Key words : Leadership, Transplant surgery, Underrepresented minority, Women in surgery

Introduction

There is growing resolve to correct the under­representation of women and racial minorities in medicine. Physicians from underrepresented minority (URM) backgrounds are more likely to treat racial minorities, as well as sicker, low-income, uninsured, and acute patients.^1,2 These individuals have reported increased levels of satisfaction when treated by a physician of their own race.³ Black and Hispanic faculty remain largely underrepresented in surgical training, practice, and leadership.⁴ In fact, the representation of Black and Hispanic physicians in most specialties has actually decreased between 1990 and 2016.⁵

The overwhelming majority (79%) of full professors in surgery are White.⁶ Black assistant professors have the lowest rate of promotion in surgery, and URM surgeons are less likely to remain in academia compared with other races.⁶ Similar trends are shown with women, who are less likely to attain and remain in senior academic positions.^7,8 This is especially problematic, as recent investigations have demonstrated the integral role of female faculty and mentors in recruiting women to surgical residency.^9,10

Women and URM face significant barriers to promotions in academia, such as disparate access to research funding and national visibility.¹¹ Holding leadership titles in national professional societies has been identified as a contributor to academic advancement. Yet women remain underrepresented in these positions; similar trends have not been evaluated for URM.¹² According to the most recent American Society of Transplant Surgeons (ASTS) survey, women comprise 13.1% of practicing transplant surgeons in the United States.¹³ One of the ASTS’ core values emphasizes fostering diversity of individuals in transplantation and its members.¹⁴ In fact, the organization has taken steps to ensure change and social progress through its “Boldly Against Racism” national campaign.

The representation of women and URM as leaders in ASTS has not been examined. We aimed to quantify the diversity in the ASTS governance. This investigation presents the current landscape of ASTS leadership as a baseline to compare future progress and developments.

Materials and Methods

We evaluated the diversity of ASTS leadership between 2019 and 2020. Members of the ASTS Council, the COVID-19 Strike Force, and 20 different ASTS committees were identified. The designated chair and co-chairs of each committee were noted directly from the ASTS website (ASTS.org). Advanced transplant provider committees and staff liaison from each committee were excluded. The pipeline advisory group and the pediatric and pipeline task forces were also not included in the analysis.

We gathered demographic information for individuals from institutional websites and other publicly available internet sources. Several authors collected details regarding member sex, ethnicity, professional credentials, training history, and academic appointments. These data were verified by multiple research team members with diverse backgrounds and experiences to ensure accuracy and to reduce bias. Similar approaches have been previously utilized for demographic analyses in the literature.^15,16 Chi-square analysis was performed, and statistics were calculated using a 5% significance interval. This study did not require institutional review board approval.

Results

Table 1 summarizes the demographics of the ASTS leadership.

American Society of Transplant Surgeons Council
The ASTS Council consisted of 15 members, including 12 men (80%) and 3 women (20%). Furthermore, 93.3% (n = 14) of the members were identified Non-Hispanic White (NHW), and 1 member (6.7%) was identified as Asian. There were no Hispanics or Blacks on the Council. Of those on the ASTS Council, 12 members (80%) completed their medical education in the United States, along with 1 (6.7%) in Canada. The remaining 2 members of the Council (13.3%) were international medical graduates (IMGs). All members were fellowship trained in transplant surgery. In addition, 10 members (66%) fulfilled some aspect of their postgraduate training, residency, or fellowship in the midwestern United States.

COVID-19 Strike Force
The COVID-19 Strike Force consisted of 12 individuals, composed of 10 men (83.3%) and 2 women (16.7%). The cohort was also primarily NHW (75%, n = 9), with 16.7% (n = 2) Black and 8.3%(n = 1) Asian. In terms of educational background, 11 members (91.7%) were US medical graduates and 1 (8.3%) was an IMG. All members except 1 were fellowship trained in transplant surgery.

American Society of Transplant Surgeons committees
Among the 20 ASTS committees included in the analysis, there were 198 individuals. Among total individuals, 151 were men (76.3%) and 47 were women (23.7%). We found that 136 members were NHW (68.7%), 33 were Asian (16.6%), 16 were Hispanic (8.1%), and 13 were Black (6.6%). With regard to education, 132 members were US medical graduates (68.4%), 54 were IMGs (28%), and 7 attended medical school in Canada (3.6%).

Next, a detailed investigation of diversity across the committees was performed. In the overall male membership (n = 151 men), 66% (n = 100) were NHW. This was followed by 19.2% (n = 29) Asian, 9.3% (n = 14) Hispanic, and 5.3% (n = 8) Black. Of
the 47 female members, most (74.5%, n = 35)
were NHW. Among the remaining women on the
ASTS committees, 10.6% (n = 5) were Asian, 4.3%
(n = 2) were Hispanic, and 10.6% (n = 5) were
Black. There were no statistically significant differences in the racial distribution in men versus women.

Medical education was also stratified by men versus women and compared. We found that 32%
(n = 48) of male committee members were IMGs, compared with 13.9% (n = 6) in the female subset. Of the IMG cohort (n = 54 individuals), there were significantly more men (89%) than women (13.9%)
(P = .020). Similarly, substantially more female committee members attended medical school in the United States (P = .038). These women represented 81.4% (n = 39) of the total 47 in the group. There were no significant differences in men versus women in medical education in Canada or fellowship training in addition to transplant surgery. These results are shown in Table 2.

Finally, the demographics of 41 chairs and co-chairs of the various ASTS committees were analyzed. Among the leaders, 32 were men (78%) and 9 were women (22%). Similar to the overall group, chairs and co-chairs were also primarily NHW (71%, n = 31), with remaining racial makeup of 15% (n = 6) Asian and 5% (n = 2) each Hispanic and Black. Of the 9 female chairs, 8 were NHW (89%). There was one Hispanic female leader in the group, and there were no Asian or Black women represented in leadership. There were 11 IMGs (27%) serving as ASTS committee chairs, 2 of whom were women.

Discussion

In this analysis of leadership diversity in the ASTS, we investigated the male versus female, racial, and educational makeup of the ASTS Council, the COVID-19 Strike Force, and 20 ASTS committees along with their chairs and co-chairs.

The ASTS Council consists of 15 members. These include the president, president-elect, secretary, treasurer, the immediate past president, and a previous president, as well as 9 councilors-at-large. The role of the Council is to carry out the duties as assigned by the Board of Directors, support fundraising efforts, manage organization finances, and provide oversight to the ASTS. They are among the foremost public facing figures in the organization. The COVID-19 Strike Force was organized to prioritize the health and safety of the transplant surgery community. They were tasked with relaying the current and specific information about COVID-19 as it pertains to transplantation in a coordinated manner. The ASTS committees are tasked with carrying out specific functions for the organization.

Councilors are elected by a simple majority of the voting members after a nomination process. The ASTS members can self-nominate or be nominated for committees and then be appointed by the current president for a 3-year term. Chairs and co-chairs are selected from current members of the committee by the president, with co-chairs typically succeeding as chairs in the subsequent term. These procedures introduce potential avenues for implicit bias in the nomination, election, and appointment processes.

Female versus male representation
We found that leadership positions in the organization were primarily held by men. They represented 80%, 83.3%, and 76.3% of the ASTS Council, Strike Force, and committee members, respectively. The chairs and co-chairs of the various committees were also 78% men. The disproportionate representation of men versus women persisted in racial subgroups. All the NHW members of the Council and COVID-19 Strike Force were men. Across the various committees, men accounted for 85.3% of all Asian, 87.5% of all Hispanic, and 61.5% of all Black members. The same comparison among the committee chairs paints an even bleaker picture, with only 1 woman present across all Asian, Hispanic, and Black leaders.

Assessing female leadership and representation in relation to the overall workforce is challenging. Historically, the ASTS has not documented member demographics. Previous appraisals of the transplant surgeon workforce have relied on survey responses. This approach has suffered from low response rates and nonresponder bias. Most recently, a 2019 survey by the ASTS membership and workforce committee reported that 13.1% of practicing US transplant surgeons were women and that 18.4% of new additions to the field since 2010 were women.¹³ This assessment featured a 30.2% response rate, consi­derably improved from the previous such survey in 2010, which only had a 22% response rate. It is important to note that this rate is similar to those reported from other specialties for workforce assessment.¹³

Female voices across all leadership groups considered in this study are present at a higher percentage than the reported 13% female membership within ASTS. Thus, despite the low numbers, women have embraced a larger leadership role within the organization. We discovered that women comprised 20% of the ASTS Council, 16.7% of the COVID-19 Strike Force, 23.7% of ASTS committee members, and 22% of ASTS committee chairs. Although unequal, female leadership is significantly greater than their membership in the transplant surgery workforce.

The low number of female transplant surgeons, which lags behind other surgical specialties, is a more pressing issue. A comparison of active female surgeons demonstrates that the American College of Surgeons has 19.2%, the American Academy of Otolaryngology-Head and Neck Surgery has 15.8%, and the American Society of Plastic Surgeons has 15% women. However, the number of women in transplant surgery remains superior to other fields like vascular surgery (11.3%), urology (8%), neurological surgery (7.8%), thoracic surgery (6%), and orthopedic surgery (5%).¹²

Recent data have indicated that 40.1% of general surgery residents and fellows are female, but new additions to the transplant workforce are limited to 18.4%.^13,17 Lifestyle considerations like high workload hours, nights on call per week, and high rates of burnout identified among transplant surgeons may limit interest in the field.^13,18 Despite these factors, practicing transplant surgeons have one of the highest levels of career satisfaction compared with other surgical subspecialties.¹⁹ The lack of female visibility and leadership is perhaps another reason that has limited the number of female general surgery residents pursuing transplant fellowships. Many have reported on the importance of female surgical faculty and role models in making career choices.^10,20 In fact, others found that encouragement by surgical mentors to pursue a surgical residency reduced the negative perception of a surgeon’s call schedules, time commitment, lifestyle, and length of residency.²¹

Representation by race
The racial background for the majority of ASTS leadership was NHW. This pattern was observed across all of the groups considered. The ASTS Council featured the highest NHW membership at 93.3%. All other leadership clusters included NHW participation of between 65% and 75%. A surprisingly high number of NHW members was also discovered among the female ASTS committee chairs and co-chairs at 89%.

The second most represented racial background in ASTS governance was Asian. This group still represented a relatively small minority. They comprised 6.7% of the ASTS Council, 8.3% of the Strike Force, 16.6% of the committees, and 15% of the committee chairs and co-chairs. There was little male versus female diversity among these members, as over 85% of them were men. Low rates of Hispanic and Black members were observed across all leadership panels. In fact, both groups were absent from the ASTS Council. The highest representation for either was on the COVID-19 Strike Force, which was 16.7% Black (n = 2) but devoid of any Hispanic members. The various committees included 8.1% Hispanic and 6.6% Black members. Meanwhile, the chairs were 5% Hispanic and 5% Black.

It is challenging to evaluate the participation of URM in ASTS governance compared with their overall membership. The most recent information on surgeon ethnicity is from the 2010 ASTS membership survey, which only had a 22% response rate. The 159 respondents, including 17 women, self-identified their ethnicity as 72% NHW, 17% Asian, 8% Hispanic, 2% Black, and 1% other races.²² This information was not collected in the subsequent 2019 survey. The limitations of the outdated and unrepresentative ethnicity data make it difficult to accurately understand racial diversity. With the use of the previous benchmarks, the representation of Asian and Hispanic members is on par with their membership. Meanwhile, Black transplant surgeons far exceed their proportional representation in ASTS governance. However, the shortcomings of comparison data cannot be overstated.

The more pressing concern is the low numbers of URMs in transplant surgery overall. Historic trends have demonstrated high attrition rates from URMs entering surgical subspecialties.²³ Underrepresented minority applicants, matriculants, and graduates remain substantially lower than all other ethnicities in general surgery programs.²³ Recent progress has improved female representation in surgical training to over 40%.¹⁷ Despite this, individuals from diverse racial backgrounds have not experienced similar benefits. In fact, the number of male and female URMs training as surgeons has remained unchanged between 2005 and 2018.²³ The concerning trend of lower proportional representation of Blacks and Hispanics in most specialties in 2016 compared with 1990 has also been shown.⁵ Some possible interventions to increase URM in surgery include creating a culturally diverse training environment and recruiting more URM faculty to serve as mentors and leaders within surgical departments.²³ The diversity of general surgery residency and several surgical fellowship program directors has been quantified.^9,24 However, similar analyses have not been conducted in transplant surgery, presenting an opportunity for future investigations to better understand the leadership in the field.

Training location
A review of the ASTS leaders’ training history revealed that the overwhelming majority completed their medical education in the United States. International medical graduates were defined as those who received their medical degree outside the United States and Canada. Their highest representation was as members of the various ASTS committees at 28% (n = 54). This was closely followed by IMG accounting for 27% (n = 11) of ASTS chairs and co-chairs. Meanwhile the ASTS Council and COVID-19 Strike Force had the lowest numbers at 13.3% and 8.3%, respectively.

An important discovery in the IMG group was that they were primarily men. All IMGs on the ASTS Council and Strike Force were men. The represen­tation on the committees and their chairs was slightly better. However, IMGs serving on committees were substantially more likely to be men (P = .020). We identified that female committee members were significantly more likely to be US medical graduates (P = .038). Women accounted for 13% (n = 7) of IMG on ASTS committees and 18% (n = 2) of IMG chairs and co-chairs.

All individuals in the analysis who had attained a medical or equivalent degree were fellowship trained except one. This was a European ex-officio member on the COVID-19 Strike Force team. Members of the committees who did not receive medical degrees or an equivalent degree were excluded from our analyses. All others on the ASTS Council and COVID-19 Strike Force were fellowship trained as abdominal transplant surgeons. Some members of the com­mittees who did not practice as general surgeons had completed other advanced fellowships within the specialty (ie, cardiothoracic transplantation, urologic malignancy, gynecology).

Limitations
There were some limitations to this study. First, data were collected during the previous ASTS Council term (between 2019 and 2020). There have been some changes to the 2020 to 2021 Council, which could skew the demographic data. However, to account for this discrepancy, we evaluated the new Council members and did not find significant changes in representation. The Council diversity was improved by the addition of 1 more female member for a total of 4 women. The racial representation also changed slightly with the influx of 2 Asian members for a total of 3 members. All others on the Council were NHW. There were no Hispanic or Black additions. This limitation did not impact the various ASTS committees as significantly because members serve 3-year terms. The chairs typically serve for 1 year but can remain in the same position for longer. The co-chairs often step up to the position of committee chair if the position is vacated, thus remaining involved in leadership positions. We omitted the ASTS Board of Directors from the governance evaluation. This was done because of the significant overlap of the same members between the ASTS Council and Board of Directors.

Another weakness was that our methodologies relied on publicly available information on member demographics, which may not be entirely accurate or up to date. Determinations of sex and race were made using member photographs along with first and last names. Although several publications have utilized similar methods to collect demographics, room for error remains.^15,16 Multiple investigators collected and verified the information to reduce bias. Next, we did not account for non-binary gender diversity and those from multiple racial backgrounds. Finally, the lack of accurate and complete data on ASTS membership makes it challenging to assess if the representation of women and URMs is commensurate with their membership in the transplant surgery workforce. The 2019 survey from the ASTS mem­bership and workforce committee suffered from nonresponder bias and did not evaluate member ethnicity.

Renewed efforts by ASTS are currently underway to measure the progress in organizational diversity more accurately as a part of its “Boldly Against Racism” campaign. Other initiatives include edu­cational outreaches for new ASTS Council and committee members, diversity and antiracism modules incorporated into the fellowship curriculum, and collaboration with other professional societies. These encouraging changes present opportunities for substantial progress and comparative studies in the future with self-reported member demographics.

Conclusions

Our study described the current composition of the ASTS governance. We hope these observations inform further research and highlight future progress in transplant surgery. The diversity in the governance of the ASTS is largely representative of its constituents. The representation of women in leadership positions is proportionally better than their membership in ASTS. There remains a lack of URM surgeons in leadership positions, especially women. Significant effort needs to be extended toward improving surgeon demographic data collection. The diversity of transplant surgery as a whole remains largely unknown. New initiatives are necessary to improve upon current measures to accurately assess the workforce.

Although the diversity in ASTS governance is representative, there remains significant room for growth to diversify the largely NHW membership. The most pressing need is to attract residents from different backgrounds to transplant surgery. The visibility of URM transplant surgeons is crucial to promote recruitment of future surgeons to transplantation. Investigations of other barriers to a career in transplant surgery for URMs are necessary. Additionally, continued examinations of the nomination, election, and appointment process for leadership positions to reduce bias should be undertaken. These evaluations will ensure that male versus female and racial composition of ASTS overall continues to improve, translating to equitable leadership representation.

References:

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