A Call to Action: Increasing Black Representation in Neurological Surgery
Donald K Detchou, BA, Alvin Onyewuenyi, MPH, Vamsi Reddy, BS, Andre Boyke, MS, Nnenna Mbabuike, MD, William W Ashley, Jr, MD, PhD, MBA, Edjah K Nduom, MD
Neurosurgery, Volume 88, Issue 5, May 2021, Pages E469–E473, https://doi.org/10.1093/neuros/nyab057
Published: 20 February 2021
In the midst of a pandemic which has disproportionately impacted Black communities,1 American society has been shaken by injustices involving police brutality and the subsequent murders of innocent Black men and women in the United States.2 We believe it is a time for reflection on diversity in neurosurgery with a focus on the Black population that is bearing the brunt of both pandemics.
Modern neurological surgery in America can be traced back to the early 20th century.3 World War I created a need to treat traumatic neurological injuries, creating opportunities for innovation.4 Innovation has always been part of neurosurgery. Our current moment calls for another wave of innovation from the leadership of neurosurgery—this time focused on recruiting an untapped and diverse source of talent. The Association of American Medical Colleges (AAMC) stated that increasing diversity in academic health centers is a significant component of efforts being made to reduce health care disparities in the United States.5 Yet, there are still major documented deficits in the number of minority academic surgeons. Studies report alarming trends in racial and ethnic discrimination during medical school and surgical residency.6-12 The negative impacts of this discrimination include overt racist acts, social isolation, differing expectations, and higher dismissal rates across all specialties.9-11,13
There also exists evidence of disparities in healthcare delivery due to ethnic and socioeconomic conditions in pediatric and adult populations of neurosurgery.14-16 In a series of publications from the Institute of Medicine's Quality of Health Care in America project, inequitable health care is shown to be incompatible with quality health care.17
In the context of the current events in this country, we intend to make the case for diversity in neurosurgery, as workforce diversity is a necessary tool in combating the racial exclusion in the US healthcare system.18 Towards that end, we will start by examining the history of Black leadership in neurosurgery; make the case for increased diversity in Patient Care and in Academia; and then outline our proposal to increase diversity in neurosurgery with a particular focus on Black Neurosurgeons—specifically, we propose the formation of a Black Neurosurgery Organization to coordinate these efforts.
A BRIEF HISTORY OF BLACK NEUROSURGEONS
Despite the challenges they have faced, Black Neurosurgeons have made important contributions to neurosurgical care in the United States. In 1953, Dr Clarence Sumner Greene, Sr, MD, DDS, became the first board certified Black Neurosurgeon.19,20 A trainee of Dr Wilder Penfield at the Montreal Neurological Institute,19 Dr Greene later served as Chair of Neurosurgery at Howard University. In 1961, Dr E. Latunde Odeku, MD, FICS, became the first Black Neurosurgeon trained in the United States, and the second Black Neurosurgeon certified by the American Board of Neurological Surgeons (ABNS).21-23 Dr Alexa Canady, MD, is a pioneer for women and Black Neurosurgeons. Dr Canady was the inaugural fellow in America's first formal pediatric neurosurgery program (CHOP), and she became Chief of Neurosurgery at Children's Hospital of Michigan.24,25 In 1985, Dr M. Deborrah Hyde, MD, MS, became the second Black female board-certified neurosurgeon and only the third woman (following Drs Carole Miller: 1971 and Janet Bay: 1980) to receive neurosurgical training in Ohio.26
Nearly 70 years after Dr Greene obtained board certification, Black people remain under-represented in neurosurgery. Out of the 5645 active neurosurgeons in the United States in 2018, only 3.8% are Black people.27,28 Within neurosurgery residency training programs, only 78 trainees out of 1475 (4.58%) identified as Black people in 2019.29 In 2004 to 2005, only 3 neurosurgery residents were Black women; 2019 to 2020 data remain abysmal, with just 13 Black women undergoing residency training in neurosurgery in the entire country.11 In 100 yr, The Society of Neurological Surgeons has had 736 members. Only 4 members in the history of this organization have been Black people, representing 0.54% of members—Dr Cargill H. Alleyne Jr, Dr Keith L. Black, Dr Mark D. Johnson, and Dr Nelson M. Oyesiku. While the achievements of the Black Neurosurgeons highlighted here are laudable, we believe that increasing diversity in neurosurgery can only serve to further strengthen our field.
MAKING A CASE FOR DIVERSITY IN NEUROSURGERY
Patient Care
As the population in the United States becomes more diverse, it is likely that inequities will persist if deficiencies in health care delivery are not addressed. Racial minorities face greater disparities due to a lack of healthcare insurance, decreased preventive services, and increased barriers to accessing care.30 When patients experience racism, we create a formula for poor outcomes.31 These inadequacies in care are exacerbated by a history of mistrust in the medical system by Black patients due to a long history of transgressions they have experienced at the hands of the medical system. These include the US Public Health Service Syphilis Study at Tuskegee and the immortal (HeLa) cell line derived from tissue taken without consent from Mrs Henrietta Lacks.32,33 We believe that diverse physicians are an important part of the solution to address these problems.
Data suggests that Black physicians are more likely to treat patients of their own race and practice medicine in geographic locations that have a higher percentage of Black residents.34 Black doctors often feel a sense of responsibility to return to communities that they are from and address the health disparities that they see.35-37 There is also evidence that Black patients are likely to talk more openly and candidly about their health problems when talking with a Black doctor, and they are more likely to initiate return visits.38,39
In addition to the benefits of racially concordant care, data states that Black physicians play a large role in providing care for low-income and medically indigent patients in the US healthcare system.40 Studies show that Black doctors treat more patients that are uninsured or are covered by Medicaid, regardless of race and ethnicity.41,42 For these reasons, we believe that an increase in Black Neurosurgeons can improve patient care for all communities.
Within Academia
Women and men of color make unique contributions to teaching, service, and research within higher education.43,44 They are more likely to implement active, collaborative learning pedagogies, increasingly facilitating higher order thinking and conceptual connections.45 Diverse faculties represent alternative viewpoints in the academy and research a broad range of topics.46,47 The presence of faculty of color in the classroom challenges assumptions about the interest and abilities of people of color, helping their students deconstruct their own biases.46
Women and men of color more often mentor students and junior colleagues, and they offer unique socioemotional support. Retention of minority trainees and their performance is positively correlated with exposure to minority professors at both the formal and informal level.48-56
In addition, faculty of color are more likely to report the importance of research in their pursuit of a career in academia.57 There is a need for researchers to engage marginalized communities to translate research findings into actionable change to address public needs.58 Diverse faculty members are highly likely to study these communities, as a recent study found a 3-fold increase in research on race and ethnicity from Black and Latinx faculty.59 Contributions from faculty of color also provide the majority of our understanding of racial and ethnic minority communities.43 As we have outlined above, Black faculty provides unique contributions to academic medicine, and neurosurgery can benefit from these contributions.
OUR PROPOSAL TO ADDRESS THE LACK OF BLACK REPRESENTATION IN NEUROSURGERY
In order to support the efforts of the field of neurosurgery to pursue equity, we believe that a Black Neurosurgery Organization should be formed. There are existing disparate efforts to improve diversity in competitive specialties like neurosurgery (Table), but we believe that our current situation calls for a coordinated effort, similar to that provided by Women in Neurosurgery. This entity must have the freedom to speak up as a representative of Black Neurosurgeons when the need arises, as a group of over 80 Black Neurosurgeons did when George Floyd was murdered.60,61 Additionally, this organization must have the freedom to enter into its own partnerships. Partnerships with organizations like the National Medical Association (NMA) and the Society of Black Academic Surgeons (SBAS), who have existing pipeline programs for Black students interested in medicine, will be critical for the achievement of our aims.
aMH B. Summer Medical and Dental Education Program. https://www.rwjf.org/en/library/research/2011/08/summer-medical-and-dental-education-program.html. Accessed 2020. Robert Wood Johnson Foundation; 2013.
bMason BS, Ross W, Ortega G, Chambers MC, Parks ML. Can a strategic pipeline initiative increase the number of women and under-represented minorities in orthopaedic surgery? Clin Orthop Relat Res. 2016;474(9):1979-1985.
cHarrington MA, Rankin EA, Ladd AL, Mason BS. The orthopaedic workforce is not as diverse as the population it serves: where are the minorities and the women?: AOA Critical Issues Symposium. J Bone Joint Surg Am. 2019;101(8):e31.
dMason BS, Ross W, Chambers MC, Grant R, Parks M. Pipeline program recruits and retains women and under-represented minorities in procedure based specialties: a brief report. Am J Surg. 2017;213(4):662-665.
eMountSinaihealth. Exploring Careers in Research and Medicine. Mount Sinai Today. https://health.mountsinai.org/blog/exploring-careers-in-research-and-medicine/. Accessed 2020.
fParmeshwar N, Stuart ER, Reid CM, Oviedo P, Gosman AA. Diversity in plastic surgery: trends in minority representation among applicants and residents. Plast Reconstr Surg. 2019;143(3):940-949.
gButler PD, Aarons CB, Ahn J, et al. Leading from the front: an approach to increasing racial and ethnic diversity in surgical training programs. Ann Surg. 2019;269(6):1012-1015.
hAAO-HNS. Diversity Grants. American Academy of Otolaryngology—Head and Neck Surgery. https://www.entnet.org/Diversity_Grants. Accessed 2020.
iChapman CH, Gabeau D, Pinnix CC, Deville Jr C, Gibbs IC, Winkfield KM. Why racial justice matters in radiation oncology. Adv Radiat Oncol. 2020;5(5):783-790.
jAbosch A, Rutka JT. Women in neurosurgery: inequality redux. J Neurosurg. 2018;129(2):277-281.
kRenfrow JJ, Rodriguez A, Wilson TA, Germano IM, Abosch A, Wolfe SQ. Tracking career paths of women in neurosurgery. Neurosurgery. 2018;82(4):576-582.
A Black Neurosurgical Organization would engage in efforts to recruit Black people into neurosurgery using various existing and new pathway initiatives, retain Black Neurosurgical trainees and practicing neurosurgeons through mentoring, develop young Black Neurosurgical faculty members into leaders in our field, and deliver equitable patient care to our communities.
Notably, such an organization will not be able to change the culture of neurosurgery on its own. Additionally, there are currently too few Black Neurosurgeons who have attained the rank of Professor or equivalent to expect them to mentor every Black person who aspires to a neurosurgical career. Existing senior neurosurgeons will need to mentor diverse neurosurgical trainees, so that this burden is shared by all of neurosurgery. The ongoing partnership of organized neurosurgery including the American Association of Neurological Surgeons, Congress of Neurological Surgeons, ABNS, the Neurosurgery Residency Review Committee of the Accreditation Council for Graduate Medical Education, The Society of Neurological Surgeons (SNS), Council of State Neurosurgical Societies, Neurosurgery Research & Education Foundation, and others will be critical. We hope these organizations will join a Black Neurosurgical Organization in the development of a shared list of initiatives that all neurosurgeons must pursue, if we are committed to creating lasting change.
CONCLUSION
Just as our field has seen tremendous success due to early neurosurgical pioneers recognizing a need for change and making historic contributions towards addressing neurological pathology, history calls for another push from the leadership in neurosurgery—this time focused on recruiting under-represented minorities into the field. We would like to recommend that the field of neurosurgery support a Black Neurosurgery Organization, with a primary focus on recruitment, mentorship, support, and advocacy. Such an independent organization will need the support of existing neurosurgical structures, but it must also be able to stand alone, raise funds, and forge partnerships.
Funding
This research was supported in part by the Intramural Research Program of the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS).
Disclosures
The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
REFERENCES
1. Yancy CW. COVID-19 and African Americans. JAMA. 2020;323(19):1891-1892.
Google Scholar
2. Dreyer BP, Trent M, Anderson AT et al. The death of George Floyd: bending the arc of history towards justice for generations of children. Pediatrics. 2020;146(3):e2020009639.
Google Scholar
3. Cushing H. I. Subtemporal decompressive operations for the intracranial complications associated with bursting fractures of the skull. Ann Surg. 1908;47(5):641-644.1.
Google Scholar
4. Carey ME. Cushing and the treatment of brain wounds during World War I: historical vignette. J Neurosurg. 2011;114(6):1495-1501.
Google Scholar
5. AAMC. The Diversity Research Forum: The Importance and Benefits of Diverse Faculty in Academic Medicine: Implications for Recruitment, Retention, and Promotion. AAMC. https://members.aamc.org/eweb/StartPage.aspx?Site=AAMC. Accessed 2020.
Google Scholar
6. Butler PD, Longaker MT, Britt LD. Major deficit in the number of underrepresented minority academic surgeons persists. Ann Surg. 2008;248(5):704-709.
Google Scholar
7. Valenzuela F, Arenas MAR. Underrepresented in surgery: (lack of) diversity in academic surgery faculty. J Surg Research. 2020;254:170-174.
Google Scholar
8. Butler PD, Aarons CB, Ahn J et al. Leading from the front: an approach to increasing racial and ethnic diversity in surgical training programs. Ann Surg. 2019;269(6):1012-1015.
Google Scholar
9. Yuce TK, Turner PL, Glass C et al. National evaluation of racial/ethnic discrimination in US surgical residency programs. JAMA Surg. 2020;155(6):526-528.
Google Scholar
10. Lett LA, Orji WU, Sebro R. Declining racial and ethnic representation in clinical academic medicine: a longitudinal study of 16 US medical specialties. PLoS One. 2018;13(11):e0207274.
Google Scholar
11. McDade WA. Diversity in Graduate Medical Education: A Data-Driven Seminar on the Current State of Training of Black Neurosurgeons. Congress of Neurological Surgeons. https://www.cns.org/black-lives-in-neurosurgery-webinar-series#:∼:text=The%20impact%20of%20racism%2C%20bias,you%20this%20new%20webinar%20series. Accessed 2020.
Google Scholar
12. Hill KA, Samuels EA, Gross CP et al. Assessment of the prevalence of medical student mistreatment by sex, race/ethnicity, and sexual orientation. JAMA Intern Med. 2020;180(5):653-665.
Google Scholar
13. Liebschutz JM, Darko GO, Finley EP, Cawse JM, Bharel M, Orlander JD. In the minority: black physicians in residency and their experiences. J Natl Med Assoc. 2006;98(9):1441.
Google Scholar
14. Lagman C, Nagasawa DT, Mukherjee D et al. Hispanic and African American adult brain tumor patients treated at Harbor-UCLA Medical Center compared to Los Angeles County and Torrance, California. J Clin Neurosci. 2018;49:22-25.
Google Scholar
15. Missios S, Bekelis K. Access disparities to Magnet hospitals for patients undergoing neurosurgical operations. J Clin Neurosci. 2017;44:47-52.
Google Scholar
16. Attenello FJ, Ng A, Wen T et al. Racial and socioeconomic disparities in outcomes following pediatric cerebrospinal fluid shunt procedures. J Neurosurg Pediatr. 2015;15(6):560-566.
Google Scholar
17. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001.
Google Scholar
18. Boyd RW. The case for desegregation. Lancet. 2019;393(10190):2484-2485.
Google Scholar
19. McClelland S III. The Montreal Neurological Institute: training of the first African-American neurosurgeons. J Natl Med Assoc. 2007;99(9):1071.
Google Scholar
20. McClelland S III, Harris KS. Clarence Sumner Greene, Sr.: the first African-American neurosurgeon. Neurosurgery. 2006;59(6):1325-1327.
Google Scholar
21. Cobb W, Epps Jr C, Kosiba M. Certification pioneers. In: A Century of Black Surgeons: The US Experience. Vol 2. Oklahoma: Transcript Press; 1987:483-528.
Google Scholar
22. Adeloye A. E. Latunde Odeku, M.D., F.A.C.S., F.I.C.S., 1927-1974. An African pioneer neurosurgeon. J Natl Med Assoc. 1975;67(4):319-320.
Google Scholar
23. McClelland S III, Harris KS. E. Latunde Odeku: the first African-American neurosurgeon trained in the United States. Neurosurgery. 2007;60(4):769-772.
Google Scholar
24. Corley J, Kim E, Philips CA et al. One hundred years of neurosurgery: contributions of American women. J Neurosurg. 2020;1(aop):1-6.
Google Scholar
25. McClelland S III. Alexa Irene Canady: the first African-American woman neurosurgeon. J Natl Med Assoc. 2008;100(4):439-443.
Google Scholar
26. McClelland S III. M. Deborrah Hyde, MD, MS: the second African-American female neurosurgeon. J Natl Med Assoc. 2007;99(10):1193.
Google Scholar
27. AAMC. Table 13. Practice Specialty, Males by Race/Ethnicity, 2018. AAMC. https://www.aamc.org/data-reports/workforce/data/table-13-practice-specialty-males-race/ethnicity-2018. Accessed 2020.
Google Scholar
28. AAMC. Table 12. Practice Specialty, Females by Race/Ethnicity, 2018. AAMC. https://www.aamc.org/data-reports/workforce/data/table-12-practice-specialty-females-race/ethnicity-2018. Accessed 2020.
Google Scholar
29. Brotherton SE, Etzel SI. Graduate medical education, 2018-2019. JAMA. 2019;322(10):996-1016.
Google Scholar
30. Jackson CS, Gracia JN. Addressing health and health-care disparities: the role of a diverse workforce and the social determinants of health. Public Health Rep. 2014;129(1_Suppl2):57-61.
Google Scholar
31. Hall WJ, Chapman MV, Lee KM et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105(12):e60-e76.
Google Scholar
32. Skloot R. The Immortal Life of Henrietta Lacks, the Sequel. New York: The New York Times; 2013:23.
Google Scholar
33. Gamble VN. Under the shadow of Tuskegee: African Americans and health care. Am J Public Health. 1997;87(11):1773-1778.
Google Scholar
34. Cooper LA, Powe NR. Disparities in Patient Experiences, Health Care Processes, and Outcomes: The Role of Patient-Provider Racial, Ethnic, and Language Concordance. NY, New York: Commonwealth Fund New York; 2004.
Google Scholar
35. Powers BW, White AA, Oriol NE, Jain SH. Race-conscious professionalism and African American representation in academic medicine. Acad Med. 2016;91(7):913-915.
Google Scholar
36. Brown T, Liu JX, Scheffler RM. Does the Under-or overrepresentation of minority physicians across geographical areas affect the location decisions of minority physicians? Health Serv Res. 2009;44(4):1290-1308.
Google Scholar
37. Wilkins DB. Identities and roles: race, recognition, and professional responsibility. Md L Rev. 1998;57 (4):1502.
Google Scholar
38. Alsan M, Garrick O, Graziani G. Does Diversity Matter for Health? Experimental Evidence from Oakland. American Economic Review; 2019;109 (12):4071-4111.
Google Scholar
39. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139(11):907-915.
Google Scholar
40. Moy E, Bartman BA. Physician race and care of minority and medically indigent patients. JAMA. 1995;273(19):1515-1520.
Google Scholar
41. Komaromy M, Grumbach K, Drake M et al. The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med. 1996;334(20):1305-1310.
Google Scholar
42. Marrast LM, Zallman L, Woolhandler S, Bor DH, McCormick D. Minority physicians’ role in the care of underserved patients: diversifying the physician workforce may be key in addressing health disparities. JAMA Intern Med. 2014;174(2):289-291.
Google Scholar
43. Griffin KA. Institutional barriers, strategies, and benefits to increasing the representation of women and men of color in the professoriate: looking beyond the pipeline. In: Higher Education: Handbook of Theory and Research. Springer Nature: Switzerland AG 2020 Vol35. 2019:1-73.
Google Scholar
44. Turner CSV. Women of color in academe: living with multiple marginality. J Higher Edu. 2002;73(1):74-93.
Google Scholar
45. Eagan, MK Jr, Garvey JC. Stressing out: connecting race, gender, and stress with faculty productivity. J Higher Edu. 2015;86(6):923-954.
Google Scholar
46. Alger J. When color-blind is color-bland: ensuring faculty diversity in higher education. Stan L & Pol’y Rev. 1998;10(2):191.
Google Scholar
47. Alger JR, Carrasco GP. The Role of Faculty in Achieving and Retaining a Diverse Student Population. Denver, CO: AACRAO Policy Summit; 1997.
Google Scholar
48. Griffin KA, Reddick RJ. Surveillance and sacrifice: gender differences in the mentoring patterns of black professors at predominantly white research universities. Am Educ Res J. 2011;48(5):1032-1057.
Google Scholar
49. O’Meara K, Kuvaeva A, Nyunt G, Waugaman C, Jackson R. Asked more often: gender differences in faculty workload in research universities and the work interactions that shape them. Am Educ Res J. 2017;54(6):1154-1186.
Google Scholar
50. Baker VL, Pifer MJ, Griffin KA. Mentor-protégé fit. Int J Researcher Dev. 2014;5(2):83-98.
Google Scholar
51. Benitez M, James M, Joshua K, Perfetti L, Vick SB. "Someone who looks like me": promoting the success of students of color by promoting the success of faculty of color. Liberal Edu. 2017;103(2):n2.
Google Scholar
52. Blake-Beard S, Bayne ML, Crosby FJ, Muller CB. Matching by race and gender in mentoring relationships: keeping our eyes on the prize. J Soc Issues. 2011;67(3):622-643.
Google Scholar
53. Brown MC II, Davis GL, McClendon SA. Mentoring graduate students of color: myths, models, and modes. Peabody J Edu. 1999;74(2):105-118.
Google Scholar
54. Patton LD. My sister's keeper: a qualitative examination of mentoring experiences among African American women in graduate and professional schools. J Higher Edu. 2009;80(5):510-537.
Google Scholar
55. Reddick RJ. Intersecting identities: mentoring contributions and challenges for black faculty mentoring black undergraduates. Mentor Tutoring. 2011;19(3):319-346.
Google Scholar
56. Bettinger EP, Long BT. Do faculty serve as role models? The impact of instructor gender on female students. Am Econ Rev. 2005;95(2):152-157.
Google Scholar
57. Antonio AL. Faculty of color reconsidered: reassessing contributions to scholarship. J Higher Edu. 2002;73(5):582-602.
Google Scholar
58. Baines D. The case for catalytic validity: building health and safety through knowledge transfer. Policy Prac Health Safety. 2007;5(1):75-89.
Google Scholar
59. Milem JF. Increasing Diversity Benefits: How Campus Climate and Teaching Methods Affect Student Outcomes. In: Orfield, Gary, Ed., Diversity Challenged: Evidence on the Impact of Affirmative Action. Cambridge, Harvard Education Publishing Group, 2001:233-249.
Google Scholar
60. Mbabuike N, Ashley WW, Nduom E et al. Statement by Black Neurosurgeons. American Association of Neurological Surgeons. https://www.aans.org/About-Us/Position-Statements/Statement-by-Black-Neurosurgeons. Accessed 2020.
Google Scholar
61. Mbabuike N, Ashley WW, Nduom E et al. Statement by Black Neurosurgeons. Physicians. https://pfcjreform.org/black-neurosurgeons-statement/. Accessed 2020.
Google Scholar
Published by Oxford University Press on behalf of Congress of Neurological Surgeons 2021.
This work is written by (a) US Government employee(s) and is in the public domain in the US.