Charleston, SC — For one resident, being a surgeon is an opportunity to ‘fix’ people. For another, it’s a chance to develop long-term relationships with patients and nudge them onto healthier paths. And for a third, it’s helping people reconstruct their appearances after cancer. All three are young, smart and ambitious – that’s a given for any Medical University of South Carolina (MUSC) surgical resident who’s bested dozens, if not hundreds, of other applicants to win a spot in one of the integrated programs that accept one intern each year.
They’re also all black women, which makes them part of an even more select group. African-Americans represent between 2 and 10.2 percent of surgical residents, depending on the specialty, according to a January 2017 article in the Journal of Surgical Education.
At MUSC, medical doctors Avianne Bunnell, Kiandra Scott and Quiana Kern comprise more than 20 percent of the 2017-18 class in the three integrated surgery programs: vascular, plastic and cardiothoracic. Integrated surgery programs are five- to six-year programs that take residents directly from medical school, unlike traditional programs that require doctors to complete a five-year general surgery residency before training in a specialty.
They’re each the first black doctor accepted into their respective programs, two of which are relatively new. Scott is the first resident ever in the plastic surgery integrated program and Bunnell is only the third resident in the vascular integrated program.
Diversity is important to MUSC, which has made “Embrace Diversity and Inclusion” one of the five pillars of its Imagine MUSC 2020 strategic plan. Research has shown that diversity in the health care workforce improves access to care and leads to better patient outcomes, according to the Association of American Medical Colleges. It’s also crucial in biomedical research, because researchers ask different questions depending on their own backgrounds and experiences, according to the association.
Inclusion goes beyond diversity. In “The Transformation of Academic Health Centers: Meeting the Challenges of Healthcare’s Changing Landscape,” the authors compare diversity and inclusion to hosting a party.
“It is one thing to invite people to the party, open the door, and then have them find their own way; it is quite another to be greeted warmly, welcomed inside, and shown around. Inclusion in health care workforce development means that the host institution is equipped to affirm the new student immediately as someone who belongs,” the authors say.
That feeling of immediately belonging was one thing that attracted Kern to MUSC. As a visiting medical student at another university, she felt invisible, she said. Though she was offered an interview there for residency, and it would have been convenient to remain in state, she felt she wouldn’t be happy somewhere that didn’t value her. Her interview experience was completely different at MUSC. When she interviewed, the faculty knew her background and knew who she was; further, they were interested in getting to know her husband, too.
That’s not to say there isn’t work still to be done at MUSC. The three doctors have had a mix of experiences, and they all point to a lack of diversity among physicians at the attending level that they feel the institution must address to further improve the quality of care.
But Scott, a Charleston native, thought it was important for all three to tell their stories to highlight MUSC’s commitment to diversity and to serve as role models for young black girls.
The Local Girl
Scott’s entire family is from James Island. Being local, she’s experienced MUSC as a patient’s family member, as a medical student and now as a resident.
The reviews from family members weren’t always great. Her grandmother complained that members of the staff weren’t treating her as well as some other patients. At the same time, Scott said she’s seen a culture of distrust among some locals toward doctors who don’t look like them or seem to understand their backgrounds. Sometimes people would rather turn to folk medicine than visit a doctor, she said.
“I think it’s important to have more physicians that, not necessarily are from Charleston, but are willing to understand and be compassionate toward the population here. Because Charleston has a very unique indigenous population,” Scott said. “Hire more physicians who are African-American or are passionate about treating the population – you don’t necessarily have to look like the population you’re treating – but just be compassionate.”
Growing up, Scott didn’t know any black doctors. No one in her family had attended a four-year college. After she graduated from Wando High School, she went to Clemson, where she majored in microbiology, thinking she wanted to do basic science research. But being in the lab didn’t suit her. A mentor suggested she apply to medical school. Scott decided to take a year off and went to work as a scribe at Nason Medical Center, where she got an up-close view of medicine. There, she realized, “Yeah, I can be a doctor.”
She attended medical school at MUSC, where she knew she wanted to go into surgery but wasn’t sure in what specialty. At nearly the last minute, she realized her heart was in plastic surgery. MUSC was just starting its integrated plastic surgery program and leadership offered her the spot as the first resident.
“I’m forever grateful to them,” she said.
Plastic surgery is more than facelifts and breast augmentation, she’s quick to note.
“I went into plastic surgery for the reconstructive side. We do a lot of breast reconstruction, which is what I’m interested in, and craniofacial, which entails repairing cleft lips and cleft palates – really, any congenital defect that involves soft tissue, skin or bone,” Scott said.
She liked that she would reach a broad patient population, from children to adults, and that plastic surgeons operate head to toe. Now in her third year of residency, she isn’t sure what she wants to do after residency, but she thinks she’d like to do a fellowship in either microsurgery or craniofacial surgery.
The Relationship Builder
Bunnell decided early on she wanted to be a surgeon. Born in Trinidad, she grew up in Arizona and attended a high school where for many students the best-case outcome would be to attend community college and get an entry-level job. But during a junior high summer camp, she heard a neurosurgeon speak about his job.
“Man, he did a great job selling it. He spoke so highly of that career and all the cool things he got to do and how privileged he was to get to do such an amazing job and make a difference in people’s lives,” she said.
At the time, Bunnell didn’t have any doctors in the family. But her sister, seven years older, began medical school while Bunnell was in high school. Although she took the OB-GYN route, her journey through medical school and residency offered a path for Bunnell to follow, and she has often acted as a sounding board for her.
Bunnell attended medical school in Florida, where her mentors suggested she try vascular surgery.
“I absolutely loved it. It was the right patient population for me; it was the right kind of disease pathology to take care of. I was very, very eager to be a part of that field. I saw a lot of my own personality in a lot of people who were practicing in that field,” she said.
Bunnell, who’s in her fifth year of residency, said she likes that vascular surgeons provide such a wide spectrum of care. They see patients with blood vessel diseases, aneurysms, peripheral arterial disease or wounds that won’t heal. They often work in collaboration with other specialists like podiatrists, wound care, and endocrinologists. Many of the patients have additional factors that play into their diseases, like obesity, diabetes or difficult social situations that affect their ability to care for wounds and recover.
“You develop a really long relationship with these patients. Once they’re in your care, they’re with you for the rest of their lives. And I enjoy that,” she said.
Vascular surgeons have to be ready, too, to provide a little tough love about such subjects as smoking.
“A lot of our patients have lifestyle issues that have contributed to their pathology, so you get to have a lot of really frank conversations with them about the things that are hindering their care, things that led to this point. You get very real with the patient,” she said.
Bunnell is still developing a post-residency plan, but she thinks she would like to work in a limb salvage center, taking care of patients on their last efforts to save their legs.
“I like to fix people.”
Kern decided as a child she wanted to be a doctor. In Milwaukee, where she grew up, she spent a lot of time in the hospital because of poorly controlled asthma and was inspired to become a physician.
Her family, she said, would probably have been happy enough with her finishing school and getting a job. She was the first to graduate from a four-year college. Because she took some time off, a younger cousin became the first in the family to graduate medical school. At Morehouse School of Medicine in Atlanta, she considered emergency medicine and trauma surgery, but watching a thoracotomy on a gunshot patient was the push she needed toward cardiothoracic surgery.
“I saw the lungs, the heart, and then I remembered how much I loved those topics in medical school,” she said.
Her mentor, a trauma surgeon, connected her to some cardiothoracic surgeons. When she did some rotations with them, she found she loved it.
Her advisors told her she had the grades and the motivation, but warned she would face barriers. One: She’s black. Two: She’s female. And three: She’s of small stature. No one takes you seriously when you’re small, she said with a twinkle in her eye.
“I said, ‘You know what, I’m not going to let that stop me.’ I knew that going into it, but I didn’t let that deter me. I wanted to be happy, and I felt like settling for something else, I wouldn’t be happy.”
Applying for a residency was an extremely competitive process. Nationwide, there were 26 programs interviewing for 36 spots the year she graduated. She applied to about 20, choosing possibilities based on location and supportive environments. She interviewed at 14 and matched with MUSC.
For the surgery programs at MUSC, choosing residents is about finding the right fit, said June Cameron, director of surgery education programs. Last year, more than 200 people applied for the plastic surgery residency, 80 for vascular surgery and 150 for cardiothoracic surgery. Each program takes one resident.
“It’s a lot of sifting through applications and finding the best of the best,” she said.
The program tries to keep the residents balanced, taking into consideration underrepresented groups in medicine, the male-to-female ratio and even geographic diversity. The university doesn’t want its residents to have “one look” that could discourage potential applicants from applying.
“We want to keep the doors wide open,” Cameron said.
Besides test scores, the team tries to get to know the applicants, she explained. Lance Tavana, M.D., program director for the integrated plastic surgery residency, would rather learn about someone’s hobbies than scour his or her application, Cameron said. The faculty try to choose young doctors whose learning styles seems to mesh well with their teaching styles. They also invite applicants to a social with the residents outside the hospital to get to know them better.
Cameron predicted success for Scott, Bunnell and Kern.
“We are obviously very lucky to have those three. They are brilliant. Women surgeons are still too rare, especially for their subspecialties, but they’re going to pave the way. They’re going to be great,” she said.
Michael de Arellano, Ph.D., College of Medicine senior associate dean for diversity, said MUSC is committed to being representative of the community it serves and creating an inclusive, culturally competent organization. The university looks at diversity broadly, considering not just ethnicity but also gender, sexual orientation, religion and more, he said.
The College of Medicine is proud of its success in enrolling and graduating students who are underrepresented in medicine, meaning of black, Native American or Hispanic heritage. It’s in the top 10 of U.S. medical schools, outside of historically black colleges, to enroll African-American students. Even more important, de Arellano said, it ranks at the 97th percentile for graduating African-American medical students.
Though it’s above the national average for its percentage of underrepresented students and residents, the college is slightly below the national average when it comes to faculty who are considered underrepresented minorities – 6.5 percent compared to the national average of 7 percent. Scott and Bunnell quickly noticed the disparity between the percentages at the student and resident level and the percentages at the attending level.
“MUSC as a whole has become more and more diverse. But I’m not sure I’m seeing that the physician population at the attending level has really gotten there or made a whole bunch of progress,” Bunnell said.
She couldn’t really put her finger on why, though.
It’s a longstanding, multi-faceted problem that academic medical centers across the nation struggle with, de Arellano said. “I’ve been told by many students that they never pictured themselves in that role,” referring to becoming faculty members at an academic medical center, he said.
De Arellano said 19 percent of College of Medicine students are from underrepresented groups. That figure jumps to 22 percent for the students starting medical school this fall. The percentages of residents considered underrepresented has also improved, from 9 percent just five years ago to 14 percent now. Department chairs are supportive of the idea of “growing your own,” de Arellano said, so the expectation is that the percentages at the attending level will begin to move as well.
“That is the perfect ground for recruitment into faculty positions here,” he said.
Bunnell agreed. “There are a lot of high-achieving minorities and people from other cultures in medicine. They’re there. You just have to work to recruit them, and you have to support them for it to be successful,” she said.
Prabhakar K. Baliga, M.D., chairman of the Department of Surgery, said diversity and inclusion are integral to the department’s vision. As part of that vision, MUSC is a member of the Society of Black Academic Surgeons and won the honor last year of hosting the Claude Organ Lectureship in African American Medicine.
“We are truly excited and delighted that Avi, Kiandra and Quiana chose our department. Each of them has such a strong and compelling personal story that serves to inspire all of us. They have built strong foundations and have shown courage in blazing trails that makes me confident that they will be national leaders in their fields. It is a joy and a privilege to be part of that journey,” Baliga said.
Envisioning the Future
As they endure the long hours and competing demands of residency, the three residents must also navigate the expectations of patients, staff and even themselves. Simply by being in the room with an “M.D.” stitched onto their coats, they’re changing perceptions about what a doctor looks like.
“Just even being present, having the opportunity for patients to see me in that light and to think about things that way, affects how they interact with people around them. And how it makes me interact with them. It’s kind of like a domino effect just even being here,” Bunnell said.
More importantly, diversifying the health care team to reflect the community as a whole strengthens it and improves patient outcomes. Only 5 percent of South Carolina’s physicians identify as black or African-American, yet the state’s population is more than 27 percent black, according to a 2014 report by the Association of American Medical Colleges.
Some patients have been around 60 or 70 years and have never seen a doctor who looks like them, Bunnell said.
“There’s a sense of honor and trust that becomes part of that. You’re forced to also be very responsible with your decisions, because there’s a lot more eyes on you than you think,” Bunnell said.