Study Highlights Diversity Deficit in U.S. Surgical Leadership

A study initiated at Duke University School of Medicine lays bare significant racial and gender disparities in America’s surgical leadership. 

Of the 2,165 faculty members included across 154 departments, men overwhelmingly claimed the top spots in surgical leadership, making up 85.9% of department chairs, 68.4% of vice chairs, and a staggering 87% of division chiefs.   

What’s more a mere 8.9% of these leadership roles were filled by those from underrepresented racial or ethnic groups. 

While women made a modest showing as vice chairs at 31.6%, they remained underrepresented elsewhere. Many of these women and those from underrepresented racial or ethnic groups were clustered in roles linked to diversity and faculty development, which might not pave the way to top department positions.  

Oluwadamilola “Lola” M. Fayanju, MD
Oluwadamilola M. Fayanju, MD, is a former Duke surgeon now serving as chief of breast surgery at Penn Medicine

The study in JAMA Surgery stands out because the research team of surgeons, trainees, and biostatisticians looked in detail at different leadership roles and the implications these disparities have for the pipeline to department chair. 

“While we’re not sure if it’s more common to be promoted from vice chair to chair or division chief to chair, the fact that the gender balance is similar in both chair and division chief roles hints that it might be the latter,” said senior author Oluwadamilola “Lola” M. Fayanju, MD, chief of the Breast Surgery Division at Penn Medicine who began the study while on faculty at Duke School of Medicine.   

In recent years, with greater attention on racial justice and work-life balance, additional vice chair roles have emerged to support the newly prioritized focus areas.  

While newer VC roles, like those focused on wellness and diversity, are crucial, if they don’t pave the way for higher leadership roles, they might inadvertently create a glass ceiling, authors said.  

The long-term impact of these roles on future leadership remains to be seen, but it is vital for institutions to reflect on the authority and opportunities they provide to those in vice chair positions.  

Other reported findings include:  

  • In roles for vice chairs of research, none of the non-white individuals hailed from groups traditionally underrepresented in medicine (URM), such as Black, Mexican-American, Native American, and mainland Puerto Rican populations, with Asians predominantly filling these positions. 

  • Among division chief roles, racial and ethnic representation was greatest in transplant surgery (13.8%) and lowest in oral and maxillofacial surgery (5%). 

  • While less than 20% of division chief roles in most specialties were held by women, breast and endocrine surgery was an exception, likely reflecting the mostly female patient demographic affected by conditions such as breast cancer and thyroid disease. 

“A disappointing part of the study is that in completely non-gendered areas, like lung disease which impacts everyone, we still found predominately male leadership,” said co-author and principal biostatistician Samantha Thomas, manager of the Duke Cancer Institute Biostatistics Shared Resource who led study analysis. 

Samantha Thomas,
Principal biostatistician Samantha Thomas

Diverse healthcare providers often yield improved patient outcomes. Similarly, leadership diversity influences medical training, operations, and the surgical department work environment.  

When making pivotal decisions, department chairs frequently seek counsel from their leadership teams. 

Fayanju emphasized that surgical departments require more than diverse leaders; their teams must be diverse too, as “those decisions don't happen in a vacuum.”  

“If you have the same kinds of people talking to each other all the time, the likelihood of significant change or cultural evolution happening in a department or across a specialty is low,” she said. 

Fayanju designed the study with co-lead authors Yoshiko Iwai, a medical student at University of North Carolina at Chapel Hill, and Alice Yunzi L. Yu, MD, a graduate of Duke School of Medicine and pediatrics resident at Northwestern.  

Authors relied on publicly available data, collected between March 15 and Aug. 15, 2021, that was collected from departmental websites, organizational charts, and occasionally, academic press releases that they carefully coded. 

The resulting comprehensive data set revealed a landscape of surgical leadership with a deep diversity deficit, but one with hope for evolving.  

In September 2021, KMarie King, MD, a hepatobiliary and pancreas surgeon, became the first Black woman to be named chair of surgery at an academic medical center when she was selected for the top spot at Albany Health Medical Center.  

“It's like shedding light on an issue that many have suspected or known about, but having the numbers in front of you can be a wake-up call,” said study co-author Nikki Daniels, who worked on study data collection and design as a Duke University undergraduate and presented the study at the 2022 Academic Surgical Congress. “Hopefully, it’s also a call to action.”   

Additional authors: Ritika Manik and Duke surgeons Ranjan Sudan, MD and Georgia Beasley, MD. 

Funding was provided by the National Institutes of Health (7K08CA241390, P30CA014236), the Duke Cancer Institute, and the Duke Global Health Institute.