Surgical societies provide tremendous opportunities for developing professional connections, career advancement, participating in scholarly activities, and dissemination of knowledge on excellence in patient care. It must therefore be a priority for academic surgeons to join societies whose mission statements, objectives, and efforts coincide with their own.

Recent events in society, especially the increases in awareness and visibility of structural racism, discrimination, and violence, have led to an unprecedented era for the surgical field as a whole, and in particular for professional surgical societies. It has been clear for some time now that addressing these systemic issues has not been prioritized, and that the growth of under-represented in medicine (URM) groups in trauma surgical societies has stagnated compared to other initiatives.

Twenty years ago, the idea of surgical societies identifying and empathizing with long-marginalized groups was unheard of. Following the disastrous events of September 11, 2001, Muslims in the USA saw a progressive rise in Islamophobic rhetoric, yet little was ever done to address the plights of those surgeons identifying with this community [41]. In sharp contrast, many surgical societies stood up in defense of the Asian American Pacific Island community when recent anti-AAPI sentiment flared during the coronavirus epidemic [42, 43].

On April 21, 2021, Dr. Richard Bosshardt, a plastic surgeon, made the decision to rescind his Fellowship of the American College of Surgeons (ACS) after nearly three decades holding the title of FACS [44]. He made public his disagreement with the ACS’s commitment to anti-racism and instead advocated for a dated concept of meritorious selection of “excellent” surgeons, failing to recognize his own implicit biases. It came as a shock to the entire medical community, which for many decades has worked hard to address structural sources of bias and discrimination within their communities. His announcement had an important implication: that even though the last few years have seen many surgical societies showcase efforts to spearhead the cause of DEI in the field of surgery, some individuals subscribe heavily to the notion of meritocracy or fail to acknowledge the existence of bias.

A Historical Perspective

Great leaders demonstrate the values of an organization with their actions and their words and understand that stagnation within a profession will ultimately render that society irrelevant. To gain an understanding of the past, present, and future of our professional societies in terms of DEI, we reviewed the published presidential addresses of the three most prominent trauma societies—the American Association for the Surgery of Trauma, the Western Trauma Association, and Eastern Association for the Surgery of Trauma.

The American Association for the Surgery of Trauma was founded by 14 “patriarchs” in 1938 [45,46,47]. The first PubMed indexed presidential address is from Dr. Basil Pruitt in 1983, when he notably used no gendered pronouns when outlining a future for trauma surgeons [46]. The following year, Dr. Sheldon stood out as one of the first in our profession to highlight diversity in the surgical field, positing that the practice of surgery would be altered by more women and fewer foreign medical graduates in the profession, and noted that it was “very positive” that “women and minorities now comprise approximately 35–40% of all medical students” and would soon “hold prominent leadership roles in medicine” [48]. Unfortunately, just 1 year later, Dr. Mulder closed his presidential address with a lesson he had learned about “the important role of a wife in any surgeon’s life and particularly in the life of a trauma surgeon,” thus limiting the profession once again to a male and heteronormative view [49].

Over a decade later in 1998, the first woman president of the AAST, Dr. Ledgerwood, after recounting how her service as the AAST women’s liaison to the American Medical Association led to her being implicated in the distribution of “female sexist material,” said she would “have no further commentary regarding women and membership in the AAST” [50]. The following year, however, Dr. Richardson did briefly acknowledge increasing gender diversity in the profession [51]. Dr. Jurkovich’s 2009 presidential address marked the first time that gender diversity was mentioned explicitly, even if only as a passing observational remark [52]. He spoke of how “identity” could “limit you from becoming who you were meant to be,” just as how explicit and implicit biases against one’s innate traits can lead to professional inequities [52]. His words aligned well with contemporary discourse.

The association’s first Black president, Dr. Britt, an inspiration for many who feel underrepresented in our profession, did not touch upon diversity, equity, or inclusion, and similar themes also followed during the address of Dr. Mackersie [53, 54]. A shift in perspective was finally noted in the 2015 presidential address by Dr. Scalea, when he cited the book The Greatest Generation by Tom Brokaw about the men who fought in World War II. Dr. Scalea made an analogy between the current generation of trauma surgeons to his generation, in that though great, they allowed “racism to exist way too long, and did not embrace women in the workplace” [55]. Later, as only the second woman president of the organization, Dr. Rozcyki spoke of generational diversity in the association’s membership for the first time [56]. In his 2017 presidential address, Dr. Coimbra spoke of how he as an immigrant came to live the “American Dream” through the support of his mentors [57]. He went on to share his gratitude to 29 of his peers, all leading trauma surgeons among whom were two Black men and three women, and 18 of his mentees, younger trauma surgeons among whom were four women and three Asian men. Though his story clearly paid homage to an increasingly diverse profession, it also showed that while women and Asians are on the rise, Blacks continue to fall behind in medicine.

The Western Trauma Association (WTA) was founded in 1970 by four White male surgeons who envisioned meetings at ski resorts [58]. The association’s early programming was marked by male and heteronormative content, including the male members’ wives being part of a “Ladies” Ski Movie and Style Show [59]. In the following years, the association transitioned to become more academic, but DEI were not considered priorities during this period. During his presidential address, Dr. Ernest “Gene” Moore lauded the “diverse group of medical specialists” comprising the organization without once mentioning women, under-represented minorities, or other excluded groups [58]. His reference to diversity meant private versus academic practice and surgical specialty. Two years later when WTA president Dr. Pierce gave his presidential address on “every surgeon’s specialty,” every surgeon with few known exceptions was a White, heterosexual male [60]. In his 1996 presidential address, Dr. Cogbill proposed an “inclusive” definition of trauma careers but by this, he meant inclusive of various biomedical lenses for the care of injured patients [61]. Finally, the following year, Dr. Benjamin clearly stated that sexism should be rooted out for the sake of education [62]. However in 1999, Dr. Hebert’s presidential address analogized the WTA membership to the nurturing of grapes into fine wine varietals, but he mentioned no unique demographic characteristics or lived experiences of trauma surgeons who were nurtured into WTA members [63]. Although Dr. Rozcyki broke many glass ceilings in the profession of trauma surgery, her 2009 address on the bidirectional joys of mentoring relationships did not make reference to the leaky pipeline issue in many science, technology, engineering, and medicine professions attributed to race and gender discordance in such relationships [64,65,66].

The Eastern Association for the Surgery of Trauma (EAST) was founded by Drs. Howard Champion, Kimball Maull, Burton Harris, and Lenworth Jacobs out of a need to diversify and combat the ageism that was present in the AAST at the time, envisioning a forum for “young surgeons to be creative and generate and discuss ideas” [67]. Given historical trends of Black representation in surgery, the creation of such an organization opened the door for Black surgeons like Dr. Jacobs to lead a major surgical society. Subsequently, addresses by Drs. Harris and Champion addressed the issue of retaining and recruiting EAST members, but diversity of membership and inclusivity beyond overcoming ageism was not yet part of the organization’s ethos. [68, 69] The organization’s second Black president, Dr. Cunningham referred to his Jamaican heritage and Colin Powell along with a number of Black athletes such as Tiger Woods, Michael Jordan, Muhammad Ali, and Marion Jones in his discussion of heroism. He noted that “EAST should come to be known as an organization that “leverages diversity” by cultivating opportunities through different kinds of people” [70]. In her presidential address, more than 20 years after the inception of the society, Dr. Nagy, the first woman president of EAST, discussed the growth of the organization both in scope and in membership. In citing multiple statistics on the make-up of the organization, she did not mention race, ethnicity, gender, or religious affiliation instead focusing on age, geography, and training level distribution of membership. [71] It was not until 2019, however, that a leader of EAST explicitly took on the cause of equity, diversity, and inclusion. Dr. Bernard expressed his call to action for an organization whose founding members had developed “an association based upon congeniality and concern—for our patients, for each other, for the future of trauma surgery” [72]. He defined diversity and inclusion and noted that effective leaders ensure that everyone on their team has a sense of belonging and meaning. He provided empirical evidence about the gender gap in compensation, advancement, education, and responsibilities at home. He spoke of an institutional culture where “subtle but very powerful cultural norms, accepted behaviors, and nonverbal messages” exist [72].

To a large extent, these historic trends in the leading trauma organizations paralleled those of American society at large. It was not until recently that these professional societies took sincere steps forward in terms of DEI.

Recent EffortsAmerican College of Surgeons Committee on Trauma (ACS COT)

The ACS COT has recognized that diversity in society is not mirrored in the surgical workforce and leadership, and in 2019, the ACS COT released a position statement on equity, diversity, and inclusion to that effect, and most recently reaffirmed this commitment by releasing a statement of solidarity with the American Asian and Pacific Islander (AAPI) community after the recent nationwide rise in Anti-AAPI sentiment.

To achieve their goals, the ACS COT developed the equity, diversity, and inclusion workgroup in December 2019, which has several short- and long-term goals, including: (1) identifying and developing strategies to bridge gaps within and barriers to COT membership and leadership with regards to equity, diversity, and inclusion; (2) developing and tracking metrics related to equity, diversity, and inclusion within the COT; and (3) developing and disseminating resources to address those gaps and barriers.

In the winter of 2020, the ACS COT DEI workgroup began conducting a self-assessment survey within the society on the topic of equity, diversity, and inclusion, and expects to release their results soon.

American Association for the Surgery of Trauma (AAST)

The AAST Diversity, Equity, and Inclusion (DEI) committee was established in 2019 by president David Spain. The objectives of the committee included providing career development opportunities for surgeon scholars and leaders from diverse backgrounds, ensuring transparency and promoting diversity and equity in all decisions related to scholarships, membership, meeting participation, and leadership and editorial board positions, and educational efforts aimed at increasing cultural awareness within the profession of trauma and acute care surgery.

One of the committee’s first activities was to sponsor a very successful essay contest for medical students, residents, and fellows, with the focus being on identifying and providing the solutions for bridging the gaps in equity, diversity, and inclusion in today’s world of trauma surgery [73,74,75,76,77]. The AAST DEI Committee also plans on addressing racial inequity in trauma surgical leadership by creating a visiting professor program for members of the Society of Black Academic Surgeons (SBAS) to promote the careers of early to mid-career AAST-SBAS members and recognize academic excellence in the Black academic surgery community.

Eastern Association for the Surgery of Trauma (EAST)

EAST strongly spearheaded the DEI initiative before any other trauma surgical society and pioneered the path toward a more equitable trauma and acute care surgery environment. In 2018, the newly elected EAST president, Dr. Andrew Bernard, chose to make this the priority of his term and determined that this fell within the core guiding principles and purposes of the EAST organization. Soon afterwards, the EAST Equity, Quality, and Inclusion ad hoc task force was created [19]. It consisted of four workgroups: assessment and research; education; development of guidelines and processes; and mentorship, dialogue, and collaboration.

The task force resulted in an unprecedented burst of productivity with regards to DEI in trauma and acute care surgery. Their first 2019 plenary session was “#EAST4All: An Introduction to the EAST Equity, Quality, & Inclusion in Trauma Surgery Practice Ad Hoc Task Force.” Session topics included gender, racial, ethnic, religious, sexual orientation, and gender identity bias while marrying the evidence with deeply personal and painful anecdotes of well-respected trauma surgeons known to all. This was, in fact, the last invited public appearance of Dr. Lynn Weaver before his death. The task force created the #EAST4ALL survey discovering that implicit and explicit biases predominate in the workplace and put out a call to action that prompted a roundtable discussion at the 2020 EAST Annual Scientific Assembly. The task force was also instrumental in the drafting and publication of the Eastern Association for the Surgery of Trauma Statement on Structural Racism, and the Deaths of George Floyd, Ahmaud Arbery, and Breonna Taylor.

This was followed by the publication of multiple landmark papers that evaluated the current climate within trauma surgical societies and surgical leadership with regards to equity, diversity, and inclusion and identified the barriers to progress [20, 21, 78, 79]. The task force also developed a comprehensive toolkit for addressing inequity in the trauma and acute care surgery profession. This toolkit consisted of important practical information on how to address harassment and discrimination, gender pay gaps, implicit bias and microaggressions, and call-out culture. The task force also sought to pursue improved equity in the peer-review and publication process and was instrumental in pushing for adoption of the Lancet’s diversity pledge among trauma journal editors. This effort, led by Dr. Ariel Santos, directly led to the double-blinding of manuscripts submitted to the Journal of Trauma and Acute Care Surgery in 2022. Additional key accomplishments of this group included the development and dissemination of practice management guidelines and monthly literature reviews that regularly address these systemic structural factors still standing in the way of achieving these ideals [80]. EAST has also attempted to identify and rectify religious discrimination [21].

Other Trauma Surgical Societies

The WTA released a statement on July 10, 2020, addressing equity, diversity, and inclusion [81]. It was an emphatic call to action, but the WTA has not identified or achieved any actionable goals toward this objective since then. Similarly, the Pediatric Trauma Society has not released any statement addressing the barriers to achieving equity, diversity, and inclusion for both the trauma surgical leadership and its patient population.

The Road Ahead

Although nearly every trauma surgical society has demonstrated at least some commitment to the ideals of equity, diversity, and inclusion, it is no longer enough to release placating statements and calls to action. Efforts to address DEI and associated issues should be incorporated into all aspects of our profession and organizations and should extend from the medical trainee level to the most senior physicians and leaders. The time is now to actively achieve these goals. Increasing focus should:

i.

Identify and provide specific language to address issues of discrimination, bias, micro- and macroaggressions, disparities, and inequity.

ii.

Promote transparency in leadership ascension.

iii.

Support research and educational activities aimed at disseminating information pertaining to the current state of inequity and disparities in trauma surgical leadership, the reasons behind these conditions, and ways to improve the situation.

iv.

Create benchmarks and tools to track the impact of changes brought about as a result of these efforts.

v.

Recruit and promote minorities and women in the trauma surgical society membership and leadership.

vi.

Mentor young trauma surgical leaders hailing from diverse backgrounds, so that future leadership is adequately prepared to tackle the challenges of inequity and discrimination.

vii.

Identify, develop, and disseminate validated toolkits to address specific issues faced by minorities and women in this profession.

viii.

Advocate for our professional medical and surgical organizations to prioritize equity, diversity, and inclusion throughout all facets of their operations, academic and educational products, and at their annual scientific meetings.

Increasing the visibility of trauma surgeon leaders from diverse backgrounds can empower, uplift, and support future trauma surgeons and provide an atmosphere where they feel comfortable expressing who they are without fear of repercussions. Increasing diverse and inclusive representation in trauma surgical society leadership will empower more trainees from diverse and underrepresented backgrounds to actively participate in the scientific process to address health issues that may have been previously understudied or overlooked. This should be our priority going forward.