Key words : Diversity, Equity, Inclusion, Transplant Surgery

Introduction

The lack of diversity within the medical workforce remains evident. Disparities are most notable in leadership roles. In nearly all specialties, the present underrepresentation of Black and Hispanic physicians in academic ranks exceeds levels observed in 1990.¹ In surgical specialties, most department chairs, vice chairs, and division chairs are held by male physicians. Physicians from racial and ethnic groups underrepresented in medicine (URiM) constitute only 8.9% of these positions.² The field of transplant surgery is not immune to such discrepancies. In 2019, 91.5% of directors in the fields of kidney, liver, and pancreatic transplant surgery were male physicians, and 55% were Non-Hispanic White physicians.³ This well-documented phenomenon emphasizes the persistent obstacles to the progression of female physicians and URiM physicians into surgical leadership positions.

Various obstacles including implicit bias, hostile workplace cultures, and limited mentorship oppor-tunities contribute to these disparities. Among surgical residents, 76.8% of Black physicians and 68.8% of Asian physicians experienced microag-gressions from their colleagues. Such incidents are thought to be underreported because of concerns about repercussions. In addition, female residents faced microaggressions more frequently than male residents.⁴ Furthermore, URiM physicians are less likely to establish mentorship relationships than their non-URiM peers.⁵ These factors contribute to heightened stress within these populations, which is compounded by the inherently demanding nature of surgical training. The potential development of imposter syndrome may dissuade female physicians and URiM physicians from seeking higher-level positions, and implicit bias can also impede the hiring of these physicians for leadership roles.

Resolution of these demographic disparities in academic and clinical ranks is essential for effective patient care. Workforce heterogeneity is associated with improved outcomes, enhanced risk assessment accuracy, and culturally competent care.^6,7 Diversity is correlated with reduced bias, improved access to care for underserved communities, and diminished racial and ethnic health disparities.^8,9 Also, the presence of racial, ethnic, and language concordance between physicians and patients is associated with increased medication adherence.¹⁰

A conscious effort to prioritize the recruitment of representative physicians is critical. One method to improve workforce demographic composition is the promotion of female and URiM surgeons into leadership positions. Mentorship and a sense of belonging are vital for success in surgical careers. Increased visibility and access provided to groups historically underrepresented in advanced clinical and academic roles may facilitate the recruitment and retention of a more representative surgical workforce.

Prior investigations have characterized the demographic details of surgical subspecialties. However, a knowledge gap remains with regard to both academic and clinical leadership among abdo-minal transplant surgeons. We assessed the present demographic landscape of abdominal transplant surgeons within the American Society of Transplant Surgeons (ASTS) registry for the period 2022-2023. This includes the examination of age, sex, race, and ethnicity details across various professorship ranks, chairs, chiefs, and fellowship program directors among this cohort.

Materials and Methods

We identified 1007 abdominal transplant surgeons, including fellows, adult specialists, and pediatric specialists, from the 2022-2023 ASTS membership registry. Residents and those without credentials for Doctor of Medicine or Doctor of Osteopathic Medicine were excluded. Demographic variables encompassed age, sex (male or female), race (White, Black, Asian), and ethnicity (Non-Hispanic White, Hispanic, Middle Eastern, East Asian, South Asian, Southeast Asian). Demographic characteristics were sourced from publicly available websites and databases. Unpublis-hed data was inferred by 2 or more members of the research team using the country of origin associated with surnames, location of schooling, languages spoken, and physician photograph. This facilitates the identification of a physician’s demographic details by leveraging criteria beyond physical attributes alone. Surgeons were excluded from the data analysis in instances where sex and race-ethnicity determinations were inconclusive. This approach aligns with methods previously used in transplantation publications.^3,11-14

Academic and clinical positions were obtained from program websites or individual professional websites. Academic titles were categorized as assistant, associate, and full professorships or no positions. Clinical titles comprised 9 categories including Chair of Surgery; Chief of Surgery, Transplant, Hepatobiliary, Liver, Kidney, or Pancreas; fellowship program directors; or no positions.

We tested the distribution of sex and race across academic positions by using the chi-square test. We examined demographic distributions across clinical positions by using the Fisher exact tests due to the sample size in each category. We compared mean ages across academic and clinical positions by using t tests. We utilized multinomial logistic regressions to assess whether any significant relationships existed among certain race or sex groups in relation to academic posi-tions. Analogous analysis for clinical positions could not be performed because of the small sample size in each clinical position. All statistical analyses were evaluated using the 5% significance level unless specified otherwise.

Results

Table 1 demonstrates general demographic charac-teristics of abdominal transplant surgeons in academic leadership. Table 2 depicts the race, ethnicity, and sex composition of surgeons in assistant and associate roles, relative to White or Non-Hispanic White full professors. Table 3 and Table 4 summarize the sex and race and ethnicity details of those in clinical leadership, respectively.

Overview of present abdominal transplant surgeons
Among a cohort of 1007 abdominal transplant surgeons, 79.84% were male and 19.76% were female. The demographic details revealed a predominance of White surgeons (73.09%); 21.65% of the cohort identified as Asian, and 3.67% of the cohort were Black surgeons. The most common ethnic category was Non-Hispanic White (56.60%). The second largest ethnic group was East Asian (12.71%). Hispanic surgeons constituted 9.14%, South Asian 8.64%, Middle Eastern 7.35%, and Southeast Asian 0.30% of the cohort. Overall, most of the surgeons held academic positions (66.63%), whereas clinical leadership was less commonly attained (42.60%).

Demographic composition of individual academic leadership positions
Age and sex
Regarding people in the cohort with academic leadership, 199 (19.76%) were assistants, 189 (18.77%) were associates, and 285 (28.30%) were full professors. Academic rank was inversely correlated with age, and mean ages were 43.59 years (SD 7.34 years) for assistants, 51.78 years (SD 8.24 years) for associates, and 61.66 years (SD 8.63 years) for full professors (P < .001) (Table 1). Female surgeons were signi-ficantly more likely to be assistant professors (31.98%) than associates (20.11%) or full professors (9.12%) (P < .001). No academic titles were held by 78.31% of male physicians versus 21.69% of female physicians (P < .001).

Race
White surgeons represented 70.26%, 71.66%, and 80.92% of assistant, associate, and full professorship roles, respectively. Asian physicians constituted 25.13%, 22.46%, and 16.96%, and Black physicians comprised 4.62%, 5.88%, and 2.12% of assistant, associate, and full professorship roles, respectively (P = .027). White physicians were the most likely to hold no academic titles (72.39%; P = .027) (Table 1). White female, Asian female, and Asian male surgeons were, respectively, 5.30 (P < .001), 2.50 (P = .008), and 1.10 (P = .005) times more likely to be assistants rather than full professors compared with their White male counterparts. White female, Black male, and Asian male surgeons were 2.29 (P < .001), 2.00 (P = .042), and 1.70 (P = .043) times more likely to be associates rather than full professors compared with White male surgeons. Asian male surgeons (P = .009) and White male surgeons (P < .001) were more likely to hold no academic titles. Notably, no Black female surgeons held full professorships. Demographic composition of assistant and associate professors in relation to White male surgeons and full professors is shown in Table 2.

When adjusted for age, many of these results did not demonstrate statistical significance. Older physicians were 20% (relative risk ratio [RRR] = 1-0.799), 9% (RRR = 1-0.907), and 9% (RRR = 1-0.912) less likely to hold assistant, associate, or no academic titles rather than full professorships, respectively (P < .001) (Table 2). Additionally, Asian male physicians were 1.43 times more likely to be assistant professors rather than full professors (P = .055).

Ethnicity
Non-Hispanic White physicians had an increased likelihood to be full professors, whereas Hispanic, Middle Eastern, East Asian, and South Asian physicians were more likely to be assistant or associate professors (P = .026) (Table 1). Female surgeons who identified as Non-Hispanic White (P < .001), Hispanic (P = .007), and East Asian (P = .005) backgrounds, along with male physicians of Middle Eastern (P < .001), South Asian (P = .004), East Asian (P = .003), and Hispanic (P = .064, significant at 10%) backgrounds, were significantly more likely to be assistant professors rather than full professors compared with Non-Hispanic White male physicians. Additionally, Non-Hispanic White female (P < .001), Middle Eastern male (P = .017), and South Asian male surgeons (P = .030) had an increased likelihood to be associates rather than full professors. No Southeast Asian full professors were identified. Finally, Non-Hispanic White female surgeons (P < .001) and East Asian male surgeons (P = .015) were the most likely to hold no academic titles. The details of ethnicity and sex composition of assistant and associate professors in reference to Non-Hispanic White male physicians and full professors are shown in Table 2.

After adjustment for age, male physicians identified as Middle Eastern (P = .004) and East Asian (P = .005), along with Non-Hispanic White female surgeons (P = .036), remained more likely to hold assistant positions. Those holding assistant, associate, or no positions were of younger age groups, compared with Non-Hispanic White male physicians in full professorship roles (P < .001) (Table 2).

Demographic characteristics of individual clinical leadership positions
Sex differences
Female transplant surgeons exhibited less likelihood to hold transplant chief positions compared with their male counterparts (P = .025) (Table 3). Male physicians predominated as liver transplant chiefs at 11.19%, versus 4.02% of female surgeons (P = .001). Additionally, the likelihood of female physicians to have achieved the rank of pancreas chief was reduced at 4.02%, versus 7.84% for male physicians (P = .037). Male surgeons were more prevalent in surgery chair positions, with no female physicians holding this title during the 2022–2023-timeframe (P = .087, significant at 10%). Finally, 67.34% of female surgeons held no clinical titles compared with 54.73% of male surgeons (P = .001).

Race
Black surgeons were more likely to hold positions as kidney chiefs, with 27.03% of Black, 10.55% of Asian, and 12.09% of White physicians in these ranks (P = .028). Furthermore, 63.76% of Asian, 51.35% of Black, and 55.35% of White surgeons held no leadership positions in clinical settings (P = .068, significant at 10%). No Black surgeons held positions of surgery chair, hepatobiliary chief, and surgery chief during the examined time frame (Table 4).

Ethnicity
Among the various ethnicities, surgeons of Non-Hispanic White backgrounds exhibited the lowest probability of holding zero clinical leadership titles (P = .061, significant at 10%), indicating an elevated likelihood of securing such positions overall. No significant relationships were identified among the different ethnicities concerning individual clinical leadership ranks (Table 4).

Discussion

The present abdominal transplant surgery cohort demonstrates a continual predominance of male (79.84%), White (73.09%), and Non-Hispanic White (56.60%) physicians, with a reduced representation of Asian (21.65%), Black (3.67%), and Hispanic (9.14%) individuals, along with those of other ethnic backgrounds. Our analysis revealed a higher preva-lence of female surgeons at approximately 20% compared with prior reports of 13.1%.¹⁵ Academic titles were more frequently obtained compared with clinical leadership roles (66.63% vs 42.60%).

Female surgeons from both minority and majority backgrounds exhibited increased rates of holding assistant or associate professor roles. This is in stark contrast to White male physicians who predo-minantly occupied full professorships. Asian and White female surgeons demonstrated a 2.50-fold (P = .008) and 5.30-fold (P < .001) higher likelihoods of holding assistant professor roles, respectively. Additionally, White female surgeons were 2.30 times more likely to assume associate positions versus their White male counterparts (P < .001) (Table 2). Non-Hispanic White, Hispanic, and East Asian female physicians exhibited increased rates of being assistant professors compared with Non-Hispanic White male physicians. Non-Hispanic White female surgeons were also 2.71 times more likely to hold associate positions (P < .001). Refer to Table 2. Notably, no Black female surgeons held full professorship ranks in 2022-2023, precluding estimations of relative risk ratios for Black female physicians in assistant, associate, or no academic titles.

Male surgeons from racial-ethnic minority groups were also less likely to attain full professorship. Asian male surgeons were 1.10 (P = .005) and 1.70 (P = .043) times more likely to be assistant and associate professors, respectively. Furthermore, Black male surgeons were 2.00 times more likely to assume associate professorships versus White male surgeons (P = .042) (Table 2). Last, Hispanic, Middle Eastern, South Asian, and East Asian male surgeons exhibited a higher likelihood of holding assistant versus full professorship compared with Non-Hispanic White male surgeons (Table 2).

Regarding surgeons with no academic positions, 21.69% of female physicians versus 78.31% of male physicians did not hold any academic titles (P < .001) (Table 1). This suggests a heightened probability for female surgeons to assume academic roles in comparison with male surgeons, which is in agreement with previously published studies.¹⁶ However, despite this finding, there remains a significant underrepresentation of women in academia, given the low number of female abdominal transplant surgeons overall. Male surgeons comprised 81.07% of all academic positions compared with 18.93% of female surgeons. As stated above, female surgeons more frequently occupied assistant or associate positions compared with male surgeons, who more often occupied full professorship. These findings align with trends observed across various fields in academic medicine.¹⁶ Although not exhaustive, plausible contributors include implicit bias against women and URiM physicians or resistance to deviations from the historical trend of Non-Hispanic White male physicians in leadership. Moreover, female surgeons are more likely to encounter imposter syndrome than are male surgeons.¹⁷ This raises the question of whether such factors compel some female surgeons to pursue promotions less frequently compared with male surgeons.

After adjustment for age, several race-related associations lose significance (Table 2). Given that White male physicians served as our reference group, this observation suggests a higher average age within this cohort, contributing to their increased propensity to occupy senior roles. Older physicians face a 20% (RRR = 1-0.799) and 9% (RRR = 1-0.907) reduced likelihood of holding assistant and associate professorships rather than full professorships (Table 2). Therefore, the decreased representation of female surgeons and URiM surgeons in academic leadership may be attributed to their younger age. Two potential explanations may account for this. First, recruitment efforts from previous decades may not have adequately translated into the presence of significant numbers of older female and URiM surgeons, and only recently has the field experienced an increase in this population. In such an instance, we would anticipate a gradual increase of this younger cohort into more senior roles as they age. Second, this observation may result from elevated attrition rates among women and URiM physicians, resulting in a younger demographic within these groups. However, additional investigations by our research team have revealed reduced attrition rates in these individuals versus their White male counterparts, decreasing the probability of the latter explanation.¹⁸

In clinical leadership positions, female surgeons exhibit a lower likelihood of being surgery chairs (P = .087, significant at 10%), transplant chiefs (P = .025), liver chiefs (P = .001), and pancreas chiefs (P = .037) compared with male surgeons (Table 3). No significant differences were shown in the proportion of White, Black, and Asian physicians occupying individual roles, except for kidney chief. Surgeons of minority backgrounds were more likely to hold positions as kidney chiefs than any other clinical leadership role (P = .028) (Table 4). Although initial assessments have been promising, broader analysis has revealed that Non-Hispanic White surgeons exhibit elevated rates of obtaining clinical leadership overall, as shown by their reduced likelihood of holding no positions compared with other ethnic groups (Table 4). Furthermore, White physicians constituted 77.23% of all clinical titles versus 4.23% of Black and 9.58% of Hispanic individuals.

The ASTS governance, including the ASTS council, COVID-19 Strike Force, and various committees from 2019 to 2020 were overwhelmingly dominated by Non-Hispanic White and male physicians.19 Among surgeons performing adult heart transplants, 73.1% were White, followed by 20% Asian, 5% Hispanic, and 1.8% Black from 2000 to 2020, with limited representation of female surgeons (3%).20 Similarly, 93.1% of liver, 91.2% of kidney, and 90.3% of pancreas transplant programs across the United States from 2010 to 2019 had male surgical directors.3 Our research expands upon this last investigation to include more recent data from the 2022-2023 ASTS registry. Furthermore, we assessed additional clinical leadership roles, beyond directors, along with professorship status for all ASTS-registered abdominal transplant surgeons.

Diverse representation in higher-ranking posi-tions is crucial for learners and patients alike. This inclusivity may attract a broader spectrum of applicants to the field and provide a greater opportunity for students to interact with mentors of diverse backgrounds. Additionally, a diverse group of physicians may improve the likelihood of culturally competent care, demonstrate reduced bias, and address concerns related to racial and ethnic health disparities.^8,9 Moreover, patients tend to experience improved outcomes and satisfaction when treated by physicians of similar backgrounds.²¹

Efforts to enhance diversity within the surgical workforce have been implemented. Specialties, such as general surgery, have adopted holistic review processes to eliminate noncomparable metrics within their residency applicants, resulting in increased interviews extended to URiM physicians.²² In addition, initiatives including the Program to Launch Underrepresented in Medicine Success were introduced in medical schools, which focus on equipping URiM physicians with the necessary resources to pursue leadership roles.²³ Last, the Accreditation Council for Graduate Medical Education (ACGME) introduced an initiative known as “ACGME Equity Matters” in July 2021 to improve diversity, equity, and inclusion efforts in residency programs, by promoting anti-racism practices and addressing structural barriers to bolster diversity in medicine.²⁴ Although these initiatives show promise, it may take time before the effect is measurable through data.

The ASTS membership registry provided us with data from one of the most robust and oldest transplant societies. This investigation was focused on demographic details and clinical and academic leadership, providing up-to-date information regarding diversity, equity, and inclusion within the field of transplant surgery. Moreover, our study expands on previous examinations on abdominal transplant leadership by incorporating a broader range of clinical titles and academic ranks.3 Other strengths include lack of reliance on voluntary surveys, which are notorious for non-response bias and lack of flexibility.

Clinical and academic leadership data were sourced from publicly available databases. These databases may lack real-time updates on surgeons’ present roles. Furthermore, unavailable demographic information required inference. Although these methods have been employed by previous publications,^3,11-14 these methods may introduce potential inaccuracies. We did not account for non-binary gender or multiracial identities. In addition, the ASTS membership registry does not include all practicing abdominal transplant surgeons. These limitations can skew data. Other limitations include lack of examining years of practice with the exclusion of time related to child-rearing. The efforts of child-rearing often result in required time off from academic and clinical responsibilities, which disproportionately falls on female physicians. This may influence the promotion likelihood of women into more senior leadership roles. Moreover, this investigation did not control for interest in pursuing the examined positions. A possibility exists that personal interest levels for senior roles may vary across demographic populations. Finally, due to the limited time frame of this investigation, we could not assess shifts among the various leadership titles. For example, although female surgeons and URiM surgeons were more likely to hold associate professorships, determining the cause (whether it is attributable to obstacles to progression to full professorship or whether it is a result of these individuals advancing from assistant to the associate level) requires further examination beyond the present time constraints.

Conclusions

Continual improvement in all facets of patient care is paramount. There are significant benefits to patient care and satisfaction associated with increased diversity among health care providers. Similar investigations have demonstrated that the field of abdominal transplant surgery continues to lack diversity within the workforce and in leadership positions. Our findings support the limited diversity within both academic and clinical leadership positions within this cohort. Non-Hispanic White male surgeons continue to dominate full professorship positions. Broader analysis revealed Non-Hispanic White male surgeons also occupied advanced clinical leadership roles more often than female and URiM surgeons. However, no associations were observed among individual clinical positions and racial-ethnic groups, with the exception of chief of kidney transplant, which Black surgeons more often occupied. Additionally, female and URiM surgeons tend to be younger and therefore exhibit a decreased likelihood of occupying full professorship roles. Despite promising initiatives in abdominal transplantation, there remains an ongoing need for increased representation in all leadership positions. Achieving this goal necessitates proactive recognition and efforts from those presently in senior ranks.

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