Surgeons that don't 'fit the culture' can increase diversity in spine, orthopedic care


For years, the field of orthopedic and spine surgery has remained remarkably undiverse, boasting the highest percentage of active physicians identifying as white. 

On top of a lack of racial diversity, orthopedic and spine surgery programs also struggle to recruit female candidates and LGBTQ+ candidates. 

Qusai Hammouri, MD, a spine surgeon at New York City-based NYU Langone Health, is aiming to change that. 

This year, Dr. Hammouri was named one of the top 66 LGBTQ+ physicians in the U.S. for 2023 by Castle Connolly, in partnership with Health Professionals Advancing LGBTQ Equality.  

In 2021, Dr. Hammouri worked to establish Pride Ortho, a proactive community of musculoskeletal specialists that works to promote diversity, equity and inclusivity to improve quality of care for LGBTQ+ orthopedic patients and improve opportunities for LGBTQ+ physicians. 

"Our push nowadays is to include [hiring] criteria that asks, "Does this add to our diversity? Does this increase the breadth of the people working or training in these institutions?" The idea behind that is simple. If you increase diversity in a team, your company makes better decisions and profits more," Dr. Hammouri told Becker's.

As Pride Ortho's founder and inaugural president, Dr. Hammouri has established a mentorship program and scholarship opportunities for up-and-coming LGBTQ+ orthopedic and spine surgeons. 

"Most residents or medical students choose to go into a program because they see people in that program that could be them. I go to a program, I see a mentor, that mentor is from where I'm from, or went to the same school, or has the same color hair I do. Whatever it is, if I can see myself in them, it'll make me want to join that," Dr. Hammouri told Becker's.

 "On the flip side, that person will see themselves in me and want to mentor me. There's a bit of belonging there and it's hard to have that happen when I look different than my mentor or have totally different interests or cultural expectations." 

Dr. Hammouri spoke with Becker's about how to improve diversity in orthopedic and spine surgery at all levels while making physicians offices a more welcoming place for patients of all cultures and identities. 

"If your physicians don't look like your population, there's an error there and that group cannot possibly understand all of the facets of the population and solve these problems. Because you're missing different perspectives. We're updating our ability to discuss and updating what criteria matter to us. Culture fit is important, but sometimes not fitting into the culture is a good thing," Dr. Hammouri said. 

Editor's note: Responses have been edited for clarity and length. 

Question: How do you think your identity has impacted your work as a spine surgeon and your interactions with patients? 

Dr. Qusai Hammouri: I think because I have multiple different backgrounds, being an immigrant, being Arab, being gay, I kind of had a chance, when I came to the U.S., to see and connect with multiple groups of people. It allowed me to connect with a group of people who don't typically have access to or are not addressed by the system. I really related to that patient population and it energized me to think, "How can we do better?" 

Are you speaking the same language as your patient, are you responding in their native language, do you understand the words they're saying linguistically, or are you getting that through a translator where you lose a certain amount of context and emotion and you lose the ability to connect with them? You see that with colleagues that interact with certain patients; you miss certain things, you don't pick up on them or you can inadvertently miscommunicate or offend patients. That typically happens in the LGBT community, but that's not specific to that group. 

I've found that a lot of my patients really respect and value the amount of effort I put into understanding them and knowing who they are. There's a good chunk of people who will come to see me from two states over. Not because I'm the world's greatest spine surgeon. New York City is filled with tons of amazing spine surgeons and I dont think I'm the best of them all. But some people really appreciate physicians being emotionally open, present and open to feedback. That is a skill we don't have a lot of in surgery. The softness, the focus on the patient, the focus on how do we do better, listen better, are we asking the right questions that matter for you. It motivated me to start thinking about problems from a patient-centered perspective. 

Q: Are you involved in any efforts to bring more diversity into the field? 

QH: I think we've been engaged in orthopedics in general in this struggle to increase our diversity. We have consistently ranked at the bottom of any diversity scale you want to check, whether it's involvement of women, people of color, LGBTQ+ people, and in some categories, we don't even know the numbers. Up until three years ago, LGBTQ was not a category you talked about. There were no gay or LGBTQ orthopedists, let alone spine surgeons.

That's the origin of Pride Orthopedics, where we just put up a flag and said, there must be gay people in orthopedics. We put a call out and started with a Zoom happy hour and had 60 or 70 people attend. We had several program directors show up and we noticed that there is a group that exists, we just never gathered them and made a home for them. Over the past two years in orthopedics, it has grown to 200 people. 

As we try to push for both increasing diversity in orthopedics and to increase the cultural understanding of a non-diverse group of orthopedic surgeons to make them more sensitive and more understanding of different cultural and diverse backgrounds, we've been trying to be more present and engage with residents and medical students. We have set up several scholarships with NYU and Columbia where we offer an internship for LGBTQ medical students to come rotate with us in orthopedics for a month to try and have them see us as the same as them, because a lot of people don't go into orthopedics because the predominate picture is that we're all straight white jocks. In reality, we come in all colors and all shades of the alphabet, so come rotate with us, compete for these great careers, join our group.

 Part of it is visibility, part of it is us ourselves modeling being present, having our name known, saying "I am a surgeon and I am gay and I am all of these other things." The next level is education, and then finally to actively go and tell students this is a great career choice and just because they don't see people who look like themselves in this field doesn't mean they should not apply. 

Q: How do you think pre-med training programs and medical schools can better encourage diversity in orthopedics? 

QH: A lot of medical schools can offer scholarships for students to rotate into orthopedics and other subspecialties that don't have as much diversity. Orthopedics specifically is the worst of them. They can also highlight the resources available. They can connect them with mentors in that field that have some sort of shared background or can help them navigate it. If you're an underrepresented minority in orthopedics, having someone in orthopedics, inside orthopedics, be your champion. As a medical student, it's hard for you to find those people. It's up to us to reach out and find the medical students who are interested. 

At NYU, we have a program that gathers any medical students from a diverse background, and they have a cohort of different attendings that mentor them and matchmake them with mentors internally who can guide them on how you can approach getting into orthopedics or neurosurgery or other subspecialties. A level above that would be mentoring orthopedic residents on how to get into hard-to-get-into subspecialties. If you think orthopedics is bad, spine is even less diverse. I am aware of only three or four gay spine surgeons; that includes one woman and two other men. Two of them are in pediatrics. It is not a big community.

Q: How can orthopedic and spine practices better integrate LGBTQ+ physicians?

QH: I think the first step is to learn. Ask what we don't know and learn. If you are curious about the topic, there are tons of resources about how to approach LGBTQ patients and transgender patients. Just because I'm a gay man doesn't mean I understand the LGBTQ alphabet soup or what pronouns are proper or not proper with a certain person. These are all things that I had to learn by educating myself. Try to get to know and interact with some of your LGBTQ colleagues, residents or patients. Sometimes having a small symbol of allyship; a small rainbow sticker or some kind of LGBTQ lanyard or any kind of symbolism in your office or on you that says, "I am a safe space. I can be trusted, don't worry I've got your back." 

The sad part is about 1 in 10 LGBTQ patients are denied care because of who they are. A quarter of transgender patients are denied care. Fifty percent of LGBTQ patients delay going to the doctor because they fear being misgendered or discriminated against. People are fearful. Give people signs you are safe and be open to them. A lot of people complain about it being complex and difficult and fearing to make mistakes. No one is out there to get you. If you make a mistake, apologize. We all make mistakes. I've made tons of mistakes myself, referring to people by the wrong pronouns. But I apologize, I am sincere, I am honest and I learn and I improve. No one is born perfect. We just want a space that is non-judgemental and accepting. It's a lot about learning and investment and making safe spaces for the LGBTQ community.

Q: Have you seen issues with surgeons denying certain patients?

QH: Orthopedic and spine surgery is a gentlemen's club. Occasionally, you find someone more upfront with liking or not liking something. There do exist some people who are set in their ways. From the time I did my residency to this time, things have changed drastically. In one of my residency interviews [in 2004/05], I was called a [anti-gay slur] by a program director. In my career I have seen this less and less. I hear this less and less. I'm sure part of this is that I am evolving and becoming more senior so it's unlikely that someone will address me in that way, but at the same time, you don't hear about issues where a word is said that's divisive. It's more that people aren't mentoring that person or not being interested in supporting someone who doesn't look like them or remind them of themselves. The classic term that used to be used in residency interviews was, "Oh, that person doesn't fit our culture." Underneath the idea of "fit our culture," a lot of people get excluded. 

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