It is widely recognized that the medical workforce in general lacks diversity, and while dermatology is making strides in terms of representation of women, other core specialties have low female representation and all core specialties have low representation of racial and ethnic minorities. Race demographics of US medical school applicants and matriculants fail to reflect the general population, with significant underrepresentation of racial and ethnic minorities.1 Analysis shows the underrepresentation of black and Hispanic individuals has increased in most specialties. In fact, underrepresentation is more significant now than in 1990 across all ranks and specialties analyzed, with one exception: black women in obstetrics and gynecology.2
Lack of diversity of race, ethnicity, and sex in the physician workforce has multiple concerning consequences. Underrepresentation of racial and ethnic backgrounds in the medical community means that the insights and rich experience of persons of color are not proportionately influencing the practice of medicine and contributing to the innovation and advancement needed to improve patient care. Additionally, there is evidence that patient care may suffer as a direct consequence of lack of diversity in the medical community. Finally, inequity in any setting is an injustice that warrants correction.
Consider the case from this year of a 25-year-old, black Milwaukee daycare worker with an enlarged heart, experiencing chest pain and shortness of breath, who was made to wait 2.5 hours in an emergency room. She waited so long to be seen that she died before being treated. Studies show that black patients wait an average of 69 minutes in emergency rooms nationwide, versus 53 minutes for white patients. This patient’s wait time was double that average, and she died.
Gender bias holds women back from being hired and advancing in their careers. Racial bias does the same and holds back various ethnicities from achieving their economic goals. Sheryl Sandberg of Lean In fame has an activity called “50 Ways to Fight Bias.” The digital versions are free. One can think through their own biases and call out others’ biases when they appear.
Dermatology has made strides in terms of representation of women in the specialty. In 2015, 47 percent of practicing dermatologists and 64 percent of trainees were women.3 However, the so-called “leaky pipeline” still affects academic leadership. Whereas 61 percent of instructors and 56 percent of assistant professors in dermatology were women in 2015, just 31 percent of full professors are women, and women comprise less than one-quarter of dermatology chairs.4
In plastic surgery, current data indicate that 31 percent of residents are women. The same data show just five residents in Ophthalmic Plastic and Reconstructive Surgery, of which one is a woman. Among practicing plastic surgeons, the ratio of female to male surgeons is approximately 1:5, and there was a 62 percent increase in the number of female plastic surgeons from 2000 to 2013.5
As in dermatology, there is evidence of a leaky pipeline in plastic surgery, with men more likely to be full professors. Women are also underrepresented as invited speakers at plastic surgery meetings.6
Results of an anonymous survey of members of the American Society of Plastic Surgeons revealed that women tended to feel their sex was a disadvantage in career advancement and were more likely than men to have experienced sexism or bias. The survey results revealed that women were less likely to be married; be satisfied with work-life balance; or feel recognized for ideas, authorship, promotions, or raises. Curiously, women respondents indicated that they believed some patients selected them as care givers because of their sex, whereas men did not report a similar sentiment.7
Many barriers to diversity are not intentional and are the result of unconscious bias.8 Both conscious and unconscious forms of racial bias in our society have resulted in less minority representation in the workplace in all fields, especially professional and science-oriented fields.
Among practicing dermatologists, data suggest that about three percent are black and 4.2 percent are Hispanic.9 A decade old report (no reliable source for updated data was identified) pegged the percentage of African American and Latino American plastic surgeons in practice at 3.6 percent and 5.7 percent, respectively. Caucasians comprised about 75 percent of academic plastic surgeons (and 82 percent of tenured full professors).10 Contributors to underrepresentation of people of color in medical school and medical practice include persistent overt racial discrimination and the lingering influence of institutional racism and implicit racial bias.
Racial and ethnic minorities are under-represented in the US work force in general. The Bureau of Labor Statistics (BLS) shows the unemployment rate for black men and women in 2017 was nearly double the rate for white men and women, at 7.5 and 3.8 percent, respectively. The disparity improved slightly in 2018, when the unemployment rate for whites was 3.5 percent, compared to 6.5 percent for blacks.
Data from the BLS show that whites and Asians have similar, relatively high levels of representation in management and professional careers while black and Hispanic individuals have notably lower levels of representation. Among white and Asian men, 17.4 percent and 16.9 percent, respectively, are in Management, business, and financial operations occupations, while among white and Asian women, representation is 14.7 and 15.4 percent, respectively. Among black men and Hispanic or Latino men, 9.7 percent, and 7.7 percent are in management, respectively, compared to 11.2 percent and 8.9 percent of black or Hispanic or Latino women, respectively.
For professional and related occupations, 17.6 and 27.6 percent of white men and women are in such roles, compared to 32.3 percent and 29 percent of Asian men and women, respectively. Contrast this to 13.8 and 22.9 percent of black men and women, respectively, in professional occupations, and 7.9 percent and 16.3 percent of Hispanic or Latino men and women, respectively.
Among professional occupations, medicine has a particularly low level of representation of racial and ethnic minorities. At Mt. Sinai Medical Center in New York City, I was only the second African American to train in the dermatology residency program. Data from the Association of American Medical Colleges (AAMC) show that blacks, who comprise approximately 13 percent of the US population, account for only four percent of physicians and less than seven percent of recent medical school graduates. This may be a direct consequence of the substantially lower acceptance rate for African American or black medical school applicants. The 2015 medical school acceptance rate was 41.1 percent overall. White (44 percent), Asian (42 percent), and Hispanic or Latino (42 percent) applicants had similar rates of acceptance in line with this benchmark. However, the acceptance rate for African American or black applicants was just 34 percent.
Percentages of medical school graduates by race and ethnicity have remained consistent, with whites (58.8 percent) and Asians (19.8 percent) representing the largest proportion of medical school graduates. Black or African American and Hispanic or Latino individuals account for just 5.7 percent and 4.6 percent of medical school graduates, respectively.
Once students are accepted into medical school, they may continue to face bias. Data suggest that student members of underrepresented minorities may be more likely to receive lower grades and assessments than their white counterparts.11,12 There is some evidence that membership in the prestigious Alpha Omega Alpha Medical honor society may be racially inequitable, as research shows that white medical students are twice as likely as Asian students and six-times as likely as black students, to be accepted.13
When medical students were asked about their interest in specialty practice, there were no significant differences among whites, blacks, Hispanics, Asians or other racial groups in trends toward family medicine, internal medicine, pediatrics, or other. However, slightly higher proportions of black (70.6 percent) and Hispanic (67.6 percent) students indicated interest in medical specialties, relative to white students (66.4 percent) (AACM).
Dermatology is arguably among the most competitive specialties today. However, it is not drawing significant residency applicants from underrepresented minority groups. Of 798 dermatology applicants for 2019/2020, 50 were black or African American (six percent of applicants to dermatology), 175 were Asian (22 percent), and 52 were Hispanic or Latino (6.5 percent of applicants); 63 (approximately eight percent) were of multiple race/ethnicity.
Among applicants to Integrated plastic surgery programs, about 37 percent were non-white: six (three percent) were black or African American, 49 (23 percent) were Asian, and seven (three percent) were Hispanic or Latino; 19 (seven percent) were of multiple race/ethnicity. It’s unclear in the 2019/2020 data report which applicants to surgical residency intend to specialize in plastic surgery, but among all surgical applicants, roughly half were white. The next largest proportion of patients was Asian, at approximately 21 percent. Black or African American, Hispanic or Latino, and multiple race/ethnicity applicants accounted for nine, eight, and six percent of applicants each, respectively.
One analysis found that while the proportion of Asian and Hispanic plastic surgery residents increased nearly three-fold and two-fold, respectively, from 1995 to 2014, African American plastic surgery residents did not increase significantly.14
Another analysis of academic plastic surgeons showed that nonwhite individuals were less likely than whites to be employed as full professors, however, adjusting for years of postresidency experience reduced the disparity below statistical significance. Importantly, nonwhite chairs employed significantly more nonwhite faculty.15
Implications for Patient Care
There are multiple potential benefits to a more diverse physician workforce, not the least of which is the potential for increased sensitivity and a reduction in bias. While it seems inconceivable in this century, news reports surfaced in 2017 of a Tennessee physician who addressed an African-American female patient as “Aunt Jemima.”16 The doctor apparently admitted using the name and says it was a misspoken blunder; the patient contends he never even apologized to her. As underrepresented minorities gain a place at the table, incidents such as these may hopefully stop.
Increased diversity amplifies the potential to achieve patient/physician concordance. It should be noted that research on the impact of racial concordance between patients and physicians is inconclusive. Widely differing methodologies and endpoints in studies make it difficult to compare findings. However, the trends in the data suggest that there is a benefit. When provided with a choice, patients are more likely to have a physician of the same race/ethnicity as themselves.17
Researchers have identified that perceived personal similarity is associated with higher ratings of trust, satisfaction, and intention to adhere to a care plan. (Race concordance is the primary but not sole predictor of perceived similarity; physicians’ use of patient-centered communication is another key factor.)18
Research published last year found that Hispanic, African-American, and Asian patients were more likely to seek preventive care and that Hispanic and Asian patients are more likely to seek care for a new-onset concern or to continue undergoing care for a diagnosed concern when they share the race/ethnicity of their physician.19 Earlier studies also showed that, compared to patients whose regular doctors are of a different race, patients who are of the same racial or ethnic group as their physicians were found to be more likely to use needed health services; were less likely to postpone or delay seeking care; and reported higher volume use of health services, compared to patients with doctors of a different race. This is especially true among white and African American patients.20 Patient-provider gender concordance positively affected cancer screening overall, but patient-provider ethnic concordance was inversely associated with cancer screening among Hispanics.21
Racial concordance could positively influence patient/physician communication. Research shows that black patients consistently experienced poorer communication quality and information-giving and had less participation and contribution to decision-making than white patients, overall. Racial concordance, however, was associated with better communication across multiple domains.22
Gender and race concordance between doctors and patients is associated with reduced mortality in the hospital setting. It is interesting to note that patients in an unmatched sample who were treated by female physicians were more likely to survive, regardless of patient gender; female patients treated by male physicians were least likely to survive a given episode of in-hospital care.23
Despite some increase in the proportion of persons of color studying and practicing medicine, the number of black men in medical schools has actually decreased over the last two decades. This represents an, “American crisis that threatens efforts to effectively address health disparities and excellence in clinical care,” according to Smith, et al.24 The crisis extends to include lack of representation of males and females of all underrepresented minorities. Clearly, change is necessary to increase diversity in the US physician workforce in general and in core aesthetic specialties, specifically. There is evidence that positive change is possible through several key steps.
Acknowledgement. The notable mismatch between the racial/ethnic make-up of the US population overall and the medical student/physician workforce is a clear indication of need for change. The factors contributing to underrepresentation are numerous and complex, and the consequences of a lack of diversity are substantial. These factors must be addressed and cannot be ignored.
It must also be noted—though beyond the scope of this conversation—that there is also a lack of diversity in medical research, including in skin of color, that also must be addressed. Hopefully, increased diversity in medical practice will lead to increased diversity in medical research.
We need to each take the implicit bias test found at Skinclusion.com. Obagi has an initiative to encourage pharmaceutical companies to hire and promote members of minorities to decision-making positions within their companies, to do clinical research on all skin types, to advertise with the full spectrum of skin colors, and to have implicit bias courses at each medical school and education on how to avoid implicit bias in residencies. (See more on the program in the sidebar.)
Mentorship. The AMA recently identified increasing workforce diversity as a key goal and continues to support its Accelerating Change in Medical Education Consortium. In announcing its commitment to increased diversity, AMA cited the work of consortium member Morehouse College of Medicine, which has established an extensive pipeline of programs with local colleges to provide mentoring support from current students and alumni. Programs designed to mentor and cultivate interest in medicine among underrepresented minority students as early as high school have shown promise.25 Researchers have concluded that pipeline programs for medical schools are necessary to maintain a diverse applicant pool.26
Holistic Review. Vick, et al. explore the potentially positive impact of “holistic review” on improved representation of minority groups in medical education, calling it “a flexible, individualized way of assessing an applicant’s capabilities by which balanced consideration is made on how the individual might contribute value as a medical student and physician.”15
The sad reality is that members of underrepresented minorities in the US may disproportionately lack the educational opportunities, the support and mentorship, and the opportunities for advancement that non-minority students do. This may reflect in traditional measures of success and achievement that lead to the exclusion of these students from advanced education.
Realistic Expectations. Finally, as medical schools and medical specialties focus on outreach and mentorship and increasing diversity, care must be taken not to misrepresent the goals of a more inclusive physician force. Patient/physician racial concordance can have benefits, and the inclusion of more persons of color in the delivery of medical care should ultimately improve the care of patients overall. However, this is not to say that members of underrepresented minorities should face “deterministic expectations” to provide care to minority populations.27
These are just a few broad steps that may be taken to help steer the medical community in the right direction. On an individual level, each of us as core aesthetic specialists can participate in mentorship and activism to increase interest in dermatology, plastic surgery, facial plastic surgery, and oculoplastic surgery as medical specialties for black and Hispanic medical students and to improve the experiences of patients of color.
This article is updated from an article Dr. Downie wrote for the July 2019 issue of Practical Dermatology®, available at PracticalDermatology.com.
1. Smith MM, Rose SH, Schroeder DR, Long TR. Diversity of United States medical students by region compared to US census data. Adv Med Educ Pract. 2015 May 15;6:367-72.
2. Kelly-Blake K, Garrison NA, Fletcher FE, Ajegba B, Smith N, Brafford M, Bogdan-Lovis E. Rationales for expanding minority physician representation in the workforce: a scoping review. Med Educ. 2018 Jun 22.
3. Bae G, Qiu M, Reese E, Nambudiri V, Huang S. Changes in Sex and Ethnic Diversity in Dermatology Residents Over Multiple Decades. JAMA dermatology 2016; 152(1): 92-4.
4. AAMC. The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership, 2015-2016. 2015. https://www.aamc.org/members/gwims/statistics/ (accessed 10/25/18.
5. Siotos C, Payne RM, Stone JP, Cui D, Siotou K, Broderick KP, Rosson GD, Cooney CM. Evolution of Workforce Diversity in Surgery. J Surg Educ. 2019 Jul - Aug;76(4):1015-1021.
6. Santosa KB, Larson EL, Vannucci B, Lapidus JB, Gast KM, Sears ED, Waljee JF, Suiter AM, Sarli CC, Mackinnon SE, Snyder-Warwick AK. Gender Imbalance at Academic Plastic Surgery Meetings. Plast Reconstr Surg. 2019 Jun;143(6):1798-1806.
7. Furnas HJ, Garza RM, Li AY, Johnson DJ, Bajaj AK, Kalliainen LK, Weston JS, Song DH, Chung KC, Rohrich RJ. Gender Differences in the Professional and Personal Lives of Plastic Surgeons. Plast Reconstr Surg. 2018 Jul;142(1):252-264.
8. Hoffman, DA. Colliding Worlds of Dispute Resolution: Towards a Unified Field Theory if ADR. Journal of Dispute Resolution 2008 (1):12-43.
9. Pandya AG, Alexis AF, Berger TG, Wintroub BU. Increasing racial and ethnic diversity in dermatology: A call to action. J Am Acad Dermatol. 2016 Mar;74(3):584-7.
10. Butler PD, Britt LD, Longaker MT. Ethnic diversity remains scarce in academic plastic and reconstructive surgery. Plast Reconstr Surg. 2009 May;123(5):1618-27.
11. Low D, Pollack SW, Liao ZC, Maestas R, Kirven LE, Eacker AM, Morales LS. Racial/Ethnic Disparities in Clinical Grading in Medical School. Teach Learn Med. 2019 Apr 29:1-10.
12. Teherani A, Hauer KE, Fernandez A, King TE Jr, Lucey C. How Small Differences in Assessed Clinical Performance Amplify to Large Differences in Grades and Awards: A Cascade With Serious Consequences for Students Underrepresented in Medicine. Acad Med. 2018 Sep;93(9):1286-1292.
13. Boatright D, Ross D, O’Connor P, Moore E, Nunez-Smith M. Racial Disparities in Medical Student Membership in the Alpha Omega Alpha Honor Society. JAMA Intern Med. 2017 May 1;177(5):659-665.
14. Silvestre J, Serletti JM, Chang B. Racial and Ethnic Diversity of U.S. Plastic Surgery Trainees. J Surg Educ. 2017 Jan - Feb;74(1):117-123.
15. Smith BT, Egro FM, Murphy CP, Stavros AG, Nguyen VT. An Evaluation of Race Disparities in Academic Plastic Surgery. Plast Reconstr Surg. 2020 Jan;145(1):268-277.
16. Accessed: https://www.nydailynews.com/news/national/tenn-doctor-refers-black-patient-aunt-jemima-visit-article-1.3329049
17. Traylor AH, Schmittdiel JA, Uratsu CS, Mangione CM, Subramanian U. The predictors of patient-physician race and ethnic concordance: a medical facility fixed-effects approach. Health Serv Res. 2010 Jun;45(3):792-805.
18. Street RL Jr, O’Malley KJ, Cooper LA, Haidet P. Understanding concordance in patient-physician relationships: personal and ethnic dimensions of shared identity. Ann Fam Med. 2008 May-Jun;6(3):198-205.
19. Ma A, Sanchez A, Ma M. The Impact of Patient-Provider Race/Ethnicity
Concordance on Provider Visits: Updated Evidence from the Medical Expenditure Panel Survey. J Racial Ethn Health Disparities. 2019 Oct;6(5):1011-1020.
20. LaVeist TA, Nuru-Jeter A, Jones KE. The association of doctor-patient race concordance with health services utilization. J Public Health Policy. 2003;24(3-4):312-23.
21. Malhotra J, Rotter D, Tsui J, Llanos AAM, Balasubramanian BA, Demissie K. Impact of Patient-Provider Race, Ethnicity, and Gender Concordance on Cancer Screening: Findings from Medical Expenditure Panel Survey. Cancer Epidemiol Biomarkers Prev. 2017 Dec;26(12):1804-1811.
22. Shen MJ, Peterson EB, Costas-Muñiz R, Hernandez MH, Jewell ST, Matsoukas K, Bylund CL. The Effects of Race and Racial Concordance on Patient-Physician Communication: A Systematic Review of the Literature. J Racial Ethn Health Disparities. 2018 Feb;5(1):117-140.
23. Greenwood BN, Carnahan S, Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci U S A. 2018 Aug 21;115(34):8569-8574.
24. Laurencin CT, Murray M. An American Crisis: the Lack of Black Men in Medicine. J Racial Ethn Health Disparities. 2017 Jun;4(3):317-321.
25. Derck J, Zahn K, Finks JF, Mand S, Sandhu G. Doctors of tomorrow: An innovative curriculum connecting underrepresented minority high school students to medical school. Educ Health (Abingdon). 2016 Sep-Dec;29(3):259-265.
26. Vick AD, Baugh A, Lambert J, Vanderbilt AA, Ingram E, Garcia R, Baugh RF. Levers of change: a review of contemporary interventions to enhance diversity in medical schools in the USA. Adv Med Educ Pract. 2018 Jan 19;9:53-61.
27. Kelly-Blake K, Garrison NA, Fletcher FE, Ajegba B, Smith N, Brafford M, Bogdan-Lovis E. Rationales for expanding minority physician representation in the workforce: a scoping review. Med Educ. 2018 Jun 22.