Plastic Surgery Research Council

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Race and Equity in Plastic Surgery: What Does Our Literature Show?
Daniel Y. Cho, MD, PhD1, Cameron J. Kneib, BS1, Jonathan P. Massie, MD2, Shane D. Morrison, MD, MS1, Danielle L. Sobol, MD1, Christopher S. Crowe, MD1, Megan Lane, MD3, Afaaf Shakir, MD4, Jacob R. Burns, MD, MBA5, Janelle D. Sousa, MD1, Eduardo D. Rodriguez, MD, DDS6.
1University of Washington, Seattle, WA, USA, 2Northwestern University, Chicago, IL, USA, 3University of Michigan, Ann Arbor, MI, USA, 4University of Chicago, Chicago, IL, USA, 5University of California, Davis, Sacramento, CA, USA, 6New York University, New York, NY, USA.

PURPOSE: Profound racial and ethnic disparities in the delivery, access, and appropriation of healthcare exist. There have been reports in plastic surgery revealing disparities in the access of minority patients to breast reconstruction, replantation in hand injuries, and clinical trials. The aim of this study was to determine if published plastic surgery images accurately reflect racial demographics of patients undergoing plastic surgery procedures as well as the general population, both within the United States and globally.
METHODS: A bibliometric analysis was performed on leading journals in the field of plastic surgery: Annals of Plastic Surgery (APS), Aesthetic Surgery Journal (ASJ), Journal of Craniofacial Surgery (JCFS), Journal of Hand Surgery (JHS), Journal of Plastic, Reconstructive, and Aesthetic Surgery (JPRAS), and Plastic and Reconstructive Surgery (PRS). The New England Journal of Medicine (NEJM) Images in Clinical Medicine feature was included as a non-plastic surgery control to better generalize any findings to other medical specialties. Journals were searched for color photographs and rendered graphics that contained depictions of human skin. The subject of each figure was categorized as "white" or "non-white" using the Fitzpatrick scale as a guide.
RESULTS: 24,209 color photographs and 1,671 color rendered graphics were analyzed. Seventy eight percent (78%) of photographs were of white patients, and 22% of photographs were of non-white patients. In plastic surgery journals, 22% of photographs were non-white and the average number of photographs per article with white skin was 5.4 compared to 1.6 with non-white skin (p<0.0001). Similar results were seen in the NEJM (18% of photographs with non-white skin, average of 1.3 white versus 0.29 non-white skin, p<0.0001). In plastic surgery journals, there was a significant increase in non-white photographs over time (r =0.086, p<0.001) and a significant association of non-white photographs with international articles (r =0.12, p<0.001). Estimates suggest that 35% of the world's population and 23% of the United States' population is non-white; 30% of patients who seek cosmetic plastic surgery are non-white.
CONCLUSIONS: This is the first large-scale study to explicitly demonstrate the implicit racial biases that exist in the clinical images portrayed in medical publishing. Proportionally, the racial breakdown of medical photographs and graphics does not reflect the world population, the population of the United
States, or the population of patients seeking plastic surgery with a significant bias towards "white" subjects. Studies published by authors from outside of the United States, or with cross-regional collaboration, were more likely to include non-white photographs. Trends over time do suggest that the plastic surgery literature is beginning to better represent racial diversity but biases in medical images persist in both plastic surgery and multidisciplinary journals. Such biases can contribute to inequalities in the delivery, access, and appropriation of healthcare. Thoughtful selection of the images used in medical publishing from both the author and journal perspective should be used moving forward to better represent the populations we serve.


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