition of minority women
with each increasing academic rank, which results in dramatically
low levels of representation at the top. This prompts the question:
why this is occurring? A recent multi-institutional survey of general
surgery residents found that there was no difference between men and
women in their desire to hold leadership positions such as department
chair, division chief, or program director.24 This demonstrates that
women enter surgical residency with the same goals as their male
counterparts, but likely face unequal barriers in pursuit of these goals,
this leads to poor representation at the highest levels. These barriers
are likely multifactorial, rooted in years of ‘‘traditional’’ organiza-
tional culture that promotes male domination of surgery and are
enhanced by societal pressures on women to strike a work-family
balance.22 Furthermore, a lack of mentorship from minority women
further discourages future minority women from seeing themselves
www.annalsofsurgery.com | 25
Aggarwal et al
TABLE 4. Demographics of Accepted Medical Students, Matriculated Medical Students, Surgical Residents/Fellows and Surgi-
cal Faculty Compared to the US Population
Black or
White African American
US population 197,546,407 (60.4%) 40,902,223 (12.5%)
Applicants 24,686 (49.6%) 4430 (8.9%)
Accepted students 11,198 (51.6%) 1596 (7.3%)
Matriculants 10,783 (51.5%) 1540 (7.4%)
US active residents/fellows 16920 (64.7%) 1188 (4.5%)
US surgical faculty 21,688 (69.8%) 1311 (4.2%)
in leadership roles.25,26 Moreover, Dworkin and colleagues demon-
strated sex inequity in academic citations, showing that female first
and last authors are cited less frequently than would be expected
when compared to male authors.27 This is important to note given
that academic productivity is often a critical component of earning
tenure or promotion.
Additionally, implicit bias may also play a role in the lack of
diversity in the medical profession.28 Johnson et al29 demonstrated
that faculty members involved in the recruitment and retention of
underrepresented minorities, on average, harbored slight implicit
pro-White racial bias. These biases may unconsciously influence the
recruiting, retention and promotion of minority physicians in
academic medicine.
Strategies to Improve Sex and Racial
Representation in Surgical Leadership
An important part of improving diversity and inclusion is
identification of specific organizational and individual barriers.
Unfortunately, different individuals, programs, or regions may have
different issues at play. A baseline assessment is critical for enacting
meaningful directed interventions.30 There are several published
tools for such assessment, including the Diversity Engagement
Survey.31 An emphasis should also be placed on faculty development
and education around the structural barriers that lead to sex and
racial imbalances.
Active recruitment and retention of women and minorities is
imperative to creating a diverse workforce. Establishment of dedi-
cated offices of Diversity and Inclusion can help facilitate these
efforts. Institution level programming can help minority community
members feel supported and encourage overall retention.32 For new
community members, it can be especially helpful for institutions to
facilitate mentorship programs, and provide resources for establish-
ing clinical practices and research careers. Importantly, effective
mentorship can be taught through providing mentorship education to
attending-level surgeons, which specifically focus on how to support
minority mentees. Maternity and paternity leave policies, along with
other child care resources, should also be an integral part of support-
ing students, residents and faculty.
Transparency in compensation and promotion is another
possible tool in improving minority female representation. Morris
et al33 showed that an objective and structured compensation plan
improved the sex pay gap after implementation, and equalized the
rate of promotion.
One of the most vital and difficult parts of promoting diversity
is in creating a culture of respect and inclusion. Surgery has long been
structured as a hierarchical system. It is imperative that the individu-
als in positions of authority model positive behavior and promote
inclusion. There is, unfortunately, a growing body of evidence that
shows that bullying34, sexual harassment,35 and microaggressions36
are prevalent in the surgical fields. These behaviors most typically
impact vulnerable groups such as women and minorities. Program
26 | www.annalsofsurgery.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery  Volume 273, Number 1, January 2021
Hispanic, Latino or Mixed Race/
Asian of Spanish Origin Ethnicity /Other Total
18,728,675 (5.7%) 59,871,746 (18.3%) 10,118,383 (3.1%) 327,167,434
11,218 (22.5%) 3297 (6.6%) 6185 (12.4%) 49,816
4948 (22.8%) 1402 (6.5%) 2576 (11.9%) 21,720
4787 (22.9%) 1350 (6.4%) 2488 (11.9%) 20,948
4458 (17.0%) 1163 (4.4%) 2420 (9.3%) 26,149
5491 (17.7%) 1044 (3.4%) 1546 (5.0%) 31,080
leadership should take a firm stance on these behaviors to promote
professionalism and encourage a safe environment for the
entire community.
The Leaky Surgical Pipeline
Research on the lack of URMs pursing medical careers
identify a number of factors, including poor precollege academic
preparation, lack of financial aid, family responsibilities, lack of
mentoring, faculty and peer discrimination, unconscious bias, ste-
reotype threat, and social isolation all as barriers to success.37– 39
Programs such as the John’s Hopkins MERIT health leadership
academy aims to address some of these issues. The MERIT program
has demonstrated success in helping Black high school students raise
SAT scores, placing students in research positions, and providing
longitudinal mentorship.40 Similarly participation in the Health
Equity Scholars Program has demonstrated higher rates of timely
college graduation.41 Investment in these pipeline programs have
demonstrated that breaking down barriers for minority students will
be imperative in improving diversity in medicine and surgery.
As shown in Table 4, the percentages of US surgical faculty
closely mirrors that of active surgical residents and fellows. This
suggests that increasing the number of minority surgical faculty will
require an increase in the number of minority surgical residents and
fellows, and should be an area of focus for intervention. Surveys of
surgical residents have demonstrated that mentorship and research
experience during medical school were the strongest factors associ-
ated with plans to pursue an academic career.15 Formal mentorship
programs like those provided by the Society of Black Academic
Surgeons42 or the Diverse Surgeon Initative43 may help encourage
more students to pursue academic surgical training. These types of
programs can be duplicated at the local level or within single
institutions.
Limitations
This study has several limitations. We cannot account for
students, residents, or faculty that identify as sex nonconforming as
this data was not collected in the AAMC datasets. The multiple race
category also presents certain limitations in that some minorities,
while filling this category, could underestimate the true size of other
demographic groups. We feel that this effect is temporized by the fact
that the multiple race groups were small. As the US and surgical
workforce become more diverse over time this will become an
increasingly larger issue when studying race. Our manuscript also
does not include geographic breakdowns or any regional information,
which could be very valuable in delineating appropriate barriers and
possible interventions.
This paper opens the door to many future areas of further
research. Analyzing demographics over time would be a clear next
step. Time trends of demographics would allow us to see if the
diversity of the workforce is moving in the desired direction toward
equitable representation.
ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery  Volume 273, Number 1, January 2021
CONCLUSIONS
Overall, there is a striking lack of minorities and women, and
notably in minority women, in surgery. This lack is exemplified as
surgeons progress throughout their careers – from student, to resi-
dent, to attending, and then to leadership positions. These disparities
in representation are likely multifactorial and there is not one single-
fix to even the playing field. However, this paper provides a call to
action and identifies several potential areas for systemic and program
level interventions.
ACKNOWLEDGMENTS
The authors thank the AAMC for providing the data on
Medical Students, Residents and Faculty for this project. We would
also like to thank Ms. Nirali Shah for her statistical consultation.
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