Minerva Romero Arenas, MD, MPH, FACS

News Breaking News Workplace Culture Leadership Diversity Equity Inclusion

By: Interview by Joe Paone

Published: 6/21/2021

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The cofounder of the Latino Surgical Society discusses the ongoing challenges in developing surgeons from communities that remain underrepresented in medicine, and how providers of all kinds can work together to improve diversity, equity and inclusion in the world of surgery.


Minerva Romero Arenas, MD, MPH, FACS, is a general and endocrine surgeon and an assistant professor of surgery at New York Presbyterian Brooklyn Methodist Hospital and Weill Cornell Medicine Department of Surgery. In May 2020, a study she co-authored that was published in the Journal of Surgical Research presented difficult-to-comprehend results: The total percentage of all academic surgeons in the U.S. who are African American, Hispanic/Latino, American Indian/Alaskan Native or Native Hawaiian/Pacific Islander is just 7%.

Dr. Romero Arenas and her colleague Fabiola Valenzuela, MD, examined publicly available data from 2005 through 2018 to see how much progress had been made in underrepresented in medicine (URM) representation among academic surgery faculty. African American representation did not significantly increase over that time. Even worse, the percentage of Hispanic/Latino academic surgery faculty actually decreased over those 13 years.

How can this be in 2021? We sat down with Dr. Romero Arenas, an immigrant to the U.S. originally from Mexico City and cofounder of the Latino Surgical Society, to take a deeper dive into this persistent and distressing trend, discuss what can be done to increase the presence of URM in surgery and reiterate exactly why increasing representation is so important.

Outpatient Surgery: These numbers are distressing, not only in the continued lack of URM representation, but also the lack of progress in that regard.

Dr. Romero Arenas: In terms of teaching hospitals, that's where the breakdown is and, unfortunately, we're not seeing much change in terms of progress in the recruitment of minority physicians. These numbers have really been relatively stagnant for decades.

Back in 2008, there was a call to action made by Paris Butler, MD, MPH, who looked at this data and said we've got to do better in terms of recruiting African American physicians into surgery. [Editor's note: Dr. Butler authored "Essential Elements of Healthcare Equality" in our February 2021 issue.] Unfortunately, it's been over a decade and we're not seeing change. We're not seeing significant improvement.

Your study closed with data from 2018, and since then there has been a lot of change and increased awareness regarding racism and inequality, and many companies and organizations have launched or refocused on DEI programs. Has any of what's happened over the last three years moved the needle in terms of URM representation in academic surgical faculty?

I think there's definitely been a lot of change in the last year in terms of the overall environment and maybe more awareness that there need to be inclusive environments created in surgery. Although we're seeing change, we also need to realize that it's a long-term investment. The process of going through surgery training starts at a minimum of five years in residency, and a lot of academic surgeons also train at programs where research is encouraged or required, so that stretches the training period to seven to eight years. After that, the majority of surgery graduates go into fellowship, which can add an additional one to three years. So, in order to make a dent in these numbers, it takes a decade to see much change, and that's just to see the change for maybe one or two classes of brand-new interns getting through the entire process.

So it will take years of commitment and nurturing for these efforts to pay off. America famously has a fickle attention span, however. How confident are you that there will be the necessary follow-through?

It has to be a very intentional effort. It's one thing to say, "Yes, we want to have a change in the face of medicine." It's another thing to say, "Why are the things we are doing not getting us the diversity we want in recruitment of new physicians?"

STANDARD BEARER Dr. Romero Arenas (right) balances her patient-care duties with her desire to help those who are underrepresented in medicine achieve successful careers in healthcare.
What are the root causes of this continued underrepresentation?

I think it's multifactorial. It's been well documented that role modeling and mentorship are definitely lacking because as we documented, those faculty that are concordant simply don't exist. But there's another side to it, which is the lack of sponsorship. If you look at the numbers, the higher you go up in the ranks, the less people you're meeting in terms of concordance with race/ethnicity. What that tends to translate to is that there's nobody who's willing to go to bat for these earlier-career physicians, to say this person deserves a promotion, or this person is bringing something different to the table that we should nurture and encourage.

Change is hard for anyone, no matter how small a change you're making. What we're seeing is that even when you get people into surgical training programs, physicians from URM backgrounds are more likely to be dismissed, less likely to have concordant mentorships, less likely to be nurtured through the entire process. A paper that came out in 2018 looked at residency training. It looked at residents who went through the entire process, and how many of them were board certified by the end of that period. They found that minority physicians and women physicians were less likely to have achieved board certification the first time they attempted that exam.

Another finding was that most physicians tend to drop out of surgical training early in their first or second year, and then it starts to level off. But they found Hispanic or Latino residents tended to drop out consistently throughout all years of their training. That's alarming because it lets you know that whatever the issues are, they are not being resolved. There's nobody keeping those residents within the system, encouraging them to get through.

Is the bias you are describing, and have experienced, implicit or explicit in nature?

It's definitely both. There's been a lot of attention recently on implicit bias. I know from other surgeons in generations previous to mine, there's definitely been a change, for example, in inappropriate comments or flat-out disruptive behaviors that maybe were seen 40 years ago. But that doesn't mean it doesn't still happen. The thing is, while we're seeing some institutions that are definitely progressing and creating more inclusive environments, plenty of other institutions simply have stayed behind.

How are we going to make change happen when we're getting one Hispanic or Latino physician graduating per state for all surgery residencies, for example? You really are not able to achieve something called critical mass, which is when a minority group is able to have enough numbers that they feel protected enough to not always be the "token" person.

What more can be done to increase representation, then, given the failures to remedy the situation thus far?

We need to have a long-term plan. These efforts have to be not only the hot topic, but they have to be planned-out, sustainable efforts. In reality, if we achieved representation by race/ethnicity, you would end up finding different elements that we could then focus on in terms of diversity efforts. For example, one issue coming to the forefront more recently is diversity by gender identification or sexual orientation, which, frankly, have not been addressed in the past. This is sort of the silent minority. These are elements of someone's personal life that can't be as easily determined as, for example, my skin color or my accent.

These are different elements that ultimately do affect patient care. We want to be able to provide care that is culturally sensitive to the patient, and provide a perspective so that when we are coming up with care plans, someone can speak up and say, "Well, for this patient, this doesn't make sense to achieve this healthcare goal." That's going to play out across disciplines. Ultimately, we're not asking for representation for the sake of meeting quotas. In the long term, really, representation impacts patients' health, and that's a really important aspect that sometimes gets lost in the conversation.

Those of Asian or Indian descent, for example, aren't URMs in surgery. Can URMs look to these other minority groups, see what worked for them, and apply it to their own race/ethnicity?

Certainly. We definitely see there has been a growth in the number of Asian Americans represented in surgical faculty. By numbers alone, you would think they've had tremendous success and are actually considered overrepresented in medicine and in surgery. But they are, unfortunately, subject to a lot of the same issues of implicit bias and underrepresentation in other categories. For example, when you look at leadership, despite certain achievements and a higher number of people of Asian descent, you're not seeing them at the higher ranks of professorships, you're not seeing them across leadership in surgical societies.

There are organizations that have tried to tackle these issues. I'm part of the The Association of Women Surgeons (AWS). The organization has had tremendous success in helping women achieve a voice at the table in the creation of programming that helps mentoring, that helps women get promoted.

The Society of Black Academic Surgeons is specifically aiming at getting black surgeons into academic positions and to help provide career development opportunities. More recently, the Society of Asian Academic Surgeons has been established. The newest organization is the Association of Out Surgeons and Allies, which aims to address issues for the LGBTQ community.

These organizations are working in conjunction with other surgical societies to help underrepresented groups achieve the success they should be achieving. The Latino Surgical Society has collaborated with these organizations. We are working on developing joint programming and opportunities to mitigate some of these hardships. We know we're all facing the same challenges, so we're trying to not duplicate or reinvent the wheel, so to speak.

Tell us more about the Latino Surgical Society and what you've accomplished since its founding in 2017.

We've created a variety of opportunities that included networking opportunities, where we would meet at surgical meetings, have a prominent surgeon deliver a talk to address that factor of lacking role models and mentorship, and lacking that peer-to-peer colleague environment. We worked with the AWS to create an award that was inaugurated in 2020 and adopted by several of the other organizations I mentioned earlier.

We've created opportunities for members to attend events such as the AWS annual conference and the American College of Surgeons scientific meeting. We were able to support 16 medical students and residents to attend the AWS conference, which was held virtually in 2020. These were opportunities for people to attend a conference to which they otherwise probably could not have gone, and they were able to benefit from the programming and the mentoring that is traditionally offered at these meetings.

We've created opportunities for people to join the editorial board of The American Journal of Surgery, which we've now partnered with to provide more diversity of the editorial board and among the surgical professionals who are reviewing articles to be published. These are the kinds of higher positions that will help people develop their CV, so when they're being reviewed for promotion, they can say they're involved in this side of academics.

We hosted a two-day surgical symposium on Latino health in 2019 in San Juan, Puerto Rico, where various speakers in a variety of disciplines addressed health issues faced by Latino communities. We created these opportunities to address specific topics that are relevant to our patients, to our callings and, frankly, personally to our families and friends. Over the past year, during COVID, we developed a series of webinars called Inside the Operating Room, where we invited Latino surgeons to share their stories. These have been very well-received. We have a wide range of audience that includes premedical students, medical students, residents and fellows, as well as faculty at all levels that are tuning in and listening to how other people have gone on to build successful careers.

COMMON PURPOSE The Latino Surgical Society, founded in 2017, has brought underrepresented surgeons together to network, learn and affect positive change.  |  Latino Surgical Society

You've mentioned the support you received from your family was an important aspect in your decision to pursue a career in surgery. How much more challenging is it for those who don't have that kind of support system?

My family never pushed me into any career, but they definitely encouraged seeking opportunities. We're an immigrant family, and we were seeking a better life in this country. That was really the only guiding principle I had. But I definitely think having their support helped me achieve my goals. It's definitely something that others may find more challenging if there's no support structure around them. There are definitely a lot of hurdles that you don't necessarily think of when perhaps you've had the privilege of not having to deal with those challenges yourself.

In another interview, you mentioned "selling out," the notion that going into surgery might not be considered a service to your community as compared to being a primary care physician or going into public health. Is this a common problem that discourages URM physicians from becoming surgeons?

Of course, we are very conscious about the fact that some of the elements affecting our communities are definitely issues that could be addressed with preventative health care and with primary care, such as diabetes, high blood pressure and obesity, just to name a few. But ["selling out"] is a concern that remains.

A lot of the pipeline programs for URM students have a strong emphasis on primary care. For example, we have loan forgiveness programs aimed at recruiting underrepresented students to enter medical school and pursue careers, but those programs traditionally only allow loan forgiveness for people who go into primary care. When you're talking about students, myself included, who paid for their medical education primarily with student loans, the significant debt they incur becomes a real issue.

Now that you're a role model yourself, how much anxiety and responsibility comes with the desire to lift people up and excel as a surgeon, which is already stressful?

I mentor students and trainees at all levels, and I always tell them I'm not particularly tied to them going into surgery. I'm tied to their matriculating into medical school and graduating and being successful, and being the best physician they can be. They're going to make a difference in any field they choose to go into. I don't see my role as guiding them into surgery as much as just being part of the safety net that keeps them in the programs, and to help them think outside the box on how to be successful.

I've seen a lot of students struggle with asking for help because they're often able to figure things out on their own. Asking for help can be embarrassing for just about anyone, so I think it's important to create safe spaces where people feel they can come to someone to ask for help and not feel judged, but also not feel like the person they're asking for help doesn't understand their problem at all.

How do I handle this in the scope of my own career? I've had to be increasingly aware of how much I take on. It's tremendous that there has been such an interest in diversity, equity and inclusion over the past year. However, I can't, for example, be the only person who is the speaker for every topic or the mentor to every student. I have to actively think about balancing out the requests to address some of these topics versus [the fact that] I'm an early career physician. I also need to prioritize my own professional development within my field, and keep in mind that my primary responsibility is to provide the best care to my patients at my institution. It can be a challenge, because I also feel a huge responsibility now that I've made myself a public role model to also be available in that role I've taken on.

In addition to being URM, you're also a woman in a male-dominated field. How much extra difficulty does that add in terms of the situations in which you've found yourself?

This is a really interesting shift. In medical school, I didn't feel particularly discriminated against as a woman. I definitely felt the URM aspect of it, being a Latina and figuring out the support in medical school around that. Now that I'm data-savvy, it makes sense, because even when I was a student, medical school were close to 50/50 in terms of male/female ratios of students.

As I transitioned into my residency, though, I went from being in this more or less 50/50 split to being back in a gender minority, and I definitely felt that a lot more than the race/ethnicity aspect. Some of the comments I received were particularly centered around being a woman. For example, I was once told that I should read more and focus less on wearing makeup. I was once told that I was being allowed to operate more independently than other people in my year, and the comment was along the lines of, "Well, the faculty is letting you do more because you're a pretty girl, not because your skills are that great."

Why is surgery still so male-dominated?

I would say the length of training can be problematic. Traditional societal roles expect women to do a more significant portion of child rearing. This expectation tends to drive women away from careers in surgery. So, unfortunately, in addition to not having positive role models or people who encourage women, there are actually people who are actively discouraging them from entering and pursuing careers in surgery.

What about patient attitudes? What is your strategy for dealing with a patient who might be hostile to your gender, race or ethnicity?

I have been able to address most of those situations in a very amicable way. Most of the time when I've had difficult interactions with patients, they weren't particularly frustrated at me as much as they were frustrated at the system, and when I was able to gather the information they needed and hear out what their frustration was, the patients were actually perfectly reasonable.

I definitely acknowledge, and I think it's great, that I'm breaking these stereotypes where someone can't imagine that a Hispanic woman could be a surgeon. From the patient's side, I definitely try to take that in the least offensive way that I could. I think that's a healthy way for me to approach patients because I don't think they mean to offend me. I meet the patient where they are and figure out a way around it.

What else is needed to improve diversity, equity and inclusion moving forward?

Allyship is a relatively new concept. It's the notion that increasing diversity and creating inclusive environments in surgery is a task that doesn't have to be left up only to those of us who are underrepresented in medicine. The way this really will change is if we actually have buy-in and support from the leadership, and from the traditionally white male surgeons who are in leadership roles understanding how important their role in moving the needle really is. That's a key element that we are definitely seeing more over the past year, and I hope it actually leads to meaningful change.

Engage with Dr. Romero Arenas (@minervies) on Twitter and Instagram.

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