Letter from the Editor: Otolaryngology Must Address Diversity, Gender Bias

Cultural conditioning shapes who we think we are at any given point in our lives. Few are those who ever challenge or outgrow the beliefs that have been instilled by family and society during those early years.—Mooji

I have always advised students to avoid the doctors’ lounge, especially those filled with pessimistic physicians who talk about how medicine is not what it used to be or reminisce about how the good old days were so much better. Unfortunately, this attitude is non-productive, is highly contagious, and reinforces old biases and behaviors. I worry about becoming one of those physicians. If I resist change in medicine, is it really different this time or am I just getting old?

While I was fortunate to be involved in our specialty’s leadership at a young age, it was obvious at the time that our leaders did not reflect the reality of my medical school experience in Ann Arbor or residency training in Houston.

In March 2007, at the AAO–HNS annual advocacy conference in Washington, D.C., during Richard Miyamoto’s presidency, I attended a meeting of multiple otolaryngology organization presidents. Everyone was discussing issues within the specialty, most of which were focused on clinical topics, specialty politics, or reimbursement problems. Duane Taylor and Lisa Perry-Gilkes, representing the National Medical Association’s otolaryngology section and the Harry Barnes Society, raised concerns about diversity, health literacy, and cultural competency in our specialty. In the room, these topics seemed out of place and were not further discussed. Yet, their comments clearly resonated with the Academy leadership and quickly led to the development of the Academy’s first diversity policy and the creation of the inaugural Diversity Committee. Around the same time, Sonya Malekzadeh and others led the creation of the Section for Women in Otolaryngology. Both groups were immediately given representation in the Academy’s Board of Directors.

When we attempt to avoid change and cling to the ‘way things were,’ we stop moving forward and growing, and we become part of the problem.

These impactful efforts, reflecting the leadership of many people over the years, opened a new era in an important ongoing conversation within our specialty. Unfortunately, the people who would benefit the most from receiving this information are the most likely to ignore relevant communications or close their minds to the benefits of different perspectives, equity, or new ways of doing things. People who are committed to change and moving forward bear the responsibility to learn, teach, and reach out to help others. Together, we need to develop better ways to frame the benefits to bring along those who are not ready. This is how change works, and there is still a lot of work to do.

Life and medicine are continuously changing at a seemingly accelerating pace. When we attempt to avoid change and cling to the ‘way things were,’ we stop moving forward and growing, and we become part of the problem. We need to open our minds, try to understand
perspectives that are unfamiliar or uncomfortable, and embrace change. Change will never end. We will never get “there.” We are fortunate to have many exceptionally talented and inspiring colleagues who can help us along this journey. They encourage us to improve and help us provide more effective care to our patients.

This issue of ENTtoday highlights ongoing critical issues related to diversity/inclusion, gender bias, and health literacy within otolaryngology–head and neck surgery. The articles include interviews with many leaders in our field who are actively addressing these issues. Erin O’Brien’s viewpoint on the gender gap in otolaryngology provides a timely update. She makes the point, which can be generalized to many problems facing the specialty, that leaders need to participate in order to address these issues, and affected groups cannot be expected to achieve parity without the support and effort of those with the power to make changes. Duane Taylor, now the current president-elect of the AAO–HNS, discusses the importance of the well-informed patient and the Academy’s new tools to help physicians and patients.

As a specialty, let’s not get stuck in the doctor’s lounge; as leaders in medicine, we should stay open minded, be active and honest participants in these conversations, embrace change, and drive our specialty forward to its ultimate potential.

Ronald B. Kuppersmith, MD, MBA
Deputy Editor, ENTtoday

ENT Today

How Far Women Have Come in Otolaryngology Compensation Parity and What Needs to Happen Next

On these pages in 2010, Linda Brodsky, MD, discussed the gender gap in compensation and leadership positions in otolaryngology (ENTtoday. February 1, 2010. Available here). How far have we come since she highlighted issues of gender inequity nearly a decade ago?

In the two decades since I was a medical student rotating in otolaryngology, women have made progress in leadership roles in our academic societies and training programs. However, progress toward equity in our specialty has not come quickly enough.

A pay gap still exists in salaries for women in otolaryngology. In 2004, Jennifer Grandis, MD, a professor of otolaryngology–head and neck surgery at the University of California San Francisco, reported a 15% to 20% gender pay gap even after controlling for confounding variables (Arch Otolaryngol Head Neck Surg. 2004;130:695–702). More recent data suggests this pay disparity persists. The 2018 Medscape survey of full-time otolaryngologists found that women were paid $75,000 (19%) less than men. A 2016 study of 10,000 university physicians also found a pay gap for female physicians despite controlling for experience, faculty rank, specialty, research productivity, and clinical volume, with surgical specialties demonstrating the largest absolute adjusted sex differences in salary (JAMA Intern Med. 2016;176:1294–1304) (See “Sex Differences in Physician Salary and Rank in U.S. Public Medical Schools,” below).

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ENT Today

How Otolaryngology Programs Are Working to Create a More Diverse Workforce

Increased diversity among medical professionals helps counteract the fears of racism, inequality, and other issues that may prevent patients of color from seeking out health care. A more diverse workforce also helps healthcare professionals learn from one another as the field expands to include people with differing backgrounds and perspectives.

For David Brown, MD, associate vice president and associate dean for health equity and inclusion and associate professor of otolaryngology-head and neck surgery at the University of Michigan Medical School in Ann Arbor, diversity’s benefits are rooted deeply in his career. He recalled a story one of his African-American residents told him when the resident first had to perform a tracheotomy on a child as an early-career otolaryngologist. The resident went to introduce himself to the patient’s family before beginning the procedure. Seeing that the resident was a person of color like themselves “created a sense of relief and trust,” he said.
“Seeing me, they said they didn’t feel like their child would be experimented on,” the resident told him.

Many marginalized communities have distrust of the healthcare system.“Having people who share their identities helps to foster stronger trust and communication and can lead to fewer healthcare disparities,” Dr. Brown added. Physicians of various ethnicities can help patients feel more comfortable, believing that the provider more fully understands their own cultural perspectives. Without that understanding, a patient’s lack of trust can be perceived as refusal to adhere to a physician’s orders.

As a result, “I no longer call a patient a non-compliant patient; if they don’t show up, you need to ask why,” said Dr. Brown. “Sometimes, they have transportation issues or there’s been a death in the family. If you are more open and more inclusive, you can find out more of the root cause, rather than just assuming they didn’t show up because they are ‘bad’ people.”

Efforts by medical schools and specialty associations and organizations to increase diversity helps build understanding among different groups of people, as well as improve the field of otolaryngology overall. Candidates with different backgrounds, perspectives, and experiences begin to fill the pipeline into medical schools, residencies, fellowships, and beyond.

“I would say [the subject of diversity] has become more front and center in the last few years, because the Accreditation Council for Graduate Medical Education has made it a priority to ask about the diversity composition of resident trainees,” said Cristina Cabrera-Muffly, MD, associate professor and residency program director in the department of otolaryngology at the University of Colorado School of Medicine in Aurora. “Unfortunately, otolaryngology has one of the lowest rates of underrepresented minorities (URM) among medical and surgical residencies.”

Diversity in the Workplace

Top Row: Carrie Francis, MD; David Brown, MD; Zainab Farzal, MD. Bottom Row: Cristina Cabrera-Muffly, MD; Duane Taylor, MD; Oneida Arosarena, MD

Top Row: Carrie Francis, MD; David Brown, MD; Zainab Farzal, MD. Bottom Row: Cristina Cabrera-Muffly, MD; Duane Taylor, MD; Oneida Arosarena, MD

The benefits of diversity in all workplaces, not just medicine, have been publicized. In 2013, the Harvard Business Review reported that diversity, both inherent (including the characteristics one is born with such as gender, ethnicity, and sexual orientation), and acquired (traits such as knowledge learned while living outside the country where one was raised), “unlocks innovation and drives market growth—a finding that should intensify efforts to ensure that executive ranks both embody and embrace the power of differences,” wrote Sylvia Ann Hewlett, the lead author of the study (Harvard Bus Rev. Published December 2013.).

A 2018 study of diversity in venture capital firms, also published in the Harvard Business Review, found that “diversity significantly improves financial performance… and even though the desire to associate with similar people—a tendency academics call homophily—can bring social benefits to those who exhibit it, including a sense of shared culture and belonging, it can also lead investors and firms to leave a lot of money on the table,” wrote lead author Paul Gompers (Harvard Bus Rev. Published July 2018. Available at: hbr.org/2018/07/the-other-diversity-dividend). And, finally, a 2004 study published in the Proceedings of the National Academy of the Sciences found that “groups of diverse problem solvers can outperform groups of high-ability problem solvers” (PNAS. 2004;101:16385–16389).

“From a social justice standpoint, increasing diversity in the physician workforce has been shown to reduce health disparities,” said Oneida Arosarena, MD, associate dean for diversity and inclusion at the Lewis Katz School of Medicine and a professor of otolaryngology at Temple University in Philadelphia.

What is medicine, and otolaryngology in particular, doing to address diversity in the field?

Diversity in Education

Different academic institutions are taking similar approaches to identifying the best candidates for their medical schools, even when those applicants might not be obvious by traditional measures. At Temple University, which in 2015 established its office of health equity, diversity and inclusion, a diversity council works among all members of the health system community to help address concerns among racial, ethnic, and gender minorities, and also implemented implicit bias training for the medical school’s admissions team. As a result, applicants are considered for admission under holistic review, which analyzes everything about a candidate, rather than merely looking for high marks on standardized tests.

“Traditional medical school and residency committees would just screen people with a cutoff based on a score on the MCATs or USMLE Step 1 test,” said Dr. Arosarena. “But by doing that, you really eliminate people who are great candidates but are not great test takers. Instead, we look at grades as a measure of academic performance, leadership qualities such as whether the candidate was involved as a leader in sports or other organizations, and also humanitarian qualities, such as how involved they were in the community.”

The process also considers how far a candidate has come to achieve what they have achieved. “If both your parents are doctors, it’s not so great a stretch to think you might be a doctor,” said Dr. Arosarena. “If you come from a single-parent and/or a low-income home, you had a lot to overcome to get to the point where you are applying to medical school.”

Holistic review takes longer than simply scanning through test scores for acceptance, and it requires more people to sit on the application committee. But more voices in the process produces a more diverse group of accepted applicants. In 2016, when Temple began using holistic review, there were six accepted URM applicants, out of a total of 210. Today, classes average between 20 and 30 URM.

The University of Michigan Medical School in Ann Arbor is currently three years into a five-year diversity, equity, and inclusion plan to improve diversity at every level so that the climate is more inclusive of all people, said Dr. Brown. Various initiatives, such as training in unconscious bias and other educational efforts, grants for diversity projects by different members of the Michigan community, and mentoring opportunities, all help to increase awareness about the importance of a diverse academic community. All medical departments are asked to attend the Student National Medical Association’s (SNMA) annual conference, where medical students can learn more about different clinical opportunities with the medical school. The students have the opportunity to work through medical simulations alongside Michigan medical faculty and residents.

At Michigan, about 20% of medical students each year are URM, said Dr. Brown, and that number has gone up about 1% each year for the past four years. The percentage of URM residents has doubled in the past three years, from 3% to 6.5% identifying as Black, Latino, Pacific Islander and/or Native American, he added.

Diversity in Otolaryngology

Otolaryngology, like other specialties, is eager to attract the brightest people to the field. To that end, there are several initiatives from organizations such as the Society of University Otolaryngologists (SUO) and the American Academy of Otolaryngology–Head and Neck Surgery (AAOHNS).

Mentoring, coaching, and early exposure to the field of otolaryngology help bring more ethnically and culturally diverse talent and voices into the otolaryngology field, said Carrie L. Francis, MD, SUO’s diversity chair and associate professor and assistant dean of student affairs in the department of otolaryngology, head and neck surgery at the University of Kansas Medical Center in Kansas City. “Having an otolaryngology presence in medical school is helpful and harkens back to early exposure.” The society does this by developing relationships with various medical student associations and historically Black colleges such as Morehouse and Meharry Medical College as well as the SNMA and the Latino Medical Student Association.

Dr. Cabrera-Muffly cites mentoring as a way to increase diversity in the field of otolaryngology. “It’s important at all levels of the pipeline,” she said. “We need to mentor students to join our field, provide support to residents during their training, and ensure continued mentorship for URM faculty so that they will stay in academics to be examples for the next generation.”

Mentors needn’t be minorities themselves, either, she added. “As a Latina in otolaryngology, my mentors have not all been female or Latino, but they have made a huge impact in my life regardless.” Irrespective of their background or ethnicity, a senior-level person who has made her/his way through the otolaryngology field has a lot to offer earlier-career otolaryngologists. “Most senior faculty are not URM, but chances are that they will be in the position to mentor URM students and residents as the numbers increase.”

Without those increases, “we are doing a disservice to our patients and we are leaving talent on the table,” said Dr. Cabrera-Muffly. “If we discriminate against any group, we leave out the potential world-changing contributions of that group.”


Cheryl Alkon is a freelance medical writer based in Massachusetts.

Key Points

  • Efforts to increase diversity help build understanding and improve the field of otolaryngology overall.
  • Academic institutions are implementing implicit bias training for medical school admissions teams.
  • Mentoring, coaching, and early exposure to the field help attract more ethnically and culturally diverse talent and voices.

Ways to Increase Diversity in Otolaryngology

  1. Implement implicit bias training for medical school admissions teams: Doing so helps widen the scope when considering candidates for medical school admission. Holistic review, a process that analyzes everything about a candidate and not merely high marks on standardized tests, can help identify diverse candidates who can show a clear interest in medicine or ripe potential that may not be obvious if test scores and grades don’t meet a specific measure.
  2. Make mentoring a priority: Formal relationships between senior and junior-level otolaryngologists is a crucial way to help bring more diverse people to the field, though if collaborations happen on their own, that is fine, too. “Some of the best relationships happen organically, but we can assign them until people find their own mentors, because it’s important for all leaders to provide mentorship,” said Cristina Cabrera-Muffly, M., associate professor and residency program director, department of otolaryngology at the University of Colorado School of Medicine. “As a Latina in otolaryngology, several of my mentors have not been female or Latino, but they made a huge impact in my life regardless.”
  3. Find opportunities to showcase early exposure to otolaryngology as a specialty: SUO has developed relationships with historically black colleges and minority student organizations so that there is an SUO presence at annual national conference and regional events, said Dr. Francis. Having SUO available as a resource for earlier career medical students allows them to learn about the field of otolaryngology and to have enough information about it to properly consider it as a specialty.—CA

The Drawbacks of Lower Rates of Diversity

Without concentrated efforts to increase diversity in the otolaryngology field, let alone in medicine itself, the profession won’t reflect the patient population it serves and won’t benefit from new ideas that come from different perspectives, experts say.

That ultimately limits opportunities for both patient care and research and widens health disparities across different populations.

“If we don’t do it, we will do the same old things and hear the same old voices,” said David Brown, MD, associate vice president and associate dean for health equity and inclusion and associate professor of otolaryngology-head and neck surgery at the University of Michigan Medical School in Ann Arbor.

Michigan’s intent is to take the best care of patients and attract the best in the field for career opportunities. “If we are seen as monolithic, and people feel they are different, they won’t have a sense of belonging and won’t want to be a part of the team,” he said. “Instead, we want to make it so that anyone can be a part of our team.”

Efforts to identify promising candidates for medical school, residencies, fellowships, and medical careers should be intentional. “The medical profession loses out on the richness of what makes us different” if diversity isn’t encouraged, said Carrie L. Francis, MD, SUO’s Diversity Committee chair and associate professor and assistant dean of student affairs in the department of otolaryngology, head and neck surgery at the University of Kansas Medical Center in Kansas City. That includes diversity of culture, the richness of thought, “and everything else related to innovation,” she said.

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