Diversity of Leadership and Its Influence on Diversity of Integrated Plastic Surgery Residency Cohorts: A Study in the Virtual Era

The lack of diversity in plastic and reconstructive surgery has been a recognized concern.¹ Although there have been successful efforts in promoting and maintaining diverse and inclusive programs, the proportions of residents who are underrepresented in medicine (UIM) lag behind those in other medical specialties.^2,3 UIM refers to racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.¹ Many points in the pipeline have been identified as points of attrition for plastic surgeons who are UIM. One important point of attrition is from medical school to residency.⁴ Residency programs have begun to shift their diversity, equity, and inclusion (DEI) efforts to include recruitment and retention of underrepresented minority applicants.

In the aftermath of COVID-19, the residency application and resident selection process has largely remained in the virtual space, introducing a new challenge to prospective integrated plastic surgery residents. Many programs enhanced their online presence to address this challenge, but both programs and applicants are still missing the in-person element in determining “fit.”^5-7 Although there are many program-level factors that influence fit, one that is essential to applicants that will further be discussed in this article is the ability to racially, ethnically, and/or culturally identify with a program.⁸

Previous studies have identified and quantified racial and ethnic diversity in plastic surgery programs as well as other fields of medicine.^2,4,9 However, none have studied the effects of leadership race on that of the resident cohort. The aims of this study are to better understand the online information that residency programs are making available to prospective applicants, characterize the racial diversity of programs, and investigate the effect of program leadership on racial diversity.

Study Design and Data Collection

A cross-sectional study of the racial makeup of US integrated plastic surgery residency programs was performed in August 2022. Residency programs were identified using American Council of Academic Plastic Surgeons lists. Data were collected using means that would be readily available to a prospective applicant. Program websites were used to collect names and photographs of program directors and residents and compared against Association of American Medical Colleges (AAMC) demographic data. Individual program websites were utilized, as the AAMC and Accreditation Council for Graduate Medical Education (ACGME) do not publicly release individual program data. If photographs were not available on the website, the official program Instagram page was used. In special cases where photographs could not be easily identified on Instagram, websites that display physician profiles (Doximity and ResearchGate) were used to populate data tables. If data subsequently remained incomplete, they were excluded from analysis. No data were collected on patients, and all data used were publicly available; no Institutional Review Board approval was required. This study conforms to all Helsinki guidelines.

Photogrammetric Analysis

While recognizing that race is a social construct rather than a biological certitude, two authors (DB and HD) independently used publicly available data to visually analyze each image. The Fitzpatrick scale was used as a guide with input from visually observable phenotypes, including hair texture and color, eye color, and facial features, using previously described methods.^10-13 Each image was categorized as “White” or “non-White”. Additionally, 5 race categories were used: East Asian, Black/African American, Central Asian, Hispanic, and Caucasian. Of note, the Asian cohort was separated into Central Asian/Indian and East Asian. A third author (OO) blindly and independently evaluated any discrepancies. Data tables were compared to publicly available self-reported race and ethnicity data from the AAMC (Table 1).¹⁴

Statistical Analysis

All responses from authors were blinded and pooled for analysis using Cohen’s kappa (κ) coefficient. The Landis and Koch cutoffs were utilized for correlation reliability, where κ <0.20 was interpreted as slight agreement, 0.21 to 0.40 was fair agreement, 0.41 to 0.60 was moderate agreement, 0.61 to 0.80 was substantial agreement, and κ > 0.80 was interpreted as almost perfect agreement.¹⁵ Proportional data using the race categories as above were evaluated for each residency program. Fisher’s exact test was used to compare categorical data among programs. For all statistical analyses, significance allowed for a type I error of α = 0.05. All data analysis was performed in SPSS v24.0 (IBM Corp).

A total of 87 integrated plastic surgery residency programs were identified from the AAMC website. Five programs were excluded due to inactive status or incomplete data. A total of 1174 residents were evaluated across the 82 included programs. Interrater reliability was determined with κ = 0.97 (P < .001), indicating almost perfect agreement. The racial composition of programs is displayed in Table 1 alongside self-reported race/ethnicity data from the 2021 AAMC report. Of note, self-reported percentages added up to over 100%, allowing for selection of more than 1 race/ethnicity. Black/African American (3.4%) and Hispanic (4.2%) represented the smallest proportions of residents.

Program directors were evaluated for each of the 82 included residency programs. Table 2 displays the program director race in comparison to the race of corresponding residents by percentage. Though not statistically significant, more residents of a given race were enrolled in programs with a program director of the same race. The highest proportions of residents in each group studied correlated to a program director of the same race/ethnicity. Of the programs with a white program director, 69.6% of the residents were white, higher than in program with program directors of any other race. This pattern followed for all of the groups studied. In programs with a Hispanic program director, 14.8% of residents were Hispanic. For Central Asian program directors, 24.6% of residents were Central Asian; for Asian program directors, 25.1% of residents were Asian. For black/African American program directors, 13.9% of residents were black/African American.

Interestingly, White (49.3%) and Black/African American (2.7%) residents were the least represented in programs with a Central Asian program director. Hispanic residents were the least represented in programs with an Asian program director, at 0.7%. Central Asian residents were least represented in programs with a Black program director at 6.9%, and Asian residents were least represented in programs with a Hispanic program director, at 11.1%.

This study provides a cross-sectional view of racial diversity in integrated plastic surgery programs in relation to race of program directors. Owing to the ample literature emphasizing the importance of diverse mentors in the recruitment and retention of diverse surgeons,^16-18 the authors hypothesized that having a program director of a given race would correlate to higher proportions of residents of that race.

Although statistically insignificant, it is still interesting to note the positive association between program director race and proportion of the same race in residency cohort. This association is logical and can be discussed from both the perspective of the applicant and that of the program director. A previous study using similar methods showed a similar positive correlation between gender of program directors and gender makeup of the residency cohort.¹⁹ Studies showed that Black medical students cite having to work in a predominantly White environment as a reason to not go into surgery.⁸ “Aversive racism,” defined as a subtle but persistent avoidance of interaction based on race/ethnicity; microaggressions, defined as everyday exchanges that intentionally or unintentionally send denigrating messages; and discrimination all contribute to concerns of not fitting in the workplace.²⁰ Further, applicants from ethnicities that are UIM consider degree of inclusivity, support of UIM physicians, and a general sense of “being wanted” to be very important factors when selecting programs.²¹ Prospective applicants may perceive a program as more inviting when their race matches that of the director. Conversely, the ability of program leadership to racially and/or ethnically identify with a prospective applicant may influence resident selection.

In the aftermath of the COVID-19 pandemic, the AAMC has dictated virtual interviewing guidelines for all residency programs.²² Applicants are advised to seek out information on residency culture and mission of programs before the interview.^20,21 For programs, it is important to be as transparent as possible, allowing applicants to make fair assessments of their potential fit.^6,7 Plastic surgery residency programs have increased their website and social media presence to meet this need.⁵ The present study found that the majority of programs (82 of 87) had complete information on program directors and resident cohorts.

Improving racial and ethnic diversity in residency programs is beneficial for hospitals, patients, residents, and faculty. Although the health care disparities in the US are multifactorial, one major contributing factor is discordance in the doctor-patient relationship.^23,24 In plastic surgery, racial disparities exist across the subspecialties and can have a negative influence on patients establishing plastic surgical care.^3,24 Physicians from backgrounds that are UIM are more likely to provide care for patients from similar backgrounds and patients in low socioeconomic settings.^25,26 Relatedly, patients from traditionally UIM backgrounds are more likely to seek care from UIM physicians.^12,23-27 Studies repeatedly show that patients who are cared for by a more diverse medical team have better outcomes. For residents, a sense of belonging was found to be protective against attrition amongst surgical trainees.²⁸ In addition to the loss of qualified and competent surgeons, attrition can cause significant time and effort as programs search for replacements.²⁹ Additionally, diversity of medical practices is associated with positive financial performance.³⁰ The University of Pennsylvania plastic and reconstructive residency program describes a successful approach for recognizing lack of diversity within trainees and faculty and has implemented strategies to increase diversity in their cohort.³¹ Future studies should aim to implement diversity, equity, and inclusion (DEI) interventions targeted toward recruitment and retention of both residents and faculty. Furthermore, studies may benefit from evaluating trends of diversity in residency programs and leadership.

There are several limitations in this study. The use of skin tone and other phenotypic attributes to classify race has been previously studied and validated.^10-12 However, a person’s race does not always correlate to their ethnicity. Race includes phenotypic characteristics, while ethnicity encompasses social factors, such as language, culture, and ancestry, and may not always include phenotypic traits.¹² For instance, the AAMC combines East Asian and Central Asian/Indian in their demographic reporting. However, for the purpose of understanding how residents identify with their respective racial group, the authors thought it helpful to maintain this distinction, as these cohorts are visibly distinct races. Although self-reported race would be the most accurate depiction of the demographic makeup, this feature of applicant data is not publicly available at the program level. Self-reported racial demographics for all plastic surgery residents are aggregated by the AAMC, and these data were compared with the present implementation of the Fitzpatrick scale. The authors thought this important because applicants themselves are not privy to the self-reported racial identification at the program level, and their overall impression of a program’s demographic makeup is often based solely on a picture and name. Furthermore, data were obtained from program websites and social media, with the potential to be outdated or inaccurate. However, the authors expect most programs to maintain accurate and up-to-date information with the increasing use of virtual platforms for applicants and patients. In addition, the authors thought it valuable to design this study based on the vantage point of potential applicants and what is available to them, as determining potential program fit may depend on the quality of publicly available promotional and informational materials.

Residents of a certain racial/ethnic makeup are more often in programs with a program director of the same race/ethnicity. Awareness of racial and ethnic disparities in plastic surgery residencies and implementation of interventions to increase recruitment and retention would help to minimize these disparities. Increasing diversity in academic plastic surgery and graduate medical education will result in a more equitable and innovative field.