3

Page 3

However, procedures involving the nasal and periorbital areas are more ethnically sensitive in nature. Therefore, techniques used for these structures should improve aesthetic appearance without distorting ethnic identity.8Traditional Caucasian-centered techniques blend well with the surrounding Caucasian features; however, when applied to the ethnic patient, they tend to distort natural structural relationships and damage ethnic identity. Plastic surgeons offering ethnically specialized procedures should aim to coordinate aesthetic ideals with cultural and patient-specific preferences. Renato Saltz, M.D., of the ASAPS Public Education Committee, articulated that “being aware of cultural differences is more than just speaking the language; it's also about understanding how patients want to enhance their natural beauty. For example, South American women typically want smaller breasts and larger buttocks than the average Caucasian American female.” Improvements in the technical aspects of ethnic cosmetic surgery and the greater willingness of plastic surgeons to tailor their care to minorities have synergistically enhanced the options for minority patients while reducing their risk of ethnically incongruent outcomes. Therefore, plastic surgeons recently have made more of an effort to preserve ethnicity with varying surgical techniques in cosmetic procedures such as rhinoplasty and blepharoplasty.Reports from the U.S. Census indicate that as of 2006, Latin Americans compose the nation's largest ethnic minority group (Table 2). They also represent the nation's fastest growing ethnic segment. In 2006, almost half of the U.S. national population growth was composed of Latin American origin. Furthermore, the U.S. Census estimates that by 2050, the U.S. Hispanic segment will grow to over 102 million and comprise 24% of the nation's population.10 The second largest ethnic minority group, African Americans, grew more slowly, but still at a rate faster than that seen with Caucasians. Census estimates expect this group to increase to 26 million people. The Asian American ethnic segment demonstrated strong growth in 2006 and is estimated to reach 33.4 million by 2050.11 This surge in non-Caucasian populations is likely to occur primarily in urban neighborhoods and their surrounding suburbs, where many plastic surgery practices are located.12 The 2006 U.S. Census data also identified Asian Americans as the population with the highest median income and largest annual income growth rates.13 Similarly, the 2000 U.S. Census identified those of Middle Eastern origin with median earnings exceeding the national medians ($41,687 vs. $37,057 for men; $31,842 vs. $27,194 for women).Wealthier minority groups are likely to display greater demand for cosmetic surgery given the positive correlation between disposable income and luxury purchases (i.e., cosmetic surgery). more likely than whites to have received clinical fellowship training (OR, 1.62; 95 percent CI, 1.16 to 2.26; p = 0.0048) and, more specifically, microsurgery fellowship training (OR, 1.78; 95 percent CI, 1.24 to 2.54; p = 0.0014). However, no difference was found among other clinical fellowship training types. There were no differences between whites and nonwhites in the rates of residency training type, advanced degree attainment, or research fellowship attainment. The distribution of career training and qualifications for academic plastic surgeons, by ethnicity, is listed in Table 3. Academic Rank and Leadership Positions for Nonwhites Measuring academic rank and leadership roles (Table 4), nonwhites represent 47.2 percent of all Table 1. Comparison of Demographics to National Average Race Academic Plastic Surgery (%) U.S. National CensusD.D.S., Doctor of Dental Surgery; D.M.D., Doctor of Medicine in Dentistry; M.B.A., Master of Business Administration; M.H.S., Master of Health Science; M.P.H., Master of Public Health; M.S., Master of Science; Ph.D., Doctor of Philosophy. *Fisher’s exact test used for analysis of qualifications not meeting Pearson χ2 assumptions. 272 Plastic and Reconstructive Surgery • January 2020 21.2 percent of whites met or exceeded this level of postresidency experience, whereas 6.9 percent of nonwhites met or exceeded this level of postresidency experience. After taking level of experience into account through adjustment using multivariate logistic regression (Table 7), none of the previously observed positional disparities remained significant, highlighting the significant role of experience in current positional disparities. The area under the receiver operating characteristic curve of 0.892 associated with the experienceadjusted full professor model further indicates the importance of experience as a significant variable associated with obtaining a full professor position. Effects of Diversity in Leadership Programs led by a nonwhite chair employed significantly more nonwhite faculty than programs led by programs led by a white chair (nonwhite chair, 42.5 percent nonwhite faculty; white chair, 20.9 percent nonwhite faculty; p < 0.0001) (Table 8). Of the 100 percent of minority faculty working under nonwhite chairs, 30.8 percent were Table 4. Academic Rank and Leadership Positions Position Nonwhite American Association of Plastic Surgeons (1921 to 2018); ASPS, American Society of Plastic Surgeons (1932 to 2018); PSRC, Plastic Surgery Research Council (1955 to 2017). Fig. 1. Distribution of white/black physicians grouped by years of postresidency experience. Brown indicates the number of nonwhite academic plastic surgeons. Green indicates the percentage of white academic plastic surgeons. Blue indicates the percentage of nonwhite academic plastic surgeons. Colored lines and numbers with asterisks highlight the proportion of each cohort that graduated within the past 10 years. Volume 145, Number 1 • Racial Disparities in Academia 273 in the assistant professor position, 33.9 percent were in the associate professor position, and 35.5 percent were in the full professor position. Of the 100 percent of minority faculty working under white chairs, 62.7 percent were in the assistant professor position, 24.6 percent were in the associate professor position, and 12.7 percent were in the full professor position. Programs led by a nonwhite chair compared to programs led by a white chair had a 31.9 percent decrease in the proportion of nonwhites in the assistant professor position and a 22.6 percent increase in the proportion of nonwhites in the full professor position. DISCUSSION Disparities in the representation of minority racial and ethnic groups have been well documented in the academic literature.2–4,20–23 Minority groups interested in academic practice have faced stark challenges obstructing entry into the field and prohibiting advancement to senior academic positions.24–27 For the field of plastic surgery, historic efforts to improve minority ethnic representation have largely proven ineffective. In 2006, minority groups represented 25.1 percent of academic plastic surgeons and 18 percent of plastic surgeon full professors (Table 9). This study found that overall minority representation among academic plastic surgeons has decreased by 0.4 percent, but that representation at the full professor position has remained nearly constant. However, among underrepresented minorities—African Americans, American Indians, and Latino Americans— overall representation in academic plastic surgery has improved 0.3 percent for African Americans and 1.7 percent for Latino Americans since 2006. Representation among Asian Americans in academic plastic surgery has further improved from 10.9 percent in 2006 to 17.7 percent in 2018, with Asian Americans now constituting 71.7 percent of minority academic practitioners.9 The role of field experience in attaining greater academic positions has been frequently acknowledged but rarely explored.28,29 In measuring years of postresidency experience, this study highlighted the role of experience inequalities in many of the positional disparities observed among minority groups. Rising minority experience, despite decreasing diversity among academics, may Table 6. Median Years of Postresidency Experience, by

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25