There has been a myriad of recent publications about the lack of diversity within orthopaedics, high attrition rates amongst African Americans/Black and other underrepresented minorities in orthopaedic surgical training programs, and the ability or lack thereof for training programs to recruit. Haruno et al. quantitatively reported the attrition rates within surgical training programs over the past two decades. To no surprise, the attrition rates (including unintended attrition) are highest amongst African Americans in all surgical subspecialties. I shared these aforementioned articles with several colleagues, and while many were shocked by the findings, others were rather skeptical.
Some believe lack of clinical acumen or inefficiency may be the etiology for the dire discrepancy in dismissal between African American trainees and others. While this may be part of the story, there is a taboo we have not addressed or rarely talk about. There are people that adamantly believe some training programs are rather hostile toward Black or other underrepresented minority trainees. I don’t believe lack of clinical acumen, inefficiency, etc., are the sole reasons for the higher attrition rates amongst African American trainees. There is no statistical metric to quantify racism or hostility, thus making it harder to attribute this as a reason for the high attrition rates. Nonetheless, the data does tell a story, and it's important that all sides are considered equally.
I am the first Black man to finish orthopaedic surgery residency at the University of Mississippi Medical Center. I can say that while residency was arduous and filled with a steep learning curve, I never felt any hostility because of the color of my skin. Conversely, there are several Black physician trainees, at different institutions, that feel their mistakes are scrutinized more than their counterparts, or that they received repercussions that were rather draconian in comparison to their peers. Hence, prospective Black applicants have to consider the affability and institutional culture when choosing a residency program to avoid any potential issues. This recent publication by Brooks et al. reported that 96% of Black orthopaedic surgeons experienced discrimination, bias, or some type of racial microaggression during surgical training. Moreover, Ode et al. presented data that several Black orthopaedic surgeons face discrimination in the workplace at exponential rates and are not afforded the same opportunities for career advancement as their counterparts. Specifically, Black orthopaedic surgeons who are women reported experiencing more microaggressions and less institutional support than their white counterparts. These publications corroborate the fact that there might be a different experience for Black people and other underrepresented groups during and after surgical training.
My father, a general surgeon (former residency program director), always emphasized the significance of training at a place where you have champions/allies. I was fortunate to train at an institution that embraced the importance of diversity, equity, and inclusion (DEI) and aspired to create a change. I truly believe one of the most important factors in increasing and sustaining diversity efforts starts with allyship. In McFarling’s editorial, she stated that several Black and brown orthopaedic surgeons feel overwhelmed with the work of advancing diversity. A common misconception is that individuals from underrepresented groups have the sole responsibility to educate others about DEI. This rationale is deeply flawed and rather inaccurate.
Dr. Bob McGuire (spine surgeon and former president of Arbeitsgemeinschaft fur Osteosynthesefragen [AO] North America) introduced the term allyship to me as a junior resident. He successfully increased diversity within several organizations he was a part of and spoke about the importance of white people as allies. He was intentional about ensuring minorities were always treated fairly, promoted accordingly, and were not an afterthought! His upbringing was unique; he's a southern white man that grew up in rural Alabama during the Jim Crow era. However, he was taught from a young age the significance of diversity and respect for all racial groups, religions, and cultures. This belief system was transformative in advancing DEI in the spaces he occupied.
How can one serve as an ally? It’s simple, but not easy. Allyship is a verb. It requires thought, empathy, active listening, sponsorship, and deliberate action for one to become an ally.
First, allyship starts with educating oneself about the history of systemic racism and contemporary latent systemic racism in American society. Allies actively endeavor to quell any workplace racism, sexism, or implicit bias, and drive a culture of inclusivity.
Second, allies respectfully seek to understand how the workplace experiences of their Black and other underrepresented minority colleagues might differ from their own experiences. It’s important to recognize these are their personal experiences, and not necessarily generalizable to all Black people or underrepresented groups.
Third, allies insist on interviewing a diverse set of candidates for available positions and don’t seek to preserve the status quo.
Last, sponsorship is an integral component of allyship. It requires allies putting their Black/underrepresented minority colleagues in positions for advancement. Sponsorship enhances access to networking engagements, grants/scholarships, and other opportunities for social mobility. These steps serve as a template for being an ally, but there are a myriad of other things that can be done to be an effective ally.
Allyship is a critical component of advancing the mission of DEI. It goes beyond advocating for diverse applicants by also ensuring they are treated equitably. In summation, I was fortunate to undergo surgical training with white physicians/staff that were true allies. They were vested in my development as a surgeon and most importantly, as a human being. If the goal is to decrease high attrition rates among underrepresented groups and increase DEI, we should start with allyship — it’s imperative!
How can you be an ally? Share in the comments.
Kevin Purcell is an orthopedic surgery fellow in joint replacement at Duke University Medical Center. He completed orthopedic surgery residency at the University of Mississippi Medical Center, and was the first Black man to finish this program. He is an advocate for increasing diversity, equity, and inclusion in health care.
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