Gender and Ethnic Diversity in Plastic Surgery: Temporal Trends among Speakers at National and Regional Plastic Surgery Conferences

Abstract

Background: 

Scientific leadership among women and underrepresented minorities is lacking in plastic surgery. It is unknown whether the underrepresentation of women and ethnic minorities extends into academic conferences. The authors evaluated the temporal trends of female and ethnic minority representation at plastic surgery conferences in the United States.

Methods: 

A retrospective analysis of all presentations from seven national and regional plastic surgery meetings between 2014 and 2018 was conducted. Gender, ethnicity, and academic rank of the first authors were determined by analyzing pronouns, institutional biographies, and accompanying images identified in online searches.

Results: 

A total of 4180 abstracts were presented by 3452 first authors. The majority of first authors were of European descent (53%), male (65%), and most commonly a resident physician (42%). Women were found to have a greater representation at plastic surgery conferences than in the plastic surgery workforce (34% versus 17%; P < 0.0001). Similarly, relative to American Association of Medical Colleges demographics, individuals of Asian descent were overrepresented as first authors (27% versus 12%; P < 0.0001), whereas first authors of European descent were less prevalent (53% versus 64%; P < 0.0001). When compared with national plastic surgery conferences, regional conferences had a greater proportion of first authors of European descent (51% versus 58%; P < 0.0001) but a lower proportion of first authors of East Asian descent (21% versus 16%; P = 0.0001). Ethnic representation remained persistently low, with first authors of South Asian descent decreasingly represented [from 2014 (10%) to 2018 (6%); P = 0.0062].

Conclusions: 

Collectively, we present multilevel data that show a promising trend of increased female representation at national meetings. However, there appears to be a decline in ethnic diversity.

Gender and ethnic diversity gaps in academic plastic surgery continue to exist despite long-running initiatives to improve these disparities. Women constitute 39% of plastic surgery trainees, whereas ethnic representation among Asian, Latinx, Black, American Indian or Alaska Native (AIAN), and Native Hawaiian/Pacific Islander-Samoan persistently remain at 20%, 7.3%, 3.2%, 0.1%, and 0.8%, respectively.¹ This trend mirrors what is seen in the plastic surgery community, with women surgeons accounting for 17% and underrepresented minorities (URMs), 20.8% of academic faculty.^2,3 Women and URM surgeons are less likely to receive authorship in journals and grant funding, and receive fewer leadership positions in medical societies—all of which are contingent on scholarly activity.^4–6 Early academic experiences appear to strongly influence career development and research in women and URM medical students, residents/fellows, and faculty.^7–9 Addressing this disparity is essential for driving scientific progress, but only a first step toward broadly increasing diversity and inclusion in plastic surgery.

In a recent survey, plastic surgery departmental leadership attributed the secret of their success to academic accomplishments.⁹ On average, leaders in plastic surgery publish five peer-reviewed manuscripts and attend 4.8 research conferences annually.⁹ Conference abstracts increase academic visibility and productivity, with 63.3% of plastic surgery conference abstracts resulting in a publication.¹⁰ Similarly, research plays a significant role in deciding candidates for residency to interview and rank.^11,12

Although studies have been conducted to explore gender differences in authorship in peer-reviewed journals^4,8,13,14 and academic rank across ethnicities,^15,16 this is only a small piece of a larger puzzle. Few studies have explored the female and URM differences in academic visibility and productivity, and the literature is void on whether representation has changed over time. Examining the demographics behind conference speaking arrangements and scholarly productivity may illuminate further inequalities in gender and ethnic diversity within plastic surgery. Therefore, the goal of our study was to characterize the gender and ethnic trends of first author abstract authors at major plastic surgery conference meetings.

METHODS

Study Design

All data for this study are publicly available; thus, it is deemed exempt by The Johns Hopkins University School of Medicine Institutional Review Board. We performed a cross-sectional study of race/ethnicity and gender representation of all first authors of abstracts from the following national and regional plastic surgery conferences from 2014 to 2018, inclusive: American Society of Plastic Surgeons, American Association of Plastic Surgeons, Plastic Surgery Research Council, Northwestern Society of Plastic Surgeons, California Society of Plastic Surgeons, Ohio Valley Society of Plastic Surgeons, Midwestern Association of Plastic Surgery, Texas Society of Plastic Surgery, Northeastern Society of Plastic Surgeons, and Southeastern Society of Plastic and Reconstructive Surgeons (Fig. 1). We accessed the websites of each plastic surgery conference or obtained the original abstract book to extract abstract details by online archives, journal supplements, or through direct contact with the meeting coordinator. Regional conferences offered membership to plastic surgeons or trainees in several states, rather than a single state. Exceptions to this were the states of California and Texas, which had their own regional associations and conferences. Poster presentations were also excluded from analysis.

Fig. 1.: Diagram of the United States demonstrating the regional plastic surgery societies included for analysis. Pink, Southeastern Society of Plastic Surgeons and Reconstructive Surgeons (SSPSRS); board-certified/board-eligible plastic surgeon-members include those from Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and Puerto Rico. Light green, Northeastern Society of Plastic Surgeons (NESPS); states include Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Light red, Ohio Valley Society of Plastic Surgeons (OVSPS) includes those practicing in the states of Ohio, Indiana, Kentucky, West Virginia, and the western part of Pennsylvania. Light blue, Northwest Society of Plastic Surgeons (NWSPS) includes members practicing in Washington, Oregon, Idaho, British Columbia, Alberta, Alaska, and Hawaii. Yellow, Midwestern Association of Plastic Surgeons (MAPS) includes members practicing plastic surgery in the states of Illinois, Kansas, North Dakota, South Dakota, Minnesota, Wisconsin, and also parts of Indiana and Michigan. Beige, California Society of Plastic Surgeons (CSPS) and Purple, Texas Society of Plastic Surgeons (TSPS) involve plastic surgeons and plastic surgery programs in the states of California and Texas, respectively.

Population Characteristics

First authors to the aforementioned plastic surgery conferences were defined by gender, ethnicity, and academic rank. The academic rank was divided into medical students, research fellows/postdoctoral fellows, allied health care professionals (nurses, physician assistants), residents, fellows, and attending physicians. Each conference program’s websites or pamphlets was analyzed to identify (1) first author names, (2) gender, (3) perceived race/ethnicity, (4) academic level, and (5) institutional affiliation. Individuals who presented multiple abstracts were considered to be one data point. Gender and race/ethnicity were determined using a combination of initial first name evaluation, pronoun descriptors, and images on publicly available websites (eg, institutional website, Google.com, Doximity.com, Linked-In.com, Facebook.com).

Demographic data of the current plastic surgery workforce from the Association of American Medical Colleges (AAMC) was used as a control for comparison.^2,3 The AAMC defines underrepresented in medicine as individuals who self-identify as African American or Black, Hispanic or Latino, AIAN, or Native Hawaiian or Pacific Islander. However, given the breadth of ethnicities, we chose to classify ethnicities into European descent, African descent, East Asian, South Asian, AIAN, Native Hawaiian/Pacific Islander-Samoan, Latinx/Brazilian, and Middle Eastern/North African.

Data Analysis

Data were compiled in Microsoft Excel Version 16.34 (Microsoft Corp., Redmond, WA) and analyzed using IBM SPSS Version 26 (IBM Corp., Armonk, NY) Differences in categorical data between groups were evaluated with the chi-square test or, if group sizes were less than or equal to five, the Fisher test. Linear regression was used to analyze temporal trends in gender and ethnic diversity. Data from the AAMC was used to compare differences in gender and ethnic minority representation among resident, fellow, and attending first authors. Statistical significance was defined as a two-tailed value of P ≤ 0.05.

RESULTS

Summary of Demographic Data

Demographics of all first authors are summarized in Table 1. Overall, there were 3452 unique first authors that attended the aforementioned meetings from 2014 to 2018. The majority of first authors were male (65%), of European descent, and most commonly resident physicians (42%). Among ethnicities, first author speakers were represented in decreasing order: European descent (53%), East Asian (19%), Middle Eastern (9%), South Asian (8%), Latinx/Brazilian (7%), and African descent (3%).

Table 1. - Demographics of First Authors from National and Regional Plastic Surgery Conferences in 2018 Compared with the 2018 AAMC Demographic Data for the Plastic Surgery Workforce

	Study Cohort (%)	2018 AAMC Data (%)	P
No.	3476	7215
Gender			<0.0001a
Female	1163 (33)	1204 (17)
Male	2273 (65)	6011 (83)
Unknown	40 (1)	0 (0)
Raceb
African descent	98 (3)	206 (3)	1.0000
European descent	1864 (54)	4606 (64)	<0.0001a
Asian	940 (27)	890 (12)	<0.0001a
East Asian	643 (18)	—	—
South Asian	297 (9)	—	—
Latinx	255 (7)	—	—
Middle Eastern	303 (9)	—	—
Other	3 (0.1)	—	0.0006a
Unknown	13 (0.4)	1019 (14)	<0.0001a
Academic rank
Medical student	701 (20)	—	—
Postdoctoral scholar	203 (6)	—	—
Resident	1471 (42)	—	—
Fellow	205 (6)	—	—
Allied health care professionals	23 (0.7)	—	—
Attending physician	776 (22)	—	—
Unknown	13 (0.4)	—	—
Countryc			0.0592
United States	3082 (89)	6418 (90)
Outside United States	394 (11)	724 (10)

^aStatistically significant.

^bAAMC has fewer racial categories and does not include categories for Latinx or Middle Eastern.

^cAAMC data from 2017.

Plastic Surgery Conferences versus Plastic Surgery Workforce

Female representation at all plastic surgery conferences was double that of the active plastic surgery workforce (34% versus 17%; P < 0.0001). Similarly, individuals of Asian descent were overrepresented as first authors when compared with AAMC demographics (27% versus 12%; P < 0.0001), whereas first authors of European descent demonstrated a less prevalent cohort relative to the current plastic surgery workforce racial demographics (53% versus 64%; P < 0.0001) (Table 1).

National versus Regional Conference Data

Several differences were noted between the national and regional conference demographics (Table 2). A greater percentage of residents (55% versus 33%; P < 0.0001) and fellows (7% versus 5%; P = 0.0014) first-authored abstracts for regional conferences than for national meetings. In contrast, attending physicians (28% versus 13%; P < 0.0001) and postdoctoral scholars (8% versus 3%; P < 0.0001) were more prevalent at national meetings compared with regional conferences. When compared with national plastic surgery conferences, regional conferences had a greater proportion of first authors of European descent (51% versus 58%; P < 0.0001) but a lower proportion of first authors of East Asian descent (21% versus 16%; P = 0.0002). Furthermore, regional conferences had a significantly smaller proportion of first authors from outside the United States than national conferences (1% versus 18%; P < 0.0001). Conversely, the gender distribution of first authors was similar; one-third of first authors were women in both regional and national plastic surgery conferences (33% versus 34%; P = 0.6315).

Table 2. - Demographics of First-Authored Abstracts from National and Regional Plastic Surgery Conferences in the United States

	National (%)	Regional (%)	P
No.	2075	1401
Gender			0.8521
Female	702 (34)	461 (33)
Male	1333 (64)	940 (67)
Unknown	40 (2)	0 (0)
Race
African descent	62 (3)	36 (3)	0.5323
European descent	1050 (51)	814 (58)	<0.0001a
East Asian	428 (21)	215 (16)	0.0001a
Latinx	154 (7)	101 (7)	0.8625
Middle Eastern	184 (9)	119 (8)	0.7518
South Asian	181 (9)	116 (8)	0.6892
Other	3 (0.1)	0 (0)	1.0000
Unknown	13 (0.6)	0 (0)	1.0000
Academic rank
Medical student	421 (20)	293 (21)	0.9203
Postdoctoral scholar	162 (8)	41 (3)	<0.0001a
Resident	686 (33)	772 (55)	<0.0001a
Fellow	101 (5)	104 (7)	0.0022a
Allied health care professionals	17 (1)	6 (0.4)	0.2367
Attending physician	591 (28)	185 (13)	<0.0001a
Unknown	97 (5)	0 (0)	<0.0001a
Country			<0.0001a
United States	1692 (82)	1390 (99)
Outside United States	383 (18)	11 (1)

^aStatistically significant.

Temporal Analysis of Gender and Ethnicity

The temporal trends in the gender and race/ethnic distribution of first authors for all plastic surgery meetings from 2014 to 2018 was assessed to evaluate change in these groups over time. Female representation among first authors of published abstracts from plastic surgery meetings increased over time (2014, 28%; 2018, 36%; P = 0.0105) (Fig. 2 and Table 3). On a national scale, female first authors significantly increased over the same period (2014, 28%; 2018; 38%; P = 0.0196). A comparable trend was noted for regional conferences (2014, 28%; 2018, 35%; P = 0.0407).

Table 3. - Temporal Analysis of Gender and Individual Ethnicities of First Authors of Abstracts from Plastic Surgery Conferences

Variable	All Conferences
	Correlation Coefficient	SE	P
Gender
Female	0.96	0.013	0.0105a
Race
African descent	−0.74	0.004	0.1562
European descent	−0.54	0.023	0.3475
East Asian	0.74	0.024	0.1568
Latinx	0.60	0.009	0.2803
Middle Eastern	0.41	0.016	0.4886
South Asian	−0.97	0.005	0.0062a

^aStatistically significant.

Fig. 2.: Temporal trend of female first authors.

Interestingly, ethnic representation remained persistently low for all ethnicities throughout the years (P > 0.0500). Strikingly, the proportional representation of South Asian first authors decreased from 10% in 2014 to 6% in 2018 (P = 0.0062) (Fig. 3 and Table 3). This pattern persisted when the cohort was subgrouped into national and regional conferences. (See Table, Supplemental Digital Content 1, which demonstrates percentage among gender and ethnicity/race at national conferences, https://links.lww.com/PRS/F852.) Contrastingly, East Asian first authors demonstrated a steady increase over time at regional conferences (2014, 11.7%; 2018, 18%; P = 0.1568), although their representation nationally showed no significant change. (See Table, Supplemental Digital Content 2, which demonstrates percentage among gender and ethnicity/race at regional conferences, https://links.lww.com/PRS/F853.)

Fig. 3.: Temporal trend of racial/ethnic representation of first authors.

DISCUSSION

Plastic surgery societies offer surgeons and trainees a professional network through which mentorship, collaboration, and innovation can occur. Similarly, the impact of sponsorship can play an essential role in career development and promotion. As the demographics of plastic surgery evolves, the need for a more diverse plastic surgery workforce is warranted. More importantly, addressing the current state of academic success among women and ethnic minorities can be informative. Our results indicate that female representation at plastic surgery conferences is increasing over time, with one-third of first authors presenting at conferences in 2018 being female. Alternatively, ethnic minority representation remained persistently low, with the exception of those of Asian descent, who are better represented than expected. Accordingly, we found that a majority of first authors were plastic surgery residents.

The underrepresentation of women in leadership and at academic rank levels within academic medicine has been thoroughly studied.^4–6,17 Although women account for half of all medical students, a gender gap continues to exist in plastic surgery that may be attributed to barriers in mentorship and inclusion.^7,8,18 The gender representation at national compared with regional conferences in our study demonstrated similar distribution among men and women, with women consisting of one-third of the demographic. This observation is consistent with other recent publications that have demonstrated modest improvements in academic visibility among women.^4,5,8 Moreover, this uptrend may be attributed to a population shift among medical students interested in plastic surgery, plastic surgery trainees, and potentially the plastic surgery workforce.

Unfortunately, underrepresentation of ethnic minority groups in the plastic surgery community continues to be a challenging problem with many contributing factors. Our study shows that ethnic minorities continue to be underrepresented in plastic surgery conference abstracts, with no significant change over a 5-year period, except for those of South Asian descent, who demonstrated a decreasing trend in representation. Although East Asian representation revealed a narrower gap, this population demonstrated a plateau effect after 2015. First authors of African descent remained strikingly few across plastic surgery conferences, which is reflective of the active plastic surgery workforce.^2,18

Similar to the barriers noted against women, it is well documented that societal elements such as disparities in educational resource allocations or lack of mentorship may limit opportunities for ethnic minority populations, thus potentially detracting these populations from the pipeline into residency and faculty positions.^19–22 However, little is known about the drivers and barriers for ethnic minorities in the plastic surgery workforce. One assumption is that for groups with lower representation at plastic surgery conferences, there may be reduced involvement in research that may be attributed to a lack of mentorship and sponsorship, contributing to underrepresentation in plastic surgery residents/fellows and leadership.

Our analysis of national versus regional conference data revealed stark differences in representation across our demographic. The overall demographic consisted of male trainees of European descent; however, no differences were noted between men and women. Residents and fellows were more likely to speak at regional conferences, whereas postdoctoral scholars and attending physicians embodied a greater percentage of individuals presenting at national conferences. Interestingly, among non-U.S. first authors, a greater proportion presented at national conferences, thus potentially contributing to the diversity of first authors. By virtue of a relatively smaller program, regional conferences had less diversity across all ethnicities. These findings reveal an ethnic disparity among residents and fellows who represent a majority of first authors at these conferences. Regional conferences offer cross-institutional mentoring and research opportunities that contribute to sponsorship and, ultimately, an academic career.

Our study examines the plastic surgery research pipeline and reveals a need to measure and identify effective strategies to improve recruitment and retention of women and underrepresented ethnic minority groups. Currently, health disparities exist for ethnic minorities in plastic surgery, especially for those considering breast reconstruction.^23–25 The lack of cross-cultural education and underrepresentation of ethnic minorities in research contribute to this disparity, highlighting the need for greater ethnic diversity among plastic surgeons. Research has shown that gender and ethnic diversity can increase with greater mentorship and exposure in the field.^26–29 To sustain diversity in the plastic surgery workforce, residency directors should identify targets for encouraging matriculation into plastic surgery and promote the development of programs.^15,16,30,31

Limitations

We identify several limitations to our study. First, the AAMC-reported data include a list of general racial/ethnic groups that do not account for the more specific ethnicities seen in our study, thus limiting our analysis. The Asian racial/ethnic group has significant heterogeneity, with many (South Asians) in this group who qualify as underrepresented. Analysis was subjective for race and ethnicity, and attempts to identify AIAN individuals were difficult. In addition, data collection may have biased race/ethnicity results by excluding individuals with multiple racial/ethnic identities, such as Latinx. Ideally, a prospective survey study of all individuals that participated in research presentations at national and regional conferences would provide a true reflection of the demographics at a conference. Despite our limited approach through publicly accessible parameters, we hope it offers some insight into the need for further diversity in plastic surgery.

Academic rank was obtained through public data at a time point in which the data collection was conducted. We recognize that the dates of data collection and the timeframe during which the conferences may have occurred may not truly reflect academic rank at that time point. Our study offers a snapshot of participation at plastic surgery conferences, and we hope that future studies will take a step further and conduct a demographic analysis over a longer timeframe to identify pitfalls. Another limitation is the lack of demographic data in plastic surgery that includes residents, fellows, and surgeons. The AAMC-reported data only included workforce demographics and failed to include medical students, residents, and research fellows in the cohort. A majority of regional conferences were included in the analysis for completeness; however, two regional conferences could not be included because of one society being in its infancy and the other being unavailable to respond.

CONCLUSIONS

Gender and ethnic diversity in plastic surgery research has the potential to drive innovation and academic excellence through cognitive diversity and societal relevance. As female representation has shown an uptrend in recent times, ethnic minority representation has remained low. Instituting foundational programs that encourage a contemporary discussion on representation among ethnic minorities in plastic surgery will have a resounding impact on surgical outcomes and approach.

DISCLOSURE

The authors have no financial disclosures to report.