Primary author: Dr. Numa Perez

Over the past decade, institutions in all facets of society have begun to appreciate the importance and intrinsic value of a diverse workforce, and the fields of medicine and surgery are no exception. Efforts to increase representation and inclusion in the workforce have often been marred by the absence of a clear definition of both the problem and the solution. As a result, the terms diversity, equity, inclusion, and representation have slowly lost their meaning, morphing into buzzwords rather than a true guiding compass.

Diversity is who we are, inclusion is what we do, and equity is how we get from the former to the latter.[1]

Diversity

Diversity refers to the intrinsic differences that make us unique. Be it our physical appearance, life experiences, or cognitive tendencies and abilities, diversity is inherent to human quality, and it has increased with the passage of time. These differences lead us to process the world around us in distinct ways, which, when aligned, allow us to generate innovative ideas and solutions to challenging problems. For example, racially and ethnically diverse academic teams produce higher impact research, [2] and companies with at least three female board members have better financial performance.[3][4] Representation alone is not enough to generate these positive effects, especially with regard to underrepresented individuals. A diverse team by itself serves no purpose if all members do not feel welcomed and counted and if their ideas and values are not regarded with equal appreciation and respect. It is here, where inclusion must follow.

Inclusion

Activist, author, and diversity thought leader Vernā Myers summed the relationship between diversity and inclusion best with her now-famous phrase, “Diversity is being invited to the party, inclusion is being asked to dance.”[5] In her talk at the Working Mother conference in 2011, Myers emphasized the key distinction between “having difference” and “experiencing the value of difference.” Inclusion, therefore, refers to the genuine appreciation of each other’s differences and the value we add to our teams because of them. Inclusion is achieved when all members of our organization are granted a seat at the table and the opportunity to express their ideas and contribute their talent. But how does an institution achieve a true and genuine appreciation of its members’ diverse nature? How do leaders, often members of the majority themselves, see what fundamentally exists in their blind spots? Setting our sights on equity is a good start.

Equity

The terms equity and equality, though often used interchangeably, refer to two very different concepts. Equality implies that every member of a group gets treated the same and has access to the same resources, regardless of a member’s condition. Equity, on the other hand, requires that everyone be treated fairly, with everyone being afforded the opportunities they require according to their unique situation and circumstance.[6] Equity, in effect, is the means by which equality is achieved, and the principle by which a diverse organization becomes an inclusive one.

Sec III Fig 1 - Inequality...Justice

Figure 1. Inequality, Equality, Equity, and Justice.[6]

Sec III Fig 2 - HIP Equality vs Equity

Figure 2. Difference between Equality and Equity from Hispanics in Philanthropy and UCSF.[7]

The path by which a health care institution, a Department of Surgery, or a clinical practice achieves a diverse workforce, especially one where individuals feel included, counted, and treated justly, requires a strong commitment by stakeholders at all levels. Measurable goals must be set and approached in a systematic manner. Constant re-evaluation of these metrics and a willingness to change are fundamental.

This toolkit establishes a framework for approaching this challenge from a pediatric surgery perspective as any one of several stakeholders: individual provider, division or department, private practice surgeon, professional organization, or institution.

Several Key Questions Should be Considered:

Where is your institution now?
A clear assessment of your institution’s composition and level of diversity is the first step in this journey. Resources exist for aiding with this as below. (See section below "What steps can my institution take...")

Where does your institution need to be?
Setting clear milestones: If change is to be realized, clear and measurable goals must be set and evaluated closely. Without clear goals and metrics (e.g., X% URM staff hired over the next year, X% URM residents granted an interview, etc.), even well-intentioned efforts are likely to be fruitless, and in fact, risk leading to more harm by engendering a false sense of awareness and action.^[17]

How do you achieve your goals?
Hire the right individuals. It is crucial to note that in a health care system and surgical field plagued with marked levels of underrepresentation, most current leaders and members of our institutions are themselves in the “in-group” and naturally suffer from blind spots. This, coupled with our innate and implicit biases, makes it virtually impossible for change to be realized without the active participation of diversity champions. Individuals, preferably from underrepresented groups, with an established track record in understanding and addressing issues related to diversity, inclusion, and equity are crucial to achieving change.

Primary authors: Dr. Cynthia Reyes-Ferral and Dr. Hira Ahmad

Extraordinary teams achieve excellence by investing in individuals with diverse talents.

Success of Diverse Teams

Social category differences such as age, race, sexual orientation, religion, nationality, ethnicity and culture contribute to cognitive development.^[18] Education, training, and innate talents further enrich cognitive attributes.[19] The complex interaction of personal characteristics and experiences produce differences in cognitive repertoires and give diverse teams access to more information, knowledge, mental models and frameworks, representations, and heuristics.[18][19] Organizations with diverse gender, racial, and ethnic identities are more profitable, creative, and innovative because they benefit from differences in thinking, also known as “collective intelligence.”[18][19][20][21] In addition to a wider range of information and talents, diverse teams have a higher tendency to focus on facts.[22] Diverse team members expect and are more accepting of differing opinions and are more aware of their own biases, whereas homogeneous team members anticipate similar opinions and tend to “go with the flow” rather than “thinking outside the box.”[23] Therein lies the diversity bonus. [19][20]

Sec IV Fig 1 - Decision-Making Team Diversity

Figure 1. Better decision making is achieved by increasing team diversity.[24]

Diversity of Medicine

The medical field strives to provide high-quality and equitable medical care to diverse patient populations, educate at multiple levels, and perform research to develop new treatment strategies. Insofar as possible, we attempt to pursue these goals in a fiscally responsible manner.[25] Success requires collaboration between health care providers, educators, researchers, and administrators who understand not only their patients’ medical conditions, but also the social and medical environments in which their patients live, work, and play.[26]Teams composed of individuals with strategically diverse education, training, racial/ethnic and cultural backgrounds, and experiences are best equipped to achieve these multifarious goals. Further diversity bonuses are found in patient experiences and outcomes. Race/ethnicity concordance between patients and providers increases the likelihood that Hispanic, Black, and Asian patients will seek preventive care.[27][28][29][30] In contrast, patients with race-discordant physician relationships experience shorter office visits, rate healthcare visits as less participatory, and report a less positive perception of care received. [27][28][29][30]

Patients with culturally competent practitioners are more adherent to treatment and experience improved health outcomes.[27][28][29][30][31][32] In pediatric medicine, it has been shown that the mortality of black infants is halved when cared for by Black physicians as compared to White physicians.[32] Language-concordant care similarly improves Hispanic pediatric surgery families’ understanding and satisfaction.[31] A representative and culturally competent medical profession is increasingly important as the country becomes more diverse. The United States is predicted to be White-minority by 2040.[33] This change is driven by an increase in minority youth. As of 2019, most children under 16 years old in the USA have racial or ethnic minority identities.[33] An increase in the proportion of minority health care providers is essential to have a greater understanding of vulnerable populations within this demographic change. Additionally, Black and Hispanic physicians are more likely to practice in communities with higher proportions of Black and Hispanic residents.[34]

Sec IV Fig 2 - Pew Research Center

Figure 2. Changing face of America, demographic distribution over time in US (Adapted from Pew Research Center and American Surgical Association).[34]

Pediatric Healthcare Disparities in the United States

Poorer surgical outcomes for underrepresented minority children are prevalent throughout surgical disciplines.
· Hispanic and Black children are less likely to be in good health and more likely to be uninsured than White children.[35][36][37]
· Teenagers with non-conforming gender identity score poorer on measures of mental and physical health. LGBT youth are at higher risk for substance abuse, sexually transmitted diseases, cancers, cardiovascular diseases, obesity, and suicide than the general population.[38][39][40]
· Minority and low socioeconomic children have a higher risk of hospitalization, morbidity, and mortality, and they experience more patient safety events in the hospital and after surgery. Healthcare disparities exist for URM children in trauma care, urology, otolaryngology, kidney transplantation, bariatric surgery, neurosurgery, oncology, and anesthesia.[37][41][42][43][44][45][46][47][48][49][50][51]
· Healthy Black children have higher rates of morbidity and mortality after surgery.[46][47][48][50][51][52][53][54][55][56][57]
· Black, Hispanic, Asian and immigrant children have a higher incidence of ruptured appendicitis irrespective of family, socioeconomic, or hospital factors.[44][45][58][59]
· Black and Hispanic children are more likely to experience complications related to appendicitis. Black or low-income family children were more likely to stay in the hospital longer. Black children with appendicitis were less likely to receive pain medication for moderate pain and less likely to receive opioids for severe pain.[44][45][58][59]
· Non-white children have higher mortality after congenital heart surgery regardless of the type of insurance.[60]
· Underrepresented minority children and children with government insurance had a higher mortality rate without ECMO after congenital heart surgery.[61]

Healthcare disparities in the US lead to poorer health for Black, Hispanic, Native American, LBGT, and physically and mentally challenged children and adolescents, as well as for those from low socioeconomic backgrounds. Pediatric health care providers are challenged to address inequities in access to healthcare and outcomes for children and adolescents.

Diversity in Research

Diversity bonuses are also achieved by research teams strategically assembled with diverse experiences and talents. A wide spectrum of cognitive repertoires will introduce information, questions, concepts, and ideas otherwise unimaginable to mainstream thinking.[62] For example, the introduction of more female researchers in the 1980s and 1990s was followed by an increase in women’s health investigations in breast cancer, heart disease, and autoimmune diseases.[63] Furthermore, ethnically-diverse teams of authors achieved more citations and high-impact publications than papers written by ethnically uniform teams of authors.[63] Female authorship increased two-fold when the senior author is female.[64] Health science researchers also require cultural awareness and a clear understanding of socioeconomic barriers to developing impactful studies that include URM populations. Despite these findings, the current population of health science researchers does not represent the communities being served.[65][66][67] Black, Hispanic, and Native American researchers and full-time academic faculty lag in numbers when compared to the US population and white colleagues.[65][66][67] Disparities in the distribution of research grants are observed at the highest level. Black applicants received less NIH funding, even when controlling for education, training, previous research awards, and publications.[65] Fewer citations of publications authored by Blacks may be due to a preference for community and population research, topics that generally receive lower-NIH ratings. Implicit bias has been implicated in these disparities.[64][67] Lack of exposure to the sciences and role models during early school years limits minority participation in academic research. Programs that introduce URM students to science and scholarships to support the education of the sciences are recommended to increase the pipeline.[68] mentorship, training, and resources available to URM researchers are significant barriers to successful research careers.[68] Blacks and Hispanics were less likely to revise and resubmit grant applications, and Blacks resubmitted grant applications more times than any other group.[64][69] An integrative literature review of publications about mentorship for new and early-stage URM health science investigators provides a list of barriers and facilitators for expansion and success in academic medicine.[70]

Sec IV Fig 4 - Barriers for R Career Dev

Barriers and facilitators for career and research development in under-represented minorities. [70]

Sec IV Fig 5 - Facilitators for Dev of R Capacity

Facilitators for Development of Research Capacity.[70]

Sec IV Fig 6 - Institutional Facilitators

Institutional Facilitators for Development of Research Capacity.[70]

Primary authors: Dr. Kate Ott and Dr. Tolulope Oyetunji

Trainees

With all of this information in mind, where do APSA and the field of pediatric surgery stand? Each year, diversity among medical school students and surgical training programs continues to rise. The pace of advancement, however, is not shared equally by all minority groups.
Information on diversity in medical schools can be found here
Some important statistics to keep in mind:
· 13.4% of the U.S. population is Black, but only 7.5% of graduating medical students and 5.3% of general surgery trainees are Black.[89][90]
· The proportion of Black medical school graduates increased by only 1.0% from 2016 to 2020.[90] Hispanics makeup 18.5% of the U.S. population but only 6.7% of medical students and 9.3% of surgery trainees.[89][90]
· The proportion of Hispanic medical school graduates increased by less than 1.0% from 2016 to 2020 (4.6% vs 5.3%).[90]
· In pediatric surgery, only 6.2% of fellows are Black and only 9.9% are Hispanic.[89] The scarcity of Black and Hispanic trainees places additional stress and burden upon them.

Sec V Fig 1 - Black/Hispanic Pop. Distribution

Figure 1. Black and Hispanic population distribution for medical students and surgical trainees.[19][91]

One study that interviewed minority residents found that they described three themes in the workplace: daily microaggressions and bias, being tasked as race/ethnicity ambassadors, and difficulty determining identity professionally and personally while being seen as “other.”[92] Women now make up the majority of medical school graduates (51.5%), however, Black and Hispanic women make up only 8.9% and 6.3% of medical school graduates, respectively.[89][90] 65.1% of women in general surgery residency have experienced gender discrimination, and 19.9% of women general surgery residents have experienced sexual harassment at work.[69]
Nearly a quarter of medical students come from families earning >$250,000 per year while only 5% come from families earning < $24,000 per year.[90]
Information regarding ethnicity, sexual orientation, and gender identity was not collected until recently. These data are also difficult to find partly because many LGBTQ students and residents are hesitant to disclose their gender and sexual identity. A 2015 study of LGBTQ medical students showed that 60% did not disclose their gender at school, mainly due to fear.[93] Since 2014, the Association of American Medical Colleges (AAMC) has asked matriculating medical students whether they identify as a gender different than their sex assigned at birth. In the US and Canada, 0.7% of the students matriculating into MD-granting medical schools self-identified as transgender and nonbinary (TGNB).[90]

Professional Membership and Departmental Leadership

The American Pediatric Surgical Association (APSA) is a professional organization with more than 1500 members. Several previous studies have demonstrated that the representation of people from diverse backgrounds within the field of academic surgery distinctly lags behind other medical disciplines.[94][95][96] Unfortunately APSA is not an exception to this trend, and the current demographic makeup of the APSA membership does not reflect national demographics. For example, as of 2019, 72% of APSA members were male and 70% were white (figure 2).[97]

Sec V Fig 2 - APSA membership demogr

Figure 2. American Pediatric Surgical Association membership.[97]

In APSA’s first 50 years, it had only four women presidents and six women Board of Governor members. The first Black President of APSA presided from 2017-2018.[98] Underrepresentation of women and minorities at higher professorial and administrative ranks is particularly glaring. Only 9% of pediatric surgery division, section and department chiefs are women.[97] As of 2020, 24% (13/41) of pediatric fellowship program directors are women. Women make up only 15% of faculty at training programs and 9% of division, section, or department chiefs.[99]
Though demographic underrepresentation exists in many medical and surgical specialties, the gaps are beginning to narrow.[100][101][102][103][104][105][106] Since 2007 there has been a significant increase in the representation of female academic surgeons across academic ranks. This has been reflected by an absolute percent increase in chairperson (3.2%), full professor (4.9%), associate professor (6.4%), and instructor (13.4%) promotions. While these data are somewhat positive, it is evident that much work remains to be done to close the gender gap in academic surgery ranks, most notably at the top of the academic hierarchy. Asian academic surgeons have shown a similar improved representation as female surgeons, yet Hispanics and Blacks have not enjoyed similar trends. Neither the Journal of Pediatric Surgery nor Seminars in Pediatric Surgery have ever had a female editor-in-chief.[99] The lack of women and minorities in leadership positions limits the pool of mentors and models of experience.[107] This adds to other barriers including inequities in training, cultures of exclusion, and social isolation for surgeons as they attempt to move up the ranks.[107]
The lack of minority pediatric surgeons negatively affects patient care. Patients from underrepresented and lower socioeconomic status populations have worse outcomes which may be influenced by the demographic incongruity between providers and patients. One study found that the mortality of Black infants is halved if cared for by Black physicians.[108] Higher practitioner cultural competence has been shown to result in better outcomes as well as better patient adherence to treatment.[109]
APSA has the transformative power to create not only more diversity within the organization but also to improve patient outcomes for those most vulnerable. The power to make changes stems from first understanding the current state of representation and inclusion within the field of pediatric surgery using historical data and participation in membership surveys. We must then imagine a more inclusive and representative workforce and understand its benefits to patient care and provider well-being. Finally, we must devise specific goals and pathways to achieve these goals, with measurable intermediate targets and the opportunity for revising out goals based on changing circumstances.

How to Assess Institutional Diversity

There are a number of ways in which institutions can assess diversity and take actions to become more inclusive. Each organization must first assess its current membership and identify its stakeholders. Race, ethnicity, and gender are important, but consideration must also be given to other identities such as sexual orientation, immigrant status, and socioeconomic background. As mentioned earlier, racial and ethnic concordance between patients and providers has been shown to mitigate healthcare disparities and improve outcomes of minority populations. It is of the utmost importance for each institution to ascertain the demographic composition of its patient population in order to create a representative staff. Membership surveys can be used to gather demographic information such as race/ethnicity, gender, sexual orientation, and religious preferences to define the underrepresented groups within that organization. Alongside these efforts, committees or groups within larger institutions can be created to specifically focus on diversity. These groups can survey the membership and assess the culture for inclusivity. Additionally, programs must assess their ability to recruit and retain a diverse workforce. Diversity committees can disseminate results of surveys focused on diversity and educate members about implicit bias and ways to make the program more diverse and inclusive. Last, diversity committees can guide organizations during the development of strategic plans that create an environment that is in line with organizational core values of diversity, equity, and inclusion.

Primary authors: Dr. Hira Ahmad, Dr. Hanna Alemayehu, Dr. Numa Perez, Dr. Kathryn Martin, Dr. Deborah Loeff, and Dr. Stephen Shew

Implicit Association Test

Personalized education regarding bias, discrimination, and an individual’s role within a wider system of inequity requires a review of the implicit biases we all have, as well as acknowledgment of explicit biases and discriminatory practices.
One of the most widely used tools to assess personal implicit bias is the Implicit Association Test which can be accessed here: https://implicit.harvard.edu/implicit/takeatest.html
It can be helpful and eye-opening to discover your own implicit biases and therefore be equipped to begin mitigating them. It is commonly used to determine implicit biases prior to involvement in decision-making committees, interviewing or recruitment activities, and personal practices during clinical care.[91] It is important however to ensure that a focus on implicit bias assessment is not used to provide an excuse for discriminatory behavior to be attributed to “unconscious" mechanisms out of our control, rather than to explicit attitudes. Therefore, it is also important to identify and measure explicit attitudes, in addition to implicit attitudes, which can then be addressed head-on. Examples of such tools include the Modern Racism Scale[110], the Modern Sexism Scaleswi[111], the subtle/blatant prejudice scalepett[112]^, and its variations to measure racism against Black individuals and women.[113] To learn more about these tools and how different prejudice measures are compared, see the thesis by Simeoni.[113]

Bias Training

Here is a discussion of the social construct of race/othering, three types of racism (institutionalized, personally-mediated, internalized), and how to disrupt it.[117]

TED Talk: Four Allegories on Race and Racism by Camara Jones MD, MPH, PhD

There are many online and in-person bias training courses available for individual and organizational use, both as open access and as paid resources. The difficulty in using these is that most remain unvalidated and it is unclear if intended outcomes are achieved. Below is just one example of an Implicit Bias training webinar hosted by APSA for its Board of Governors and adapted for its broader membership, based on implicit bias mitigation tools described below[118].

APSA DEI Implicit Bias Training Webinar: Recognizing and Responding to Implicit Bias with Quinn Capers MD

Sec VI Fig 1 - AWS Implicit Bias

Figure 1. AWS #HeForShe Taskforce Best Recommendations for Reducing Implicit Bias.[119]

Microaggressions and Microaggression Training

Microaggression:
Subtle snubs, slights, and insults directed towards minorities, women, and other stigmatized groups, that communicate or engender hostility or lack of belonging [115][120]

Sec VI Fig 2 - Microaggressions Types

Figure 2. Types of microaggressions.[120]

Sec VI Fig 3 - Microaggressions Examples

Figure 3. Examples of microaggressions.[121]

Find More Examples of Microaggressions at: https://www.microaggressions.com/

Group activity to learn to recognize microaggression:

Breaking the Prejudice Habit

Upstander Training

Bystander vs Upstander: A bystander is someone who witnesses an act of discrimination and does not intervene, while an upstander is someone who witnesses an act of discrimination and takes action.

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Hollaback’s 5 D’s: Distract, Delegate, Document, Delay, and Direct
Right To Be is a global organization whose mission is to end harassment by transforming cultures that perpetuate hate and harassment. They provide free resources and training to teach people to create safe and welcoming environments for everyone.
Right To Be Organization Resources

Step UP! Is a prosocial behavior and bystander intervention program developed by the University of Arizona C.A.T.S. Life Skills Program in partnership with national leading experts, that educates students to be proactive in helping others. Teaching people about the determinants of prosocial behavior makes them more aware of why they sometimes don’t help. As a result, they are more likely to help in the future.

Step UP! Bystander Intervention Program

Cultural Competence and Awareness

Learn More

Adult Books:

Sister Outsider, by Audre Lorde and Cheryl Clarke
Lose Your Mother: A Journey Along the Atlantic Slave Route, by Saidiya Hartman
Uprooting Racism: How White People Can Work for Racial Justice, by Paul Kivel
Assata: An Autobiography, by Assata Shakur and Angela Davis
Black Noise: Rap Music and Black Culture in Contemporary America, by Tricia Rose
Witnessing Whiteness, by Shelly Tochluk

Making all Black Lives Matter, by Barbara Ransby
Dark Matters: On the Surveillance of Blackness, by Simone Browne
Race Talk and the Conspiracy of Silence: Understanding and Facilitating Difficult Dialogues on Race, by Derald Wing Sue
Building a Movement to End the New Jim Crow, by Daniel Hunter
The Hate U Give, by Angie Thomas
The Emperor Has No Clothes: Teaching about Race and Racism to People Who Don’t Want to Know, by Tema Jon Okun
Killing Rage: Ending Racism, by Bell Hooks
The Bluest Eye, by Toni Morrison
Towards the Other America: Anti-Racist Resources for White People Taking Action for Black Lives Matter, by Chris Crass
From #BlackLivesMatter to Black Liberation, by Keeanga-Yamahtta Taylor
Pushout: The Criminalization of Black Girls in Schools, by Monique Morris, Mankaprr Conteh, et al.
Understanding White Privilege: Creating Pathways to Authentic Relationships Across Race, by Frances Kendall
Freedom is a Constant Struggle, by Angela Y. Davis
Eloquent Rage, by Brittney Cooper
The Possessive Investment in Whiteness: How White People Profit from Identity Politics, Revised and Expanded Edition, by George Lipsitz

Coming of Age in Mississippi, by Ann Moody
So You Want to Talk About Race, by Ijeoma Oluo
Waking Up White, and Finding Myself in the Story of Race, by Debby Irving
I Know Why the Caged Bird Sings, by Maya Angelou
The Fire This Time: A New Generation Speaks About Race, by Jesmyn Ward
How I Shed My Skin: Unlearning the Racist Lessons of a Southern Childhood, by Jim Grimsley
When They Call You a Terrorist, by Patrisse Khan-Cullors and Asha Bandele
White Rage, by Carol Anderson
Everyday White People Confront Racial and Social Injustice: 15 Stories, by Eddie Moore, Marguerite W. Penick-Parks, and Ali Michael
Killing the Black Body, by Dorothy Roberts
Why Are All the Black Kids Sitting Together in the Cafeteria?, by Beverly Daniel Tatum
Understanding and Dismantling Racism: The 21st Century Challenge to White America, by Joseph Barndt
The Warmth of Other Suns, by Isabel Wilkerson
Why I’m no Longer Talking to White People About Race, by Reni Eddo-Lodge
Beyond the Pale: White Women, Racism, and History, by Vron Ware, Mikki Kendall
Me and White Supremacy, by Layla F. Saad and Robin J DiAngelo
Southern Horrors and Other Writings: The Anti-Lynching Campaign of Ida B. Wells, 1892-1900, by Jacqueline Jones Royster
Charleston Syllabus: Readings on Race, Racism, and Racial Violence, by Chad Williams, Kidada E. Williams, and Keisha N. Blain
Say Her Name, by Kimberlé Crenshaw, Andrea J. Ritchie, et al
Natives and Race: Class in the Ruins of Empire, by Akala
We Have Not Been Moved: Resisting Racism and Militarism in 21st Century America, by Elizabeth Betita Martinez, Matt Meyer, Mandy Carter, Cornel West, Alice Walker, and Sonia Sanchez
Breathe: A Letter to My Sons, by Imani Perry
Just Mercy, by Bryan Stevenson
Acting White?: Rethinking Race in Post-Racial America, by Devon W. Carbado, Mitu Gulati
Sister Citizen: Shame, Stereotypes, and Black Women in America, by Melissa V. Harris-Perry
Medical Apartheid, by Harriet A. Washington
Towards Collective Liberation: Anti-Racist Organizing, Feminist Praxis, and Movement Building Strategy, by Chris Crass, Roxanne Dunbar-Ortiz, and Chris Dixon
Stamped from the Beginning: The Definitive History of Racist Ideas in America, by Ibram X. Kendi
White Like Me: Reflections on Race from a Privileged Son, by Tim Wise
White Fragility: Why It’s So Hard for White People to Talk About Racism, by Robin DiAngelo, Michael Eric Dyson
How to be an Anti-Racist, by Ibram X. Kendi
Their Eyes Were Watching God, by Zora Neale Hurston

Childrens Books:

I am Rosa Parks, by Brad Meltzer
Last Stop on Market Street, by Matt de la Peña
Let’s Talk About Race, by Julius Lester
I am Martin Luther King, Jr, by Brad Meltzer
Not my Idea, by Anastasia Higginbotham
The Skin I’m In, by Pat Thomas
A is for Activist, by Innosanto Nagara
The Day You Begin, by Jacqueline Woodson
A Kid’s Book About Racism, by Jelani Memory
Sulive, by Lupita Nyong’o
Little Leaders: Bold Women in Black History, by Vashti Harrison
The Colors of Us, by Karen Katz

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Watch, Listen, and Donate

Primary authors: Dr. Sara Mansfield and Dr. Richard Wood

Although it is important for individuals to take steps to incorporate diversity, equity, and inclusion in their everyday practice, it is imperative that institutions also formalize these concepts into their working models. When departments and institutions take steps to prioritize inclusion, not only do members feel more supported, but they send a strong message to the community and help redefine their role in identifying and fighting systemic racism.[143]

Develop a Diversity Statement

Diversity, inclusion, and equity statements are important for defining the institution’s mission and vision related to these topics. The development of an effective statement should consider the rationale behind the statement, the intended audience, and the messengers.[144]

A diversity statement should provide a concise snapshot of your institution’s commitment to supporting patients, families, and employees from diverse backgrounds and promoting equity and inclusion-focused initiatives.

Diversity Statement examples include:

Childrens National

Michigan Medicine Department of Surgery – Michigan Promise

Nationwide Children’s Hospital – Everything Matters

Seattle Children’s Pediatrics Residency

Stanford Medicine Pediatrics Residency

VCU Health

University of Iowa Department of Pediatrics

Create a Diversity Committee

When creating a committee, it should ideally include members across levels and teams, and be representative of the diversity of the department or institution as well as your patient population. Strategic invitations of key stakeholders may help engage prospective committee members, but participation should be voluntary. ‘Representation burnout’ refers to the stress, fatigue, and exhaustion of being the only person of a particular identity within a certain environment. This kind of burnout affects anyone who identifies as the “only one” in their given institution. It is experienced by underrepresented minorities whose daily lives are within non-diverse spaces. Additionally, the “minority tax” refers to the “burden of extra responsibilities placed on minority faculty” as a result of efforts to promote diversity.[145] Involvement in numerous diversity committees can contribute to this phenomenon.

Sec VIII Fig 1 - Disparities in Academic Med

Figure 1. Addressing Disparities in Academic Medicine.[145]

Promote Cultural Competence and a Culture of Inclusion

Organizations have several aspects of institutional structure that can be harnessed to promote cultural competence as described in the section above. Below is an example of system-level LGBT cultural competence which can be mirrored for any aspect of diversity to be addressed

Sec VIII Fig 2 - System LGBT Cultural Competencies

Figure 2. Examples of system-level LGBT cultural competence at VA Boston Healthcare System.[146]

Additionally, many institutions offer formal workshops for employees to improve their individual cultural competence. Examples include the Safe Zone Project and the National Coalition Building Institute.

Institution-supported Memberships:

Membership in local, regional, and national organizations can promote personal and professional development for staff from backgrounds traditionally underrepresented in medicine. Institutions can provide financial support for membership, and allow time to attend meetings focused on advancing diversity, equity, and inclusion initiatives. This kind of support indicates a culture of respect and support that can allow minorities to flourish. Institution-supported memberships also begin to address some of the disparities in academic promotion and advancement experienced by minority groups, as well as combatting the increased levels of burnout also experienced by these groups.

Association of Women Surgeons (AWS)

The mission of the AWS is to engage current and future women surgeons to realize their professional and personal goals; to empower women to succeed; and to excel in those aspirations through mentorship, education and a networking community that promotes their contributions and achievements as students, surgeons, and leaders. (Twitter: @WomenSurgeons).

National Hispanic Medical Association (NHMA)

The mission of NHMA is to empower Hispanic physicians to lead efforts to improve the health of Hispanic and other underserved populations in collaboration with Hispanic state medical societies, residents, medical students, and other public and private sector partners. (Twitter: @NHMAmd)

Society of Black Academic Surgeons (SBAS)

The mission of SBAS is to improve health, advance science, and foster careers of African American and other underrepresented minority surgeons. (Twitter: @SocietyofBAS)

Society of Asian Academic Surgeons

SAAS was founded to focus on the personal and professional development of Asian academic surgeons with the belief that the best way to increase Asian representation in the leadership of academic surgery is to prepare future generations to succeed. (Twitter: @AsianAcadSurg)

Association of American Indian Physicians (AAIP)

The mission of the AAIP is “to pursue excellence in Native American health care by promoting education in the medical disciplines, honoring traditional healing principles, and restoring the balance of body, mind, and spirit.” (Twitter: @AAIP1971)

Association of Out Surgeons and Allies (AOSA)

The AOSA is an organization of LGBTQ+ Surgeons and allies that promote acceptance, inclusion, and equity in the surgical specialties to further learner engagement, support individual clinicians and researchers, and build a community. (Twitter: @OutSurgeons)

Diversity-focused Resident/Fellow Recruitment and retention

Mentorship and visibility:

The Medical University of South Carolina has found success in recruiting diverse classes by partnering with more than 40 colleges, including historically black colleges and universities (HBCUs). Dedicated liaisons make frequent recruitment visits to each institution. Students expressing interest are offered career mentoring as early as possible. MCAT preparation courses are offered for students at the partner institutions.[147]

Strategic partnerships with regional minority organizations may aid in increasing exposure to specific medical fields and establishing mentoring networks

LGBTQ students often find it difficult to identify a mentor or navigate the institutional culture. Conscious efforts to include LGBTQ resources, promote support groups, and improve visibility can greatly enhance the success of these students. Harvard Medical School established a Harvard LGBTQ office in 2014 dedicated to LBGTQ support and has since seen a steady increase in the number of LGBTQ students matriculating.

Avoiding bias in letters of recommendation:

An observational study of nearly 90,000 clerkship evaluations from core clinical rotations at two medical schools in different geographic areas of the United States found that many words and phrases reflected students’ personal attributes rather than competency-related behaviors.[148] There was a significant difference observed in narrative evaluations associated with gender and underrepresented-minorities-in-medicine status, even among students who received the same clerkship grade.

Admission committees, candidate evaluations, and interview formats:

Acknowledging and mitigating implicit bias within medical school admission committees is a vital aspect of improving barriers to medical training. Capers et al. examined the racial biases of committee members using the implicit association test (IAT). They found that members of all levels harbored unconscious bias in favor of white applicants. Male faculty members had the greatest degree of bias, while female faculty members and medical student committee members had less bias.[149] Several forms of bias are part of normal human behavior. Understanding these biases and how to mitigate them is useful for everyday encounters as well as for participation on admissions and hiring committees. A review of these biases with ways to mitigate is presented by Jessica Halem at the APSA 2020 Meeting.[150]
Consider blinding interviewers to applications. Knowledge of applicants’ STEP scores influences interviewers’ evaluations. Eliminating such bias is relevant given historically lower STEP scores for URMs.[151] Structural racism has contributed to the overrepresentation of URM students in underperforming schools.[152] Observed differences in test performance may also reflect stereotype threat.[153] Stereotype threat occurs when individuals are at risk of confirming negative stereotypes about their group, such as the stereotype that racial and ethnic minority students score lower on standardized tests.[154] Additional resources for understanding unconscious biases and mitigating actions can be found here:

American College of Surgeons - Mitigating implicit bias in virtual interviews

Catalyst Organization - Harmful types of unconscious bias

Resident and faculty leadership development and career advancement:

Mentorship has been shown to have a significant impact on mentees’ academic career paths, as well as both personal and professional development.[155] While often used interchangeably, mentorship and sponsorship have long been considered unique in the business world. Mentorship is a long-term relationship that occurs when an experienced person within a field gives advice to a less experienced person to promote their success. Sponsorship occurs when an experienced colleague recommends a less experienced protégé for career advancement opportunities.

Some examples are hosting workshops (suturing or other surgical skills) for high school students. Surgeons may volunteer time at “career days” or serve on informational panels [APDS Toolkit].[156]

“Mentors give you perspective. Sponsors give you opportunities.”[157]

Faculty from under-represented groups suffer from a lack of mentorship, low institutional expectations, and isolation.[119][158][159] Given the current lack of diversity among mentors, it is often difficult for mentees to find gender- or racial-concordant mentors. While an effective mentoring relationship may still result, these actions must be deliberate even though there are also benefits to mentoring relationships of different races and genders. Women and minorities have unique mentorship needs that should be acknowledged (institutional racism, stereotype threats, imposter syndrome, etc.). Intentional mentorship strategies should be in place at every level of medical education and training to improve the pipeline of students becoming doctors, surgeons, and ultimately pediatric surgeons.

DiBrito et al. provide an overview of strategies to promote mentorship, including the following:

• Engage a diverse set of experienced mentors
• Train mentors on bias and diversity issues
• Create intentional mentor-mentee pairs at every educational level (ie., undergrad to senior faculty)
• Engage in national surgical associations’ mentoring programs

Diversity-focused Faculty Recruitment

The lack of underrepresented candidates within the applicant pool is often cited as an explanation for the failure of diversity recruitment initiatives. The reality, however, is that search leaders generally rely on existing networks that do not capture a diverse applicant pool. Leaders should be creative and intentional. Duke’s Office of Inclusion and Equity talent acquisition strategies designed to broaden and diversify the candidate pool are listed below.

Pipeline programs:

The path to medicine, surgery, and ultimately pediatric surgery is long and arduous. The odds are frequently stacked against minority applicants from the outset. Lack of access to high-quality schools is frequently tied to geographic poverty. A lack of relatable role models and mentors is frequently a problem. Socioeconomic factors can impact the ability to excel at scholastic activities. Lack of knowledge about scholarships and resources for test preparation worsens the academic chasm.[160]

Supporting URiM students:

The Medical University of South Carolina (MUSC) has developed a successful Post-baccalaureate Reapplication Education Program (PREP). Applicants who demonstrate potential but who were not accepted into a medical school during their first application cycle are invited to the program (2-3 students per year). Students then complete advanced-level science courses at a local university supported by scholarship funding, an additional financial stipend, and regular academic and career mentoring. Upon successful completion of the course with at least a 3.0 GPA, the students are admitted to the next medical school class. This program has played a critical role in increasing the opportunities for students from academically disadvantaged backgrounds.[147]

The Georgetown Experimental Medical Studies Program (GEMS) is another example of a successful pipeline program. This is a one-year, non-degree, post-baccalaureate program designed to equip under-represented and disadvantaged students for success in medical education. Students attend medical school classes supplemented with small group learning and “learning how to learn” activities.

Financial considerations:

“High application costs send a message that medical education isn’t designed to be obtainable for low-income people, which could potentially deter some people from applying at all.”[144]

There have been programs developed to help applicants with the financial burden of applying to medical school. Many medical schools now offer hosting programs, which arrange for current medical students to host applicants so that applicants can avoid hotel expenses. General surgery residency programs could consider adopting a similar practice to offset the financial burden of interview-associated lodging. Some programs such as Ohio State University College of Medicine have even been able to pay for applicants’ lodging. Virtual interviews offer applicants a financially accessible way to present themselves and meet potential future colleagues. General surgery residency programs could consider adopting a similar practice to offset the financial burden of interview-associated lodging. Some programs have even been able to pay for applicants’ lodging. Virtual interviews offer applicants a financially accessible way to present themselves and meet potential future colleagues. Mentors should also be familiar with the AAMC Fee Assistance Program (FAP). The AAMC FAP assists those who, without financial assistance, would be unable to take the Medical College Admission Test® (MCAT®), apply to medical schools that use the American Medical College Application Service® (AMCAS®), and more. Encourage your institution to waive secondary fees for applicants who qualify for the program.[161]It is likely past due for a similar program to be put forward for residency and fellowship applications which are just as pricey as their medical school counterpart. Many institutions offer sponsored surgical sub-internships for URiM medical students to increase the diversity of their recruiting pool and defray costs for these experiences. The AAMC provides an excellent searchable resource: URiM Opportunities for Visiting Students. Similar programs could be created for rotations during surgical residency to encourage URiM and LGBTQ+ surgical residents to spend time at programs with pediatric surgery fellowships.

Institutional Diversity Metrics and Practices:

Once institutions have made a commitment to diversity and inclusion, baseline assessments should be performed, and goals created to be reviewed and re-assessed in a timely manner. Below are examples of Key Performance Indicators from American Surgical Association DEI Handbook, vers 2018.[162]

Sec VIII Fig 3 - ASA DEI Handbok Mayo model

Figure 3. The Mayo Clinic “Listen-Act-Develop” model as represented in the ASA DEI Handbook.[162]

Global HR resources:

The institutional responsibility for diversity, equity, and inclusion does not just lie within academic departments and among faculty, trainees, and students. Healthcare systems and institutions as a whole must take on the responsibility of creating a culture of inclusion at all levels. Human resources departments should have diversity and equity-focused expression of policies, recruitment strategies, advancement opportunities and complaint mitigation.

Examples of diversity-focused CME activities:

• Institutions and departments should have diversity-focused activities, like Grand Rounds, that provide CME credit. This provides faculty with expertise in diversity education an opportunity to present their research and experience to a large target audience.
• Track demographics of grand rounds speakers and diversity of grand rounds topics.
• Include cultural competence discussions in educational conferences and M&Ms.
• Mandatory implicit bias training for all faculty and leadership.

Cultural competence M&M:

Cultural competence deserves formal didactic training and education. An example of a curriculum conceived by a partnership between the University of Maryland and University of Michigan - Cultural Complications.[163] This was designed to be included at standard hospital M&M conferences. The curriculum covers several themes in DEI and includes sample cases to drive discussion.

Sec VIII Fig 4 - Cultural Complications

Figure 4. UMich “Cultural Complications” curriculum.[163]

The University of Michigan also shares how they implemented “Cultural Complications” into their curriculum on their UMich Dept of Surgery Blog.

Another collaborative, multi-institutional effort is represented by the Association of Program Directors in Surgery (APDS) and its determination to uphold the highest standards of inclusion and promote equity and diversity in training programs. The PDF document linked below compiles practical resources and data on the subject of diversity as it pertains to race, religion, sexual orientation, and other groups underrepresented in surgery.

APDS DEI Toolkit

Other organizational DEI efforts Eastern Association for the Surgery of Trauma (EAST) which developed in 2019 EAST Equity, Quality, and Inclusion in Trauma Surgery Practice Ad Hoc Task Force. This task force developed the #EAST4ALL EAST Equity, Quality, and Inclusion Toolkit, which discusses harassment and discrimination, the gender pay gap, implicit bias and microaggressions, and call-out culture.