“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Sunday, February 17, 2008

Does diversity matter?

“We all should know that diversity makes for a rich tapestry, and we must understand that all the threads of the tapestry are equal in value no matter what their color.”
~Maya Angelou

I am not a poet and don't claim to have some great understanding of poetry. I do appreciate poetry and the allusions that many authors use to explain certain opinions. The Hollow Men, by T.S. Elliot, is one such poem. It makes many allusions and references to other poems and historical figures to explain his displeasure of society and war. Some believe that it is written from 5 different perspectives; each perspective representing a phase of the passing of a soul into one of death's kingdoms. This is a complex poem which requires an understanding of the time in which it was written, past history, and previous writings of both the author and other authors (such as Dante's Divine Comedy). As complex as this poem is, it is easier to understand than understanding another's perspective.

(Image Credit)
Our perspectives are formed over time. We are affected by our upbringing and experiences. There is no denying this fact. Like our musical tastes, our perspective is shaped by our initial influences and changes with our experience. Differences of perspective is one of the reasons for the emphasis on diversity. Some believe this is a repackaging of "affirmative action", but in my view it is not. Diversity is about bringing together different perspectives. I have been avoiding this topic because it is a hot button issue. Now, with our current political race placing both a African-American man vs a woman and having seen a number posts in different forms that have mentioned the topic, I felt it was time.

Before I speak about diversity, I think I have to give you my personal perspective and history. Who am I? I am the great-great grandson of a Bishop of the AME church. I am the great grandson of a former president of Wilberforce University and one of Yale's first African-American graduates. The nephew of a Yale medical school dean and a descendant of Henry O. Tanner. My parents met at a Williams and Bennington college social function. In the 60's and early 70's, my father was very involved in both SNCC and CORE. In my youth, I grew up with Afro's and dashikis. I listened to stories about Medgar Evers and other leaders in the Black power movement. Yes, I am a black man.

I am the oldest in my family. I have a total of 5 sisters, 1 by marriage and 4 half sisters. I was raised in Wilkinsburg, PA and went through the Wilkinsburg public school system. Considered one of the smart ones, I was protected by many of my friends from some of the bad influences. At age 16, my best friend had his first child; he was 15. At age 18, I had mine. At age 19, my best friend was shot in the head, because he was selling drugs in the wrong area. Needless to say, I grew up in what some would consider a "rough" area.

If you look at my family history and my environment, you may say that they were at odds. In truth, it was always understood in my family that academics was important. There was an unspoken understanding that going to college was a given, which one was the only question. You see, the competition came from within the family, not outside. My cousins class rank of 2 bettered mine by 2 positions. My other cousin's SAT score of 1580 bettered my uncle's (her father) by 20 points. I wasn't that close. Although I grew up with gangs and teenage pregnancy, my overpowering influences came from history, family history.

For me, college was initially a culture shock, but I continued to do well. I majored in Biomedical Engineering and like many times in my life, I was "the only." For some reason, may be I had vision or laps of judgment, I decided to go to medical school in the second semester of my junior year. The prerequisites were made up over the summer, and the next year I applied to medical school.

For me, medical school wasn't that hard. It was a lot of work, but nothing was nearly as hard as some of my engineering courses. My medical school resume was pretty good. As I look back, it was not as good as I thought, but still it was pretty good. Because of concerns about this "affirmative action", I chose not to state my race on my application and did not provide a picture. It may have been a stupid move, but it was a choice I made at the time because I wanted to get there on merit only. Fortunately, it didn't hurt me. You see, because of my fair complexion, people usually can't place my race. It wasn't until I was a 3rd year resident that my chairman realized I was black. That still gives me a little chuckle.

Since medical school, I have been the only black resident, fellow, and faculty member. I am different in a number of ways. You can pick any one of the many things that makes me different. Whether it be race, family history, area where I was raised, or my marriage to a British citizen, I bring something different to the mix. There are people in my field that have the similar backgrounds, but not many. Can you now see my perspective?

Diversity is important. Different opinions and upbringings are important. Whether it be race, gender, or social status, it is important to have a heterogeneous population of physicians. Physicians that can relate to different patient populations. Be it a small town or the inner city, people from these areas tend to return to provide care in these needed areas. Patients also like to see people who are like them providing care. It is important that we mirror our population.

As I have seen and heard many times in the past, if a majority student doesn't get a spot and a under represented minority (URM) does, they wonder if they "lost a spot" to an under qualified URM. Well, let's look at the numbers. In a recent article in the Journal of the American Academy of Orthopaedic Surgeons, Templeton et al addressed the discrepancy in the percentages of URM and women between the medical school population and the orthopaedic resident population. The opening statement of the article states this:
Women and underrepresented minorities make up smaller proportions of orthopaedic residency programs than their numbers in medical school would predict, according to our evaluation of self-reported orthopaedic residency data from 1998 and 2001, as well as information on medical students published in 2002. Based on race, ethnicity, and sex, comparisons were made between students entering and graduating from medical school and those in orthopaedic residency programs. With few exceptions, the percentages of women and underrepresented minorities were statistically significantly lower among those training in orthopaedic residency programs compared with those same groups entering and graduating from medical school. The percentage of women and minorities in orthopaedic residency programs remained constant between 1998 and 2001. Further study is necessary to determine whether fewer students of color and women apply to orthopaedic residency programs becauseof lack of interest, lack of appropriate mentoring and role models, or other factors.
When I hear or read majority students make statements in relation to URM getting spots over a qualified majority students, I laugh a little. If you look at the numbers, there are far more white males competing than any other demographic. If you take a look at the tables from this article in 1998 and 2001, the discrepancy is incredible, especially for women. Majority students occupy 78.8% of orthopaedic spots in 1998 and 76.9% in 2001. The biggest discrepancy noted in the study is with women. The percentage of women in medical school was 44.3% of students in 1998 and 47.6% in 2001 with the percentage in orthopaedic residencies being 7.6% and 9.8% respectively. These numbers are not even close to the general population.

Even our national organization AAOS has started an initiative to encourage URM and women to apply to residency programs. The AAOS realizes that this is something that needs to change and they make this statement:
As the demographic face of our nation changes, the orthopaedic community is evolving to reflect and adapt to these critical shifts in the landscape. Recognizing the value and strength inherent in our diverse population is a first step. But our larger goal remains embracing solutions and mechanisms that give all people access to and a place in our healthcare system.

These are exciting times! The world is changing. Its face grows more diverse each day. The AAOS is committed to keeping, and setting, the pace. As our population grows rapidly more diverse, our need grows significantly for physicians who reflect this diversity and are accessible to communities and individuals with unique needs. The AAOS is taking the lead to ensure all people will be served appropriately by the field of orthopaedics.

Diversity is not just for the underrepresented populations, it is also for those majority students and physicians. It brings the different perspective to a program. Many may take care of these populations, but do they understand the perspective? Whether it be understanding the differences in the Hispanic cultures, or understanding the inner-city culture, having a diverse group of physicians helps everyone become more sensitized to all of these issues.

If we go beyond the clinical setting to research, there are diseases and conditions that are specific to certain populations. Issues like gender differences in bone structure and outcomes after total knee arthroplasty have created a new line of gender specific implants. There have been a number of studies that have looked at Ethnic and Racial Disparities in Diagnosis, Treatment, and Follow-up Care and Disparities in Orthopaedic Surgical Intervention; they have noted both racial and cultural differences. Who is more likely to investigate these conditions and issues than those who could or have been directly effected by the conditions.

Understanding that our numbers are low, how can we improve the numbers? One of the biggest problems is the lack of mentors. In my education, I lacked a "like" mentor. My mentors came from my "majority" physician mentors and my family. Looking specifically academic physicians, the numbers of URM or female are few. Nationally, there are powerful people who fit these groups. Dr. Rankin will be our academy president next year. In my own field, Dr. Crawford has been a leader in the pediatric orthopaedic community for years. The problem is that, if you are a URM or female student interested in my chosen field, it is hard to find someone "like" you who can share their experiences. If I look at my own background, I don't know if I ever could have found a mentor with the same history, but I don't think that was as important as finding someone that I could have related to. Be it cultural similarities or personal history, having a mentor who I could speak frankly about my fears and insecurities would have definitely helped me along the way.

Over the years, I have learned to adapt to my different situations. As such, I am able to view things from many perspectives. I have stated in this blog previously that I have tried hard to remain humble and approachable. Today, I put myself out there as someone that medical students and residents can relate to. I believe it is important that we understand our differences. Whether it be race, gender, culture, religion, or generation, we probably have more in common than we think.

T.S. Elliot writes a poem from 5 different perspectives. Like this poem, each physician/patient interaction is seen through multiple perspectives. The perspective of the patient with all of his/her fears and past history. The perspective of the physician and his/her personal experiences, as well as previous interactions with like patients. The perspective of the nurse and other physician extenders who bring their past history and experiences to view this interaction. Ultimately, understanding our differences is what helps make these interactions better. Regardless if it makes us color blind or more culturally sensitive, diversity ultimately makes us all better physicians.

“All truths are easy to understand once they are discovered; the point is to discover them.”
~Galileo Galilei


Chrysalis said...

Excellent post. Also interesting to learn more about your background. I already knew your race (don't know how, just did).

I love to read your perspectives on things. I love that none of us are completely alike. How boring would that be? I think it's wonderful too, for children to meet others like themselves; it lets them know they can aspire to become anything they set their minds to.

"Today, I put myself out there as someone that medical students and residents can relate to." You also help those of us that are not in the field, to learn more about what it is you do and how you feel about doing it. I always enjoy reading your posts. Well done.

rlbates said...

I felt some of that as a woman trying first to get into an ortho residency (didn't happen) and then into general surgery before moving on to plastic surgery. I wanted to do hand surgery. Made the mistake of coming back to Arkansas where the ortho guys have the hand surgery pretty well sewn up.

I get pleasure out of the reconstructive (fixing things) side of plastics much more than the cosmetic side.

I envy you that your family put the pressure on you to go to college. Mine did not. I felt like a "failure" in my mother's eyes until I got married at age 33. I think she is proud of me now, but she grew up in the "culture" of woman got married and had babies. My out-side influences (and inner self) bucked that. I think maybe she thought I didn't think "highly enough" of her.

We are all influenced by many things, aren't we? Take care. Lovely post!

make mine trauma said...

Excellent post. I have a mixed heritage and I always put other or leave blank the ethnicity box. It always irritates me when I see that question.
There are some older women general surgeons in my town and they awe me for having made it through what had to be an intimidating men's club at the time they were training. As for orthopaedic surgeons, there is only one woman in my town and though I have never worked with her, I hear that she is excellent.

make mine trauma said...

You have a very rich heritage! It is wonderful that you know it. So many of us don't. I knew there was artistry in your blood. ;^]

Anonymous said...

It is a very odd thing to be a woman in ortho. I have attendings who ask [with concern] if the program is "female friendly", then whine about being "tortured" by working with the woman resident...it is offensive and demeaning. It also makes me see through the "concern."

I just keep trying to remind myself that I have more options open to me than my parents because of their hard work. I hope to open more doors for those who follow...

Anonymous said...

You’ve touched on a very sensitive issue. Let me preface this with I am not easily bother nor usually surprised by things that often.

I am currently in medical and our school holds a “hospital day” once a year. Not sure how common among med schools it is. This is a day where a hotel conference room is rented out by our school and representatives from prospective hospitals have booths in where we can get information about their sites. They try and sell us on their hospital for electives during our latter years in medical school.

This day was probably my worst day in medical school so far, a jaw dropping experience. Although, not yet completely certain of what I want to specialize in, I have been looking into several selective subspecialties. I thought this was a opportunity for me to find out more about the programs. Hmmmm my first conversation went something like this:
Representative: “Hi, nice to meet you. So what subspecialty are you interested in.”
Me: “ I’ve heard great things about the ortho program at your facility, could you please tell me a little more about the program.”
Rep: “you know, our ortho program is highly selective. It’s a tight-knit, group of guys. You spend a whole lot of time with these individuals and I just don’t think you would fit in.”
No joke, my jaw physically dropped! In this day and age, because of who I am would still exclude me from certain programs?!? Are you serious? This individual knew nothing about me: who I was as a person, what my grades, scores, or what my values are. Ok I thought, maybe it was just that one program/representative. Well as the day wore on, subsequent representatives were not as blunt but I seemed to get the same general response from more than one. Maybe my viewpoint was a bit bias due to the first encounter. Maybe I read too much into it what the subsequent reps said. Yet, I feel like I’m a good judge of character and can read people very well. These representatives were very friendly and cordial when I first introduced myself and met them. Then, once they realized my program of interest within their school it seemed like they no longer wished to continue the conversation.
Even through organizations like the AAOS have started encouraging minorities to apply to certain programs I don’t think this will drastically change the discrepancy ratios within the field. What needs to change is the attitude among certain programs. An attitude I honestly didn’t know still existed.
You expressed the idea that a problem is a lack of “like” mentors. I would have to disagree. I am a strong person and don’t need anyone to have treaded before me to make way. I think a problem is the likeness among the mentors themselves and their naivety and inability to see beyond certain superficial aspects. I understand it is changing, albeit slowly.

Someonect said...

Chryalis: you know our minds were separated at birth :) ... cosmic connection.

life would be pretty boring if we were all the same. like reliving the same day over and over. BORING.

rlbates: hey you know we have a resident in our program that started on the plastic route an switch with plans to pursue hand. no she like a number of things other than hand. reconstructing is probably the most rewarding part of what i do. i couldn't do cosmetics.

as a woman, the pressures are so different. societal views have changes, somewhat, but the family pressure is still there. i have been influenced by many strong women in my family. in truth, i probably wouldn't be here without them. HI MOM :)

mmt: hello my brown sister ;). the whole categorizing of people bothers me. probably the most bothersome question i get is "soooo, where are you from?" ... interpretation, what are you?

and yes, the older women who came through surgery had to endure some significant hardships along the way. it definitely made them tougher.

anon: i personally don't care about race, religion, gender or social status, i just want someone who wants to work, wants to learn, and give good care. ortho is STILL a very testosterone driven specialty. if you are a woman in ortho, for know, they do have to try to be the one of the guys and tolerate some of the male adolescent behavior. for me, the torture comes with uninterested, unprepared, slacking residents. gender and race don't matter.

dc: i am sorry you had that experience. my jaw would drop as well. i think things are changing, but people don't changes as quickly. the ratios won't change quickly. it is not because of encouragement, it is more because of the numbers applying. i don't thing the numbers are that high.

i disagree with you in regards to mentors. mentors, great educators, or important people in your life influence decisions. if you had a like mentor (in this field), s/he could help you through this incident. all my mentors were "majority," they did have significant influence on me. it is part of the reason why i am doing peds. if students see people like them in a program, they would be more likely to select that program or specialty. ratio difference is not because their match rate is low, it is because the number of applicants is low.

Chrysalis said...

You know it, Someonetc.;) (We can't have boring now, can we?)

I felt mad reading what DC ran up against. How dare they! For all their feelings of superiority - their lack of intelligence was showing. It just burns me to think they could potentially turn away a bright, qualified individual. It makes no sense to me. Good luck in whatever you decide to do DC. Don't let anyone keep you from what you want out of life. Let those like that, only fuel you to succeed!

Bongi said...

i enjoyed this post. i delight in diversity. i would definitely have asked you 'what' you are if it wasn't obvious to me but not to discriminate. just because i love diversity and personal history so much. even personal ethnic history. as far as mentors being race specific, in kalafong i had 2 black consultants. one was an arrogant bombastic moron of questionable surgical ability. the other was a hard working humble genius. in all groups you get the excellent ones and the bad apples. i despised the one and had nothing but respect for the other. race was not even a consideration. my white seniors also fell both sides of the line. once again race didn't play a role for me.

having waxed lyrical, in my country both the previous government and the present government hold race up as the most important factor. discrimination breeds discrimination. i will not be a part of that.

Anonymous said...

I would like to thank you, thank you for posting, sharing and teaching. I am a medical student in a European country and i found your blog by accident.I am not planning to be a orthopaedic surgeon however i love reading you blog. I find your posts inspiring. It is obvious to me through your posts that you are caring and passionate as teacher and as a person. I know from experience that an educator with those qualities can make all the differnce. I just wanted you to know that you make me think and you inspire me. Thank you very much.
Please forgive my english,english isnt my mother language!

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