The Importance of Diversity and Inclusion in Cardiothoracic Surgery

The current COVID-19 pandemic has shed a light on health care disparities that affect those of racial and ethnic minority groups. 

The Centers for Disease Control and Prevention (CDC) reports numerous reasons for such disparities, including social elements such as residential segregation, multigenerational households, and lower socioeconomic status that prohibits people from taking time off work. In addition, many patients tend to be uninsured, have more comorbid conditions, and have less access to medical care. Cultural factors, such as distrust of the health care system and language barriers, also may play a role. 

As I was reading through the CDC data coming out of New York, I was reminded of a conversation that I had a few days earlier. While hosting a Zoom meeting with pre-medical and medical students, a young woman asked me, “Can one want to help address health care disparities and still pursue a surgical subspecialty?” Her question caught me a little off guard because I had never considered that some people might feel like subspecialty surgery is mutually exclusive with addressing health care disparities.

After a discussion about how heart disease and lung cancer also affect racial and ethnic minority groups disproportionately for the same reasons mentioned above, the discussion turned in a different direction. “Does your specialty value diversity, and what is your specialty doing to address some of these issues?,” a young man asked.

Despite an ever-diversifying population in the United States, women and underrepresented minorities (URM) lack proportionate membership in the cardiothoracic surgery (CTS) workforce. A survey conducted by the American College of Surgeons in 2009 identified CTS as the surgical specialty practiced by the oldest surgeons as a group.

• 55 to 69 years (42.3%)
• 70 years or older (11.6%) 

These results foreshadow a shrinking CTS workforce that will be compounded by a lack of diversity. A contributing factor is the fact that the number of applicants continues to be low. According to the Association of American Medical Colleges, the percentages of medical school graduates by race and ethnicity also have remained consistent over time:

• Non-Hispanic white (58.8%)
• Asian (19.8%)
• African-Americans (4.6%) 
• Hispanics (5.7%)

Within Surgical Academia, disparity is striking. Among tenured surgical professors:

• African-Americans (1.8%) 
• Hispanics (2.7%)

The number of URM applicants to CTS will continue to remain low if the overall number of URM applicants to medical school remains low. 

Another problem with recruitment is the overall lack of exposure to the field of CTS. Few URM medical school matriculants decide to pursue surgical careers. Of those who do go into surgery, very few have exposure to CTS. The requirements from the Accreditation Council for Graduate Medical Education (ACGME) for general surgery cases are minimal and include zero cardiac surgery requirements. 

ACGME Defined Category Minimum Numbers for General Surgery Residents 

With such limited exposure to CTS, it is no surprise that trainees shy away from this specialty as a career option. What can we do as a specialty attract qualified applicants?

Possible solutions
After reviewing the literature, I identified some areas for improvement. 

Recruitment 

In the 2014 STS Workforce Report, Ikonomidis reported that 48% of survey respondents identified their decision to pursue a career in CTS was made before or in medical school. These survey results suggest that recruitment must start earlier than residency.

Similarly, Meza et al. conducted a survey of Integrated CTS program (IP) applicants. In their survey, a specific question was asked:  

When did you develop an interest in CT Surgery?

• 61% had interest in CTS before clinical clerkships
• 93% tailored their clinical education to meet that interest

These results are consistent with the 2014 STS Workforce Report (Ikonomidis).

Suggestions to help with recruitment

• Target pipeline efforts here
• Active recruitment strategies to these demographics
• Target URM specific organizations such as the Latino Medical Student Association, Student National Medical Association, and Women in Medicine 
• Mentor students starting in pre-medical years, possibly even as early as high school
• Mentor medical students throughout their clinical years and offer research opportunities

Retention

Davis and Yang looked at the National Resident Matching Program (NRMP) data and identified 147 individuals who applied to IP from 2008 to 2011 and were unmatched. Only 20 of those individuals (14%) ended up in a CTS residency programs.

This brings up an important point. As mentioned earlier, IP applicants have a strong interest in CTS at the time of application. Why is it that only such a small number of them continue to pursue CTS?  

Suggestions to help with retention

• Continue to engage these applicants to keep them interested
• Offer research opportunities 
• Provide CTS electives
• Organizations must be willing to support and invest in program such as the STS Looking to the Future scholarships

In my opinion, it is imperative that we as a specialty create mechanisms to keep these talented individuals within the pipeline. The STS Workforce on Diversity and Inclusion was created to address the needs of our specialty to better reflect and understand (cultural competence) our evolving communities. The Society understands that achieving a diverse CTS workforce is important. If CTS is to continue advancing and attracting the brightest, most skilled, and innovative people, we must invite, encourage, and guide qualified individuals from all races, cultures, genders, sexual orientations, and experiences to join us.

Luis A. Godoy, MD, is a cardiothoracic surgeon at the University of California (UC), Davis School of Medicine and UC Davis Health. He is the assistant program director for the cardiothoracic surgery residency. Dr. Godoy also holds a position on the STS Workforce on Diversity and Inclusion.