Diversity in Neurosurgery: View from USA

Diversity in Neurosurgery: View from USA

¹Eliana E. Kim, ²Andrea L. Klein, ^3,4Jean W. Lartigue, ²Gail Rosseau

¹University of California San Francisco School of Medicine, San Francisco, CA, USA
²George Washington University School of Medicine & Health Sciences, Washington, DC, USA
³Harvard Program in Global Surgery and Social Change, Boston, MA, USA
⁴Université d'Etat d'Haïti, Port-au-Prince, Haïti

The neurosurgical workforce is evolving. As individuals with backgrounds and identities historically underrepresented in the field are entering and excelling as neurosurgeons, there is an increasing recognition of the need for diversity, equity, and inclusion in the field. In this report, we highlight diversity issues in neurosurgery. We present evidence from other disciplines that illustrate the essential role of diversity, and demonstrate that both justice and excellence require the system-wide promotion of diversity, equity and inclusion in neurosurgery.

Diversity Issues in Neurosurgery

Although the field of neurosurgery has historically been structured for and dominated by men, pioneering women have made their marks. The world’s first women neurosurgeons were from Europe in 1940s: Alice Rosenstein from Germany, Diana Beck from England, and Sophia Ionescu from Romania.^1–3 They were followed by Aysima Altinok in Turkey and Ruth Kerr Jacoby in the United States, board-certified in 1959 and 1961, respectively.^4,5 In Asia, T. S. Kanaka became the first woman neurosurgeon in India in 1968.⁶ In Africa, Najia El Abbadi was the first. She has served as the Professor and Chair of Neurosurgery at the Ibn Sina Hospital in Morocco since 1990.⁷

Not only have women made significant contributions to neurosurgery as leading scientists and surgeons, they have been active champions for gender equity. Women In Neurosurgery (WINS) has advocated for recruitment and retention of women in the field since 1989.⁸ The Women In Neurosurgery Committee of the World Federation of Neurosurgical Societies (WFNS) has mobilized a global network of women neurosurgeons.⁹ The European Association of Neurosurgical Societies (EANS) has also established a Task Force on Diversity.¹⁰

BIPOCs (Black, Indigenous, People of Color)¹¹ are vastly underrepresented in the neurosurgical workforce. It is worth recognizing the individuals who succeeded despite structural racism. In 1953, Clarence S. Greene, Sr. became the first board-certified African-American neurosurgeon.¹² Alexa Canady and Deborrah Hyde were the first African American women neurosurgeons, board-certified in 1981 and 1985, respectively.^13,14 The Society of Black Academic Surgeons was established in 1989 to foster the careers of African-American surgeons.¹⁵

Neurosurgeons who are not native to their country of practice have enriched the field. Gazi Yasargil was born in Turkey, but became a world-famous microneurosurgeon in Switzerland.¹⁶ Renowned Barrow Neurological Institute (BNI) surgeons Robert Spetzler and Volker Sonntag emigrated as children from Germany.^17–19 Nelson Oyesiku, Editor-In-Chief of Neurosurgery, hails from Nigeria.²⁰ Other notable “geographic transplants” include: Alfredo Quinones-Hinojosa (Mexico), Jacques Morcos (Lebanon); Raymond Sawaya (Syria, Lebanon); Ossama Al-Mefty (Syria, Saudi Arabia); and more. Perhaps the great success of these individuals is reflective of the resilience, strength, and adaptability that they have built through their experiences as immigrants. There is much progress to be made to improve diversity in neurosurgery. Women comprise more than half of graduating medical classes each year in the United States, yet only 6% of ABNS- certified practicing neurosurgeons are women.²¹ Less than 4% of all neurosurgeons in the United States are Black/African-American.²² Gender-race intersectionality leads to compounded forms of inequality. Thirty-three neurosurgeons identify as African-American and female, making up 0.6% of the neurosurgical workforce in the United States.²² The global situation is similar.^23,24

Systemic inequities form “leaky pipelines” and hinder the career progress of individuals in underrepresented groups at every level. Significant pay gaps based on gender and race exists across all of academic medicine; neurosurgery is no exception.^21,25–28 Implicit biases put these groups at a disadvantage in academic promotions, leadership positions, evaluations, and research funding.^29–

³¹Sexual harassment and discrimination of all forms are pervasive issues that are often unaddressed.25 To promote diversity, equity and inclusion in the field, there need to be deliberate and systematic efforts to change the status quo.

Lessons Learned from Business & Politics

In business, the notion of diversity has emerged naturally with cultural and demographic shifts in consumers in the era of globalization.³² One of the most valued effects of diversity is its problem-solving advantage. A group of people with different backgrounds and perspectives tend to come up with innovative and creative solutions to new situations, according to a Harvard Business Review study.³³ Gender and racial diversity has also been associated with corporate profitability. Research by the Boston Consulting Group showed companies with substantial diversity among leadership and management teams were associated with 19% higher revenue due to innovation.³⁴ Business and neurosurgery are disciplines driven by teamwork. Qualities such as flexibility, problem-solving skills, cultural competency and humility are key. Business models clearly illustrate that diverse environments can best foster these qualities.

The importance of diversity in politics was recently showcased through the COVID-19 pandemic. Many observed that countries led by women tended to orchestrate the most effective responses to this health crisis.^35,36 Evidence also shows that when women are elected into political positions, they bring to the table critical issues that are otherwise neglected.³⁷ The UN has found that at a global level, women representation in governments has led to increased childcare coverage, access to water and sanitation, and policies to address gender-based violence.³⁷ Female legislators sponsor more bills related to women’s health, and pass twice as many bills in general compared to their male colleagues.³⁸ Having women in leadership leads to radical policy changes that improves the lives of women and families.³⁸ For instance, in 2018 Iceland became the first country in the world to legally enforce equal pay.³⁹ It has consistently ranked the most gender- equal country in the world by the World Economic Forum.³⁸

The impact of women in leadership shows that representation of diverse individuals in politics can elicit progressive change that will serve not only the dominant group but also those who are less privileged in society. Likewise, diversification of leadership in neurosurgery can better address the needs of neurosurgeons of all backgrounds, and can help improve the neurosurgical environment for all.

Benefits of Diversity: Biological & Economic Perspectives

An increasing interest in the critical role of diversity is not unique to medicine. In fact, references to the importance of diversity can be found in the Bible, Torah, Talmud, Quran, Vedas, Tripitaka, and Shakespeare. More recently, work in the vastly different domains of ecology and economic theory has become strongly rooted in diversity.

For decades, ecologists have pondered and debated the value of biodiversity. Is it merely chance that there are estimated to be at least 5.3 million species of life on earth? Or is there some Darwinian advantage conferred to nature by the presence of such diversity? Countless studies and experiments consistently supported three key findings:^40–46

1. Biodiversity improves the average level of performance of a system.
2. Biodiversity enhances productivity and stability of a system.
3. Biodiversity improves resilience to negative change and lowers the risk of negative outcomes when a system is threatened.

The field of economics relies on diversification to achieve better outcomes. Economist Harry Markowitz was awarded the 1990 Nobel Prize in Economic Sciences for his work developing the modern theory of diversification.⁴⁷ Twentieth century economist Benjamin Graham, the “father of value investing,” describes the theory of portfolio diversification as such:

“As the number of such commitments is increased, the more certain does it become that the aggregate of the profits will exceed the aggregate of the losses.”⁴⁸

Graham’s student, John Templeton, applied this theory and advanced the market with globally diversified mutual funds, which further expanded investment options.⁴⁹ John Maynard Keynes, one of the most successful investors of the twentieth century, demonstrated that investing in a large collection of random, unassociated entities carried the lowest risk and highest likelihood of positive gains.⁵⁰ Modern day investors including Warren Buffett, Jeff Bezos, and Bernard Arnault have also implemented Markowitz’s model of diversification to achieve tremendous success, and continue to advise it to new investors.

In an Editorial in Acta Neurochirurgica, Karl Schaller articulated a view held by many that excellence must be maintained as the specialty attracts gender and racial minorities in increasing numbers.⁵¹ Diversification has objectively demonstrated its capacity to improve performance without jeopardizing the integrity of the system in other fields and it is logical that the outcomes will be the same in neurosurgery. It would be a false assumption that individuals who are of different gender or race from those who have traditionally dominated the field would not be as well-equipped or would lower the standards of the field. It is important to acknowledge that the underrepresentation of certain groups in neurosurgery is not due to their lack of capability or skills but due to the systemic barriers and discrimination against these groups.

Conclusion

The pursuit of diversity is not only just but also rational; its benefits are evidence-based and have been quantified in the biological and economic contexts. For the field of neurosurgery to continue to advance, it must move into the future with the team best equipped for success. One key to this success is diversity.

Acknowledgement

We would like to acknowledge the editors of the book “Surviving Neurosurgery,” Drs. Nitin Agarwal and Vamsi Reddy, for their original suggestion for us to write on the topic of diversity in neurosurgery.

References

1. Collmann H, Eisenberg U. History and Neurosurgery Collide: The Evolution of Neurosurgery in Germany. AANS Neurosurgeon. 2017;26(4). Accessed July 28, 2020. https://aansneurosurgeon.org/inside-neurosurgeon/history-neurosurgery-collide-evolution- neurosurgery-germany/
2. Ciurea A-V, Moisa HA, Mohan D. Sofia Ionescu, the first woman neurosurgeon in theworld. World Neurosurg. 2013;80(5):650-653. doi:10.1016/j.wneu.2013.02.031
3. Gilkes CE. An account of the life and achievements of Miss Diana Beck, neurosurgeon (1902-1956). Neurosurgery. 2008;62(3):738-742; discussion 738-742. doi:10.1227/01.neu.0000317324.71483.e5
4. Balak N, Elmaci I. A pioneering female neurosurgeon: Dr. Aysima Altinok. Acta Neurochir (Wien). 2007;149(9):943-948; discussion 948. doi:10.1007/s00701-007-1252-8
5. Corley J, Kim E, Philips CA, et al. One hundred years of neurosurgery: contributions of American women. J Neurosurg. Published online February 14, 2020:1-6. doi:10.3171/2019.12.JNS192878
6. Satyarthee GD, Jagdevan A. T. S. Kanaka: First Asian Woman Neurosurgeon, Who Pioneered Stereotactic, Functional and Cerebral Electrode Implant Surgery and Developed Separate Neurosurgical Speciality in India Early 1970. Asian J Neurosurg. 2019;14(3):1050. doi:10.4103/ajns.AJNS_287_18
7. RSN Congress Speakers: Najia El Abbadi. Published 2018. Accessed June 21, 2020. https://rsncongress.medevents.ro/speakers/najia-el-abbadi/
8. WINS White Paper Committee:, Benzil DL, Abosch A, et al. The future of neurosurgery: a white paper on the recruitment and retention of women in neurosurgery. J Neurosurg. 2008;109(3):378-386. doi:10.3171/JNS/2008/109/9/0378
9. Bakhti S. Women in Neurosurgery Committee of WFNS. World Federation of Neurosurgical Societies. Published August 8, 2018. Accessed June 21, 2020. https://www.wfns.info/news/49/women-in-neurosurgery-committee-of-wfns
10. Silvia Hernandez-Duran. European Association of Neurosurgical Societies. Published 2020. Accessed June 21, 2020. https://www.eans.org/page/SilviaHernandez-Duran-Bio
11. Jones M. What Does BIPOC Stand For? Why It’s Important You Know What That Phrase Means. Reader’s Digest. Published June 16, 2020. Accessed June 21, 2020. https://www.rd.com/culture/what-does-bipoc-stand-for/
12. McClelland S, Harris KS. Clarence Sumner Greene, Sr.: the first African-American neurosurgeon. Neurosurgery. 2006;59(6):1325-1327. doi:10.1227/01.NEU.0000245611.09356.6D
13. Shaw G. Black History Month Honors Alexa Canady, MD: First African-American Woman Neurosurgeon. Indiana University School of Medicine. Published February 24, 2020. Accessed June 17, 2020. https://medicine.iu.edu/blogs/women-in-medicine/black-history- month-honors-alexa-canady-md-first-african-american-woman-neurosurgeon
14. McClelland S. M. Deborrah Hyde, MD, MS: the second African-American female neurosurgeon. J Natl Med Assoc. 2007;99(10):1193-1195.
15. About SBAS. The Society of Black Academic Surgeons. Accessed June 16, 2020. http://www.sbas.net
16. Past Honored Guests: M. Gazi Yasargil. Congress of Neurological Surgeons. Published June 9, 2019. Accessed June 16, 2020. https://www.cns.org/meetings/past-honored-guests- detail/m-gazi-yasargil
17. Rodts GE. Book Review: Backbone: The Life and Game-Changing Career of a Spinal Neurosurgeon. Neurosurgery. 2018;83(4):E144-E145. doi:10.1093/neuros/nyy351
18. Sonntag VKH, Lombardo JB. Backbone: The Life and Game-Changing Career of a Spinal Neurosurgeon. Lisa Hagan Books; 2017.
19. Robert Spetzler, MD. Barrow Neurosurgical Institute. Published 2020. Accessed June 21, 2020.https://www.barrowneuro.org/get-to-know-barrow/person/robert-spetzler-md/
20. Nelson M. Oyesiku MD, PhD, FACS. Winship Cancer Institute of Emory University. Published 2020. Accessed June 21, 2020.https://winshipcancer.emory.edu/bios/faculty/oyesiku-nelson-m.html
21. Abosch A, Rutka JT. Women in neurosurgery: inequality redux. J Neurosurg. 2018;129(2):277-281. doi:10.3171/2018.4.JNS172878
22. AAMC. Diversity in Medicine: Facts and Figures 2019. AAMC. Accessed June 1, 2020. https://www.aamc.org/data-reports/workforce/report/diversity-medicine-facts-and-figures- 2019
23. Wolfert C, Rohde V, Mielke D, Hernández-Durán S. Female Neurosurgeons in Europe - on a prevailing glass ceiling. World Neurosurg. Published online May 24, 2019. doi:10.1016/j.wneu.2019.05.137
24. Jung T-Y, Kim E-Y, Park M-S. Herstory of the Korean Women Neurosurgical Society since 2008. J Korean Neurosurg Soc. 2019;62(6):619-625. doi:10.3340/jkns.2019.0043
25. Jagsi R, Griffith KA, Stewart A, Sambuco D, DeCastro R, Ubel PA. Gender differences in the salaries of physician researchers. JAMA. 2012;307(22):2410-2417. doi:10.1001/jama.2012.6183
26. Jena AB, Olenski AR, Blumenthal DM. Sex Differences in Physician Salary in US Public Medical Schools. JAMA Intern Med. 2016;176(9):1294-1304. doi:10.1001/jamainternmed.2016.3284
27. Ducharme J. The Gender Pay Gap for Doctors Is Getting Worse. Here’s What Women Make Compared to Men. Time. Published April 10, 2019. Accessed June 16, 2020. https://time.com/5566602/doctor-pay-gap/
28. Ly DP, Seabury SA, Jena AB. Differences in incomes of physicians in the United States by race and sex: observational study. BMJ. 2016;353. doi:10.1136/bmj.i2923
29. Zhuge Y, Kaufman J, Simeone DM, Chen H, Velazquez OC. Is there still a glass ceiling for women in academic surgery? Ann Surg. 2011;253(4):637-643. doi:10.1097/SLA.0b013e3182111120
30. Heath JK, Weissman GE, Clancy CB, Shou H, Farrar JT, Dine CJ. Assessment of Gender- Based Linguistic Differences in Physician Trainee Evaluations of Medical Faculty Using Automated Text Mining. JAMA Netw Open. 2019;2(5):e193520. doi:10.1001/jamanetworkopen.2019.3520
31. Sege R, Nykiel-Bub L, Selk S. Sex Differences in Institutional Support for Junior Biomedical Researchers. JAMA. 2015;314(11):1175-1177. doi:10.1001/jama.2015.8517
32. Eswaran V. The business case for diversity is now overwhelming. Here’s why. World Economic Forum. Published April 29, 2019. Accessed June 18, 2020. https://www.weforum.org/agenda/2019/04/business-case-for-diversity-in-the-workplace/
33. Hewlett SA, Marshall M, Sherbin L. How Diversity Can Drive Innovation. Harv Bus Rev. 2013;(December 2013). Accessed June 1, 2020. https://hbr.org/2013/12/how-diversity-can- drive-innovation
34. Lorenzo R, Voigt N, Tsusaka M, Krentz M. How Diverse Leadership Teams Boost Innovation. BCG. Published January 23, 2018. Accessed June 1, 2020. https://www.bcg.com/en-us/publications/2018/how-diverse-leadership-teams-boost- innovation.aspx
35. Wittenberg-Cox A. What Do Countries With The Best Coronavirus Responses Have In Common? Women Leaders. Forbes. Published online April 13, 2020. Accessed June 1, 2020.https://www.forbes.com/sites/avivahwittenbergcox/2020/04/13/what-do-countries- with-the-best-coronavirus-reponses-have-in-common-women-leaders/#19cc1f5d3dec
36. Taub A. Why Are Women-Led Nations Doing Better With Covid-19? The New York Times. https://www.nytimes.com/2020/05/15/world/coronavirus-women-leaders.html. Published May 15, 2020. Accessed June 1, 2020.
37. Thomson S. Donald Trump could be the best thing that happened to America’s stalling feminist movement. World Economic Forum. Published December 21, 2016. Accessed June 18, 2020. https://www.weforum.org/agenda/2016/12/donald-trump-could-be-the-best- thing-that-happened-to-america-s-stalling-feminist-movement/
38. Topping A. There’s proof: electing women radically improves life for mothers and families. The Guardian. https://www.theguardian.com/us-news/2017/dec/06/iceland-women- government-better-for-mothers-america-lessons. Published December 7, 2017. Accessed June 18, 2020.
39. Henley J. “Equality won’t happen by itself”: how Iceland got tough on gender pay gap. The Guardian. https://www.theguardian.com/world/2018/feb/20/iceland-equal-pay-law-gender- gap-women-jobs-equality. Published February 20, 2018. Accessed June 18, 2020.
40. McGrady-Steed J, Harris PM, Morin PJ. Biodiversity regulates ecosystem predictability.Nature. 1997;390(6656):162-165. doi:10.1038/36561
41. Tilman D, Knops J, Wedin D, Reich P, Ritchie M, Siemann E. The Influence of Functional Diversity and Composition on Ecosystem Processes. Science. 1997;277(5330):1300-1302. doi:10.1126/science.277.5330.1300
42. Tilman D, Wedin D, Knops J. Productivity and sustainability influenced by biodiversity in grassland ecosystems. Nature. 1996;379(6567):718-720. doi:10.1038/379718a0
43. Johnson KH, Vogt KA, Clark HJ, Schmitz OJ, Vogt DJ. Biodiversity and the productivity of ecosystems. Trends Ecol Evol. 1996;11(9):372-377.
44. Case TJ. Invasion resistance arises in strongly interacting species-rich model competition communities. Proc Natl Acad Sci. 1990;87(24):9610-9614. doi:10.1073/pnas.87.24.9610
45. Chapin Iii FS, Zavaleta ES, Eviner VT, et al. Consequences of changing biodiversity.Nature. 2000;405(6783):234-242. doi:10.1038/35012241
46. Naeem S, Li S. Biodiversity enhances ecosystem reliability. Nature. 1997;390(6659):507- 509. doi:10.1038/37348
47. The Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel 1990. NobelPrize.org. Published October 16, 1990. Accessed June 2, 2020. https://www.nobelprize.org/prizes/economic-sciences/1990/press-release/
48. Graham: The Pursuit Of Guaranteed Profits. Seeking Alpha. Published June 13, 2012. Accessed June 2, 2020. https://seekingalpha.com/article/655311-graham-the-pursuit-of- guaranteed-profits
49. About Sir John Templeton. Templeton World Charity Foundation. Published 2020. Accessed June 2, 2020. https://www.templetonworldcharity.org/about-us/our-founder
50. Wasik J. John Maynard Keynes as an Investor: Timeless Lessons and Principles. American Association of Individual Investors. Published March 2014. Accessed June 2, 2020. https://www.aaii.com/journal/article/john-maynard-keynes-as-an-investor-timeless-lessons- and-principles?
51. Schaller K. Women in European neurosurgery. Acta Neurochir (Wien). 2020;162(2):239- 240. doi:10.1007/s00701-019-04165-z