Diversity in Neurosurgery

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- Hello, ladies and gentlemen, and thank you for joining us for another session of the Virtual Operating Room. Our guest today is Dr. Gail Rosseau from George Washington University. Gayle is a clinical professor of neurosurgery there. And I have to definitely mention this important note that she has been chosen as the humanitarian award winner by the WNS for 2021. You know, Gail, that award truly encapsulates your immense contributions to neurosurgery, what you have done for so many people. And I'm so absolutely proud to have you with us today. As we know you have been with us for two other operative sessions, including microvascular decompression surgery, as well as pituitary surgery, which definitely documents your expertise in complex intracranial surgery. Today, however, you're gonna talk to us about something extremely important, and that's diversity in neurosurgery. I have two daughters myself, and are very interested in medicine, and I've always been a big advocate of women and minorities in neurosurgery because they add such a new dimension for us to provide care to a variety of our patients, and to be able to advance our profession. Their talent is so important. So again, honored to have you with us today, and I appreciate you advising us about diversity and how we can all do better, please proceed.

- Well, thank you very much, Aaron. It's a real honor and a privilege to be with you today. We've been friends and colleagues for many years, and I'm just delighted that you've asked me to address your large and growing audience of neurosurgical Atlas, congratulations to you for this fine program that you've provided for education for us all. I am happy to be talking with you about diversity in neurosurgery. It's a different topic than you and I have addressed before as you said, but it's very timely and very important. And I want to give credit both at the beginning and at the end of this talk to the diverse group that put this talk together and the papers and chapters and all of the written material that accompanies this, that has been published. So shout out to them and I'll introduce them at the end. And it would just not be right to mention one of the giants of neurosurgery, global neurosurgery in particular, whom we lost within the last month, Dr. William Harkness from the United Kingdom, past president of the ISPN, outstanding neurosurgeon, passionate global surgery advocate and also really a devoted friend. I give my heart felt condolences as all of you I'm sure do to his loving family, he will be missed and we will carry on the many initiatives that he started in global neurosurgery. Well, I want to be sure that those in the audience who are residents know where this idea came from, certainly as a woman neurosurgeon over these last three decades, I've been aware of being a minority, but I haven't really focused on the diversity aspect of my practice, but this fellow Dr. Agawal is currently chief resident at the University of Pennsylvania, University of Pittsburgh. One of my alma maters contacted me last year, and probably many of you in the audience about a book idea that he had in mind called "Surviving Neurosurgery". And he randomly assigned me to write a page or two about diversity, obviously because I was a woman, but I decided to expand upon his offer and assemble a diverse group of authors and really explore this theme. And this was well before black lives matter and the manifestations that we all witnessed last summer, but that's what makes it timely. I want to give a shout out to this chief resident who made us all think long and hard about this topic. So based on his invitation, the book is still in press, but we put together our initial investigations into diversity in neurosurgery in this publication from World Neurosurgery in September. And my talk is based upon that. There are a couple things that unify us all. I think we can all agree that we need the best possible people to come and join us in this profession that we love. And the point of this talk and the point of reaching toward diversity in neurosurgery is that I believe the evidence shows that a key driver of excellence and innovation in our field, as well as in others is diversification. That's what I'll try to convince you of in the next few minutes we have together. So our outline for presenting it is this. First we'll talk a bit about academic neurosurgery and its history of diversity, some other diversity issues within neurosurgery then, because we don't always have to reinvent the wheel. We'll see what we can learn from other professions. And then we'll see what the benefits of diversity are when we examine economic or ecological systems. Well, first of all, academic neurosurgery. Now we all know that you can't get very far in academic neurosurgery without being involved with getting support from the NIH. And so lest you think that diversity is just being nice or what nice guys and gals do, the NIH takes diversity seriously and it's part of their funding schema and their support of academic investigations. So this is just a mosaic of screenshots from the NIH website. I encourage you to go to it, but the NIH is committed as you know, to discovery. And so what they have found is that there a science behind diversity and that diversity actually leads to innovation. So the NIH is actively studying this topic, finding ways to mitigate obstacles to scientific discovery that are based upon lack of access for diverse members of scientific communities. They're looking at things like institutional bias and implicit bias so that we can get beyond those, not just because it's the nice thing to do, but because we want to advance science and we need the best minds available to do that. Well, what about neurosurgery? Now, you can make the case that neurosurgery has always been diverse. Look at this picture, this very early picture of the members of the Harvey Cushing Society, which became our American Association of Neurological Surgeons. Dr. Louise Eisenhardt was not a neurosurgeon. She was a neuropathologist, but she was a renowned expert and well-regarded by her peers even then. She was the first woman to be president of the AANS. And as we all know, she was the first editor in chief of the Journal of Neurosurgery. And she led it ably and well because she insisted upon science and did that for many decades. There's been gender diversity in neurosurgery for many decades. So if we start with the first women to do primarily neurosurgery in the United or in the, in Europe, as in many other parts of the world, it generally started as Harvey Cushing did where you have general surgeons who narrow their focus to neurosurgical cases. And so Dr. Diana Beck in the UK, Dr. Sophia Ionescu and Romania were general surgeons who really through most of their practice limited their practice to neurological surgery as Harvey Cushing did. The first woman to be board-certified in the world in neurosurgery was Dr. Altinok from Turkey who was board-certified in 1959. Well, I'm proud to say that the first woman to be board-certified in neurosurgery in the United States was at my own alma mater, my current institution, George Washington, that was Dr. Ruth Kerr Jakoby, who was trained by Hugo Risley in 1961. And then we go to other parts of the world to see how this trend of women going into neurosurgery continues. So we have the small, but mighty TS Kanaka, all 4'11 of her, who is board-certified in India in 1968. You have Dr. Alexa Canady, the first African-American woman to be board-certified in the United States and note that she was certified a full 23 years, more than a generation after Dr. Kerr Jakoby. So interesting to see how that intersectionality makes things even more difficult for people who represent two minority groups. And then my good friend, Najia El Abbadi who was the first woman Professor of Neurosurgery in Africa, as recently as 1994. Well look at this group with me in the front row, can't believe the big hair and the young phase, but gender diversity in neurosurgery formally started in 1989, when this group of women left a plenary session of a major neurosurgical meeting and for the first time, saw other neurosurgeons who looked like us, we got together socially. And from that was born women in neurosurgery, which developed a charter and became incorporated in the years following 1989. Well progress wasn't particularly rapid, but it was progress. So much so that by 2008, almost two decades later, the AANS board of directors requested a white paper on the future of neurosurgery, wanting to know more about how organized neurosurgery could aid in the recruitment and retention of women in the field. And this paper was written and published in that year. And I want to give a shout out to the then president of the AANS, Jim Bean, who asked to write an editorial about that paper in which he supported the findings. And very importantly, and I think eloquently said that by recognizing these findings of this report, that I've just mentioned that we, the board of directors of the AANS "Acknowledge the need for active measures to ensure that every neurosurgeon enjoys the same benefits and opportunities by dismantling the barriers and offering a hand across the remaining gulfs that separate the privileged from the deserving." So this vantage point on diversity is that it's the right thing to do or the kind thing to do. And it certainly is, but that's not the only reason why we as neurosurgeons should seek diversity. But a few more reasons that echo Dr. Bean's editorial currently only about 6% of ABNS certified practicing neurosurgeons are women, less than 4% are black or African. And then here's that intersectionality that I mentioned with Dr. Canady that if you're both black and a woman, you represent less than 1% of all neurosurgeons. There are systemic barriers to academic profession that have been observed by anybody who's been in neurosurgery for very long. And we see that even as more and more women are entering the profession, and we're getting larger numbers of women, neurosurgery residents in each entering class. We're not seeing the same pace of acceleration for women to be able to advance to full professorship. And then the pay gap, Dr. Cohen mentioned that he has two daughters who are interested in medicine, and certainly any man who is married to a woman in neurosurgery or anyone who has a spouse, who's a neurosurgeon wants to be sure that they are paid a fair wage for their work. And there are these systemic barriers in pay gaps that remain despite the progress that we've made. Well, the progress hasn't only been in North America, the World Federation of Neurosurgical Societies has had a women in neurosurgery group for almost a decade. And you see some of the women who've led it there on your right. The EANS, our European colleagues, started a diversity task force just a couple years ago, but they're doing great work and making the differences and potential solutions known to all of us. Well last year in celebrating the first 100 years of neurosurgery one of the papers that we produced was one that looked back so that we could look forward on the contributions of American women to the field of neurosurgery. This paper was published in JNS. I'm pleased to say that it set off a group of writing and research consortia all over the world so that there have now been during and immediately towards the end of COVID here, papers published on the progress of women neurosurgeons in Australasia, in the Middle East, in Central and South America, multiple papers about European progress and African progress. And I think it's important that we recognize that someone no less stellar of a leader than Robert Spetzler wrote as far back as 2011, that the scant historical literature devoted to women in the field of neurosurgery suggest that not that their contributions are less worthy than their counterparts, but that they had yet to be fully recounted. So here in 2021, a number of papers have been published now that recount that history. Well, let's move a bit from the gender issue of diversity in neurosurgery to the racial issue. Dr. Clarence Greene was the first African-American neurosurgeon to be board-certified and he was in 1953. So as you can see, eight years before Dr. Jakoby. Deborah Hyde was the second African-American woman neurosurgeon after Dr. Canady following her by just one year. And I hope all neurosurgeons, regardless of gender, race, or creed, know about this extraordinary individual, Dr. Latunde Odeku who has been the mentor and the inspiration to many neurosurgeons in the United States and around the world. Dr. Odeku was Nigerian born, but trained at the University of Michigan, graduating in 60 and was board-certified in 61. He's a poet that image of Twilight is from my bedside stand. He is a remarkable thinker, inspiration and excellent neurosurgeon. He has been an inspiration to many of us, including many of our colleagues who in the last year have stood up as African-American black neurosurgeons during the black lives matter protests of last summer and wrote this. "We are in the unique position to speak up against cyclical and eminent public health threats to the black community, fiercely and persistently. Excessive use for police force and violence is a public health issue." And that was signed by most every black neurosurgeon in America that you know, we simply have to use our bully pulpit to stand for justice and equity. And there are other racial issues in diversity too. Dr. Linda Liau, one of the most outstanding neurosurgeons of our time, chairman of UCLA's Department of Neurosurgery inductee into the National Academy of Medicine in 2018. But she will tell you that she regularly has people ask her to bring them coffee, or to help with some task that one would normally not ask the department chairman to perform. And there were other types of diversity as well. There are gender minorities, there are immigrants and geographic transplants. Let's just think of it about what neurosurgery would be if these three individuals pictured here had not immigrated. We may think what we want about immigration to the United States, but neurosurgery has definitely benefited from the presence of immigrants among us. There seems to be something about being tempered by steel and building resilience as an immigrant, that seats itself well with becoming a neurosurgeon. And what about neurosurgeons who are living with a disability? What about their contributions? Well, my good friend Karin Murazsko would be happy to have me presenting her, in fact she's given me her permission. And she talks openly about the fact that her position as a neurosurgeon, who now operates from a wheelchair has made her more sensitive to the needs of others. But it certainly has not in any way impaired her academic progress. She's the first woman to be a professor of neurosurgery and chairman, excuse me, to be a chairman of a department of neurosurgery. And she is respected and admired by all. And what about this? Our colleague from Australia, my friend, Michael, who was actually told as a neurosurgery registrar, that he would have to seek a different specialty because you just couldn't be a neurosurgeon and have a stutter. Well, now we have a president of the United States who has a stutter as well as an outstanding neurosurgeon and many others. And then one of the major speakers at the most recent EANS meeting was a neurosurgeon, who was speaking entirely about his perspective as a wheelchair bound neurosurgeon. So these only contribute to and enhance our ability to be able to communicate with our patients and with one another. So I'll leave Shakespeare who is so eloquent the final word on that phase of our talk. "In nature there's no blemish but the mind, none can be called deformed but the unkind." And then I get older, here's another ism that I'm concerned about, and that is ageism. But truly when you think about it, we are the first generation in the history of the world that is likely to at or after age 65 have up to two more decades of healthy life ahead of us. And as neurosurgeons, generally financial security and how much golf can you play, as much as you may love the sport. There's so much that society and individuals have invested in the career of each and every neurosurgeon that we ought not to have people hang up their scalpel and not participate in the last two or three decades of their lives. So I'm so convinced of that I've started to study those in other fields who do this. And in this invited editorial in JNS, we talked about some of the great examples outside of neurosurgery who have embraced encore careers, notably Bill Gates, who stepped down from Microsoft at age 53, to focus on his philanthropic efforts, which have been the most important to him part of his career and others who have likewise done the same, our mayor, Michael Bloomberg of New York or our General Stanley McChrystal, all of whom have taken on encore careers, have spoken about it, written about it and are finding ways to contribute that are very meaningful, well past the central part of their careers. Well, now what can we learn from other professions about diversity as well? Well, if you look at this quotation from FDR in 1943, he could be speaking today. He said, "Today we are faced with the preeminent fact that if civilization is to survive, we must cultivate the science of human relationships, the ability of all people of all kinds to live together and work together in the same world and at peace." Boy, you could have written that and said that yesterday or today. And it was his vision for the military that was left to his successor, president Truman and Truman famously signed executive order 9981 in July of '48, which segregated the armed forces. And what we found about things like this, these kinds of diversification efforts is that it needs high level political commitment. It must reach the leadership level and longterm policy commitments are required to be able to make a difference. So if you look at the leadership level, we see that the US military has done a very good job in recruiting from diverse groups, from women, from Latin X groups, from African-American groups. But this has not been reflected in promotion to the leadership level so much so that the army pictured here, but every one of the armed forces has a roadmap to diversity, not just in the entrance ranks for recruitments, but all the way up to four star generals. And in order to be certain that those roadmaps are followed, the military, luckily has a congressional research service, and Congress does oversight on this in order to be sure that diversity, inclusion and equal opportunity in the armed services are part of our national culture. Well, now let's shift to business and we examine this in some detail as well. And I'm just giving you the highlights from a year of study of these topics. But what we have learned is that diversity in business improves performance, improves creativity and drives innovation. It increases competitiveness, and it certainly improves customer-employee relationships. So you could look at any of the major consulting groups. This happens to be from BCG Boston Consulting Group, but Booz Allen, McKinsey, Bain all have similar data that you can look up readily. And what they show, now they're not trying to be nice. They're trying to earn money. And what they show is that companies with more diverse leadership teams report higher innovation revenues, and it's significant so much so that there are those who, experts who want to reward CEOs for making diversity targets, either giving top executives a financial incentive to hire and promote black and Latino people, or perhaps to do as was done during the days of South African apartheid to provide a public scorecard that allows employees and shareholders to determine which companies are promoting diversity and therefore be able to have all of us who invest in stocks and mutual funds, be able to put our money where our values are. And then there are recent lessons from politics, responses to the pandemic were generally quite good in fact, very good from nations that had women leaders. And then finally, let's look at some of the benefits of diversity if we examine economic systems or ecological perspectives. So here we are just in the week after Easter, and I'm telling you, don't put all your eggs in one basket. And that is kind of a colloquial way of saying what Harry Markowitz won the 1990 Nobel Prize for. It seems obvious to us right now as investors, but he was the one who worked on the economic theory of diversification, which simply proved that the more types of investments a person has, the more likely they are to have a net gain with lower risk. So if you look at all of these people who have advocated diversification of one's economic portfolio, I admit that the group across the top doesn't look very diverse, does it? But I'm happy to have added the second row, the more current group in colored photographs. And that is a diverse looking group. And that is a group of highly esteemed economists who also champion diversification. And then finally, as we close, what about ecologic diversity? We should ask ourselves the questions. Is it merely chance that there are estimated to be over 5 million species of life on earth? Or is there perhaps some Darwinian advantage conferred to nature herself by the presence of such diversity? So here, there are just simply too many, too numerous peer reviewed studies for me to cite, but there's a common thread here. If one looks at the biodiversity literature, we know that diversity improves the average level of performance of an ecological system. It enhances both the productivity and the stability of that system, and it improves the resilience to negative change, which will always happen and we can often not anticipate. And it lowers the risk of negative outcomes whenever a system is threatened. So if we synthesize all the evidence we've been talking about here, not because it's the nice thing to do, but because we're scientists and we're looking at evidence. Ecology and economics have shown us that diversification increases the likelihood of positive gains and lowers the risk. If we all go back to what we said at the beginning of our time together, that we need the best possible people in neurosurgery. Then I think the evidence demonstrates that excellence, innovation and strength, are greatest with diversification. And with that, I'd like to introduce you to the team that put this together, but we continue to work on it. And it's a very diverse team of young and future neurosurgeons. Andrea Klein from California, Eliana Kim from Korea, Jean Wilguens Lartigue from Haiti, myself and I want to especially thank my good friend and colleague, Dr. Shawn Hervey-Jumper, who is our reviewing author on our papers. And then finally, I want to share with you some elements of just the graphics of this presentation that also represent diversity. So this is Javier Yepp who is a Peruvian student who was getting his master's in graphic design at San Jose State and his thesis was to create this, the unity and diversity flag. And I use it whenever I can, and always with his permission. And then finally, I want to bring your attention to Jeff Hanson, who is an artist and philanthropist extraordinaire. All of these images that have decorated and enhanced our presentation are used with his permission and that of his parents, Jeff has neurofibromatosis and bilateral optic nerve gliomas. And that's why his painting is so vivid in both color and texture. He sees his visual challenge as an opportunity and at age 26, he's well on his way to raising his first $10 million through his art and for the causes that he believes in. So with that, I'd like to thank you. I'll leave you with my email address in case there is anyone who would like to continue the conversation by email. Aaron, thank you very much for this opportunity to be with you and your large audience today.

- Thank you, Gail, tremendous lecture, an extremely important topic, which we sincerely appreciate. Would you mind elaborating on how as neurosurgeons, we can advance the opportunities for women and minorities in neurosurgery? What are the strategies we should keep in mind to cultivate their talent?

- Well, there are number and the answer won't be the same for everyone. If you're a department chair, you can do some things that a fellow resident can't do, but there are, let me start with some things that we can all do. We can all defend those who need defending. We've all been in settings in which someone who is perceived as being the other and of a minority, or even perceived as an inferior status is not believed or is not listened to. This may be a nurse on morning rounds. It may be a junior resident or a medical student on the team, someone who is talked over or ignored or treated without dignity. And I think we can all commit to creating an atmosphere of dignity for everyone, no matter what position we're in, we all lead by example. And we need to be able to advocate for those who are the only one of a group who don't feel that they can advocate for themselves. Now, as we move on in our neurosurgical careers. And that means once you're a PGY two, you start to have some seniority and people look at you. And then as a higher PGY level, and then as a chief resident and as faculty, and then as leaders within neurosurgical organizations, then we start to have arrows in our quiver so that there are positive things we can do going from mentorship to sponsorship, to being a champion for someone and putting some of our own political capital on the line and saying, "I'd like to recommend this person to give this lecture, chair this committee, or take on this event or this project, because I know them. And I know that they can do the job."

- Very much I appreciate that. I agree with you completely that for us to be able to be successful and neurosurgery to be successful, we have to give everyone an opportunity because there's so much talent in the populations you talked about that if we're not able to have them be attracted to neurosurgery, it will be a huge loss for neurosurgery more than anything else. So I think that is really what is absolutely most critical for us to remember that for us to have a inclusive culture drives neurosurgery to be a better profession. And on the way, we also provide better care for our patients. So with that in mind, I want to sincerely thank you, early congratulation for your humanitarian award, which is absolutely so critical for the tremendous work you have done in global neurosurgery. And I'm truly so proud and honored to have you as a friend. Gail, it's a tremendous accomplishment. Thank you for being with us today. And we sure look forward to having you with us again for another operative site.

- That's great. Thank you very much, Aaron. Pleasure to be with you.

- Same here as always, thank you Gail.

- Thank you. Bye now.

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