The least-diverse specialties in the US

The US is headed toward a majority-minority population, which means that by 2030, less than half of Americans will be non-Hispanic White. Nonetheless, there is a lack of racial and ethnic  diversity and representation among US medical trainees, practicing physicians, and academic leaders.

In addition to lack of racial diversity in specialty care, women are also underrepresented in various fields. Although the number of female physicians has grown overall, they tend to specialize in the care of children, women, and families, and to not enter fields like surgery.^[]

Least-diverse specialties

According to the AAMC’s Physician Specialty Data Report, which highlights the number of practicing physicians, residents, and fellows by demographic data, women are poorly represented in orthopedic surgery, thoracic surgery, and neurosurgery and represent 5.9%, 8.3%, and 9.6% of these fields, respectively.^[]

Outside of the surgical specialties, women are better-represented and make up just greater than 50% of fields like dermatology, geriatric medicine, and endocrinology. In OB/GYN, they make up 60.5% of the workforce, as well as 65% in pediatrics and 54.6% in child and adolescent psychiatry. 

Like women, minorities are poorly represented in surgical specialties. For instance, only 4.2% of neurosurgeons are Black; that number is 2.7% for otolaryngologists and 3.2% for orthopedic surgeons.

Understanding underrepresentation

Although there is limited evidence regarding underrepresentation in medical specialties, various causes have been suggested.

With regard to diminished female representation, gender discrimination and concerns over work-life balance could play a role in specialty choice, according to the authors of an article in Medical Education Online.^[] Women could also prefer continuity of care and long-term patient care. Other factors could be related to test scores, grades, and research-related activities (eg, publications and presentations).

These researchers conducted a study on which factors might account for underrepresentation of women in the largest medical specialties. They found that female trainee representation was correlated with three specific factors: a higher percentage of female faculty, higher average board scores, and exposure as part of the third-year core rotations.

As for racial and ethnic underrepresentation, researchers publishing in JAMA Network Open found that ethnic representation was most robust across specialties among White and Asian applicants to residency, whereas it was least evenly distributed among American Indian, Alaska Native, and Black applicants.^[]

In these contexts, a phenomenon called occupational sorting is at play. Occupational sorting refers to a systemic pattern of worker distribution across occupations according to demographic factors. These demographic factors frequently arise from discrimination and segregation, as well as resource allocation among minority physicians.

“The finding that racial and ethnic representation across specialties was most unevenly distributed among American Indian or Alaska Native and Black applicants suggests a complex racialized occupational sorting process that reinforces societal inequities within the physician workforce,” the authors wrote.

“The variable sorting of Black students, who are already overrepresented among those economically disadvantaged, into medical specialties that are less lucrative may perpetuate economic and racial inequities within the physician workforce, further amplified by racial disparities in earnings within specialties.

"Beyond the inequities within the physician workforce, these disparities in representation may have second-order consequences for patient access to subspecialty care, given that [underrepresented in medicine] medical students and physicians are more likely to report an interest in serving underserved communities,” they added.

Efforts to support diversification

Because outside forces often influence an applicant’s decision of specialty, mentorship programs through professional organizations are designed to support the inclusion of  ethnic minorities and women. One example, cited in the JAMA Network Open article, is Nth Dimensions, which is a nonprofit organization that focuses on increasing the numbers of female and underrepresented minorities in medicine. This program offers minority students exposure to surgical specialties during the first summer of medical school via internship and formal mentorship opportunities.

Minority specialists, however, have described their involvement in such diversity measures as a “minority tax,” which incurs further responsibilities and duties in an already busy schedule.

Although internship and mentorship opportunities aimed at women and minorities are positive steps forward, some experts call for more radical change. Publishing in Otolaryngologic Clinics of North America, authors noted racial bias in metrics used for residency selection, including Step 1 scores, clerkship grades, Alpha Omega Alpha membership, and number of publications.^[] Moreover, these measures did not predict residency success. Putting too much weight on these criteria may exclude Black medical students from matching into otolaryngology, per the authors.

“Residency interview selection should include a more holistic review of medical students’ applications, implicit bias training for residency selection committee members, and intentional reviews of Black medical students’ applications to identify candidates with qualifications that align with the department’s goals, including the goal of increased diversity,” the authors wrote.

“In order to intentionally increase the number of Black physicians in the specialty, one must take active steps to recruit and mentor Black medical students through outreach in the first and second year of medical school, mentoring, and funded research and clinical opportunities,” they recommended.