key: cord-0783817-5clw0nur authors: Kim, Eliana E.; Klein, Andrea L.; Lartigue, Jean W.; Hervey-Jumper, Shawn L.; Rosseau, Gail title: Diversity in Neurosurgery date: 2020-09-03 journal: World Neurosurg DOI: 10.1016/j.wneu.2020.08.219 sha: 4328af89f3e7ee724f068ccc73b19b8b1c6b31f7 doc_id: 783817 cord_uid: 5clw0nur Over the past century, the field of neurosurgery has evolved and expanded in various directions. Neurosurgeons have continuously pushed the boundaries of the specialty with scientific discovery and innovation. A diverse array of neurosurgical techniques, treatments, and new areas of study have emerged within the field. Meanwhile, the neurosurgical workforce has stayed demographically homogeneous throughout time. Certain groups remain underrepresented due to systemic barriers based on social identities and categorizations including gender, race, ability status, and others. In this paper, we highlight some of the underrepresented groups in neurosurgery and chronicle the important contributions and achievements that individuals from these groups have made in the field despite structural barriers and discrimination. We present evidence from the basic sciences, economics, business, and other disciplines that illustrate that diversity is not only just but also the most rational pursuit for positive growth and advancement. Diversity is needed to enrich the specialty and augment its capacity to serve the heterogeneous population of patients that reflect our society. In order to promote equity and diversity in the field, there need to be ongoing deliberate, organized and systematic efforts to change the status quo and make the field more inclusive. Neurosurgery has experienced tremendous growth over the past century since its beginning as a new specialty. 1 Its history is filled with pioneers who have expanded and diversified the field in a multitude of directions, harnessing advancements in scientific knowledge and technology to devise innovative solutions and treatments for neurosurgical conditions. The wide breadth of subspecialties that have emerged within the field -from pediatric neurosurgery to neuro-oncology, functional neurosurgery, endovascular surgery, peripheral nerve surgery, traumatology, skull-base surgery, and to spine surgery -reflect the great diversity with which the neurosurgical practice has evolved over time. The neurosurgical workforce is also progressing towards diversification, as individuals with increasingly heterogeneous backgrounds and identities are entering the field. In this paper, we recognize some of the underrepresented groups in neurosurgery and highlight individuals from these groups who have excelled in the field despite structural barriers and discrimination. We demonstrate data from the basic sciences, economics, the military and other fields that illustrate the universal and essential role of diversity in promoting positive growth and progress. Finally, we present evidence that both justice and excellence require the system-wide promotion of diversity, equity and inclusion in neurosurgery. Not only have women made significant contributions to the field of neurosurgery as leading scientists and surgeons, they have also been active champions for gender equity. In the North American context, the Women In Neurosurgery (WINS) has advocated for systemic efforts to promote recruitment and retention of women in the field since 1989. 9 The Women In Neurosurgery Committee of the World Federation of Neurosurgical Societies (WFNS) has mobilized a global network of women neurosurgeons for advocacy and empowerment. 10 The European Association of Neurosurgical Societies (EANS) has recently established a Task Force on Diversity, spearheaded by Dr. Silvia Hernandez, which works to address gender diversity in neurosurgery in the European context. 11 philanthropist, who was devoted to improving education opportunities for African American students. 16 Sawaya (Syria, Lebanon); Dr. Ossama Al-Mefty (Syria, Saudi Arabia); and many more. Perhaps the great success of these individuals is a reflection of the resilience, strength, and adaptability that they have built through their lived experiences as immigrants. One area of diversity that is not very often discussed in medicine, especially in technical disciplines such as surgery, is the ability status of individuals in these professions. Strict American. 31 The intersection of gender and race leads to more compounded forms of inequity. There are 33 neurosurgeons who identify as African American and female, making up 0.6% of the neurosurgical workforce in the United States. 31 The global situation appears to be similar. [32] [33] [34] Neurosurgeons of various other gender identities and neurosurgeons who have disabilities are so poorly represented in the field that statistics regarding these groups are unknown. quintile. 43 Because the neurosurgical workforce has historically been homogenous, its policies, practices, and cultural norms have been largely formed by and geared towards a specific dominant group. 44, 45 This history is known to have had marginalizing impact on underrepresented groups. In order to promote diversity, equity and inclusion in the field, there need to be ongoing deliberate, organized and systematic efforts to change the status quo and make the field more inclusive. While we acknowledge the particularity of the field of neurosurgery, it is worthwhile to consider the efforts that have been made in other domains to promote diversity. In this section, we draw attention to military, business, and politics, and the lessons these three non-medical fields can provide on diversity. Although the U.S. military as an institution is not a perfect example of workforce diversity and equity, it is worthwhile to examine its diversity agenda and its efforts to promote it. First, the U.S. military has acknowledged that to serve the United States as a nation and protect its best interests, it must recruit and retain a workforce that "mirrors the demographic composition of the nation as a whole." 48 This principle is also relevant to the medical institution which is tasked to provide equitable healthcare to all individuals in society. The U.S. military has also shown that in order to improve diversity, political will at the highest level of an institution is crucial. President Truman's executive order was a catalyst to initiate the process and to the continued efforts of the congress to improve representation of diverse groups both at the global and executive levels of the army. 49 It demonstrated that efforts for diversity and inclusion do not stop at the "membership" level but must also reach leadership. Representation matters; experts believe that when enlisted soldiers see people of the same cultural and ethnic origin as them at the executive level, this encourages them to pursue a military career. 50 Finally, the wide range of army commissions and divisions working on diversity reminds us that promoting systemic change for equity and diversity requires consistent efforts and a dedicated organization as a whole. In business, the notion of diversity and inclusion has emerged naturally with continuous cultural and demographic shifts in companies and consumers in the era of globalization. 51 One of J o u r n a l P r e -p r o o f Kim 11 the most valued effects of diversity is its problem-solving advantage. A group of people with different backgrounds and cultural perspectives tend to come up with more innovative and creative solutions to new situations, according to a Harvard Business Review study. 52 In addition, gender and racial diversity in the workforce has been associated with corporate profitability. Global studies by McKinsey found that companies in the top quartile for racial and ethnic diversity are likely to have financial returns from 15 to 35% higher than the median of their national industry. 53 Research done by the Boston Consulting Group showed that companies with substantial diversity among the leadership and management teams were associated with 19% higher revenue due to innovation. 54 Major companies such as Bain and Booz Allen Hamilton now showcase their commitment for diversity and spearhead conscious efforts to promote diversity and inclusion in company culture. 55, 56 Booz Allen Hamilton now boasts 67% representation of ethnic and gender minorities in its Board of Directors. 56 In addition, ageism is detrimental to business; in fact, the encore careers movement championed by Bill Gates and Michael Bloomberg, among others, has led to stimulating and productive engagement for individuals and corporations alike. 57 Although completely different fields, business and neurosurgery are disciplines that are both driven by teamwork. Qualities such as flexibility, as well as effective problem-solving skills are valued. Cultural competency and humility are also key, especially in effective and equitable provision of health care. Business models clearly illustrate that diverse environments can best foster these qualities. J o u r n a l P r e -p r o o f The importance of diversity in the world of politics was recently showcased through the COVID-19 pandemic. Many observed that countries led by woman leaders tended to orchestrate the most effective and successful responses to this urgent health crisis. 58, 59 The United Nations (UN) has in fact launched an all women-led initiative to mobilize funds to support global response to and recovery from COVID-19. 60 However, this phenomenon is not new: multiple examples illustrate that when women are elected into political positions, they bring to the table critical issues that are otherwise neglected. 61 The UN has found that at a global level, women representation in local governments has led to increased childcare coverage, access to water and sanitation, and policies to address gender-based violence. 61 In addition, studies show that women in politics simply get more work done than men. Female legislators and Congress members sponsor more bills related to women's health. On average, they also pass twice as many bills compared to their male colleagues. 62 But divide your investments among many places, for you do not know what risks might lie ahead. In nature there's no blemish but the mind. None can be called 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 also 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. 73 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." 74 Graham's student, John Templeton, was another tremendously successful investor and follower of the theory of diversification. He advanced the market with globally diversified mutual funds, which further expanded investment options. 75 John Maynard Keynes, one of the most successful investors of the twentieth century, also adhered to this theory staunchly. J o u r n a l P r e -p r o o f A common argument against diversification of the neurosurgical workforce is that this prioritization may compromise the field's standards of excellence. 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. 37 Diversification has objectively demonstrated its capacity to improve performance without jeopardizing the integrity of the system in other occupational environments and it is logical that the outcomes will be the same in neurosurgery. It would be a false assumption that individuals who are different in terms of gender, race, etc. 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. Over the past century, the field of neurosurgery has evolved, expanded and diversified in numerous directions. There is more work to be done to improve diversity within its workforce and augment its capacity to serve the heterogeneous population of patients that reflect our society. Lessons can be learned from other disciplines that illustrate the essential role of diversity in improving performance, stimulating growth, and promoting equity. The case for diversity is rooted on justice but it is also the most rational pursuit, as its benefits are evidenced in 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. A key to this success is diversity. J o u r n a l P r e -p r o o f Jeff Hanson is an artist, philanthropist and entrepreneur. As a result of neurofibromatosis, he is visually impaired. He believes, "Every act of kindness helps create kinder communities, more compassionate nations and a better world for all...even one painting at a time." 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