More of the Same: Why isn’t otolaryngology becoming more diverse?

As America grows and evolves, its face necessarily changes. Our country rests solidly on the idea that life, liberty and the pursuit of happiness should be available to all. Our collective understanding that access to health care and healthy living are essential to that ideal happiness continues to mature. But while the population becomes more diverse and blended, cultural disparities in health care not only persist, they do not appear to be diminishing. Collectively, African-Americans, Hispanic Americans and Native Americans comprise over one-quarter of our population. Yet, in the year 2000, they made up less than 10 percent of the physician workforce.^1,2 These numbers dwindle even more when we consider surgical subspecialties.

According to data from the Association of American Medical Colleges (AAMC), of the 493 applicants to otolaryngology from allopathic medical schools, only 26 (5 percent) were African-American, forty-two (8.5 percent) were Hispanic and five (1 percent) were Native American, Alaskan Native, Hawaiian or Pacific Islander.³ For comparison, almost 11 percent of applicants for neurological surgery positions were African-American and 6 percent were Hispanic. Native American, Alaskan Native, Hawaiian and Pacific Islander residents together made up less than 1 percent of all applicants.

Otolaryngology-head and neck surgery has been slow to enact policies to adapt to our changing world. When Paul Keller wrote in 1983 in the Southern Medical Journal about the maturation of otolaryngology from 1940 to 1983, he remarked, “The residencies that once had to search for young men to fill vacancies now have a choice of the finest minds coming out of our medical schools, and the future of the specialty looks bright indeed. We are privileged to be part of this group of enthusiastic, capable and well-trained young men who will, I am sure, carry the specialty on to heights of which we can only now catch a faint glimpse.”⁴ While the author did not explicitly say so, this quote almost assuredly referred to young Caucasian men; in my opinion, our collective history supports the assertion that young African-American, Hispanic American, and Native American males were not thought to possess the finest minds coming out of medical school in the American South in 1983. The idea that a premium was placed on the recruitment of Caucasian males is, perhaps, the unstated policy we still need to address.

Other disciplines have been exemplary. In 2008, the Council of Emergency Medicine Residency Directors (CORD) requested a panel to lead a workgroup on racial and ethnic diversity in emergency medicine as part of the best practices track.⁵ The move was not only intentional but integrated into the fabric of what the specialty considers the best practices for the field. Kane and colleagues looked at the trends in workforce diversity for vascular surgery, interventional radiology, interventional cardiology and general surgery.⁶ These groups were compared with orthopedic surgery because the American Academy of Orthopedic Surgery has been intentional, directive and active in pursuit of increased diversity in its specialty.⁷

Kane’s findings suggest that many programs may have inadvertently met diversity goals by increasing the number of women in their programs. While this is a noble and necessary objective, it sidesteps consideration for the value that socioeconomic and cultural diversity bring to the table. Women represented 14 percent of vascular surgery trainees, while African-American and Hispanic trainees accounted for 4 to 5 percent of all surgeons training in the subspecialty.⁶ Simply looking at the numbers, one must conclude that Caucasian women have derived more benefit from diversity programs than have other underrepresented groups in vascular surgery.

Returning to our specialty, an analysis of the data from 1996 to 2004 revealed that the population of women in otolaryngology increased from 18.5 percent to 23 percent. For African-Americans, representation fell from 3.6 percent in 1996 to 2.3 percent in 2004.⁸ For Hispanic and Native American physicians, the amount of data was apparently too small to submit to statistical analysis. These statistics, coupled with the absence of any plan to rectify the problem, lead to some conclusions.

First, there is a dearth of concrete evidence to support an assertion that the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) has any sense of concern or urgency about addressing the problem. It is not clear that there is a feeling of unease or discontent with the status quo. Secondly, there are examples in other specialties of a more decidedly active response. Drawing on the example of our colleagues in orthopedic surgery, perhaps the first and most critical step is recognition of the problem. Mark Gebhardt, MD, a professor of orthopedic surgery at Harvard University Medical School, writes, “Diversifying residency programs positively affects all residents and their ability to deliver care and create positive physician-patient relationships.”⁷ The author clearly understands that increasing diversity benefits both underrepresented minorities and traditionally represented groups of people. There must be a realization that encompassing myriad cultural backgrounds to create a diverse health care delivery team enhances the team itself as well as the team’s collective ability to provide health care.

The third conclusion is, perhaps, the most important. It is not too late. We are poised to have an impact. It is true that the ship of status quo turns slowly toward inclusion, but the first step is being purposeful about navigating in a new direction. We can follow the leads taken in general surgery, vascular surgery, geriatric medicine and a host of other medical disciplines. Specifically, neurosurgery and orthopedic surgery have embraced diversity, and census data prove that these two fields are trending toward increased cultural diversity in their respective workforces.⁸ We can also learn from business models that have repeatedly shown that a diverse team handles situations more effectively and that diversity in the workforce is a benefit rather than an imposition.⁹ Hopefully, the AAO-HNS, along with other societies and otolaryngology educator organizations, can take the steps and expend the energy necessary to create meaningful change.

References:

1. AAMC FACTS: Applicants and Matriculants Data [database]. Washington, D.C.: Association of American Medical Colleges; 2006. Updated March 16, 2006.
2. AMA Physician Masterfile [database]. Chicago, Ill.: American Medical Association; 2006.
3. AAMC ERAS [database]. Washington, D.C.: Association of American Medical Colleges; 2009. Updated November 19, 2009.
4. Keller AP Jr. Otolaryngology–head and neck surgery: retrospective and prospective view. South Med J. 1983;76(9):1158-1162.
5. Heron SL, Lovell EO, Wang E, et al. Promoting diversity in emergency medicine: summary recommendations from the 2008 Council of Emergency Medicine Residency Directors (CORD) Academic Assembly Diversity Workgroup. Acad Emerg Med. 2009;16(5):450-453.
6. Kane K, Rosero EB, Clagett GP, et al. Trends in workforce diversity in vascular surgery programs in the United States. J Vasc Surg. 2009;49(6):1514-1519.
7. Gebhardt MC. Improving diversity in orthopaedic residency programs. J Am Acad Orthop Surg. 2007;15 Suppl 1:S49-S50.
8. Andriole DA, Jeffe DB, Schechtman KB. Is surgical workforce diversity increasing? J Am Coll Surg. 2007;204(3):469-477.
9. Miller EK. Utilizing the rich resources of a diverse workplace. Physician Exec. 1993;19(5):18-21.