Trends in Racial and Ethnic Diversity Among Micrographic Surgery and Dermatologic Oncology (MSDO) Fellows and Fellowship Directors

doi:10.21203/rs.3.rs-8060499/v1

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Trends in Racial and Ethnic Diversity Among Micrographic Surgery and Dermatologic Oncology (MSDO) Fellows and Fellowship Directors

https://doi.org/10.21203/rs.3.rs-8060499/v1

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Dermatology is one of the least racially diverse medical specialties, which extends to Mohs Micrographic Surgery (MMS). Improving representation of diverse racial and ethnic groups within Micrographic Surgery and Dermatologic Oncology (MSDO) fellowships is important for addressing this inequity. The impact of improving diversity in MMS is widespread, and has the potential to improve patient trust, satisfaction, and outcomes in dermatologic oncology care.

This study evaluates racial and ethnic trends among MSDO fellows and program directors in 1996–2000 compared with 2021–2025. The software “rethnicity” was used to predict likely race and ethnicity from the names of all American College of Mohs Surgery (ACMS) fellows and directors listed on the ACMS website from 1996 to 2025. Linear regression was utilized for statistical analysis.

From 1996–2000, 25.1% of Mohs fellows were Asian, compared to 32.6% in 2021–2025, reflecting a statistically significant increase in Asian representation. No statistically significant differences were observed in the proportions of Black (16.4% vs 12.6%), Hispanic (7.2% vs 8.4%), and White (51.3% vs 46.4%) fellows between 1996–2000 vs 2021–2025, respectively. Among program directors, the proportion of Asian directors had a statistically significant increase from 15.5% in 1996–2000 to 25.2% in 2021–2025. Hispanic program directors also increased from 1.4% to 4.5%. Conversely, there was a statistically significant decrease in White program directors, from 70.4% to 54.1%. Among program directors, 12.7% were Black in 1996–2000, while 16.2% were black in 2021–2025, representing no statistically significant difference.

A limitation of this study is the absence of self-reported racial and ethnic backgrounds, as “rethnicity” infers race and ethnicity based on names. Although “rethnicity” has been validated on large voter registration datasets and demonstrates strong predictive accuracy, its probabilistic design may introduce misclassifications. Despite this limitation, name-based inferences provide a practical and reproduceable approach for evaluating large datasets when self-reported demographic data are unavailable, allowing assessment of longitudinal trends that would otherwise remain unexamined.

Our findings underscore the persistently low representation of individuals underrepresented in medicine (URiM) among MSDO fellows and fellowship directors. Efforts to diversify the MMS pipeline must remain a priority as the specialty continues to grow.

Mohs micrographic surgery

Diversity

Fellowship

Program Directors

Underrepresented in medicine (URiM)

Dermatology remains one of the least racially diverse medical specialties, which extends to Mohs Micrographic Surgery (MMS) [1–2]. Increasing representation of diverse racial and ethnic groups within MMS is essential to providing equitable care for patients. When patients perceive similarity with their physicians, they report higher levels of trust, satisfaction, and intention to adhere, thereby strengthening the overall physician-patient relationship [3]. This is particularly important as the morbidity and mortality related to skin cancers are disproportionately higher among non-Caucasian patients [1]. Over the last decade, substantial efforts have been made to increase diversity within dermatology residency and fellowship programs, including MMS. Herein we evaluate ethnic and racial diversity trends among Micrographic Surgery and Dermatologic Oncology (MSDO) Fellowship Directors and Fellows to assess progress and identify ongoing gaps.

All names of American College of Mohs Surgery (ACMS) fellows and directors listed on their website from the years of 1996 to 2025 were analyzed. Analysis was performed using R (version 4.4.2) and the package “rethnicity” which estimates most likely race/ethnicity from names using a neural network trained on Florida voter registration data [4]. Statistical significance was determined using a linear regression trend test.

From 1996–2000, 25.1% (n = 49) of Mohs fellows were Asian, compared to 32.6% (n = 155) in 2021–2025, reflecting a statistically significant increase in Asian representation (p = 0.030). No statistically significant differences were observed in the proportions of Black (16.4% [n = 32] vs 12.6% [n = 60]), Hispanic (7.2% [n = 14] vs 8.4% [n = 40]), and White (51.3% [n = 100] vs 46.4% [n = 221]) fellows between 1996–2000 vs 2021–2025, respectively (Table 1 and Fig. 1a).

Among Mohs fellowship program directors, the proportion of Asian directors had a statistically significant increase from 15.5% (n = 11) in 1996–2000 to 25.2% (n = 28) in 2021–2025 (p < 0.001). Hispanic program directors also increased from 1.4% (n = 1) to 4.5% (n = 5) over the same time period (p = 0.017). Conversely, there was a statistically significant decrease in White program directors, from 70.4% (n = 50) in 1996–2000 to 54.1% (n = 60) in 2021–2025 (p < 0.001). Among program directors, 12.7% (n = 9) were Black in 1996–2000, while 16.2% (n = 18) were Black in 2021–2025, representing no statistically significant difference (p = 0.900) (Table 1 and Fig. 1b).

Among MSDO fellows, the only statistically significant change observed was an increase in Asian representation, while the proportions of White, Hispanic, and Black fellows remained stable when comparing fellows during 1996–2000 to 2021–2025. Our findings underscore the persistently low URiM representation among MSDO fellows, with 12.6% Black and 8.4% Hispanic, compared to 46.4% White and 32.6% Asian. Therefore, 79% of our cohort is non-underrepresented in medicine (non-URiM).

These results align with prior literature demonstrating limited diversity in MMS. Feng et al. reported that underrepresented minorities (URMs), including Hispanics, African Americans, Native Americans, and Pacific Islanders, remained markedly underrepresented among Mohs surgeons in 2014, comprising only 4.5% of the Mohs surgery workforce compared to 31% in the general U.S. population and 13% among all physicians. Notably, they found that 80.2% of Mohs Micrographic Surgeons identified as White [1]. Frech et al. analyzed MMS fellowship applicants from 2016 to 2020, and found that 6.6% of matched applicants and 10.9% of unmatched applicants identified as URMs prior to 2018, compared to 8.1% and 10.1% after 2018, respectively. Although the proportion of matched URM applicants increased, the increase was not statistically significant [2]. In contrast, a study of Accreditation Council for Graduate Medical Education (ACGME) accredited dermatology fellowships demonstrated that URiM Mohs surgery trainees increased from 2.6% in 2011 to 14.1% in 2021. URiM included American Indian or Alaskan Native, Black or African American, Hispanic, Latino or of Spanish origin and Native Hawaiian or Pacific Islanders, whereas non-URiM included White and Asians [5].

Among program directors, we observed an increase in Asian and Hispanic representation. Literature evaluating racial and ethnic diversity among MSDO fellowship directors is limited. Although we observed an increase in Hispanic representation among program directors, overall URiM representation remains low (16.2% Black and 4.5% Hispanic). Leadership diversity is important given that program directors play a key role in recruitment and mentorship. Increasing representation among directors may have downstream effects on attracting and supporting URiM applicants to MMS fellowships.

One limitation of the study is that “rethnicity” does not identify American Indian/Alaskan Native, or Native Hawaiian/Pacific Islander individuals, who are historically underrepresented groups. Another limitation is the absence of self-reported racial and ethnic backgrounds, as the “rethnicity” software infers race and ethnicity based on names. Although “rethnicity” has been validated on large voter registration datasets and demonstrates strong predictive accuracy, its probabilistic design makes individual misclassifications possible. Nevertheless, the method is peer-reviewed and used under sampling to correct class imbalances, improving accuracy among minority groups to reduce bias. Despite these limitations, name-based inferences provide a practical, reproduceable approach for evaluating large datasets when self-reported demographic data are unavailable, enabling assessment of longitudinal trends that would otherwise remain unexamined. Future efforts to gather self-reported race and ethnicity among MSDO Fellows and Fellowship directors are needed to confirm the results of our study.

Persistent barriers for URiM groups may stem from structural inequities in medical education and training, limited representation within dermatology, and limited mentorship opportunities, which collectively influence the likelihood of applying to and matching into MSDO fellowships. Efforts to diversify the MMS pipeline must remain a priority. As the specialty continues to grow and advance, commitment to diversity will improve representation as well as patient trust, satisfaction, and outcomes in dermatologic oncology care.

Table 1
Racial and Ethnic Representation of MSDO Fellows and Program Directors, 1996–2000 vs. 2021–2025
Race/Ethnicity	1996–2000	2021–2025	p-value
MSDO Fellows
Asian	25.1% (n = 49)	32.6% (n = 155)	0.030*
Black	16.4% (n = 32)	12.6% (n = 60)	0.169
Hispanic	7.2% (n = 14)	8.4% (n = 40)	0.302
White	51.3% (n = 100)	46.4% (n = 221)	0.208
MSDO Fellowship Program Directors
Asian	15.5% (n = 11)	25.2% (n = 28)	< 0.001*
Black	12.7% (n = 9)	16.2% (n = 18)	0.900
Hispanic	1.4% (n = 1)	4.5% (n = 5)	0.017*
White	70.4% (n = 50)	54.1% (n = 60)	< 0.001*
*Indicates p-value < 0.05 (statistically significant trend)

Funding: None

Conflicts of Interest: None declared

Author Contribution

R.O., O.M., K.N., A.E., and J.M.L. wrote the main manuscript text, R.O. prepared figure 1, and O.M. prepared table 1. All authors reviewed the manuscript.

Feng H, Feng PW, Geronemus RG. Diversity in the US Mohs Micrographic Surgery Workforce. Dermatol Surg. 2020 Nov;46(11):1451-1455. doi: 10.1097/DSS.0000000000002080. PMID: 31397775.
Frech FS, Ghanian S, Hernandez L, Dreyfuss I, Nouri K. Trends in matching into Mohs Micrographic Surgery fellowship among underrepresented minority applicants from 2016 to 2020: a retrospective review study. Arch Dermatol Res. 2023 Mar;315(2):287-289. doi: 10.1007/s00403-022-02367-7. Epub 2022 Jun 25. PMID: 35751662.
Street RL Jr, O'Malley KJ, Cooper LA, Haidet P. Understanding concordance in patient-physician relationships: personal and ethnic dimensions of shared identity. Ann Fam Med. 2008 May-Jun;6(3):198-205. doi: 10.1370/afm.821. PMID: 18474881; PMCID: PMC2384992.
Xie F. rethnicity: an R package for predicting ethnicity from names. SoftwareX. 2022;17:100965
Okorie CL, Elkady D, Nambudiri VE. Trends in sex and ethnicity among U.S. dermatopathology and Mohs surgery trainees: 2011-2021. Arch Dermatol Res. 2023 Oct;315(8):2471-2473. doi: 10.1007/s00403-023-02670-x. Epub 2023 Jul 24. PMID: 37486415.

No competing interests reported.

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Trends in Racial and Ethnic Diversity Among Micrographic Surgery and Dermatologic Oncology (MSDO) Fellows and Fellowship Directors

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