Source: STAT News
Written By Usha Lee McFarling
For 15 years, orthopedic surgeon Charles S. Day has been working to highlight the striking lack of diversity in his field, publishing studies showing orthopedics had the fewest Black, Hispanic, and female residents of any surgical specialty.
Day himself is Asian American, a group that’s abundant in medicine. But as he dug further, his datasets and personal experiences began to collide. He found that white doctors were more than four times as likely as their Asian American colleagues to be promoted to medical school department chair positions in a wide array of medical specialties, and that Black and brown doctors were more than twice as likely as Asians to be promoted.
In 2019, according to a new analysis by Day, Asian Americans made up 13% of orthopedics faculty at U.S. medical schools but held just 5% of chairs. When Day looked across a range of specialties, including family medicine and OB-GYN, he found that Asian American physicians held more than 20% of faculty positions but less than 11% of chair positions. He also found near complete silence about this leadership gap.
The issue remains largely invisible because Asian Americans are considered overrepresented in medicine: They make up just 7% of the nation’s population but are 20% of its doctors. Asian Americans also are often considered the “model minority” — statistics show that as a group they tend to be healthier, wealthier, and more educated than other racial groups, including white Americans. As a result, the progress and challenges of Asian Americans in medicine have been little studied or discussed.
To be sure, Black and Hispanic doctors are a far smaller percentage of faculty in all specialties than white and Asian American doctors, but analyses by Day and others show a larger proportion of the smaller pool of Black and Hispanic faculty eventually advance to chair positions than Asian Americans.
“I was so blinded to the issue, but as I’m doing the research it dawned on me,” said Day, who is executive vice chair of orthopedic surgery at the Henry Ford Health System in Detroit and is a professor of orthopedics at Wayne State University. “I’d been feeling like, huh, I’m not being considered for this position, or that position.”
As he spoke to Asian American colleagues about the disparity in recent months, he realized they felt similarly. They hadn’t talked about it openly, but told Day they’d been passed over for higher-level jobs several times and knew very few Asian American physicians in top roles within medicine.
“I’m beginning to think it hurts to be Asian American,” said one physician who requested anonymity because he is currently seeking a leadership job. “I’ve been struggling to get any kind of leadership. I’ve been told many times I have all the talent and the whole package, but I’m just ‘not the right person.’”
This gap is invisible in many data analyses. Because they are not underrepresented in medicine, Asian American physicians are regularly lumped with white physicians in many demographic analyses. The racial makeup of U.S. medical school deans posted by the Association of American Medical Colleges, for example, shows white and Asian American doctors have held more than 90% of medical school dean positions for the last 30 years, which makes it appear there are large numbers of Asian American deans.
But there are not. A study published in 2013 found not a single Asian American medical school dean in the United States between 1997 and 2008.
Peter T. Yu was a surgical resident at the University of California, San Diego, when he led that study. When he interviewed for fellowships and jobs, he said, the absence of Asian American physicians in leadership was palpable. “When you interview, you see the chairs and division chiefs,” he said. “Asian Americans are not overrepresented in those roles.”
To Yu, the most obvious parallel is the NFL, where the vast majority of players are Black, but Black head coaches are rare. “You can do a hand count,” he said. “It’s the same in our profession.”
When Augustine M.K. Choi became dean of Weill Cornell Medicine in 2017, he was one of two Asian American deans leading one of the country’s more than 150 allopathic medical schools, he told STAT. In recent years, Choi said, the number has hovered between five and six deans. “I know, because I know them all,” he said.
Barriers to leadership for Asian Americans are also an issue elsewhere in medicine. In its 176-year history, for example, the American Medical Association has had one president with Asian ancestry.
At the National Institutes of Health, a recent study found Asian Americans make up 20% of the permanent workforce but hold only 6% of senior leadership positions. The analysis showed Asian American employees had more obstacles moving up the ladder, with many reporting “the everyday experience of exclusion and invisibility.”
It’s a problem in business and tech as well. A 2017 report on Silicon Valley found Asian Americans were less likely than any other racial group, including those who are Black and Hispanic, to be promoted. At Goldman Sachs, 25% of the U.S. workforce is of Asian descent but just 15% of executives are.
In science, disparities also exist in funding rates. A 2022 study of National Science Foundation funding found Asian American scientists, while receiving a large number of grants, were funded at the lowest rate per submission of any racial or ethnic group. A 2012 study showed Asian Americans were less likely than white or Hispanic researchers, but more likely than Black researchers, to receive prestigious NIH R01 awards.
It’s no different for biomedicine’s most prestigious research prizes, in which more than 90% of awardees are white and less than 7% are of Asian descent, despite the fact that people of Asian descent make up more than 21% of biomedical faculty, according to a study by University of California, San Francisco, physiologist Yuh Nung Jan, who called the numbers “pretty appalling.”
In interviews with STAT, many Asian American physicians wondered if cultural norms that promote humility and listening over speaking up and self-promotion diminished their chances for leadership positions and helped keep this issue hidden. But they are becoming more vocal. The recent surge of anti-Asian violence, including attacks on physicians in the wake of the Covid-19 pandemic, has prompted many to speak out about what they see as the bias, stereotyping, and unfair treatment they have experienced.
Choi, for one, said he was inspired to co-author a JAMA editorial on the lack of Asian representation in medical school leadership in 2021 after the shooting deaths of six women of Asian descent in Atlanta earlier that year.
For Day, the numbers he’s recently revealed dovetail with personal frustration. He was interim medical director of his hospital for two years and interim chair of his department for nearly a year. In his view, his long surgical and teaching experience, his publication record, and his MBA and deep knowledge of hospital finances more than qualified him to lead the department permanently.
He waited patiently as a decision was postponed and then as two outside candidates were brought in. “They were both white, by the way,” he told STAT. One of those candidates, without demonstrably more qualifications or experience than Day, was recently chosen for the job, he said.
The decision has forced Day to consider leaving a medical school and hospital system he loves. He knows his individual experience isn’t enough to prove a trend. But numbers from national databases in academic medicine suggest he is far from alone, and that systemic bias may be at play. “You look at the data and you say, ‘there’s a disconnect here,’” he said.
“We’re good enough to be star faculty, division chiefs, program directors, and vice chairs, but not ‘good enough’ for the next echelon,” said Day, who is Taiwanese American. “Working hard and having all kinds of accomplishments may get you into medical school or a faculty appointment, but it doesn’t get you into the C-suite.”
There’s no telling this story without addressing the elephant in the room: Asian Americans are overrepresented in medicine while many people from other non-white racial and ethnic groups are struggling to gain entry into the profession in significant numbers — and come from communities that face staggering health disparities. To Black, Hispanic, and Indigenous physicians — as well as Native Hawaiians and Pacific Islanders who are included under the broader AAPI umbrella but are severely underrepresented in medicine at all levels — the concerns of Asian American physicians may seem less urgent, or perhaps not important at all.
Such sentiments may be one reason Asian Americans have not felt comfortable bringing their concerns forward, particularly now amid the clear racial disparities seen during the Covid-19 pandemic and after the police violence highlighted by George Floyd’s murder brought the horrific racism faced by many Black Americans — and Black physicians — into the national spotlight.
The issue is also politically sensitive. Many see the recent debates over affirmative action, with the Supreme Court overruling its use in admission to colleges and medical schools, as pitting Asian Americans against those who are Black and Hispanic.
Asian American physicians interviewed for this article said they felt strongly that physicians from underrepresented groups needed and deserved their support and that the pipeline into medicine needs to be broadened and diversified. But that doesn’t mean, they say, that the leadership disparities affecting them should be ignored or that their academic success and hard work should not be rewarded. “It puts Asians in an awkward position” to bring these issues up, Day said.
For Asian Americans, the pipeline to enter medicine is wide open — but it appears to squeeze shut abruptly for many with higher career aspirations.
“We’re left out of DEI efforts because we’re well represented, yet we have a glass ceiling that people aren’t talking about,” said physician Richard Pan.
Pan is a pediatrician who trained at some of the nation’s top programs and had been moving up the faculty ranks at the University of California, Davis. He went from assistant to associate to full professor, was awarded numerous research grants, and served as interim director of the medical school’s pediatric residency program. But there, his upward trajectory ended.
A well-known community leader, Pan then did something unusual for a physician. He ran for office. He was elected to the California Assembly in 2010 and then the state Senate in 2014, serving until last year when he termed out. His legacy was a slate of new laws protecting children’s and public health and a reputation for strong leadership. At UC Davis, he told STAT, “I wasn’t being offered section chief, or department chair, yet I go out and get elected. When the people vote, I get elected. When it’s a club, I don’t get selected.” He is now running to become Sacramento’s next mayor.
The son of Taiwanese immigrants, Pan had wanted to be a doctor from a young age — a decision that pleased his highly educated parents who urged him to do something practical and technical that would make him needed. “Then when you face discrimination,” his parents had told him, “those people will have to swallow it, because they need you.”
Pan, a self-professed data wonk, is leading efforts to collect and disaggregate data on Native Hawaiians and Pacific Islanders to understand health disparities in those groups. But his effort to get specific numbers on Asian Americans in medical leadership positions has been frustrating. “I’ve been trying to look at this for several years,” he said. “It’s really hard to figure out because they put white and Asians together.”
The data now trickling out confirms Pan’s belief that systemic factors — racism and stereotyping — may be keeping Asian Americans from reaching leadership positions in a host of fields.
A recent study shows the devaluing of the skills and prowess of Asian American physicians may begin early in their careers. In a study of nearly 10,000 internal medicine residents who finished their training in 2016 or 2017, those of Asian descent were assessed by their program faculty to be nearly 25% less likelythan their white counterparts to be ready to practice medicine unsupervised; residents from groups underrepresented in medicine were 15% less likely than white residents to be deemed ready. The differences in ratings, the authors wrote, suggests a “global devaluation” of these physicians that may “accumulate longitudinally and prevent career advancement.”
The trope going around when he attended medical school in the early 1990s was “Asian Americans are good at tests but they’re not good with people,” said Pan. “That trope is still going around unfortunately.”
STAT spoke to nearly a dozen Asian American physicians who discussed the pain, uncertainty, and confusion they have felt as they have been bypassed again and again for promotions they feel they had earned.
Many said they faced discrimination while growing up, but found success in medical school and their early careers, even in difficult and competitive surgical specialties. “I’d worked my ass off early on and had many accolades, all the doors opened,” said one physician, who like some others requested anonymity to avoid harming their career. “As I got to the middle of my career and later, all the doors started to shut.”
Many said they doubted themselves, and thought that if they just worked even harder and shined even brighter, opportunities would follow.
“I would think, maybe if I just write another 100 papers, someone will notice me,” said the physician, who has received several million dollars in grant funding over the years and has a lengthy publication record. “I made excuses for why I wasn’t getting things — I thought I needed to work on my personality, my manner of speaking — that’s a very Asian thing.”
Others, including Day, said they defy the stereotype of quiet and reserved Asian Americans and possess the assertiveness usually tied to leadership in the U.S. “By the way, I’m not soft-spoken,” said Day. But that didn’t seem to help. “It’s always something intangible — being told, ‘You’re not quite a leader.’”
Another Asian American physician who requested anonymity told STAT: “I’ve been told I’m too direct, not subtle enough, that my energy and enthusiasm is overwhelming,” he said. “Well, I’m a surgeon. You give me a problem, I’m going to fix it.”
The surgeon and many others are frustrated that the decades of hard work they’ve put in has not taken them further, and said they have started to feel medicine is not the meritocracy they were told it was. “It’s shaking up the foundation of 40 years of how we worked,” he said. “Why do you not go to parties, spend every weekend in the lab doing research? It’s to get to the next step.”
Others said they had realized over time, and after many disappointments, that leadership doors were not open to them. They described being sent to satellite hospitals instead of more visible jobs at main teaching hospitals, not being asked if they were interested in leadership, and having promotions delayed or withheld with little reason.
“There are chosen ones and unchosen ones. I learned quickly in my career I wasn’t going to be groomed for leadership,” said another physician who requested anonymity.
“We’ve got several strikes against us. We’re not getting credit for being a minority. We tend to be shorter. We tend to do our jobs and not complain,” he added. “That combination makes us easy to overlook.”
“I thought as long as I did a good job, it would be OK, that someone would be looking out for me,” said the physician. “I was so naive.”
What could be causing the deficit in leadership positions for Asian American doctors? Many who have thought about the issue point to bias and stereotypes as part of the problem, but say the culture of their communities also likely plays a role.
Pan and others said many Asian Americans grew up in households where they were urged to study hard, keep their heads down, and not make waves. “In my own culture, that would be seen as too aggressive [to push for a leadership position],” he said. “We’re supposed to be humble.”
James Kang is a spine surgeon who chairs the department of orthopedic surgery at the Harvard-affiliated Brigham and Women’s Hospital in Boston. When he sits in a room of the 50 or so department chairs, he said, he’s the only Asian American in the room. It’s the same when he’s in a meeting of his hospital’s top leaders. “I have said, ‘It’s strange to me that I’m the only Asian face in this room of 180 people,’” he said.
Kang is about to become president of the American Board of Orthopaedic Surgery. He’ll be the first Asian American president in the group’s 90-year history. It’s something he’s reflected on — why he’s risen to leadership while so many of his Asian American colleagues have not. He thinks it’s clear there is subliminal bias, but says “some of this is on us.”
Kang was born in Korea, and was taught, as many Koreans are, that gentlemen aren’t supposed to talk much, or mouth off, but to listen and behave. “But if you want to get ahead in Western society, you have to give your opinion. You have to show charisma,” he said. “A lot of decisions are made based on meetings and how you represent yourself, and a lot of Asians fall short on that.”
Kang attributes his ability to cross over to a Western leadership style to the late Freddie Fu, a legendary physician at the University of Pittsburgh Medical Center who was one of the first Asian department chairs in medicine. “He was very charismatic. He talked a lot. He was from business Hong Kong. His father was a billionaire and people just loved him,” Kang recalled.
“I lived under that regime and saw how Freddie operated,” Kang said. “I learned to speak out and become a leader based on Western culture.”
Now, said Kang, he’s seen a number of Asian American candidates for top positions that don’t interview well. “They’re highly accomplished, but they’re so quiet,” he said. “I want to take them into the other room and say, ‘No, you’ve got to do it this way.’”
“I’m trying hard to be a good role model as Freddy was to me,” Kang said. “I tell them, ‘Don’t go against what your parents told you, but be a little bold.’”
Yu, a Chinese American who led the study on the decade-long absence of Asian American medical deans, said the reasons for the disparities are complex, and that culture certainly plays a role. “I think my experience is fairly common. The push was to go to a top college and there’s a strong push to go to medical school, but there was never a strong push for me to become a dean or chair — being a doctor was a pinnacle in my family.”
Asian Americans, he said, are very family-oriented. Leaving time to spend with children, and taking care of aging parents, he said, may preclude some from avidly climbing career ladders.
More research needs to be done to understand the role these cultural issues play. A 2020 study of business leadership found that South Asians were more likely to be promoted than East Asians and even more than their white colleagues, though they reported experiencing more prejudice and East Asians were equally interested in leadership. The authors attributed the difference partly to South Asians communicating more assertively.
They emphasized the onus should not be on East Asians to change their behavior, but rather on American organizations to evolve their definition of leadership and recognize that the “group-focused, protection-oriented” leadership style of East Asians could benefit them. “The bamboo ceiling is not an Asian issue, but an issue of cultural fit,” they wrote.
“The question is,” said Kang, “is it up to us to rise to white standards? Or is it up to them to realize this is a cultural issue?”
There is some change afoot, perhaps most visibly on the West Coast. Yu, for example, is the chair of the department of surgery at his Southern California hospital, and the department of surgery at UC Irvine where he is an associate professor has an Asian chair as well. More data are being collected, including a study published this March that found a similar Asian American leadership gap in internal medicine as Day found in orthopedics, and that for females of Asian descent, the leadership numbers are far lower than for males.
More conversations are starting within academia. Colby College psychologist Jin X. Goh tweeted this month that “an Ivy League psych dept reached out to me and many of my Asian American assistant prof friends to apply for a SENIOR position. They just didn’t have enough POC applicants. They hired a White person at the end.” His tweet got 2 million views.
And in what may be the first formal effort to bring more Asian American doctors into leadership, physicians at the Icahn School of Medicine at Mount Sinai recently started the Mount Sinai Center for Asian Equity and Professional Development. The program got its start during the pandemic and the upsurge in violence against Asians, said Amanda Rhee, an anesthesiologist and associate professor at the medical school who serves as the center’s inaugural director.
A town hall convened to discuss anti-Asian violence, she said, uncovered the fact that many Asian American physicians felt they were being overlooked for leadership and advancement.
“So many people came out of the woodwork to ask for help,” she said. “They said they had nowhere to go to talk about these difficult issues.”
That’s something Norma Poll-Hunter, senior director for workforce diversity at the Association of American Medical Colleges, has seen firsthand from Asian American physicians when she runs leadership workshops and DEI discussions.
“Oftentimes they ask, ‘Am I welcome?’ They certainly are,” she said. “Many Asian faculty, like their Black and Hispanic colleagues, don’t have access to information and networks that white faculty do.”
It was clear from discussions at Mount Sinai that many felt overlooked because medical leaders and others consider Asian Americans to be doing well educationally and financially. But that’s not always true: A recent study found nearly one-quarter of Asian Americans adults in New York City live in poverty. “That model minority myth leads to a blind spot,” Rhee said.
James Tsai is the center’s executive adviser. He also chairs the medical school’s ophthalmology department, is president of the New York Eye and Ear Infirmary of Mount Sinai, and was recently asked to join the board of the Council of Teaching Hospitals and Health Systems, a group of physician leaders that focuses on national issues affecting medical schools. He is the only Asian American physician in the 20-person group.
Tsai is hoping to transmit some of what he’s learned about leadership to others. “I think I made the quick realization that at some point, talent won’t get you all the way up,” he said. “It’s how you position yourself. It’s being collaborative.”
He has an MBA and said the degree helped him understand “the soft skills of leadership.” “It’s not the person who’s the smartest person in the room who’s the leader, it’s more the person who can be the conductor, the coordinator,” he said. “A lot of Asian physicians who are super talented and with the most achievements don’t always see this.”
Mount Sinai’s center is the first Tsai knows of that is focusing on professional development for Asian American physicians. Center leaders hope to study the issue of implicit bias against Asian Americans and offer leadership training and more formal mentorship. He is eager for similar centers to follow.
Tsai, Rhee, and others want their work to enable a new generation of Asian American physicians to serve as medical leaders. For the many who have been in medicine for decades and never reached the level of department chair or higher, it’s likely too late. Said one Asian American physician: “It would have made my dad so proud.”