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A Call to Action: Black/African American Women Surgeon Scientists, Where are They?

Berry, Cherisse MD; Khabele, Dineo MD; Johnson-Mann, Crystal MD; Henry-Tillman, Ronda MD§; Joseph, Kathie-Ann MD, MPH; Turner, Patricia MD; Pugh, Carla MD, PhD||; Fayanju, Oluwadamilola M. MD∗∗; Backhus, Leah MD, MPH||; Sweeting, Raeshell MD††; Newman, Erika A. MD‡‡; Oseni, Tawakalitu MD§§; Hasson, Rian M. MD¶¶; White, Cassandra MD||||; Cobb, Adrienne MD∗∗∗; Johnston, Fabian M. MD, MHS†††; Stallion, Anthony MD‡‡‡; Karpeh, Martin MD§§§; Nwariaku, Fiemu MD¶¶¶; Rodriguez, Luz Maria MD||||||; Jordan, Andrea Hayes MD∗∗∗∗

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doi: 10.1097/SLA.0000000000003786
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Abstract

Academic surgery is pursued by many surgeons because of its challenges and rewards. Conducting novel research and discovery science is critical to expand medical knowledge and improve the care for all surgical patients. The presence of underrepresented minorities (URMs) in academic departments is also an important aspect of discovery, because they are more likely to study diseases afflicting minority populations. URMs in general have been excluded from this process in the past. The recognition of this disparity has led several funding agencies such as the National Institutes of Health to develop programs including the Minority Access to Research Careers, Minority Supplements, and developing Centers for Health Disparities. Others such as the Robert Wood Johnson Foundation, have developed programs such as the Harold Amos Medical Faculty Development Program which seek to promote faculty diversity and health equity. However, there are few programs focused specifically on the development of Black/African American (AA) women academic surgeons. In the USA, it is estimated there are 15,671 Academic surgeons of which 2281 (14.6%) are White women, 7692 (49%) are White men, 123 (0.78%) are Black/AA women, 303 are Black/AA men (1.9%), and 5272 (33.6%) represent all other ethnic backgrounds.

Black/AA women continue to be critically underrepresented within the field of academic surgery, despite the advent of initiatives by many medical organizations including the American Medical Association, the Institute of Medicine, the Society of Black Academic Surgeons (SBAS), the American Association of Medical Colleges (AAMC), the National Medical Association, training programs, minority faculty development programs, pipeline programs, and offices of diversity and inclusion.1,2

The promotion and tenure process is relatively standard amongst universities, but each institution has its individual rules and regulations, whilst relying on subjective impressions by the promotion and tenure committees to augment the applicant's objective data. At most institutions, the Chair of surgery is responsible and has the final decision for ‘putting someone forward’ for promotion. The promotion of Black/AA women from the level of instructor to professor is grossly disproportionate when compared to their White male colleagues.3,4 One cornerstone metric of academic productivity is the receipt of extramural grant funding of which the National Institutes of Health (NIH) have been a major funding source. Disparities in grant funding have been described not only within departments of surgery, but among PhD researchers who receive NIH R01 funding. Ginther et al5 found that White researchers receive NIH grants at nearly twice the rate of Black/AA researchers even after controlling for publication record and training.

In addition to disparities in academic rank, promotion, and research funding, it is not surprising that Black/AA women surgeons are also underrepresented in leadership positions such as department Chairs, Deans, society presidents, conference moderators, grand rounds speakers, and award recipients.6 The scarcity of senior Black/AA women within the field of academic surgery has direct implications for the recruitment, mentorship, and retention of minority students, and potentially leads to a cycle of underrepresentation throughout the healthcare system.7,8 Thus, the objective of this study was to report the prevalence of Black/AA women surgeons among U.S. medical school faculty and to assess the number of NIH grants awarded to Black/AA women surgeon-scientists over the past two decades. Such knowledge will raise consciousness and inform programmatic faculty development in academic surgery.

METHODS

A retrospective review of data from the AAMC 2017 Faculty Roster and funding data from the NIH 1973–2017 was performed. Data from the AAMC included the total number of medical school surgery faculty, academic rank, tenure status, and department Chair roles. This data was then stratified by race (as defined by the AAMC) and sex. Although many races were included in the total number of medical school faculty, for the purpose of this study, data for Black/AA, Latino/Hispanic, Asian, and White race were specifically evaluated with all other races (ie, American Indian/Alaskan Native, Multiple-Race Hispanic, Multiple-Race Non-Hispanic, and Native Hawaiian/Pacific Islander) combined as other/unknown. The number of NIH grants awarded to surgeons was obtained from the NIH Freedom of Information Act Office and also stratified by race and sex. The number of NIH grants submitted by Black/AA women academic surgeons and subsequently funded by the NIH from 1998 to 2017 were identified. Academic surgeons were defined by the NIH as principal investigators (PIs) or multiple principal investigators with an MD or MD-PhD in an academic institution within a Department of Surgery, Neurosurgery, or Plastic Surgery. The NIH analysts determined “surgeons” by their department within academic institutions. The analysts only know the name of the department that the research is classified under and they do not have information on the specialties or sub-specialties of PIs. The reports are based on academic institutions and do not include hospitals or research institutes. PIs from other surgical sub-specialties were not included. All mechanisms for NIH funded grants were included except contracts, intramurals, interagency agreements, loan repayments, and withdrawn or terminated awards. Due to the provisions within the Privacy Act, when the absolute count of recipients per year is less than or equal to 11, NIH data by fiscal year are reported in aggregate for individual years. Individuals were counted in each fiscal year that they applied and may be counted more than once in the total. Descriptive statistics were performed. The study was approved by the institutional review board of New York University School of Medicine.

RESULTS

To assess the prevalence of Black/AA women in surgery, we abstracted data from the AAMC 2017 Faculty Roster. Of the 15,671 U.S. medical school surgical faculty, 426 (2.72%) were identified as Black/AA (Fig. 1). Only 123 (0.78%) were Black/AA women and 303 (1.93%) were Black/AA men. Hispanic men and women totaled 319 (2.03%) and 82 (0.52%) respectively. Asian men 1616 (10.3%) and Asian women 552 (3.5%) accounted for 13.8% of surgical faculty. White men 7,692 (49%) and White women 2,281 (14.5%) accounted for 63.6% of all surgical faculty.

FIGURE 1
FIGURE 1:
2017 Medical School Surgical Faculty. Other- American Indian/Alaskan Native, Multiple-Race Hispanic, Multiple-Race Non-Hispanic, Native Hawaiian/Pacific Islander.

We stratified the medical school surgical faculty data by race, sex, academic rank (Table 1), and tenure status (Table 2). Of the 3870 Professors of Surgery, 0.26% were Black/AA women, 0.13% were Hispanic women, 1.3% were Asian women, and 8.2% were White women. 68.6% of White males comprised the majority of Professors of Surgery compared with 1.8% of Black/AA males, 1.6% of Hispanic males, and 8.3% of Asian males. Although there were 3319 Associate Professors of Surgery and 6894 Assistant Professors of Surgery, only 0.19% and 1.1%, respectfully, were Black/AA women. Of the 123 Black/AA women surgical faculty, there were 73 (59%) assistant professors, 18 (15%) associate professors, and 10 (8%) professors of surgery. Most Black/AA women surgical faculty (74%) were not on the tenure-track (Table 2). Of 2011 tenured surgical faculty, only 11 (0.54%) were Black/AA women. There were no Black/AA women Chairs of surgery among the 372 departments represented (Table 3). There were 10 (0.8%) Black/AA men, 6 (1.6%) Hispanic men, no Hispanic women, 29 (7.8%) Asian men, 2 (0.5%) Asian women, and 16 (3.2%) White women. White men made up the overwhelming majority of surgical department Chairs with 74.2%.

TABLE 1
TABLE 1:
2017 Medical School Faculty Rank
TABLE 2
TABLE 2:
2017 Medical School Faculty Tenure
TABLE 3
TABLE 3:
2017 Department of Surgery Chairs

To determine the success rate of NIH funding by Black/AA women surgeons, we obtained data spanning 2 decades of NIH grants awarded to academic surgeons. Between 1998 and 2017, only 31 (0.34%) of the 9139 NIH grants awarded to academic surgeons were awarded to Black/AA women surgeons and 163 (1.7%) were awarded to Black/AA men surgeons (Table 4). Interestingly, of the 80 submitted applications, fewer than 12 Black/AA women surgeons (15%) were awarded funding. These rates of funding have remained relatively stable over the observation period.

TABLE 4
TABLE 4:
NIH Funding Data

DISCUSSION

Black/AA women account for less than 1% of surgical faculty, and nationwide, there are only 10 full professors of surgery. As of the writing of this manuscript, there were no Black/AA women Chairs of surgery. In parallel, Black/AA women are significantly underfunded and account for less than 1% of NIH funded surgeon scientists, with only 31 Black/AA women in surgical departments awarded NIH grants over a 20-year period. Low NIH funding rates for Black/AA women contribute to academic disparities. One of the most important metrics for academic promotion, particularly on the tenure track, is the ability to secure extramural funding. NIH funding remains an academic gold standard. Ginther et al9 found that when compared with NIH R01 applications from White investigators, applications from Black investigators were 13.2 percentage points less likely to be awarded (P < 0.001). When controlling for demographics, education and training, employer characteristics, NIH experience, and research productivity, Blacks were 10% points less likely to receive R01 funding compared with Whites.10 A NIH Black Funding Disparity Working Group follow up analysis of data from 2008 to 2014 found disparities at each stage of the application process: initial applications, re-submissions, review outcome (score), number of applications discussed, and the number of funded applications. This working group found that applications from Black/AA scientists constitute only 1.5% of the pool and the odds of a Black/AA scientist being funded was 35% less than a White scientist being funded.11

Modern academic medical centers serve student and patient populations that reflect the changing demographics of the U.S., academic medical societies, including the American College of Surgeons and the American Surgical Association, recognize the importance of ensuring equity, diversity, and inclusion in academic surgery.12 Though the pipeline seems to be challenging but better for White women in surgery to achieve leadership positions,13 focused and programmatic strategies are urgently needed to achieve equity in academic advancement for Black/AA women and other URMs.

The most significant barriers are difficult to identify, specifically for Black/AA women surgeons. Barriers faced by all women in addressing the “glass ceiling” effect which include constraints of traditional sex roles, sexism and sex discrimination, scarcity of mentors, especially same-sex mentors, and “second-generation sexual bias” as documented by Zhuge et al.14 Second-generation sexual bias as described by Pories et al13 is a complex concept that describes organizational barriers limiting women from assuming leadership roles. Although Carr et al15 reported that female medical school faculty members in general were 2.5 times more likely than male faculty members to perceive sex discrimination in the academic environment, Cochran et al16 found that women in departments of academic surgery were 10 times more likely to perceive sex discrimination than their male colleagues. Strategies at the level of the individuals and at the level of institutions to reduce these burdens, especially in critical phases of early career development, are needed.17 Acknowledging these contributing factors could provide broader recognition in surgical societies and to promotion and tenure in academic surgery.

It is well known that multiple submissions are required to obtain successful grant funding. Indeed, there is no difference in award probability for grants submitted three or more times between ethnic/racial groups. However, Black/AA women physicians are less likely than White men to re-submit an unfunded grant application.5,9 Minority physician scientists face multiple environmental and personal constraints that de-incentivize a research career including limited exposure and encouragement, few culturally competent mentors and sponsors, and high student loan debt. Many Black/AA women may have the ability but not the time, money, mentorship, or sponsorship required for research. Mentorship and sponsorship are key elements. Schroen et al18 found that the environment of academic experiences differs for men and women and that disparities in publications or advancement in academic medicine exist. One factor in particular that may play a role in this disparity is a woman's choice to have children. Parental status, in addition to systems’ inability to accommodate a flexible work-life balance that would allow women to be fully productive, has been shown to affect women's productivity by limiting their expandable work hours.18,19 Disparities in institutional support afforded to women faculty which include being offered less office or laboratory space, less dedicated time for research, and less assistance with grant support early in their careers have also been identified.18,20 Finally, disparities in networking opportunities exist.18,21 Having access to fewer women colleagues in higher ranking positions and having fewer or less effective mentoring relationships, results in a smaller net social capital when compared to men.18,21 Programs that address these constraints and realities are needed to encourage more Black/AA women and other minorities to pursue careers as surgeon scientists.

The surgeon scientist is a well-established path for academic promotion and tenure for many surgeons. In recent years, additional tracks such as the clinical scholar and surgical educator are also rapidly gaining prominence as additional paths to an academic career and tenure.22 Although these tracts have become viable avenues for promotion for many, they remain underpopulated by Black/AA women. Successful mentorship and sponsorship of Black/AA women along all academic tracts will increase the number of Black women and URMs in academic medicine.

Finally, one cannot ignore existing implicit bias in medicine and science.5,23 Black/AA women may experience combined burdens of racism, sexism, homophobia or religious bias which starts early on in their careers. When controlling for U.S Medical Licensing Examination Step 1 scores, research productivity, community service, leadership activity, and Gold humanism membership, Black students are less likely to be inducted into the Alpha Omega Alpha honor society when compared to their White counterparts, despite documented cases of equally stellar academic performance which may affect future opportunities.24 In a broad range of academic institutions, faculty have been found to be more responsive to White men than “all other categories of students.”25 Programs that reduce implicit bias in academics are emerging as popular solutions. However, one-off trainings are not likely to make an impact.26 Comprehensive diversity, equity, and inclusion policies accompanied by dedicated resources (personnel and funding) are needed to address systemic bias in institutions. Although this is a complex and multifactorial problem to which several solutions could be generated, a careful look at all factors involved is important and cannot be overemphasized. It is not as simple as unconscious bias. There may be no bias… just lack of knowledge and attention to this issue. Many may be unaware that this disparity exists.

We acknowledge the limitations of the data. The number of Black/AA women represented in both datasets is small and limits our ability to obtain additional details without breaching the identity of individuals. For the NIH funding data, we were not able to obtain details as to whether the submissions were initial submissions or renewals. Also, the data may be limited by self-reporting and limited options for other independent variables. For example, some of the faculty represented may be non-surgeons (eg, Internists, PhDs, etc), which could lead to an over estimation of funding rates for clinically active surgeons. In addition, the datasets do not take into account all surgical subspecialties. Moreover, in Table 1, the Other/Unknown category includes forty females at the Professor rank and Table 2 includes twenty female faculty with tenure. Again, it is unknown how many of these women faculty are non-surgeons. The Other/Unknown category also includes 2 women chairs of surgery. It is well-established that overall NIH funding rates for surgeons have declined. Narahari et al27 found that whereas total NIH funding had significantly increased from 2006 to 2016, NIH funding to surgeons during this time period had significantly declined from a peak of $314 million (2007) to $292 million (2016) at a rate of $3 million decrease per year (P = 0.04). Surgery departments had significantly lower funding rates when compared to either Internal Medicine (20.7%, P = 0.0001) or the NIH in its entirety (19.2%, P = 0.011). Finally, funding rates for White and Asian women were requested but not made available or provided by the NIH Freedom of Information Act Office. Despite these limitations, this data provides further impetus to address persistent and significant disparities and achievement gaps in academic surgery. It is also important to note that whereas our goal was to investigate the representation of Black/AA women surgeons in academic medicine, it is notable that the numbers for Latino/Hispanic women are also drastically lower than the number of Asian or White women faculty.

Although we do not have enough data in this study to demonstrate cause and effect, we have provided an important snapshot of the disparate state of Black/AA women surgeons in academic medicine. SBAS continues to fulfill its mission in promoting educational and leadership opportunities for Black/AA and other URMs in academic surgery. SBAS reaches out to local high school and college students interested in science to expose and connect them to SBAS members during our annual Scientific meeting. To foster and support diverse academic surgeons, SBAS provides one-on-one mentoring, workshops, panel discussions, and career development opportunities for medical students, residents, and faculty. Topics include leadership, grant-writing, organizational, and negotiation skills. Medical students and residents may attend the SBAS scientific meeting and with or without having an oral presentation, at a 90%–80% discount respectively. SBAS also provides grant writing workshops for young academic surgeons at a nominal cost. In the last few years, SBAS has instituted a Women in Surgery Committee and has been able to significantly increase the number of female surgeon attendants to SBAS. Finally, SBAS hosts its Annual Meeting at academic institutions and co-sponsors fellowships and visiting professorships with other surgical societies to promote diversity within academic surgery.

Based on the leadership SBAS has shown in supporting Black/AA and other URMs in academic surgery and the marked increase in SBAS women, we encourage the following strategies:

We encourage departments of surgery to help stimulate the pipeline as young as elementary school students and continue to support the development of academic surgeons along the pipeline. We encourage surgical societies and departments of surgery to offer low cost or grant writing workshops throughout the academic continuum.

We encourage academic institutions to: (a) incorporate implicit bias training in education plans and in recruitment of medical students, residents, and faculty, (b) make the promotions process more transparent at the time of hire and at annual reviews, (c) provide effective mentors, mentorship teams, and sponsors for URM women to navigate the promotion and tenure requirements of their institution, and (d) intentionally advance qualified and accomplished Black/AA women surgeons to departmental leadership teams and decanal roles.

We encourage surgical societies such as the American College of Surgeons, the Association of Women Surgeons, the American Surgical Association, and the Society of University Surgeons to continue to partner with SBAS, SBAS women in surgery, and other organizations that focus on overcoming disparities in academic surgery.

CONCLUSIONS

Black/AA and Latino/Hispanic women are sorely underrepresented in the field of academic surgery. Few attain promotion to the rank of professor with tenure and a Black woman has yet to ascend to the role of department Chair of surgery. Programmatic recommendations are needed for the academic advancement and retention of Black/AA and Latino/Hispanic women, which in turn will benefit Black/AA and Latino/Hispanic men, and women of other racial/ethnic minorities, and other demographic groups currently underrepresented in the field of academic surgery. SBAS provides leadership in mentoring and sponsoring Black/AA and Latino surgeons and other URMs. Our call to action is to increase our efforts in partnership with academic institutions and surgical organizations to provide structured opportunities to improve diversity and overcome disparities within academic surgery.

Acknowledgments

Society of Black Academic Surgeons Women in Surgery Committee, Research and Education Committee, Health Disparities Committee, and Executive Council.

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Keywords:

academic surgery; African American women; black women; disparity; diversity; NIH funding; surgeon scientists

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