Keywords

Introduction

A culturally diverse work force is important in addressing health disparities [1,2,3,4,5]. Yet underrepresented minority in medicine physicians (URMM) remain relatively scarce in the health care work force. In fact, African-, Hispanic-, and Native-Americans in particular are underrepresented in surgery—especially academic surgery. This disparity is due to multifactorial reasons and the main reason is a dearth of URMM candidates in the pipeline. In other words, the gap between the proportion of the U.S. minority population and the percentage of these students graduating from U.S. medical schools continues to widen. As a consequence, URMM surgical leaders, who have made it through the gauntlet of the complex climb from pre-medical training to the politics of faculty life in academic health centers, face responsibilities as URMM surgical leaders that their counterparts may not encounter. For instance, they not only must establish their legitimacy as academic superstars and earn the respect and esteem of the broader surgical community, but also serve as URMM role models, advocates, mentors and sponsors for surgical trainees and faculty, and finally, as social activists for reducing or eliminating health disparities. In this chapter, these themes are explored in the context of academic surgery, and we will present the approach to overcoming some of these barriers by illustrating the work of pioneering URMM surgical leaders.

Barriers to Attaining a Position of Leadership in Academic Surgery

Health disparities between the minority populations and European-Americans remain a vexing problem in contemporary American society. Minorities have shorter life expectancies and suffer a disproportionately higher rate of cardiovascular disease, cancer, birth defects, asthma, diabetes, stroke, sexually transmitted diseases and mental illness than whites [1, 2]. The etiology of such disparities is multifactorial with historical implications and includes, but is not limited to, inequalities in income and education, biological differences among ethnic groups, cultural dissonance, access to and quality of health care, as well as racial and ethnic discrimination. In fact, the Institute of Medicine argues that racial or ethnic prejudice on the part of health care providers underlies disparities in health care for URMM even when they have adequate or equal access [1]. Thus, a culturally diverse work force is important for addressing health disparities. Given the fact that physicians from URMM are more likely to practice in underserved areas following completion of their training, regardless of their chosen subspecialty, this argument provides greater impetus to train more URMM physicians in an effort to mitigate the effects of racial and ethnic discrimination [4]. Yet URMM physicians remain markedly underrepresented in the medical work force, and there are small numbers of African-, Hispanic-, and Native-Americans in academic surgery.

To understand the dearth of African-, Hispanic-, and Native-Americans in academic surgery, one needs to consider the decrease in candidates along the academic pipeline. Although African-, Hispanic-, and Native-Americans comprised 33% of the United States population in 2017 combined, they accounted for only 12% of U.S. medical students that same year [6, 7] (Table 18.1). In 2017, these URMMs accounted for less than 13% of surgical residents in the U.S. [9]. Among U.S. surgical faculty, URMMs accounted for only 6% and roughly 3% of the tenured surgical faculty [8]. Thus, given the small pool of surgical residents, it is understandable that there are a disproportionately lower number of URMM physicians on the surgical faculty at most institutions, and consequently in leadership positions in academic surgery.

Table 18.1 Profile of U.S. population and medical school matriculants
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In spite of increasing numbers of medical students graduating from U.S. medical schools over the past 5 years, there remains a disparity between URMM medical school graduates and the relative population proportion in the U.S. For instance, in 2013, African-, Hispanic-, and Native-Americans accounted for 10% of U.S. medical school graduates and 31% of the U.S. population [3, 10]. By 2018, there was a net increase of 1099 medical school graduates during that 5-year period. European-American students accounted for 5%, Asian-Americans for 37%, while African-, Hispanic-, and Native-Americans accounted for 7%, 10%, and 0.6% of the net increase respectively. Overall, URMMs accounted for 11% of U.S. medical school graduates in 2018 while representing 33% of the U.S. population [11]. Thus, despite the overall increase in the number of medical school graduates, the gap between the proportion of the U.S. population of URMMs and the populations graduating from U.S. medical schools persists. This trend is particularly concerning since Hispanic-Americans and African-Americans will grow to nearly 35% of the U.S. population by the year 2030. Beyond that, by the year 2020, African-Americans and Hispanic-Americans will account for over 37% of the college age population (18 year-olds), which represents the future pool of U.S. physicians [12]. Failure to understand and reverse this alarming trend could result in increasing health care disparities.

The foregoing paragraphs suggest that one of the key barriers to having more URMM surgeons assuming leadership positions in academic surgery is the relatively small pool of candidates in the pipeline. For those URMM students who aspire to pursue a surgical career after graduating from medical school, they face challenges during surgical residency and as junior faculty that may impede their professional development and subsequent advancement up the academic ladder (Fig. 18.1). Challenges include lack of URMM role models and mentors, insufficient counseling, minimal financial support and research infrastructure [5, 12,13,14]. Many of these barriers are not specific to URMMs but they can be amplified if the URMM lacks the social capital to overcome these barriers at a particular institution.

Fig. 18.1
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Barriers that impede professional advancement of potential URMM leaders along the academic ladder and potential remedies

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Trailblazers in Overcoming These Barriers

Trailblazers such as Charles Drew and Samuel L. Kountz, and more recently, LaSalle Leffall, Claude Organ, and L.D. Britt, to name a few, have been able to overcome all sorts of barriers to reach the apogee of American Surgery. These giants of American surgery, who happen to be from an URMM, share one common thread: they personified excellence. According to an anonymous writer, excellence is the “the result of caring more than others think is wise, risking more than others think is safe, dreaming more than others think is practical, and expecting more than others think is possible.” Indeed, these pioneers exemplified the notion that excellence will silence all critics. Undoubtedly, they would be inducted into the “Hall of Fame of American Surgery” if such an entity existed. The following paragraphs will highlight some of the phenomenal URMMs in American surgery and serve as examples of outstanding results that are possible against all odds.

Daniel Hale Williams served as Vice President of the National Medical Association and was the only African-American charter member of the American College of Surgeons. Credited with performing the first successful open heart surgery after carefully asserting no other surgeon completed such feat in 1893, Williams also established a lasting legacy by founding the first non-segregated hospital in the U.S.: Chicago’s Provident Hospital [15]. During his service as Chief of Surgery at Freedmen’s Hospital, he welcomed the community to come scrutinize, criticize, and attempt find flaw in the technique of African-American surgeons in order to demonstrate the capabilities of their skill [16].

Having served at Howard University/Freedman’s Hospital as faculty to improve the education of African-American surgeons, Charles R. Drew epitomized excellence. His brilliant work while a research fellow and surgery resident at Columbia University Presbyterian Hospital helped to elucidate the causative factors in the pathogenesis of shock. In conjunction with John Scudder, he studied the efficacy of blood plasma in the treatment of secondary shock. It is widely held that his doctoral thesis on “Banked Blood” not only provided the basis for separating the components of whole blood, such as plasma from the red cells, but also may have led to the establishment of the modern blood bank [17]. As such, he was appointed Director of the first American Red Cross Blood Bank at Presbyterian Hospital. Not only does Charles Drew’s legacy include his innovations in blood banking, it also encompases the training and mentorship of such surgeons as Asa Yancey, LaSalle Leffall, William Sinkler, and many more.

Asa Yancey Jr. was the eighth resident at Freedman’s Hospital, training under Charles Drew [18]. Asa Yancey’s excellence in surgery would later translate to an important advancement in the management of Hirschsprung’s Disease. He first reported on the modification of the Swenson technique in the Journal of the National Medical Association in 1952 [19]. Despite his publication, Soave is credited with the modification [18].

Similarly, Samuel L. Kountz distinguished himself as a superb academic surgeon. His seminal work on the “Mechanism of Rejection of Homotransplanted Kidneys” was published in Nature in 1963 [17]. In addition to serving as Chair of the Department of Surgery at the State University of New York at Downstate, he held numerous leadership positions in prestigious academic surgical societies, ultimately culminating with his ascendancy to the Presidency of the Society of University Surgeons in 1975. Samuel L. Kountz later erected the Center for Human Values at UCSF to discuss ethical issues about transplants with an overall goal to improve the care of African-Americans in urban areas [20].

Dorothy Lavinia Brown is said to have declared, “Dr. Matthew Walker was a brave man” of Matthew Walker who accepted her into Meharry’s surgical residency [21]. She was the first African-American woman to become a Fellow of the ACS, and the first African-American woman senate in the state of Tennessee in 1966. Women’s health care and livelihood were her passion, and she believed that a bill regarding abortion rights would have the potential of saving many Tennessee women [21]. Unfortunately, the bill did not pass. Beyond the awards and buildings named after Dr. Brown, she was a role model in every meaning of the phrase [21].

The first URMM President of the American College of Surgeons was LaSalle D. Leffall, Jr. Dr. Leffall’s brilliance was evident as early as his high school years, when he was named valedictorian of his class at 15 years old [22]. He repeated this feat 7 years later at Howard University College of Medicine, graduating at the top of his class. This was followed by a fellowship in surgical oncology at Memorial Sloan Kettering Hospital during which he distinguished himself as one of the stellar fellows. Upon his return as an Assistant Professor of Surgery at Howard University, he quickly rose through the ranks to become Chair of the Department. In addition, as a distinguished surgical oncologist, he rose to become President of the American Cancer Society and the Society of Surgical Oncology, the first African-American to hold these positions, prior to his election as President of the American College of Surgeons in 1995. Finally, in 2002, he was named chairman of the President’s Cancer Panel.

Claude H. Organ, Jr. holds the distinction of being the first African-American to assume the Chairmanship of a Department of Surgery at a predominantly white medical school, his alma mater, Creighton University [23]. His tremendous work ethic, exceptional commitment to excellence, and unparalleled dedication to mentoring not only earned him the respect of his colleagues and students but also contributed to his success as an academic surgeon. Dr. Organ was the first African-American editor of the surgical journal with the largest distribution in the country, Archives of Surgery. His two-volume historical text on African-American surgeons remains an invaluable addition to his legacy [24]. In addition, he was a founding member of the Society of Black Academic Surgeons, an organization devoted to promoting mentoring and scholarship among surgical trainees and faculty from an URMM background. In 2003, Dr. Organ became the second African-American President of the American College of Surgeons.

L.D. Britt graduated from Harvard Medical School and Harvard School of Public Health on his way to becoming the first African-American Professor of Surgery in the Commonwealth of Virginia and chair of the department of surgery at Eastern Virginia Medical School [25]. During his tenure, he has received numerous accolades nationally and internationally, including the Robert J. Glaser Distinguished Educator Award, the highest teaching award or accolade in medicine given by the Association of American Medical Colleges [26]. He has served as President of numerous prestigious academic surgical societies including the Southern Surgical Society, the American Surgical Association, the American Association for the Surgery of Trauma, the Society of Black Academic Surgeons, and the American College of Surgeons.

In 1994, Lori Arviso Alvord became the first Navajo woman board certified in surgery. She bridges traditional Navajo healing and Western medicine to treat her patients. Her appointments in leadership have led her to serve as Associate Dean for Student Affairs at Dartmouth Medical School (1997–2009), and, more recently, associate dean for student affairs and admissions at the University of Arizona College of Medicine in Tucson (2012–present) [27]. Throughout her academic appointments, Lori Arviso Alvord emphasized elements of her Navajo culture into her practice. It is a long time coming for Native American representation.

Likewise, Alfredo Quiñones-Hinojosa is a neurosurgeon who crossed the U.S.-Mexico border for the purpose of a better life. He worked as a migrant worker, eventually leaving this job at the advice of his cousin [28]. Alfredo Quiñones-Hinojosa’s work ethic and excellence in performance certainly transcended the barrier of immigration in the U.S. Certainly, there is a national divide with the repeal of the Development, Relief, and Education for alien Minors Act (DREAM) Act and, more recently, President Barack Obama’s Deferred Action for Childhood Arrivals (DACA) program. And with the ongoing health disparity and URMM crises, this nation needs giants like Alfredo Quiñones-Hinojosa.

There are many other worthy URMM surgical leaders who have had to overcome significant barriers to ultimately play an influential role in American surgery. Suffice it to say, they all shared the same relentless passion for the pursuit of excellence. However, while one can argue that excellence is the essential scaffold for success, it is the quest for significance, or the desire to make the biggest difference possible in the lives of others and in their community, that propelled these trailblazers, legendary pioneers and role models to the heights of American surgery.

What Are the Challenges Facing Surgical Leader from an URMM?

“True leadership lies in guiding others to success. In ensuring that everyone is performing at their best, doing the work they are pledged to do and doing it well.”—Bill Owens

“The growth and development of people is the highest calling of leadership.”—Harvey Firestone

One of the challenging problems that impede the development of surgical leaders from an URMM is the vicious cycle fueled by a limited pipeline, lack of diversity in the surgical work force, paucity of role models, lack of mentorship, inadequate research infrastructure, counseling, and financial support, institutional barriers, and racial discrimination and/or implicit bias that result in isolation or “imposter syndrome” for both URMM surgical trainees and faculty (Fig. 18.1) [13, 29, 30]. In fact, a recent survey of faculty from 26 U.S. medical schools reported that compared to non-URMM faculty, URMM faculty feel like outsiders because of a lack of inclusion, trust, and relationship with their non-minority counterparts [13]. A similar survey of surgical residents confirmed these sentiments, indicating that these feelings begin to evolve during training [14]. In addition, according to Pololi and colleagues, a significant proportion of URMM faculty reported being subjected to racial or ethnic discrimination by a superior, and they also noted a lack of institutional effort to promote equity and diversity. Yet, despite these observations, URMM faculty was more likely to aspire to higher leadership positions than their non-URMM counterparts. However, as noted by the authors, the juxtaposition of high leadership aspirations with the perception of isolation, lack of trust and inclusion predisposes URMM faculty to become disillusioned and to abandon academic medicine completely or miss opportunities for promotion due to discrimination, thus further eroding the pool of future leaders.

Based on the foregoing discussion, URMM surgical leaders face a daunting task. A leader in academic surgery, who happens to be an URMM, has to first establish himself or herself as an academic surgeon. This designation is typically defined by unbiased metrics. In general, those metrics include promotion up the academic ladder, assumption of institutional leadership positions, and national recognition or acknowledgment of the URMM leader’s accomplishments by his or her selection for leadership positions by external bodies such as academic surgical societies, boards, national committees, NIH study sections, etc. As noted by Charles Drew, “excellence of performance will transcend artificial barriers created by man” [31]. In addition to establishing his or her credentials as a bona fide academic surgeon and earning the respect of his or her peers, the leader in academic surgery who is from an URMM is asked to fill in many roles including: mentor; coach; sponsor; and advocate for URMM surgical trainees and junior faculty by providing them access to growth opportunities (Fig. 18.2). Indeed, the URMM surgical leader has the unique responsibility or duty to serve as a role model for members of his or her underrepresented minority constituency, to help them grow, develop, and to guide them to success. In this context, the URMM mentor or leader must be able to attract, inspire, empower, and ultimately liberate the URMM surgical trainee or mentee to complete the maturation process, while at the same time continuing to advocate for his or her needs, albeit from a distance [12]. Thus, the URMM surgical leader must have a commitment to both mentorship and sponsorship (Fig. 18.3). In essence, URMM surgical leaders have to pay “the minority tax” [32]. The “minority tax” is a complex chain of responsibilities endowed upon minority populations. With this additional burden, URMMs must compete in academia against their colleagues who are not saddled with these requests. Unfortunately, these additional tasks are not always acknowledged as a burden to the URMM. Each additional task for the URMM leads to diminishing satisfaction, lack of promotion, and poor retention. In addition to the added tasks, unconscious bias in workplace, lack of diversity, suboptimal mentorship, institutional racism, professional isolation, and unrelenting clinical duties compound the pressures on the URMM faculty [32]. Ironically, the URMM is then tasked with improving institutional diversity in addition to the standard call of duty. Despite the institutional claims of valuing this diversity, there is often little application of this work as a marker for promotion. And because the URMM may care for the populations that are targets for health disparities more so than the non-URMM, a clinical burden often prevails and thus limiting the URMM from valuable academic or research time. Nevertheless, many URMMs feel the desire to amplify their impact beyond their academic contributions by using their platform to help the local community. They also subscribe to the credo that “EACH ONE REACH ONE” [33]. However, the URMM surgical leader also has a special responsibility to ensure that expanding opportunity for URMM surgical trainees or faculty should never be confused or equated with lowering the standards. There needs to be continued emphasis on the relentless pursuit of excellence and sustained scholarly productivity. URMM mentees have to be prepared to perform “better” than their non-URMM colleagues. URMM surgical leaders must serve as role models for all trainees and colleagues, including students, residents, faculty, deans, presidents and CEOs, to demonstrate that URMM surgeons have made and continue to make significant contributions to the field of surgery. In short, they must have broad appeal to influence the larger sector of society or the surgical community to follow them in expanding opportunities for competent or meritorious URMM surgical trainees and faculty, because, to paraphrase Peter Drucker, there is no leadership without “followership” [34].

Fig. 18.2
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Crucial functions in leadership development. The surgical trainee or future leader is responsible for developing his or her skill set. He or she must have an unwavering commitment to excellence and the desire to succeed. Mentors collaborate with surgical trainees or junior faculty (leaders in development) by coaching, training, supporting, and providing candid advice on choices and performance. Mentors also help develop and monitor the mentee’s personal strategic plan. Sponsors recognize talented surgical trainees (emerging future leaders) and provide them access to growth opportunities. Sponsors may also support long strategic maneuvers

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Fig. 18.3
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Obligations of an established underrepresented minority leader. URMM surgical leaders have an obligation to develop potential and promote leadership in talented URMM surgical trainees and junior faculty. They should identify promising surgical trainees and junior faculty and provide them access to differing levels of professional challenges and networks at the next level of influence. They also need to find promising talent and mentor them along the path to an emerging leader

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To illustrate the foregoing concept, consider how Charles Drew’s outstanding research at Columbia University catapulted him to a position of national and international prominence, which put him in position to advocate for a surgical oncology fellowship position for Jack White, the first African-American fellow at Memorial Sloan Kettering Hospital. In turn, Jack White’s advocacy later helped LaSalle Leffall obtain a surgical oncology fellowship at Memorial Sloan Kettering Hospital [22, 35]. Dr. Leffall has helped and inspired hundreds, if not thousands, of African-American and other URMM surgeons through his roles as President of the American Cancer Society, the Society of Surgical Oncology and the American College of Surgeons as well as his 25-year Chairmanship of the Department of Surgery at Howard University [36]. As noted earlier, numerous other African-American surgeons have held leadership positions in mainstream academic societies that invariably helped pave the way for the new generation of contemporary and future URMM surgical leaders. Sam Kountz’s brilliance and tenacity paved the way for his election to the Presidency of the Society of University Surgeons. Claude Organ served as Chair of the American Board of Surgery, Chair of the Residency Review Committee, President of the American College of Surgeons, President of the Society of Black Academic Surgeons, and Editor of Archives of Surgery. L.D. Britt is Past President of the American College of Surgeons, the American Surgical Association, the Southern Surgical Society, the American Association for the Surgery of Trauma, and the Society of Black Academic Surgeons. Haile Debas, another prominent URMM academic surgical leader, served as Dean of the University of California at San Francisco, President of the American Surgical Association, and President of the Society of Black Academic Surgeons. Steven Stain is former Chair of the American Board of Surgery and past president of the Society of Black Academic Surgeons. Henri R. Ford served as President of the Association for Academic Surgery, the Surgical Infection Society, and the Society of Black Academic Surgeons. Lastly, Fiemu Nwarieku is a past president of the Association for Academic Surgery. The significant increase in the number of African-American chairs of departments of surgery and deans of U.S. medical schools in recent years is arguably directly related to the contributions made by previous URMM surgical leaders who were the trailblazers in academic surgery.

The historical achievements of past surgical heroes impart important lessons for leaders confronting present struggles. Their memory is perpetuated in quotes, named lectures, named services, streets, buildings, institutions, etcetera. They privately and publicly worked to move systems in order to construct foundations for new opportunities. They include the late legacies who posthumously educate and mentor the academic surgeons who follow. Also, not forgotten are our current giants in leadership who are shaping the present. They engage in active, meaningful community service as an essential component in their portfolio. They exercise their influence to address, at a policy level, the problems or challenges that limit the pipeline of URMM students achieving the necessary proficiency in reading, math and science to enable them to ultimately be competitive for medical school. They combat racial and ethnic prejudice as well as other barriers that hinder upward social mobility, promote and champion diversity, and lobby for improved access to quality health care for underserved communities while serving as visible role models and as a source of inspiration for their underrepresented minority constituencies. Such grassroots advocacy is a sine qua non in order to ultimately reduce or eliminate health disparities. Hence, the responsibilities of URMM surgical leaders are profound.

In summary, the pathway to becoming a leader in academic surgery is challenging in general given the stressors of health care economics, clinical workload and burnout. For URMMs the addition of other social barriers such as discrimination, lack of mentorship, and financial burdens pose additional challenges to reaching the highest leadership positions in academic surgery. Contemporary URMM surgical leaders must also recognize that whatever stature they have achieved in American surgery is the result of the legacy of excellence and advocacy of past URMM trailblazers such as Drs. Drew, Kountz, Leffall, and Organ. Yet these individuals were invariably aided along their journey by non-URMM mentors and sponsors who recognized their brilliance and gave them an opportunity to shine. Although current URMM surgical leaders should accept to pay the “color tax” of role modeling, mentoring, sponsoring or enhancing opportunities for other URMM surgical trainees and faculty, their leadership should recognize this additional burden and make sure they do their part to support the success of these individuals and the community they are serving. Today, we are reminded that our predecessors faced far greater obstacles in climbing to success in spite of a paucity of role models, mentors and sponsors. They in some ways with far less resources and access to social media had to pay a much greater and more stressful tax in order for us to enjoy the privilege of reaching the highest echelon of American surgery. Indeed, these obstacles are apparent as the building blocks of adversity that define and, invariably, refine the minority leader in academic surgery.