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  • Editorial:
    Diversity and Why it Matters

    Authors: Martina Stippler, MD and Sirin Gandhi, MD

    This issue of Congress Quarterly is titled “This is neurosurgery.” It is time to have a discussion about diversity in general, but also specifically in neurosurgery. Is neurosurgery diverse?

    Let’s look at the current demographics of the United States. US ethnic minority populations are increasing at a much faster pace than the majority white population. Between 1980 and 2000, the country’s white population grew by nine percent; the African-American population grew by about 28 percent; the Native American population by 55 percent; the Hispanic population by 122 percent; and the Asian population grew by more than 190 percent. As a result, by somewhere near the middle of this century, more than half of U.S. citizens will be members of “minority” groups. Meanwhile, according to the Census in 2000, women made up 50.9 percent of the population.

    Now let’s compare and contrast this to the demographics of the neurosurgery workforce today. The lack of gender diversity in neurosurgery is readily apparent with an overwhelming majority of neurosurgeons being men. The most recent data shows there are 219 board-certified women in neurosurgery in the United States which accounts for about 5% of all neurosurgeons. African-Americans are even less well represented; Association of American Medical Colleges (AAMC) figures put the number of African-American neurosurgeons at 4% of active neurosurgeons in the United States. These numbers explain neurosurgery’s reputation for a lack of diversity. But this is changing. The percentage of female neurosurgery residents has increased from 12% in 2011 to 19% in 2017. And although it took almost 40 years after the first female African- American neurosurgeon, Dr. Alexa Canady, started to practice as pediatric neurosurgery in 1982, Dr. Odette Harris recently made history for becoming America’s first black female tenured neurosurgery professor at Stanford University.

    Why does diversity matter? There is a compelling business case for supporting equity and striving for inclusion. Companies that prioritize employee diversity have greater profitability. Numerous studies have shown that groups perform better than the best individuals, and that teams with various viewpoints and perspectives achieve the very best results. Evidence also suggests that the performance of teams working across multiple tasks correlates positively with the proportion of female members on a team. And companies with 30% or more women in the C-suite have reported higher profits than companies that lacked women in their leadership team. A diverse workforce brings diverse perspectives, experiences, and skills to the table and it pays off.

    When Lou Gerstner took over as IBM CEO in 1993, he noticed that IBM’s leadership and workforce failed to reflect the diversity of the talent market or the diversity of IBM’s customers. Although IBM was already known as a progressive workplace when Gerstner took the helm in 1993, he wanted to take it even further. Rather than attempting to eliminate discrimination by deliberately ignoring differences among employees, he created workforces to explore how the differences at hand could be leveraged for the benefit of all.

    Gerstner’s efforts and the initiatives that followed led to a 370% increase in the number of IBM female executives worldwide, and the number of US-born, ethnic minority executives increased by 233%. Just over a decade after he took over, 52% of IBM’s Worldwide Management Council (WMC)—the top 52 executives who determine corporate strategy—was composed of women, ethnic minorities born in the United States, and non-U.S. citizens.1 The dramatic change to achieve diversity did not happen overnight but was an active process, which took time and effort. In IBM’s case, as in so many others, the effort paid off financially.

    But the benefits of diversity aren’t limited to the corporate world. There is growing evidence that a diversity of opinion leads to better outcomes and fosters innovation and creativity across a variety of disciplines.2 For departments of neurosurgery, different perspectives and skills will enhance both surgical outcomes and patient satisfaction. Further, Gerstner’s argument that the workforce should reflect the diversity of the customer base holds true for health care as well. Our patients are as diverse as they come and although one might argue we’re all the same once under the scalpel, I would argue that cultural, religious, socioeconomic, ethnic and racial differences play a big role in preoperative and postoperative care and patient-doctor relationships, and that they impact patient satisfaction, patient compliance, and health care outcomes.

    These are all compelling ethical and pragmatic reasons to support greater diversity in neurosurgery. We cannot sit back and let changes in society simply happen to our specialty. Achieving diversity by osmosis, so to say, is too slow and may never happen at all, because people tend to hire people who look like them.

    Although we have a more diverse group of residents in neurosurgery than ever before, we need to work hard to keep these residents on board and make sure they not only survive but thrive and succeed. There is little information about ethnic minorities in residency, but the pipeline is leaky for female medical students. What is more, the dropout rate of surgical residents is staggering. A systematic review and meta-analysis of attrition among surgical residents showed that the pooled estimate of attrition prevalence among general surgery residents was 18 percent and female residents were more likely to leave than male residents (25 percent female vs 15 percent male).3 Rates of attenuation based on gender were similar, at 13.7% for men and 12.7% for women (P = .66) at year one, but these rates deviated after the first year, with more women leaving surgery residencies. By the fourth year, the rates of attrition among women were 21.9%, compared to 16.3% for men (P = .05).4 The attrition rate is lower in neurosurgery at 10% but this still means that one out of 10 of our residents will not complete their training.5

    Factors associated with an increased rate of attrition are older age at the beginning of residency, female gender, and junior resident year. Work stress is commonly cited as the reason. However, one should not assume that this relates only to long and unpredicted work schedules. Microaggressions, lack of collegial relationships, and tolerance of unacceptable behavior by faculty should be considered as well. In addition, the culture suggests an overall underrepresentation of workplace discrimination because of lack of mechanisms for reporting such as addressing fear of shame, authority, retaliation, or not advancing; these need to be challanged.6

    It is not enough to focus on micro-level interventions that target minorities’ sense of belonging and worthiness; we also need to look at organizational structures and attitudes that push women and minorities away from surgery in particular. It has been shown that interventions focused on cultural competencies in health care organizations improved the hospital’s diversity climate. These interventions have focused, among other aspects, on diversity attitudes, implicit bias, and racial/ethnic identity status. But too few health care organizations treat workforce diversity as a business imperative and driver of strategy. Individual-level factors such as prejudice, stereotypes, and personal identity are determinants of diversity climate but organizational context factors (e.g., structures and human resource systems) play an equally important role and need to be addressed if we truly want to increase diversity in neurosurgery.7 It is not so much the lack of look-like-me role models, but it might be the overt and implicit from of discrimination minorities face in an open way from their patients and more hidden from their peers.

    Diversity attitudes, implicit bias, and racial/ethnic identity status have been shown to influence behavior and decision-making. As surgeons, we need to constantly enhance our awareness of and ability to manage our own diversity attitudes, implicit biases, and racial/ethnic identity.7 We need to apply our critical appraisal skills, honed to perfection, to treat our seriously ill patients, and to recognize that both explicit (conscious) and implicit (subconscious) biases can stand in the way of increased diversity and inclusion. Academic neurosurgery has a duty to act.

    In his 2004 bestseller, “Moneyball,” Michael Lewis wrote: “What begins as a failure of the imagination ends as a market inefficiency: when you rule out an entire class of people from doing a job simply by their appearance, you are less likely to find the best person for the job.” However, in health care we still have strong prejudices about race, class, and educational attainment.8 In the area of a large disparity in access to health care and health care outcomes the lack of diversity in our ranks might contribute to the disparity and hold us back as a specialty. We all want to attract the best and brightest young people to join our specialty. Diversity strengthens neurosurgery. Attracting people with different strengths and backgrounds to our profession can help unleash new sources of talent and creativity that can only benefit our profession and our patients.

    References

    1 Thomas DA. Diversity as Strategy.; 2004. www.hbr.org. Accessed November 4, 2019.

    2 West MA, Hwang S, Maier R V., et al. Ensuring Equity, Diversity, and Inclusion in Academic Surgery. Ann Surg. 2018;268(3):403-407. doi:10.1097/sla.0000000000002937

    3 Khoushhal Z, Hussain MA, Greco E, et al. Prevalence and causes of attrition among surgical residents a systematic review and meta-analysis. JAMA Surg. 2017;152(3):265-272. doi:10.1001/jamasurg.2016.4086

    4 Abelson JS, Sosa JA, Symer MM, et al. Association of expectations of training with attrition in general surgery residents. JAMA Surg. 2018;153(8):712-717. doi:10.1001/jamasurg.2018.0611

    5 Agarwal N, White MD, Pannullo SC, Chambless LB. Analysis of national trends in neurosurgical resident attrition. J Neurosurg. February 2019:1-6. doi:10.3171/2018.5.jns18519

    6 Khan NR, Ii CMT, Rialon KL. Resident Perspectives on the Current State of Diversity in Graduate Medical Education. doi:10.4300/JGME-D-19-00062.1

    7 Weech-Maldonado R, Dreachslin JL, Epané JP, Gail J, Gupta S, Wainio JA. Hospital cultural competency as a systematic organizational intervention: Key findings from the national center for healthcare leadership diversity demonstration project. Health Care Manage Rev. 2018;43(1):30-41. doi:10.1097/HMR.0000000000000128

    8 Cohen JJ, Gabriel BA, Terrell C. The case for diversity in the health care workforce. Health Aff. 2002;21(5):90-102. doi:10.1377/hlthaff.21.5.90

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