The Value of Diversity: Spectrum of Tissue, Training, and Individuals in Hand Surgery

“It falls to few men to originate a surgical specialty."— Sterling BunnellThe field of Hand Surgery was founded by Dr Sterling Bunnell, who was asked by the US Surgeon General, during World War II, to develop regional hand centers at Army Hospitals in the United States. The history of the founding of Hand Surgery is important knowledge. The “few men” were the founders of the field and included only White men (Fig. 1). Dr Bunnell believed that Hand Surgery was a “composite problem requiring the correlation of the various specialties—Orthopaedic, Plastic and Neurologic Surgery—the knowledge of any one of which alone is inadequate for repairing the hand.” This concept of bringing together several surgical specialties becomes essential to take care of all the tissues of the hand and upper extremity to repair and reconstruct all the necessary structures in a coordinated fashion.

Diversity, equity, and inclusion may be a topic that seems irrelevant to the field of hand and upper extremity. However, with close attention, there is a significant correlation. To become a hand and upper-extremity surgeon, one must either complete an Orthopedic, Plastic, or General Surgery residency and then complete an additional one-year fellowship in hand and upper extremity. We are all aware the foundation of training in Hand Surgery is based upon the amount of Hand Surgery that was experienced in residency. This can be incredibly different experiences depending on the training program. There is significant variability in Hand Surgery fellowships with the breadth of Hand Surgery performed (from shoulder to fingertip), which can include shoulder, elbow, forearm, distal radius, wrist, congenital hand differences, microsurgery, replantation, complex reconstruction, and so on. This variability in training and interests results in variable types of practices. Orthopaedic Hand surgeons can sometimes be less comfortable with microsurgery and therefore less likely to perform. Plastic Hand surgeons can sometimes be less comfortable with complex distal radius and forearm injuries and less likely to perform them. When we think about Hand Surgery, this field combines all these levels of expertise with our ability to change form and anatomy, change function, and use technology such as the microscope and hardware to best reconstruct the diverse tissue of the upper extremity. As Hand surgeons, we clearly value the diversity of pathways for training so that we can consider all the tissues when performing reconstruction.

In a similar fashion, we should value the diversity of who is being trained to become a Hand surgeon. Why should we care? Because diversity in the physician/surgeon workforce has been shown to improve patient outcomes. The disparity in health care access and outcomes across the United States has been made readily apparent during the COVID-19 pandemic. In Hand Surgery, the number of women entering the field has increased over time, although remains low, and the number of underrepresented minorities have remained persistently low. Hand surgeons of the United States should reflect the diversity of our populations. We have disparity in the access for Hand surgeons in the United States; therefore, we should be working on recruiting the next generation of Hand Surgeons that are, it is hoped, more likely to work within their own community to help close these gaps.

We are excited to provide you with this series of thoughtful articles by Hand Surgery leaders on crucial topics within diversity, equity, and inclusion. Our history becomes incredibly important and includes many contributions from Hand surgeons from diverse backgrounds. Our diverse patient populations come from different demographics, ethnicity, and race, whose outcomes are affected. Research in health equity and policy is important for understanding where to improve outcomes. We value having Hand surgeons from diverse backgrounds, including race, ethnicity, sex, and sexual orientation, which clearly drives excellence. Improving diversity comes from the top, from our leadership, and therefore, it becomes important to have a sustainable approach in improving diversity within academics and the community. Success in this subspecialized field requires mentorship and sponsorship, with the goals of aligning this topic for the mentee. Women have made significant contributions to the field over time, and there are important considerations that must be considered for a supportive environment in Hand Surgery. The underrepresented minority is rare in Hand Surgery, and the goal should be to make them commonplace. The LGBTQ+ experience within Hand Surgery for surgeons and patients is also an important consideration for inclusivity. The international medical graduate perspective, both historical and challenges, has never been openly discussed before within the field of Hand Surgery. To survive training and practice, microaggressions and implicit bias are important considerations for many. Our leaders serve as allies and advocates for those that come from diverse backgrounds, and their support is essential. Finally, we must focus on medical students and residents for the recruitment and retention of the next generation of diverse Hand surgeons. We are proud of these essential topics that deserve a presence within our literature.

An active and concerted multifaceted approach will foster change. We respect and honor the founders of our society, but it is time to implement diversity and advocate for allowing others to sit at the table (Fig. 2) and contribute, with the hopes of better reflecting our diverse patient populations of the United States. We hope that you enjoy this issue and can take the information, the data, and the drive, and join us in taking action and moving our field forward.

"It falls to many committed individuals, from diverse backgrounds, to continue and expand excellence in the subspeciality of hand and upper-extremity surgery."