Training Pathways and Practice Distribution of Underrepresented Plastic Surgeons in the United States

Background: Medically underserved areas (MUAs) remain prevalent in the United States, with plastic-surgery services unevenly distributed. Across the broader physician workforce, clinicians underrepresented in medicine (URM) are more likely to serve underserved communities; whether this holds within plastic surgery is less clear. We tested whether URM plastic surgeons are more likely to practice in MUAs and assessed training factors including medical school type, residency pathway, and fellowship training that might explain observed patterns. Methods: We built a national cohort of plastic surgeons from the National Provider Identifier (NPI) registry. Race and ethnicity was inferred using a multi-system pipeline (BISG/BIFSG/Ethnicolr) under strict (95%), balanced (85%), and lenient (70%) probability thresholds. For pathway-specific analyses, we constructed an integrated-pathway cohort from American Board of Plastic Surgery (ABPS) newsletters (2010–2016) with web verification of training pathway. Medical-school “community-based” designation was captured via AAMC and fellowship completion was gathered via websearch. Associations between URM status and MUA practice were tested with chi-square or Fisher’s exact tests, with effect sizes summarized as odds ratios (OR) or relative risks (RR). Results: In the national plastic-surgery cohort (n=8,154), URM surgeons were significantly more likely to practice in MUAs across all confidence schemes (RR=1.86–2.67; OR=2.2–2.9; all p<0.001). Results were directionally concordant and of similar magnitude in a general-surgery comparator cohort (n=30,029; OR=2.3–2.8; all p<0.001), supporting external consistency. Sensitivity analyses across strict, balanced, and lenient race-inference thresholds yielded stable inferences. In the ABPS integrated-pathway cohort (n=564; 2010–2016), URM status was not significantly associated with MUA practice. Notably, among URM integrated surgeons practicing in MUAs, none had attended a community-facing medical school, and medical-school type did not explain national-level associations. Fellowship training of surgeons practicing in MUAs included completion of fellowships in 33% of the cohort (34% hand, 11% craniofacial, 10% aesthetic, 14% microsurgery, 3% burn, 1% pediatric, 17% multiple, and 10% other). Conclusion: In the national cohort of integrated and independently trained plastic surgeons, those that are underrepresented in medicine are more likely to practice in MUAs, a pattern that is consistent with broader trends in medicine; however, when evaluating only integrated plastic surgeons, we do not see a statistically significant association. Evaluation of community-based medical school training does not appear to play a role in this finding. Further evaluation of differences between integrated and independent residency training programs and review of temporal changes in training modalities may reveal targetable factors that can influence where plastic surgeons practice.