'Linsanity' in Surgical Oncology?

Asian American Bias Under Scrutiny

Nick Mulcahy

March 06, 2012

March 6, 2012 — There are many Asian Americans in academic departments of surgery in the United States, but only a scant few have achieved the top leadership position of department chair, according to a study published in the March issue of the Annals of Surgery.

Of 383 academic departments of surgery, 8 are chaired by Asian Americans (2.1%), reports study author Don Nakayama, MD, MBA, chair of the Department of Surgery at the Mercer University School of Medicine in Macon, Georgia.

This is a low percentage given the fact that Asian Americans comprise 10.8% to 12.2% of all surgical faculty members, and that Asian Americans have shown great talent in the field; they are the principal investigators of nearly 20% of all National Institutes of Health (NIH)-supported grants in surgery, according to the study.

The study also revealed that Asian American surgical oncologists are more likely to have the right stuff to be department chair.

Of the 8 chairs held by Asian Americans in academic departments of surgery, 3 were held by surgical oncologists.

"If you look at the numbers, if you are Asian American, the likelihood of being the chair of the department of surgery is higher if you are a surgical oncologist than if you are in one of the other surgical subspecialties," acknowledged Quyen Chu, MD, from the Louisiana State University Health Sciences Center in Shreveport, where he is chief of surgical oncology and serves under an Asian American department chair, Benjamin Li, MD.

But uncovering any would-be leadership mojo of surgical oncologists was not the point of the study, explained Dr. Chu, who was not involved with the study but is a friend of Dr. Nakayama, in an interview with Medscape Medical News.

"There is a lack of awareness about this disparity," said Dr. Chu about the underrepresentation of Asian Americans in the leadership circles of surgery in the United States.

The disparity is even more pronounced outside of academic departments, according to the study.

Take the example of the governing boards of professional surgical organizations, of which there are 10. Although there is some Asian American representation on the boards of 3 of the organizations, there are no Asian Americans on the boards of the 7 others. In these 10 organizations, only 2.3% of the board members are of Asian heritage.

Worse yet, there are no Asian Americans on the Boards of Regents of the American College of Surgeons, the American Board of Medical Specialties surgical boards and councils, or the American residency review committees for surgery.

Also, of 302 American surgeons on the editorial boards of 5 leading surgical journals, only 6 are Asian American (2.0%), according to Dr. Nakayama, who searched a variety of databases for surnames common in China, Japan, Korea, the Indian subcontinent, Southeast Asia, the Philippine and South Pacific Islands, and the Middle East.

What's Being Lost

Dr. Nakayama believes that "unconscious bias," which has been described as "the strange juxtaposition of egalitarian attitudes and discriminatory behavior," might be at work. He also told Medscape Medical News that Asian Americans need to become better at networking and gain the "softer skills" related to interpersonal and cross-cultural relations.

Dr. Chu echoed this advice, saying that Asian Americans are in an "incubation period" as an ethnic group, still developing social skills in American culture.

However, by not tapping Asian Americans for leadership positions now, the surgical community, and the country in general, loses out, said Dr. Nakayama.

"It's a great loss to the creativity and vitality of your organization when you don't have everyone engaged," he said. "If you don't have a Yo-Yo Ma or Maya Lin or James Gilbert, you're losing big time," he added, referring to celebrated Asian Americans.

Dr. Nakayama, who is a big fan of professional basketball, might have added Asian American Jeremy Lin to that list.

Dr. Nakayama's study of Asian Americans and surgery leadership has the added and unintentional intrigue of being published on the heels of "Linsanity," the moniker ascribed to the phenomenon of Lin's sudden ascension in the National Basketball Association (NBA) and his emergence as a leader of the New York Knicks.

Lin, a relatively unheralded player who was not drafted by any of the NBA's 26 teams after his graduation from Harvard University in 2010, ended up on the New York Knicks after the start of this year's season. Other players' injuries and incompetence afforded Lin a chance to play point guard, which is also known as the "floor general," and thus is a de facto leadership position.

Lin's outstanding play (he set a league record for the most points in his first 9 games started, eclipsing standards set by many legends such as Magic Johnson) has been followed by millions around the world, including President Barack Obama.

His ascension has also been accompanied by ugly comments in the media, revealing a rarely analyzed element of American race relations: that some appalling slurs await Asian Americans who grab the spotlight unexpectedly in the United States.

We tend to not rock the boat.

In effect, Lin has challenged a number of stereotypes of Asian Americans, including those of being unathletic and not endowed with leadership qualities.

In surgery and medicine in general, said Dr. Chu, stereotypes need to be challenged. "Asian Americans need to let people know we are capable of leadership. We tend to not rock the boat," he asserted.

Glass Ceiling, Discriminations?

The lack of advancement to leadership found in the world of surgery by Dr. Nakayama occurs "all across the American academy," said Ved P. Chaudhary, PhD, a volunteer coordinator of the 80-20 National Asian American Political Action Committee. Dr. Chaudhary is a retired assistant commissioner of the New Jersey Department of Environmental Protection.

"Asian Americans are well represented in graduating classes, postgraduate schools, doctoral degrees, and in entry-level faculty/staff positions in American academics, but face barriers in upward career progression in higher echelons of academic hierarchy. This is also true in the private corporate world, in government departments, and in the judiciary," he told Medscape Medical News in an email.

Dr. Nakayama does not know whether Asian Americans are underrepresented in leadership roles in other medical specialties. "I am told that it's not that way in ob/gyn from colleagues." However, Asian Americans are definitely underrepresented in surgery leadership, compared with women and blacks, according to Dr. Nakayama.

Asian Americans should replicate these groups' efforts, he suggests.

"An organization of Asian American surgeons may be helpful, in a way similar organizations have supported women (Association of Women Surgeons) and African Americans (Society of Black Academic Surgeons) in their professional development in academic surgery," he writes.

An official at the NIH has raised the possibility that Asian Americans are being discriminated against.

"There's an appearance of a glass ceiling, which is troublesome. It makes you wonder if there's an inherent bias," said Michael Gottesman, MD, who heads the NIH's intramural research program, in an article on the subject published in Science (2005;310:606-607).

Of course there is bias, said an American expert in the history of both medicine and immigrant groups.

This is an old story.

"This is an old story — that there are broad patterns of discrimination in medicine, targeting a particular ethnic group," said Alan Kraut, PhD, professor of history at American University in Washington, DC. He reviewed the Dr. Nakayama's study at the request of Medscape Medical News.

He cited the example of Eastern European immigrant Jews in the 1920s and 30s, when discrimination was much more blatant than anything going on today. For instance, such Jews could not hold staff positions at hospitals and could not even refer patients to some institutions, said Dr. Kraut. Jewish hospitals in major metropolitan areas in the United States were started in part because of this discrimination.

The good news is this passes.

Dr. Kraut, who is also a big fan of the NBA and has been thrilled by the Jeremy Lin story, offered hope. "The good news is this passes," he said about ethnic discrimination.

Both Dr. Nakayama and Dr. Chu wonder when that passing might occur. Asian Americans have been prominent in American academic surgery for the "past 50 years," observes Dr. Nakayama in his study.

But 50 years is "not such a long time," said Dr. Kraut, explaining that it is potentially the time span of just one professional career.

"It takes a long time to do the kind of networking and developing of social skills to arrive at the top of professional institutional life," he said. "People have to be comfortable with you. It's about being liked as well as respected."

Ascension is "a process of cultural adjustments," Dr. Kraut explained. For instance, "Jeremy Lin chest bumps and fist bumps; he has absorbed the African American contribution to basketball comportment."

Dr. Nakayama agrees that Asian Americans in the ranks of surgery need to make adjustments. "More Asian American surgeons need to join local and regional organizations," he suggested as a key starting point. There has been some progress in this arena, said Dr. Nakayama. For example, the percentage of active members of the Society of University Surgeons who are Asian American is now at 15.6% — a healthy proportion that is in keeping with their overall presence in the profession.

Dr. Nakayama, Dr. Chaudhary, and Dr. Kraut have disclosed no relevant financial relationships.

Ann Surg.2012;255:583-588. Abstract

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