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Gender, racial, and ethnic disparities in representation were observed not only among department chairs in a cross-sectional study of leadership in academic surgery, but also in vice chair and division chief roles in most surgical specialties.

Of 2,165 faculty across 146 medical schools in the U.S. and Puerto Rico, men occupied more leadership positions at all levels compared with women, including department chairs (85.9% vs 14.1%), vice chairs (68.4% vs 31.6%), and division chiefs (87.1% vs 12.9%), and only 8.9% were from racial or ethnic groups that are underrepresented in medicine, reported Oluwadamilola Fayanju, MD, of the University of Pennsylvania in Philadelphia, and colleagues.

Notably, of the three leadership positions, 83.8% were men and 75% were white, they noted in .

Individuals underrepresented in medicine were most commonly vice chairs of diversity, equity, and inclusion (DEI; 51.6%) or faculty development (17.9%). Vice chairs of faculty development were split evenly between men and women, while 64.5% of vice chairs for DEI were women. The authors noted that these roles "may not translate into future promotion."

Women also held more vice chair roles than chair or division chief roles, which was also true for women of color; for example, Black women made up 4% of vice chair roles versus 1.5% of chair roles and 0.6% of division chief roles.

"While it is unclear whether promotion from VC [vice chair] to chair or from DC [division chief] to chair is more likely, similar gender distribution between chairs and DCs suggest the latter and may partially explain persistent nondiversity among surgical chairs," Fayanju and team wrote.

Within division chief roles, representation of those commonly underrepresented was highest in transplant surgery (13.8%), and lowest in oral and maxillofacial surgery (5%). No American Indian, Alaska Native, or Native Hawaiian or Other Pacific Islander individuals held any surgical leadership positions.

While a lack of diversity among department chairs in medicine has previously been reported, surgical leadership positions in non-chair roles have been less thoroughly explored. One 2020 study looked at the -- chairs, vice chairs, and division chiefs -- in academic general surgery programs, and found similarly limited gender and racial diversity. women held a bigger portion of program director positions than other academic ranks, where they were underrepresented.

Fayanju told MedPage Today that this kind of distribution in surgical leadership might put women and underrepresented candidates at a disadvantage, not only because they are underrepresented, but because of differences in the roles themselves. Division chiefs might manage a team of trauma or pediatric surgeons, for example, while vice chairs oversee what Fayanju said is an academic "thematic entity," like faculty development or research. "Divisions are much more like the departments, while ... vice chairs, those [roles] are much less well described domains of oversight," she said.

"Given that often the steps towards becoming a chair requires demonstration of your ability to not only be critically excellent, excellent as an academician, excellent as an educator, but also that you have the ability to manage people, manage a budget, and have some understanding of operations," Fayanju noted, "the question was, do you have an opportunity to do those kinds of things as a vice chair?"

She said medicine may also do well to re-examine what "leadership" in a department looks like. "There are excellent surgeons, excellent researchers, who shouldn't be in charge of anyone," she said. "But at the same time, there are people who by dint of demography are not, quote unquote, 'seen as being leadership material,' and have been systematically not tapped for those opportunities."

In an , M. Libby Weaver, MD, and Melina R. Kibbe, MD, of the University of Virginia School of Medicine in Charlottesville, noted that "although well meaning, diversification efforts that are limited to leadership positions viewed primarily as service roles may ultimately have a superficial, rather than substantive, impact on diversification at the departmental level."

"It is important to acknowledge and overcome our implicit bias of appointing women to roles traditionally thought of as nurturing (i.e., vice chair of faculty development, vice chair of education, etc) and men to roles that are more clinical, operational, or tactical (i.e., vice chair of clinical operations, executive vice chair, etc)," they added.

For this study, the researchers used medical school and hospital websites to identify chairs, vice chairs, and division chiefs of 165 surgical departments -- including general surgery and five surgical subspecialties: neurosurgery, obstetrics and gynecology, ophthalmology, orthopedics, and otolaryngology -- affiliated with 146 medical schools in the first half of 2022.

Two independent reviewers determined race, ethnicity, and gender based on medical school physician profiles, hospital biographies, medical school and hospital websites, press releases, and reviewer determination. If they disagreed, a third reviewer resolved the determination, and if all three disagreed, Fayanju was consulted.

Of the 2,165 faculty included in the study, 83.8% were men, 75% were white, 16% were Asian, 5% were Black, and 3.8% were Hispanic, Latino, or of Spanish origin.

One limitation to the study, Weaver and Kibbe noted, was how gender and race were assigned. "Conclusions drawn from analyzing self-identified versus socially assigned demographic information may differ and this should be thoughtfully and intentionally considered in health care and workforce disparities studies in the future," they wrote.

The authors of the study also acknowledged this limitation, along with potential coding errors from sites not updated to reflect current leadership, and potential differences in leadership roles overlooked because of the study's attempt to standardize heterogenous organizational structures. They said errors in determining primary hospital affiliations from medical school surgery departments were also possible.

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