Disclosure Information: Grant funding for the Diverse Surgeons Iwas provided by Ethicon Endosurgery, Inc. The initiative is educatnature and no gifts or other items were given to the residents or facattending or teaching the program. No funding was providedresearch or composition of this article. All authors have nothing to

Received October 10, 2014; Revised December 4, 2014; ADecember 8, 2014.From the Department of Surgery, University of PennsylvaniaSystem (Butler, Chang, Serletti), Perelman School of Medicine at tversity of Pennsylvania (Richard), Philadelphia, PA, Department ofEastern Virginia Medical School, Norfolk, VA (Britt), BariatricServices, Fort Worth, TX (Green), and Department of Surgery,University School of Medicine, Washington, DC (Fullum).Correspondence address: Paris D Butler, MD, MPH, DepartmSurgery, University of Pennsylvania Health System, 10 Penn ToweSpruce St, Philadelphia, PA 19104. email: paris.butler@uphs.upenn.e

ª 2015 by the American College of Surgeons

Published by Elsevier Inc.

EDUCATION

The Diverse Surgeons’ Initiative: LongitudinalAssessment of a Successful National Program

Paris D Butler, MD, MPH, LD Britt, MD, MPH, FACS, Chase E Richard, BS, Benjamin Chang, MD, FACS,Joseph M Serletti, MD, FACS, Michael L Green Jr, MD, FACS, Terrence M Fullum, MD, FACS

BACKGROUND: The Diverse Surgeons Initiative (DSI) is a program that was created to provide underrepre-sented minority surgical residents with the clinical knowledge and minimally invasive surgicalskills necessary to excel in surgical residency and successfully transition into surgical practice.The early success of the graduates of the program has been published; however, a more lon-gitudinal assessment of the program was suggested and warranted. This study provides a5-year follow-up of the 76 physicians that participated in the DSI from 2002 to 2009 todetermine if the trend toward fellowship placement and academic appointments persisted.Additionally, this extended evaluation yields an opportunity to assess these young surgeons’professional progress and contributions to the field.

STUDY DESIGN: The most current professional development and employment information was obtained forthe 76 physicians that completed the DSI from 2002 to 2009. The percentage of DSIgraduates completing surgical residency, obtaining subspecialty fellowships, attaining boardcertification, receiving fellowship in the American College of Surgeons, contributing to thepeer-reviewed literature, acquiring academic faculty positions, and ascending to profes-sional leadership roles were calculated and compared with the original assessment.

RESULTS: Of the 76 DSI graduates, 99% completed general surgery residency. Of those eligible, 87%completed subspecialty fellowships; 87% were board certified; 50% received fellowship in theAmerican College of Surgeons; 76% had contributed to the peer-reviewed literature; 41%had obtained faculty positions; and 18% held local, regional, or national professional lead-ership positions.

CONCLUSIONS: This longitudinal analysis has revealed sustained success of the DSI in preparing underrepre-sented minority residents to excel in their training and transition into practice, obtain postsur-gical fellowships, acquire faculty appointments, and contribute to the advancement of the fieldof surgery. (J AmColl Surg 2015;220:362e369.� 2015 by the AmericanCollege of Surgeons)

Recognizing the paucity of underrepresented minority(URM) surgeons receiving minimally invasive surgical(MIS) training in the late 1990s, the Diverse Surgeons

nitiativeional inulty forfor thedisclose.

ccepted

Healthhe Uni-Surgery,SurgicalHoward

ent ofr, 3400du

362

Initiative (DSI) was created. This program, financiallysupported by Ethicon Endosurgery, originally intendedto enhance the exposure of MIS equipment and tech-niques to practicing URM surgeons throughout the coun-try. With stellar reviews from participants, in 2002 theDSI organizers redirected the focus of the program totarget highly motivated URM surgical residents with thehope of encouraging and preparing them to seek outand obtain fellowships in MIS.With the main emphasis involving preparedness and

mentorship, the program immediately showed signs ofsuccess. Increasing numbers of surgical residency programdirectors were nominating their residents to DSIorganizers in hopes of securing an opportunity for theirresidents to participate. Consequently, numerous DSIgraduates pursued and successfully obtained MIS fellow-ships, withMIS fellowship program directors commenting

http://dx.doi.org/10.1016/j.jamcollsurg.2014.12.006

ISSN 1072-7515/14

Abbreviations and Acronyms

DSI ¼ Diverse Surgeons InitiativeFACS ¼ fellowship in the American College of SurgeonsMIS ¼ minimally invasive surgeryURM ¼ underrepresented minority

Vol. 220, No. 3, March 2015 Butler et al Longitudinal Assessment of Diverse Surgeons’ Initiative 363

on their advanced skills even at the onset of their formaltraining.In successive years, an increasing number of URM sur-

gical residents that did not intend to pursue MIS fellow-ships became interested in the DSI purely to enhancetheir general surgery training, as they desired to seek fel-lowships in other subspecialties. Aware of the dearth ofURMs represented in all of the surgical subspecialties,the DSI faculty quickly embraced this originally unin-tended effect. Additionally, it became evident thatnumerous DSI graduates were securing positions on surgi-cal faculty after the completion of their definitive training.The inadvertent consequences of the DSI program

serving as a potential template to help increase the num-ber of URMs obtaining subspecialty training and surgicalfaculty positions was formally assessed and published in2009.1 At that point in time, 76 URM residents hadparticipated in the program. Of those eligible, 86% hadobtained postegeneral surgery fellowships representingalmost all general surgery subspecialties. Additionally, itwas determined that an astounding 57% had obtained po-sitions on surgical faculty nationwide.1

Although the results were promising, an admittedshortcoming of the study was a lack of sufficient time toassess the longitudinal results of the program. Many ofthe DSI graduates were still in the midst of their trainingand, therefore, were ineligible for either fellowship orpractice opportunities.The purpose of this study is to provide a 5-year follow-

up of the 76 physicians that participated in the DSI from2002 to 2009 to determine if the trend toward fellowshipplacement and academic positions persisted. Additionally,this extended evaluation yields an opportunity to assessthese young surgeons’ professional progress and contribu-tions to the field.

METHODSThe most current professional development and employ-ment information was obtained for the 76 physicians thatcompleted the DSI from 2002 to 2009. The 2010 to2013 participants were not included, as the aim of thisstudy was to evaluate the potential protracted effect ofthe DSI. Therefore, to remain consistent with the

previous study, the same 76 graduates (now 5 years older)were appraised.The information obtained for this group included suc-

cessful completion of their general surgery residency,completion of a postegeneral surgery fellowship, currentemployment in a private practice or academic setting, cer-tification by the American Board of Surgery, and fellow-ship in the American College of Surgeons. Additionally,to assess the potential contributions of these DSI partici-pants to the enrichment of the surgical discipline, thenumber of peer-reviewed publications recognized byPubMed as well as local, regional, or national surgicalleadership positions held were also captured.

RESULTS

Completion of residency and subspecialty training

Of the76 DSI participants from 2002 to 2009, 75 (99%)completed their general surgery training, and the otherparticipant completed a residency in urology. Of the 76 par-ticipants, 74 were eligible for fellowship immediately aftercompletion of general surgery. The one participant thathad an immediate military obligation and the aforemen-tioned participant that switched into urology were excluded.Of the 74 fellowship-eligible DSI graduates, 87% (64 of 74)went on to complete a postegeneral surgery fellowship.Minimally invasive surgery was the most frequently chosenfellowship (22 of 64). Other DSI graduates pursued fel-lowships in cardiothoracic (13 of 64), trauma/critical care(6 of 64), surgical oncology (6 of 64), transplantation/hepatobiliary (3 of 64), breast (3 of 64), plastic andreconstructive (3 of 64), colorectal (3 of 64), vascular(2 of 64), pediatric (2 of 64), and endocrine surgery(1 of 64) (Fig. 1).

Academic positions

Of the 76 DSI graduates, 69 had completed their defini-tive surgical training and were currently in practice. The 5DSI graduates that were still completing fellowships, the 1graduate that switched to urology, and the 1 resident thatreceived a Fogarty International Research Fellowship andwas subsequently hired by the CDC were excluded. Ofthe 69 DSI graduates now in practice, 41% (28 of 69)currently held positions as full-time faculty memberseither as assistant, associate, or full professor in an aca-demic medical center. Part-time clinical instructors werenot included (Fig. 2).

Board certification and fellowship in the AmericanCollege of Surgeons

Of the 76DSI graduates, 71 were included in assessment ofboard-certification status. Three graduates were excluded,

Figure 1. The Diverse Surgeons Initiative 2002e2009 graduates’ postegeneral surgerysubspecialty training. MIS, minimally invasive surgery.

364 Butler et al Longitudinal Assessment of Diverse Surgeons’ Initiative J Am Coll Surg

as they were completing cardiothoracic surgery fellowshipsthat no longer require American Board of Surgery certifica-tion. They intend to become boarded by the AmericanBoard of Thoracic Surgery after completion of their fellow-ships. The graduate that switched to urology and the grad-uate that immediately began working for the CDC wereexcluded. Of the 71 included in assessment of board-certification status, 87% (62 of 71) were currently certifiedby the American Board of Surgery (Fig. 2). The graduatethat became a urologist received board certification bythe American Board of Urology.We determined that 60 of the 76 DSI graduates were

eligible for fellowship in the American College of Sur-geons (FACS). Eleven graduates were excluded becausethey were currently in training, switched to another spe-cialty, recently began their military career, or unfortu-nately suffered from an untimely death soon aftercompletion of their definitive training. Five additionalgraduates were excluded because they were within 4 years

Figure 2. The Diverse Surgeons Initiative 2002eaccomplishments.

of the completion of their training and not realisticallyeligible for FACS status. Of the 60 that were eligible,50% (30 of 60) held the title of FACS (Fig. 2).

Peer-reviewed publications and leadershippositions

With the use of PubMed, assessment of all 76 DSI grad-uates was performed with regard to their contributions tothe medical peer-reviewed literature.2 Of the 76 DSI grad-uates, 76% (58 of 76) had contributed to the literaturewith a minimum of a single peer-reviewed publication.In addition, 45% (34 of 76) had 4 or more peer-reviewed publications (Fig. 3).The same exclusion criteria that were used to assess

FACS status were also applied to the evaluation of currentleadership positions held. Of the 60 DSI graduates realis-tically eligible, 18% (11 of 60) currently held one or morelocal, regional, or national professional leadership posi-tions (Fig. 3).

2009 graduates’ percentages of professional

Figure 3. The Diverse Surgeons Initiative 2002e2009 graduates’ percentages of peer-reviewedpublications and service in local, regional, or national leadership positions.

Vol. 220, No. 3, March 2015 Butler et al Longitudinal Assessment of Diverse Surgeons’ Initiative 365

DISCUSSION

Racial/ethnic diversity in academic surgeryremains a challenge

Despite the recent passage of a health care reform law thatspecifically addresses the need for the alleviation of healthcare disparities according to race and ethnicity,3 US med-ical institutions continue to have an insufficient numbersof URM trainees and faculty members to be commensu-rate with the patient populations they treat.4 Although thevast majority of medical disciplines have historically strug-gled with diversity among their faculty, none has beenmore apparent than surgery and its various subspecialties(Table 1).5-12

The cause of the deficit in URM faculty in academicmedicine is undeniably multifactorial. An insufficientnumber of URM medical school graduates, URM resi-dents that are uninformed of or ill prepared for successin academic medicine, educational debt burden, institu-tionalized racism, and a paucity of role models and men-tors, have all been cited by the literature.17-20 Recentreports profoundly state that the continued underrepre-sentation of minorities in the medical profession is havinga deleterious effect on the health of our nation.4,21-23

Underrepresented minority physicians have historicallybeen more likely to deliver care to underserved commu-nities than their Caucasian colleagues.24-28 Additionally,several studies have revealed that there is a positive associ-ation between physicianepatient racial/ethnic concor-dance and patients’ receiving preventive medical care,being satisfied with their medical care experience, and rat-ing their physicians’ participatory decision-making stylesas excellent.12,29-31

From a research perspective, there is evidence that URMpatients have a heightened willingness to participate in a

clinical trial if a member of the research team is also aURM.32,33 These findings suggest that to alleviate racialand ethnic disparities in US health care, enhanced effortsto increase diversity in the physician workforce will beimperative.

The Diverse Surgeons Initiative

Nivet4 suggested that faculty and leadership positions heldby URMs in academic medicine were pivotal to stimu-lating the diversity of the field. Serving as a quadruplethreat, academic surgeons treat patients, participate inresearch, educate students, and serve as mentors androle models for the next generation of surgeons. Thisimportant role of academicians emphasizes why a lackof sufficient representation of URMs in academic medi-cine is a critical component to this health care disparityimpasse. Strategically addressing several key factors thatlead to residents ability to obtain fellowship positions,the DSI adventitiously propelled its participants to notonly obtain competitive subspecialty training, but alsoother evidence of professional success.In the late 1990s, MIS was becoming fully embraced by

academic training programs nationwide, and the DSI or-ganizers and faculty believed that MIS was clearly thefuture of surgical interventions. From 1998 to 2001 theinitial DSI program was established to provide advancedMIS skills to young URM surgeons in practice. At thattime, URMs were poorly represented in various MIS pro-fessional organizations, such as the Society of AmericanGastrointestinal and Endoscopic Surgeons, the MinimallyInvasive Surgery Fellowship Council, and the AmericanSociety for Metabolic and Bariatric Surgery. This onceagain reflected the scarcity of URMs receiving state ofthe art MIS training. In an attempt to rectify this deficit,

Table 1. Demographics of US Medical Student Graduates, Surgical Residents, and Surgical Faculty Compared with OverallUS Population (2006)

Race

US population(N ¼ 299,398,484)13

US medicalschool graduates(n ¼ 15,810)14,*

US surgicalresidents

(n ¼ 15,668)15,*,y,zUS surgical faculty(n ¼ 13,901)16,*,z

US surgicaltenured professors(n ¼ 3,661)16,*,z

n % n % n % n % n %

White 199,744,494 66.4 10,030 63.4 10,096 64.4 10,294 7.4 3,139 85.7

Asian American 12,881,639 4.3 3,232 20.4 2,689 17.2 1,515 10.8 181 4.9

African American 36,689,680 12.3 1,122 7.1 736 4.7 415 2.9 67 1.8

Latino American 44,321,038 14.8 1,063 6.7 793 5.1 508 3.6 99 2.7

Other 5,987,969 2.2 363 2.3 1,354 8.6 1,196 8.6 179 4.9

*Statistically significant compared with overall US population (p < 0.001).yMost current data available were from 2004.zIncludes general, orthopaedic, otorhinolaryngology, urology, plastic and reconstructive, cardiothoracic, vascular, transplantation, and neurosurgery.Reprinted from Butler PD, Longaker MT, Britt LD. Major deficit in the number of underrepresented minority academic surgeons persists, Ann Surg2008;248:704e711, with permission.

366 Butler et al Longitudinal Assessment of Diverse Surgeons’ Initiative J Am Coll Surg

the DSI organizers redirected their focus in 2002 to targethighly motivated URM surgical residents during PGY2through PGY5. Therefore, the inaugural year of theDSI program for residents was 2002.The DSI faculty originally had two main objectives in

mind. The first was to provide promising URM residentswith solid fundamental MIS skills that would permit themto excel in their current training programs and facilitatetechnical readiness for the onset of MIS fellowships. Thesecond objective was to provide URM residents with expo-sure to DSI adjunct faculty members, many of which wereMIS fellowship directors. The URM residents had an op-portunity to learn from and personally interact with theseMIS fellowship directors, and vice versa. With this addedexposure on both ends, the DSI graduates were predictedto be in a more favorable position to match in a compet-itive MIS fellowship training program.1

Each year, 8 to 14 URM residents were selected toparticipate in the program. General surgery residency pro-gram directors nominated candidates from their programto participate in the DSI and, historically, most nomineeswere granted acceptance. The DSI program includedthree, 2-day sessions at the Ethicon training facility duringthe course of a 9-month period. The sessions includedMIS fundamentals (eg, laparoscopic knot tying and sutur-ing), porcine surgical laboratory for simulating procedures(eg, laparoscopic cholecystectomy and laparoscopicNissen-fundoplication), surgical anatomy review, diseasepathophysiology lectures, and case-based question andanswer sessions reflecting the American Board of SurgeryIn Training Service Examination format.1

As was mentioned in the introduction, initial evalua-tion revealed that the DSI had notable success in attain-ment of subspecialty fellowships of its graduates (MISand other subspecialties). Additionally, there was a trendof these graduates pursuing and obtaining faculty ap-pointments, which was a welcomed positive association.

Limitations of this study

There are admittedly several limitations of this study. Asmentioned in the original publication, the DSI wasinitially organized as a developmental program to provideURM residents with additional MIS skills and also toencourage them to pursue fellowships in MIS. It evolvedinto a program that has helped equip many of its gradu-ates for successful attainment of subspecialty fellowshipsand faculty positions. At its onset, the DSI organizerswere aware of the shortage of URMs comprising generalsurgery residencies, fellowships, and surgical faculties,which had been formally documented.7 Therefore, simul-taneously tracking the careers of a control group of URMand non-URM residents that did not complete the DSI,although scientifically beneficial, was not performed. Aswas also mentioned in the initial assessment of this pro-gram, the authors recognize that the findings of this studydo not hold up to the strict scientific scrutiny prudent forscientific articles, as the data are admittedly descriptive innature. However, recognizing that during the last few de-cades relatively small gains have been made in improvingthe number of URMs in academic surgery, the merits andsuccess of the DSI are worthy of consideration.The authors also recognize that this study’s findings are

subject to selection bias, as these URM residents werechosen to participate in the DSI because of their high levelof motivation and laudable credentials. Admittedly, someof these residents likely would have gone on to pursuefellowship experiences and acquire faculty appointmentswithout taking part in the DSI. However, historicallyspeaking, it is unlikely that such a high propensity withinthe group would have obtained this level of success. EachDSI graduate’s professional pursuits and achievements areundoubtedly multifactorial, and the authors are notimplying that the DSI deserves all of the credit for the suc-cess of these physicians. However, the DSI has providedmany of the necessary skills and, most importantly, the

Vol. 220, No. 3, March 2015 Butler et al Longitudinal Assessment of Diverse Surgeons’ Initiative 367

vital mentoring that is essential for successful navigationof the complex surgical training process.

Longitudinal assessment and evidence of sustainedsuccess

The original study revealed that of those eligible, 86% ofDSI graduates had obtained postegeneral surgerytraining.1 Now that all 76 DSI graduates were eligible,it was promising to elucidate that the previous findingwas basically unchanged, as 87% of the graduates wenton to obtain and complete subspecialty training. The87% of graduates acquiring fellowship training remainsnoteworthy, as the most recent assessment of graduatingsurgical chief residents securing fellowship positions na-tionally is 77%.34

This extended follow-up of the DSI graduates providedthe opportunity to reveal additional evidence of success ofthese young surgeons. Although general surgery residencyprograms have cumulative attrition rates of 9.35% amongresidents PGY3 through PGY5 and in their research years,99% of the DSI graduates successfully completed theirgeneral surgery training.35

According to the universally accepted American Boardof Medical Specialties, board certification demonstrates aphysician’s exceptional expertise and commitment to life-long learning in their specialty practice. Board certifica-tion is considered the gold standard and frequently themeasure by which physicians are judged by patients, col-leagues, insurers, and quality organizations.36 Accordingto the American Board of Surgery from 2009 to 2013,the pass rate for the qualifying examination and the sub-sequent certifying examination were 78% and 76%,respectively.37 The rate of board certification of the DSIgraduates, implicit that they had passed both examina-tions, was 87%. Admittedly, information about numberof examination attempts and other examination specificsis not readily available, but regardless, a board-certification rate of this stature is commendable.Historically, one of the greatest honors that a US sur-

geon could receive was the title of FACS. Holding the titleof FACS is an indication that the surgeon is committed tothe highest standards of surgical care through educationof, and advocacy for, their patients and colleagues, andto safeguarding ethical standards of care.38

It is estimated that approximately 40% of US surgeonshold the distinction of FACS. With 50% of the eligibleDSI graduates obtaining fellowship into the ACS, itspeaks to the type of surgeon that the DSI has helpedto produce.39

At the time of the initial assessment, only 42 of the 76DSI graduates had completed their definitive surgicaltraining and were in practice. Of those in practice, 57%

(24 of 42) held positions as full-time faculty in academicsurgical training programs.1 This current assessment re-veals that 69 DSI graduates are currently in practice and41% of them (28 of 69) currently hold a faculty appoint-ment. Although there was a decline from the originalassessment, the number of DSI graduates obtaining posi-tions in academia exceeds the estimated 33% overall na-tional percentage of residents acquiring positions in anacademic setting.40,41 The decline is likely multifactorialand is a trend seen throughout the country, irrespectiveof race/ethnicity or sex. The difficulty convincing thenewest generation of surgeons about the merits of an ac-ademic career has been cited previously, with a challengeissued to institutions to make faculty appointments moreflexible and financially rewarding.42

Contributions to the peer-reviewed literature as ameans of revealing evidence of scholarly activity hasbeen a renewed emphasis of the ACGME Residency Re-view Committees.43 These publications are intended toenhance the field, but also are critical to the advancementof physicians with academic pursuits.44 To date, there isno reliable evidence of how many peer-reviewed publica-tions the typical general surgery trainee or those recentlyout of training produce. However, our assessment of theDSI graduates revealed that a notable 76% had publisheda minimum of 1 peer-reviewed article and 45% had 4 ormore peer-reviewed publications. Devoid of a directcomparison in the surgical literature, one could arguethat the >450 peer-reviewed publications produced byDSI graduates have provided a substantial contributionto the field.In addition to contributions to the medical literature, it

was also promising to find that 18% of the DSI graduatesheld local, regional, or national leadership positions.Recognition of the paucity of URMs in leadership rolesin the Society of American Gastrointestinal and Endo-scopic Surgeons, American Society for Metabolic andBariatric Surgery, and the Minimally Invasive SurgeryFellowship Council was one of the impetuses behindstarting the DSI. Evidence that the DSI graduates wereassuming leadership roles in relatively early stages of theircareers is additional evidence of success of the programand progress in the field.

A program to model

The focus of the DSI was preparedness and mentorship.The DSI organizers in agreement with Cregler and col-leagues17 believed that URM residents and fellows mustbe armed first and foremost with the necessary knowledgebase and skills if the intention is to generate more minor-ity physicians in academic surgery. While helping to pro-vide these residents with the necessary clinical and

368 Butler et al Longitudinal Assessment of Diverse Surgeons’ Initiative J Am Coll Surg

technical acumen, the DSI faculty also served as mentorsboth during the sessions and throughout the duration oftheir residency training. Numerous publications describethe tremendous impact that mentorship had on the suc-cess of physicians seeking academic careers.45,46 The liter-ature continues to support the idea that residents alignedwith a mentor are considerably more likely to reveal evi-dence of superior career preparedness compared withthose deficient of a dedicated faculty mentor.4,47

The DSI faculty consisted of both URM and non-URM faculty who supported URM residents throughboth technical instruction and mentorship. Their impacthas undoubtedly been critical to the vitality of the initia-tive as well as the education of the participants. Thereremained a universal understanding of the importanceof supporting diversity initiatives to increase the numberof future URM fellows and faculty. This was not to bethe sole responsibility of current URM academic sur-geons, but rather an initiative to be supported by all aca-demicians regardless of race and ethnicity until thedisparity no longer exists.With this longitudinal assessment of DSI participants

showing evidence of successful transition into practice,attainment of academic positions, and increasing contri-butions to the field, the authors encourage the extensionof programs like the DSI. Recognizing that providingthis kind of opportunity to all URM surgical residentsis not likely feasible, but due to its success, continuationand limited expansion of this program should be pro-moted and supported.

CONCLUSIONSThis longitudinal assessment of the DSI has revealed itssustained success in providing URM residents with theclinical knowledge and surgical skills necessary to excelin their training and transition into practice. Althoughit might lack strict scientific rigor, bringing attention to,and awareness of, the success of the DSI in hopes ofgarnering support for the continuation and extension ofsuch programs is the ultimate goal of this follow-uparticle. It also remains the authors’ hope that these find-ings motivate other specialties to consider similar nationalprograms to increase the number of URM medical facultythroughout all of medicine.

Author Contributions

Study conception and design: Butler, Britt, Richard,Chang, Serletti, Green, Fullum

Acquisition of data: Butler, Britt, Richard, FullumAnalysis and interpretation of data: Butler, Britt, Richard,Chang, Serletti, Green, Fullum

Drafting of manuscript: Butler, Britt, Richard, Chang,Serletti, Green, Fullum

Critical revision: Butler, Britt, Richard, Chang, Serletti,Green, Fullum

Acknowledgment: The authors would like to send our mostsincere condolences to the family and loved ones of three ofthe DSI graduates who suffered untimely deaths early intheir careers. Drs Keith Amos, William Olorunto, andEdwin Preston were talented physicians, wonderful people,and are sorely missed.

REFERENCES

1. Butler PD, Britt LD, Green ML Jr, et al. The diverse surgeonsinitiative: an effective method for increasing the number ofunder-represented minorities in academic surgery. J Am CollSurg 2010;211:561e566.

2. US National Library of Medicine. PubMed Health [updatedSeptember 1, 2014]. Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/. Accessed September 14, 2014.

3. Patient Protection and Affordable Care Act (Public Law111-148) and Health Care and Education ReconciliationAct of 2010 (Public Law 111-152). x10344, 4302, 3502,5207.

4. Nivet MA. Minorities in academic medicine: review of theliterature. J Vasc Surg 2010;;51[Suppl]:53Se58S.

5. King TE Jr, Dickinson TA, DuBose TD Jr, et al. The case fordiversity in academic internal medicine. Am J Med 2004;116:284e289.

6. Wesson DE, King TE Jr, Todd RF, et al. Achieving diversityin academic internal medicine: recommendations for leaders.Am J Med 2006;119:76e81.

7. Butler PD, Longaker MT, Britt LD. Major deficit in the num-ber of underrepresented minority academic surgeons persists.Ann Surg 2008;248:704e711.

8. Cohen JJ, Gabriel BA, Terrell C. The case for diversity in thehealth care workforce. Health Aff (Millwood) 2002;21:90e102.

9. Merchant JL, Omary MB. Underrepresentation of underrepre-sented minorities in academic medicine: the need to enhancethe pipeline and the pipe. Gastroenterology 2010;138:19e26 e1e3.

10. Butler PD, Britt LD, Longaker MT. Ethnic diversity remainsscarce in academic plastic and reconstructive surgery. PlastReconstr Surg 2009;123:1618e1627.

11. Okike K, Utuk ME, White AA. Racial and ethnic diversity inorthopaedic surgery residency programs. J Bone Joint Surg Am2011;93:e107.

12. Reede JY. A recurring theme: the need for minority physicians.Health Aff (Millwood) 2003;22:91e93.

13. US Census Bureau. Population Division. US Census Bureau.Available at: http://www.census.gov/popest/data/historical/2000s/vintage_2006/index.html. Accessed November 12, 2007.

14. Association of American Medical Colleges. AAMC data book:1992-2006 FACTS- applicants, matriculants, graduates. Avail-able at: https://www.aamc.org/data/facts/. Accessed November12, 2007.

15. AssociationofAmericanMedicalColleges. AAMCdiversity in theworkforce: facts and figures 2006. Available at: https://members.

Vol. 220, No. 3, March 2015 Butler et al Longitudinal Assessment of Diverse Surgeons’ Initiative 369

aamc.org/eweb/upload/Diversity%20in%20the%20Physician%20Workforce%20Facts%20and%20Figures%202006.pdf. AccessedNovember 12, 2007.

16. Association of American Medical Colleges. AAMC faculty roster2006. Available at: http://www.aamc.org/data/facultyroster/reports/. Accessed November 12, 2007.

17. Cregler LL, Clark LT, Jackson EB Jr. Careers in academicmedicine and clinical practice for minorities: opportunitiesand barriers. J Assoc Acad Minor Phys 1994;5:68e73.

18. Butler PD, Longaker MT, Britt LD. Addressing the paucity ofunderrepresented minorities in academic surgery: can the“Rooney Rule” be applied to academic surgery? Am J Surg2010;199:255e262.

19. Clark S, Corcoran M. Perspective on professional socializationof women faculty. J Higher Educ 1986;57:20e43.

20. Cohen JJ. The consequences of premature abandonment ofaffirmative action in medical school admissions. JAMA2003;289:1143e1149.

21. Sullivan Commission’s Report on Health Professions Diver-sity. Washington, DC: National Academies Press; 2004.Available at: http://depts.washington.edu/ccph/pdf_files/Sullivan_Report_ES.pdf. Accessed February 5, 2010.

22. Smedley B, Stith A, Nelson A, eds. Unequal treatment: con-fronting racial and ethnic disparities in health care. Washing-ton, DC: National Academies Press; 2003.

23. Grumbach K, Coffman J, Rosenhoff E, et al. Strategiesfor improving the diversity of the health professions. WoodlandHills, CA: California Endowment; 2003. Available at: http://www.calendow.org/uploadedfiles/strategies_for_improving_the_diversity.pdf. Accessed February 8, 2010.

24. Sarto G. Of disparities and diversity: where are we? Am JObstet Gynecol 2005;192:1188e1195.

25. Komaromy M, Grumbach K, Drake M, et al. The role of blackand Hispanic physicians in providing health care for under-served populations. N Engl J Med 1996;334:1305e1310.

26. Rabinowitz HK, Diamond JJ, Veloski JJ, Gayle JA. Theimpact of multiple predictors on generalist physicians’ careof underserved populations. Am J Public Health 2000;90:1225e1228.

27. Moy E, Bartman BA. Physician race and care of minority andmedically indigent patients. JAMA 1995;273:1515e1520.

28. Brown T, Liu J, Scheffler RM. Does the under- or overrepresenta-tion of minority physicians across geographical areas affect thelocation decisions of minority physicians? Health Serv Res 2009;44:1290e1308. Available at: http://www3.interscience.wiley.com/cgi-bin/fulltext/122377122/PDFSTART?CRETRY¼1&SRETRY¼0. Accessed September 15, 2014.

29. Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient-physician racial concordance and the perceived quality anduse of health care. Arch Intern Med 1999;159:997e1004.

30. Saha S, Taggart SH, Komaromy M, Bindman AB. Do patientschoose physicians of their own race? Health Aff (Millwood)2000;19:76e83.

31. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender,and partnership in the patient-physician relationship. JAMA1999;282:583e589.

32. Branson RD, Davis K Jr, Butler KL. African Americans’participation in clinical research: importance, barriers, and so-lutions. Am J Surg 2007;193:32e39; discussion 40.

33. Corbie-Smith G, Thomas SB, St George DM. Distrust, race,and research. Arch Intern Med 2002;162:2458e2463.

34. Borman KR, Vick LR, Biester TW, Mitchell ME. Changingdemographics of residents choosing fellowships: longtermdata from the American Board of Surgery. J Am Coll Surg2008;206:782e788; discussion 788e789.

35. Yeo H, Bucholz E, Sosa JA, et al. A national study of attritionin general surgery training: which residents leave and where dothey go? Ann Surg 2010;252:529e534; discussion 534e536.

36. American Board of Medical Specialties. What board certifica-tion means. Available at: http://www.absurgery.org/default.jsp?publiccertprocess. Accessed September 15, 2014.

37. American Board of Surgery. General surgery examination sta-tistics: 2009�2013. Available at. Accessed, http://www.absurgery.org/default.jsp?statgeneral; September 14, 2014.

38. American College of Surgeons. History of the College.Available at: https://www.facs.org/about%20acs/archives/onlineresources/acshistory. Accessed September 14, 2014.

39. American College of Surgeon Health Policy Research Institute.The surgical workforce in the United States: profiles and recenttrends. April 2010. Available at: http://www.acshpri.org/documents/ACSHPRI_Surgical_Workforce_in_US_apr2010.pdf.Accessed September 15, 2014.

40. Fry DE. Academic apoptosis. Surg Infect (Larchmt) 2003;4:229e230.

41. Balch CM, Shanafelt TD, Sloan JA, Satele DV, Freischlag JA.Distress and career satisfaction among 14 surgical specialties,comparing academic and private practice settings. Ann Surg2011;254:558e568.

42. Bickel J, Brown AJ. Generation X: implications for facultyrecruitment and development in academic health centers.Acad Med 2005;80:205e210.

43. Grady EC, Roise A, Barr D, et al. Defining scholarly activity ingraduate medical education. J Grad Med Educ 2012;4:558e561.

44. Straus SE, Straus C, Tzanetos K, International Campaign toRevitalise Academic Medicine. Career choice in academicmedicine: systematic review. J Gen Intern Med 2006;21:1222e1229.

45. Johnson JC, Williams B, Jayadevappa R. Mentoring programfor minority faculty at the University of Pennsylvania Schoolof Medicine. Acad Med 1999;74:376e379.

46. Pololi L, Knight S. Mentoring faculty in academic medicine. Anew paradigm? J Gen Intern Med 2005;20:866e870.

47. Ramanan RA, Taylor WC, Davis RB, Phillips RS. Mentoringmatters. Mentoring and career preparation in internal medi-cine residency training. J Gen Intern Med 2006;21:340e345.