Diversity, Equity and Inclusion Committee
In 2018, the APSA Board of Governors modified the foundation of the APSA Strategic Pillars to read “Inclusion, representation, and participation for all.” A fifth pillar was adopted, termed “Equity and Social Justice,” and the Diversity, Equity, and Inclusion Committee were formed to guide the organization’s efforts in these regards.
DEI Committee Mission Statement
Diversity, equity, and inclusion are core values for APSA that drive excellence and innovation in clinical care, research, education, advocacy, and leadership. We will broaden organizational diversity across cultural, demographic, cognitive, and practice style domains. Our environment will advance pediatric surgeons to attain their greatest potential, work in partnership to eliminate health inequities, and provide the highest quality of pediatric surgical care for all.
To achieve these goals, we will leverage and connect diverse talents through programmatic development that spans education, innovation, and research in the following domains:
Organizational environment and culture
- Implicit bias awareness and training (implicit biases can perpetuate gender and racial disparities in impactful areas such as policy development and leadership opportunities)
- Sensitivity training
- Building cultural competence (a process that includes cultural awareness, cultural knowledge, cultural skill, cultural engagement, cultural desire- Campinha-Bacote model)
- Culture assessment and survey
Equity and inclusion
- Diversity in representation throughout the organization - includes membership, committees, committee chairs, APSA Board of Governors, and leadership
- Mentorship and sponsorship programs for women and underrepresented minorities
- Leadership development programs to prepare underrepresented groups
The DEI Committee has created four working groups made up of members committed to addressing the following themes:
- Community engagement
- Lowering bias
- Empowerment and governance
As its inaugural publication, members of the DEI Committee, in conjunction with the APSA Board of Governors, wrote and published a position paper outlining APSA’s commitment to Diversity, Equity, and Inclusion as a strategic priority for the organization. The following statements were agreed on:
- APSA acknowledges the potential for enhanced productivity, creativity, and innovation within diverse organizations.
- APSA recognizes the positive impact a diverse cadre of pediatric surgeons may have on healthcare outcomes, patient satisfaction, and patient compliance.
- APSA adopts “Equity and social justice” as the fifth pillar of its organizational mission statement and “Inclusion, representation, and participation for all” as the foundation of its pillars.
- APSA endorses the activities of a member committee dedicated to the study and promotion of diversity, equity, and inclusion in pediatric surgery.
- APSA supports implicit bias assessment to enhance awareness and generates discussion and reflection regarding existing disparities in the care of pediatric surgery patients.
- APSA urges medical schools, general surgery residency programs, and pediatric surgery training programs to enact measures targeted at increasing the diversity of learners who will become pediatric surgeons.
- APSA encourages transparency and intentional hiring and promotion practices that are inclusive, fair, and open for women, underrepresented minority groups, surgeons with disabilities, and for all.
- APSA champions the establishment of mentorship and sponsorship programs specifically aimed at increasing the retention and recruitment of women and underrepresented pediatric surgeons.
- APSA uniformly condemns discrimination, racism, verbal and physical abuse, and sexual harassment.
- APSA promotes the importance of wellness, mental health, and work-life balance to the well-being of its membership and to the positive health outcomes of pediatric surgery patients.
- APSA advocates for efforts to create workplaces that are conducive to new parents at all levels of surgical training and practice.
- APSA pledges to engage in initiatives and strategies to address differential healthcare outcomes related to social determinants of health.
- APSA commits to achieving organizational benchmarks in the quest for increased diversity and inclusion among its membership and leadership.
APSA Diversity Mission Statement
Primary author: Dr. Erika Newman
Creating a unified and clear organizational vision of diversity, equity, inclusion, and justice that aligns with the values of APSA members.
To comprehensively build strategies that address issues of representation, inclusion, and equity in the field of pediatric surgery, the APSA Diversity, Equity, and Inclusion Committee (DEI Committee) was established in the summer of 2018. The DEI Committee’s purpose is to guide APSA in this arena, and committee members were selected from APSA membership. Through a process of iterative group revision, the following committee mission statement was created:
Diversity, equity, and inclusion are core values for APSA that drive excellence and innovation in clinical care, research, education, advocacy, and leadership. We will broaden organizational diversity across cultural, demographic, cognitive, and practice style domains. Our environment will advance pediatric surgeons to attain their greatest potential, work in partnership to eliminate health inequities and provide the highest quality pediatric surgical care.
Equity and Social Justice as an APSA Pillar
Primary author: Dr. Erika Newman
To underline the organization’s commitment to equity and justice, the APSA Board of Governors in 2018 created a fifth organizational strategic pillar termed “Equity and Social Justice” and modified the foundation of APSA’s strategic pillars to read “Inclusion, representation, and participation for all.”
The DEI Committee works to advance these goals by leveraging and connecting diverse talents through programmatic development that spans education, innovation, and research in the following domains:
- Organizational environment and culture
- Implicit bias awareness and training: Implicit biases can perpetuate gender and racial disparities in impactful areas such as policy development and leadership opportunities. Subtle biases and microaggressions can create an environment where not everyone feels included.
- Sensitivity training: Gender and racial sensitivity training will empower APSA members to be more cognizant of their interactions with others and recognize things they can do to foster a welcoming work environment for all.
- Building cultural competence: This process includes increasing cultural awareness, broadening cross-cultural knowledge, honing cross-cultural communication skills, engaging in cultural activities, and cultivating multicultural desires within the health care worker .
- Consciousness-raising: By engaging with the APSA membership through educational sessions at the APSA Annual Conference, quarterly journal article recommendations, original publications, and other avenues, the DEI Committee will increase understanding of DEI-themed principles among the APSA membership.
- Culture assessment and survey: The DEI Committee has distributed a survey to APSA members to understand the demographic composition of the current organization. Results were presented at the 2022 APSA Annual Conference
- Equity and inclusion
- Leading by example: The DEI Committee will model equity and inclusion to the larger APSA membership by including members from all backgrounds.
- Assessment: Regular demographic assessment of the APSA BOG, committee chairs, and membership-at-large will give a rolling understanding of how our organizational composition changes over time.
- Leadership development
- Mentorship, sponsorship, and leadership development programs: The DEI Committee advocates for career development programs aimed specifically toward women and other historically underrepresented groups in medicine.
Defining Diversity and Developing Common Goals
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.
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,  and companies with at least three female board members have better financial performance. 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.
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.” 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.
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. Equity, in effect, is the means by which equality is achieved, and the principle by which a diverse organization becomes an inclusive one.
Underrepresented in Medicine
The American Association of Medical Colleges uses the term underrepresented in medicine (URM) to refer to "those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population." This definition is meant to evolve as local demographics change. Importantly, it removes the focus from specific features such as race and sex and broadens the focus to include other factors such as religion, sexual orientation, gender identity, primary language, country of origin, socioeconomic status, cognitive background, etc. As data continue to demonstrate that a more diverse group of physicians provides better care for diverse patient populations,  a sharp focus must be placed towards achieving a workforce that reflects its surrounding community.
Health vs. Healthcare Disparities and Health Equity
Health disparities are differences in “health status that result from the social disadvantage that is associated with characteristics such as race or ethnicity and socioeconomic status.” On the other hand, health care disparities are differences in the “quality of health care experienced by those with social disadvantage.” Health equity is “the attainment of the highest level of health for all people…with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.”
Social Determinants of Health
The Centers for Disease Control and Prevention (CDC) defines social determinants of health (SDOH) as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” SDOH contribute to a wide array of health disparities and inequities. Healthcare teams and public health organizations with partners in sectors like education, transportation, and housing can act to collectively improve the upstream conditions that impact children and families. Healthy People 2020 divides SDOH into five key domains, each with critical descriptive issues. This framework was further advanced by the Healthy People 2030 Initiative, which provides not only an initial set of objectives related to SDOH, but also evidence-based resources that may be implemented by providers and institutions. Additional resources on SDOH are available through the Kaiser Family Foundation.
Developing Common Goals and a Path Forward
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.
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.
The Diversity Bonus-Why Should We Care?
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. Education, training, and innate talents further enrich cognitive attributes. 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. 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.” In addition to a wider range of information and talents, diverse teams have a higher tendency to focus on facts. 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.” Therein lies the diversity bonus. 
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. 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.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. 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. 
Patients with culturally competent practitioners are more adherent to treatment and experience improved health outcomes. 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. Language-concordant care similarly improves Hispanic pediatric surgery families’ understanding and satisfaction. 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. 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. 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.
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.
· 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.
· 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.
· Healthy Black children have higher rates of morbidity and mortality after surgery.
· Black, Hispanic, Asian and immigrant children have a higher incidence of ruptured appendicitis irrespective of family, socioeconomic, or hospital factors.
· 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.
· Non-white children have higher mortality after congenital heart surgery regardless of the type of insurance.
· Underrepresented minority children and children with government insurance had a higher mortality rate without ECMO after congenital heart surgery.
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. 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. Furthermore, ethnically-diverse teams of authors achieved more citations and high-impact publications than papers written by ethnically uniform teams of authors. Female authorship increased two-fold when the senior author is female. 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. Black, Hispanic, and Native American researchers and full-time academic faculty lag in numbers when compared to the US population and white colleagues. 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. 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. 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. mentorship, training, and resources available to URM researchers are significant barriers to successful research careers. Blacks and Hispanics were less likely to revise and resubmit grant applications, and Blacks resubmitted grant applications more times than any other group. 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.
Opportunities in Research
Academy of Surgical Research offers a mentorship program
American College of Surgeons offers research scholarships
Network of Minority Health Researchers is committed to building the network of minority health research investigators through mentorship, collaboration and technical skills training
NIH’s Research Centers in Minority Research Program provides grants to develop an advanced research infrastructure to reduce health disparities. These funds are available to institutions that award doctoral degrees to underrepresented students
Promoting the Well-Being of Current and Future Pediatric Surgeons
Work life balance (WLB) is defined as "prioritizing between work (career and ambition) and lifestyle (health, pleasure, leisure, family, and spiritual development/meditation)." In contrast to the general population, the United States physicians tend to work longer hours and struggle more with WLB. This remains true even when compared with other professional degree holders who have similar work hours. The “physician personality,” noted for hard work and perfectionism, drives success in medical school and residency. Physician burnout is a state of physical, emotional, and intellectual exhaustion due to unrelenting work stressors. Burnout is characterized by high levels of emotional exhaustion and depersonalization that impairs professional performance.
Work–life balance for surgeons is particularly complex. Many surgeons were raised by mentors who gave up much of their life to virtually live at the hospital as “residents” and continued on working long hours as staff surgeons.In the three “A’s of physician excellence”—able, affable, and available—available is often the easiest to perfect, at least early on. Multiple studies have demonstrated negative physical effects of long working hours, lack of access to healthy foods, and loss of sleep. Even in their personal life, many physicians do not take time to ensure their own good health. Most residents do not access preventative health care regularly.The increase in burnout observed in US physicians between 2011 and 2014 translated into approximately a 1% reduction in the professional effort of the US physician workforce, roughly equivalent to eliminating the graduating class of seven US medical schools. Physicians in minority racial/ethnic groups were less likely to report burnout compared with non-Hispanic White physicians. For female faculty, the major theme of gender bias in the workplace as a risk factor for burnout was prominent.
- Wellness and burnout in pediatric surgery
Current estimates are that approximately 15% of all physicians will be impaired at some time in their careers and will be unable to meet professional responsibilities because of mental illness, alcoholism, or drug dependency. Studies involving national samples of surgeons from surgical subspecialty societies and graduates of surgical training programs suggest that burnout rates among surgeons range from 30% to 38%.Of the 16 specialties included, pediatric (86% to 96%) and endocrine (96%) surgeons demonstrated the highest career satisfaction, whereas a portion of plastic surgeons (33%) and vascular surgeons (64%) were least satisfied. The effect of sex was variable. Residents demonstrated a significantly higher risk for burnout than attending surgeons across multiple specialties. 96% of pediatric surgeons were satisfied with their career choice. Female surgeons are more likely to report less career satisfaction than their male counterparts. A Canadian Association of Pediatric Surgeons’ study showed that working less than 60 hours per week and having one night on call per week has been shown to be favorable for surgeon well-being while working more than 60–80 hours per week and taking two or more nights on call per week promotes burnout. Healthcare professionals throughout the developed world have markedly high rates of sickness absence, burnout, and distress compared to those working in other sectors.
- Promoting the well-being of current and future pediatric surgeons
Work-life balance (WLB) is defined as "prioritizing between work (career and ambition) and lifestyle (health, pleasure, leisure, family, and spiritual development/meditation)." In contrast to the general population, the United States physicians tend to work longer hours and struggle more with WLB. This remains true even when compared with other professional degree holders who have similar work hours. The “physician personality,” noted for hard work and perfectionism, drives success in medical school and residency. Physician burnout is a state of physical, emotional, and intellectual exhaustion due to unrelenting work stressors. Burnout is characterized by high levels of emotional exhaustion and depersonalization that impairs professional performance. Work-life balance for surgeons is particularly complex. Many surgeons were raised by mentors who gave up much of their life to virtually live at the hospital as “residents” and continued on working long hours as staff surgeons.In the three “A’s of physician excellence”—able, affable, and available—available is often the easiest to perfect, at least early on. Multiple studies have demonstrated negative physical effects of long working hours, lack of access to healthy foods, and loss of sleep. Even in their personal lives, many physicians do not take time to ensure their own good health. Most residents do not access preventative health care regularly.
- Improving wellness
Interventions to improve healthcare staff health and wellbeing have primarily focused on supporting or improving individual coping skills rather than affecting the workplace environment such that it promotes healthier behaviors. The Boorman Review, commissioned by the UK Department of Health to specifically address the health and wellbeing at work of healthcare staff, highlighted the need for whole-system interventions which incorporate input from staff regarding their local needs and the involvement of management at all levels. A systematic review from 2016 found that incorporating Boorman’s recommendations and the whole-system healthy workplace interventions can improve health and wellbeing and promote healthier behaviors in healthcare staff. There are many stress factors in the healthcare workplace that have been shown to increase the risk of distress and burnout. These factors include administrative workload, contact with suffering and dying patients, verbal and physical abuse by patients, bullying by colleagues, the need to hide negative emotional responses, risk of litigation, role conflicts between professions, and organizational changes.
Fortunately, stress management and coping skills are learnable. In a randomized controlled trial, 126 healthcare professionals were instructed in stress management and adaptive coping. Subjects who participated in a six-week program designed to improve coping reported significant short-term decreases in emotional exhaustion and feelings of lack of personal accomplishment, two dimensions of burnout. Subjects who received one-hour coping “refresher” sessions at 5, 11, and 17 months showed consistent decreases in burnout throughout the two-year study period. Interventions aimed at addressing the well-being of healthcare workers have been categorized into three groups by the Finnish Institution of Occupational Health.
Categorization of interventions for improving well-being in healthcare workers
1) Person-directed: Interventions aimed at changing personal characteristics without explicit reference to functioning at work
2) Person–work interface: Interventions aimed at improving the fit between the person and the organization (e.g., role conflict–ambiguity, relationships, employee involvement in decision making)
3) Organizational: Interventions targeting organizational or social environments that may produce stress (e.g., organizational restructuring, training, and job redesign)
- Surgeon Well-being Resources
- The Accreditation Council for Graduate Medical Education (ACGME) has expanded its efforts to “promote well-being, mitigate the effects of stress, and prevent burnout” in the GME community. https://www.acgme.org/What-We-Do/Initiatives/Physician-Well-Being/Resources
- Tools to improve professional, emotional, social, physical, and spiritual wellness are available on the American College of Surgeons website. https://www.facs.org/member-services/surgeon-wellbeing
- The American Medical Association Burnout and Well-Being website. https://edhub.ama-assn.org/steps-forward/pages/professional-well-being
- Association of Women Surgeons Resource Center. https://www.womensurgeons.org/page/ResourceCenter
- University of North Carolina Medical Center well-being toolkit. https://www.unchealthcare.org/wellbeing/toolkit/toolkit-overview/
- American Society of Plastic Surgeons Wellness Resources: https://www.plasticsurgery.org/for-medical-professionals/resources/wellnes...
- National Suicide Prevention Lifeline. https://suicidepreventionlifeline.org/
- Stanford Surgery Wellness. https://surgery.stanford.edu/about/wellness.html
- Resident wellness during a pandemic: University of British Columbia general surgery. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368914/pdf/main.pdf
- Surgeon Masters: How surgeons improve their practice and well-being. https://surgeonmasters.com/
- ChristianaCare.org / Johns Hopkins Resident Wellness Toolkit.
- Pediatric Orthopedic Society of North America: Surgeon Wellness and Burnout. https://posna.org/Resources/Physician-Wellness-(1)
What is the current state of Pediatric Surgery?
Primary authors: Dr. Kate Ott and Dr. Tolulope Oyetunji
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.
· The proportion of Black medical school graduates increased by only 1.0% from 2016 to 2020. Hispanics makeup 18.5% of the U.S. population but only 6.7% of medical students and 9.3% of surgery trainees.
· The proportion of Hispanic medical school graduates increased by less than 1.0% from 2016 to 2020 (4.6% vs 5.3%).
· In pediatric surgery, only 6.2% of fellows are Black and only 9.9% are Hispanic. The scarcity of Black and Hispanic trainees places additional stress and burden upon them.
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.” 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. 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.
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.
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. 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).
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. 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).
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. 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. 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.
Though demographic underrepresentation exists in many medical and surgical specialties, the gaps are beginning to narrow. 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. The lack of women and minorities in leadership positions limits the pool of mentors and models of experience. 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.
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. Higher practitioner cultural competence has been shown to result in better outcomes as well as better patient adherence to treatment.
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.
How Can I Learn More?
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. 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 Scale2, the Modern Sexism Scaleswi3, the subtle/blatant prejudice scalepett4, and its variations to measure racism against Black individuals and women5. To learn more about these tools and how different prejudice measures are compared, see the thesis by Simeoni.5
Variations of Bias
Prejudice in favor of or against a person or group. Informs attitudes in the form of prejudice, cognition in the form of stereotypes, and behaviors in the form of discrimination.
Explicit bias is intentional. It manifests as macroaggressions including acts of overt racism, misogyny, homophobia, and transphobia. Explicit bias exerted at an institutional and structural level manifests as discriminatory policies and governance that disproportionately benefit one group over another.
The bias of the subconscious mind. Emerges from instinctive pre-formed associations tend to prevail during moments of increased pressure, such as when we are busy, distracted, or fatigued. Often manifests as microaggressions.
Here is a discussion of the social construct of race/othering, three types of racism (institutionalized, personally-mediated, internalized), and how to disrupt it.9
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.10
APSA DEI Implicit Bias Training Webinar: Recognizing and Responding to Implicit Bias with Quinn Capers MD
Tools to Mitigate Bias:
Common Identity Formation
Ask about possible common group identities (i.e., hometown, sports teams, music, movies, hobbies)
Pause and consider the stress a person may be under, and what their daily life is like
Consider the Opposite
After coming to a conclusion about a person, pause to consider the opposite conclusion before making a final decision
Consider individuals you admire and respect who are from a demographic you have a bias against
Microaggressions and Microaggression Training
Subtle snubs, slights, and insults directed towards minorities, women, and other stigmatized groups, that communicate or engender hostility or lack of belonging 
Find More Examples of Microaggressions at: https://www.microaggressions.com/
Instruments to assess the presence of microaggressions in the work environment:
Inventory of Microaggressions against Black Individuals (IMABI)
14-item measure intended to assess the frequency and impact of racial microaggressions, particularly microinsults and microinvalidations, against Black individuals
Racial and Ethnic Microaggressions Scale (REMS)
45-item self-report inventory was used to assess the frequency of racial microaggressions in daily interactions along with six subscales: 1) Assumption of Inferiority, 2) Second-Class Citizen and Assumption of Criminality, 3) Microinvalidations, 4) Exoticization and Assumptions of Similarity, 5) Environmental Microaggressions, 6) Workplace & School Microaggressions
Racial Microaggressions Scale (RMAS)
32-item scale used to assess the frequency and impact of racial microaggressions along with six subscales: 1) Invisibility, 2) Criminality, 3) Lowing Achieving/Undesirable Culture, 4) Sexualization, 5) Foreigner/Not Belonging, 6) Environmental
Group activity to learn to recognize microaggression:
-Offer to repair the issue
-Explain what went wrong
-Repent for the problem
Open the Front Door
A - Ask clarifying questions
C - Come from curiosity, not judgment
T - Tell what you observed in a factual manner
I - Impact exploration, discuss the impact of the statement
O - Own your thoughts and feelings
N - Next steps
"I feel X when you say Y because Z"
R - Redirect the conversation
A - Ask probing questions
V - Values clarification
E- Emphasize your own thoughts and feelings
N - Next steps
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.
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.
Cultural Competence and Awareness
The concept of cultural competency has evolved over the last 30 years, and numerous definitions exist.15 With respect to healthcare, cultural competency can be thought of as the augmentation of clinical skill with knowledge of a patient’s cultural background – including customs, common beliefs, values, and behaviors - to enhance patient care.
Fundamentals of Cultural Competence:
Barriers to Cultural Competence:
Respect for people and their autonomy
Implicit and explicit bias
Appreciation for the “other” and identity markers: race, ethnicity, gender identity, sexual orientation, genetics, socio-cultural-political characteristics
Provider assumptions and paternalism
Social and distributive justice (healthcare disparities and access)
-Communication and language
Statutory regulations and mandates:
Title VI, Civil Rights Act of 1964
Joint Commission Cultural Competency Guidelines and Standards
Achieving and improving cultural competence for individuals and organizations:
USHHS – National Culturally Linguistically Appropriate Services (CLAS) Standards
USHHS - A Physician’s Practical Guide to Culturally Competent Care
AAMC - Cultural Competence Education
HRSA - Culture, Language, and Health Literacy
AHRQ - What Is Cultural and Linguistic Competence?
NIH - Cultural Respect in Research
AMA Journal Ethics- Ethics and Multiculturalism in the Patient-Physician Encounter
Georgetown University - Cultural and Linguistic Competence Health Practitioner Assessment
Cultural Competence PubMed Articles of Interest:
Culturally Linguistically Appropriate Services (CLAS) in Health Care
Language-Based Inequity in Health Care
Ethics of Responsibility in a Multicultural Context
Culture: Missing link in health research
Values in clinical decision making
Ethical, Cultural, Social, and Individual Considerations Prior to Transition to Limitation or Withdrawal of Life-Sustaining Therapies
Incorporation of Cultural Competence and Professionalism into Institutional Conferences:
Cultural complications www.culturalcomplications.com
University of Michigan & University of Maryland collaborative curriculum for M&M conferences and discussion with surgical trainees including data-based modules and scenarios covering 12 core competencies in DEI multiculturalism.
What is known:
What this adds:
Racism is a social determinant of health that has a profound impact on the health status of children, adolescents, emerging adults, and their families. Evidence to support the continued negative impact of racism on health and well-being through implicit and explicit biases, institutional structures, and interpersonal relationships is clear.
This policy statement from the American Academy of Pediatrics provides an evidence-based focus on the role of racism in child and adolescent development and health outcomes. By acknowledging the role of racism in child and adolescent health, pediatric health professionals will be able to improve the health and well-being of children and adolescents by optimizing clinical care, workforce development, professional education, systems engagement, and research.
Social Inequality and Racial Discrimination: Risk Factors for Health Disparities in Children of Color
Social experiences and environment influence a child’s sense of control over life and health outcomes. Experiences of racial discrimination can foster perceptions of powerlessness, inequality, and injustice for racial minority children. These perceptions may influence child health outcomes and disparities by affecting biologic functioning, the quality of the parent-child relationship, and psychological stress levels.
This article reviews existing theoretical models and empirical studies of the impact of racial discrimination on the health and development of children of color in the United States. A conceptual model of exposure to racial discrimination as a chronic stressor and risk factor for poor health outcomes and child health disparities is presented.
Surgical time out: Our counts are still short on racial diversity in academic surgery
Health care disparities according to race and ethnicity remain a persistent problem in the United States despite several decades of initiatives to improve them. The increasing diversity of the physician workforce may be one method to improve the care of minority patients. Surgery and its subspecialties have historically amplified challenges in physician diversity.
In 2014-15, Blacks represented 12.4% of the US population but only 5.7% of graduating medical students, 6.2% of general surgery trainees, 3.8% of assistant professors of surgery, and 2.0% of full professors of surgery. Similar underrepresentation can be seen in the Hispanic population. A multi-level national focus is imperative to elucidate effective mechanisms to make academic surgery more reflective of the US population.
Working toward gender diversity and inclusion in medicine: myths and solutions
Women’s representation in science and medicine has slowly increased over the past few decades. This increase in gender diversity has not been matched by a rise in gender inclusion – despite increasing representation, women still encounter bias and discrimination when compared with men in these fields across a variety of outcomes.
This review draws on several decades of research to identify five myths that continue to perpetuate gender bias and five strategies for improving not only the number of women in medicine, but also their lived experiences, capacity to aspire, and opportunity to succeed. The argument is made for interventions that address structural and systemic changes rather than focusing on interventions aimed at targeting individual attitudes and behavior.
African Americans, Latinos, and Native Americans are severely underrepresented in the health professions. Increasing the diversity of the physician workforce is desirable for several reasons: to decrease health disparities; to improve the care of a diverse patient population; and to increase the trust of minority populations in research participation.
This paper describes a systematic plan launched by the Medical University of South Carolina to infuse diversity among its students, resident physicians, and faculty in 2002. Diversity became a central component of the College of Medicine’s strategic plan, and efforts resulted in a doubling of the number of underrepresented-in-medicine (URM) students; a more than threefold increase in URM resident / fellows; expansion of mentoring and pipeline programs; the advancement of women and URM individuals into leadership positions; and enhanced learning for individuals from all backgrounds.
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
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
Watch, Listen, and Donate
Oprah Winfrey’s conversation on OWN: Where do we go from here?
Intersectionality Matters! Hosted by Kimberlé Crenshaw (Apple Podcast)
Learn More Section References:
1. Capers, Q. How clinicians and educators can mitigate implicit bias in patient care and candidate selection in medical education. ATS Scholar. 2020;1(3):211-217. DOI: 10.34197/ats-scholar.2020-0024PS
2. McConahay, J. B. (1986). Modern racism, ambivalence, and the Modern Racism Scale. In J. F. Dovidio & S. L. Gaertner (Eds.), Prejudice, discrimination, and racism (p. 91–125). Academic Press.
3. Swim, J., Aikin, K., Hall, W. (1995). Sexism and racism: Old-fashioned and modern prejudices. Journal of personality and social psychology, 68, 199-214.
4. Pettigrew, T., Meertens, R. (1995). Subtle and blatant prejudice in western Europe. European Journal of Social Psychology, 25, 57-75.
5. Simeoni, B. Zeus, "Testing Tests: Determination of the Efficacy of Prejudice Measures" (2005). Electronic Theses and Dissertations. 434. https://digitalcommons.georgiasouthern.edu/etd/434
6. Hewstone M, Rubin M, Willis H. Intergroup bias. Annu Rev Psychol. 2002; 53:575-604. DOI:10.1146/annurev.psych.53.100901.135109.
7. Molina MF, Landry AI, Chary AN, et al. Addressing the elephant in the room: Microaggressions in medicine. Ann Emerg Med. 2020;76L387-391. DOI:10.1016/j.annemergmed.2020.04.009.
8. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systemic review. Am J Public Health. 2015;105:e60-76. DOI:10.2105/ajph.90.8.1212.
9. Jones, C. TED Talk: Four allegories on race and racism. Website link accessed May 3, 2022. https://www.youtube.com/watch?v=GNhcY6fTyBM
10. APSA DEI Implicit bias training webinar: Recognizing and responding to implicit bias, with Dr. Quinn Capers.Website link accessed May 3, 2022. https://www.youtube.com/watch?v=3W_ZQHbjfGw.
11. DiBrito SR, Lopez CM, Jones C, et al. Reducing implicit bias: Association of Women Surgeons #HeForShe Task Force Best Practice Recommendations. J Am Coll Surg. 2019;228:303-309. DOI:10.1016/j.jamcollsurg.2018.12.011.
12. Torres MB, Salles A, Cochran A. Recognizing and reacting to microaggressions in medicine and surgery. JAMA surgery. 2019;154:868-872. DOI:10.1001/jamasurg.2019.1648.
13. Smith, S., Kamm, D. Cultivating and maintaining a respectful environment. The University of Chicago Office of Access and Equity, 2020
14. DeBlaere C, Jordan T, David Z. Racial microaggressions. American Counseling Association Practice Brief. 2017. Retrieved from: https://isucounselingresources2017.weebly.com/uploads/1/1/3/4/11344496/aca_practice_brief_racial-microaggressions.pdf
15. Cultural Enhancement Module Series | Georgetown University Center for Child and Human Development [Internet]. [accessed 9 Apr 2022]. Available from: https://nccc.georgetown.edu/curricula/culturalcompetence.html
16. Trent M, Dooley DG, Dougé J; Section on Adolescent Health; Council on Community Pediatrics; Committee on Adolescence. The Impact of Racism on Child and Adolescent Health. Pediatrics. 2019;144(2):e20191765. doi:10.1542/peds.2019-1765
17. Sanders-Phillips K, Settles-Reaves B, Walker D, Brownlow J. Social inequality and racial discrimination: risk factors for health disparities in children of color. Pediatrics. 2009;124 Suppl 3:S176-S186. doi:10.1542/peds.2009-1100E.
18. Abelson JS, Symer MM, Yeo HL, et al. Surgical time out: Our counts are still short on racial diversity in academic surgery. Am J Surg. 2018;215(4):542-548. doi:10.1016/j.amjsurg.2017.06.028.
19. Kang SK, Kaplan S. Working toward gender diversity and inclusion in medicine: myths and solutions. Lancet. 2019;393(10171):579-586. doi:10.1016/S0140-6736(18)33138-6
20. Deas D, Pisano ED, Mainous AG 3rd, et al. Improving diversity through strategic planning: a 10-year (2002-2012) experience at the Medical University of South Carolina. Acad Med. 2012;87(11):1548-1555. doi:10.1097/ACM.0b013e31826d63e0
How Can I Optimize Surgical Care in Diverse Children and Families?
Primary author: Dr. Jonathan Hills-Dunlap
Health care disparities (differential access, quality of care, and outcomes secondary to race, ethnicity or socioeconomic factors) are well established, even among pediatric surgery patients. As pediatric surgeons, it can be challenging to optimize care for children from diverse sociodemographic backgrounds; it can be especially challenging when patients come from different socioeconomic backgrounds than your own, or merely constitute a small proportion of your patient population.
Despite the many challenges, we must strive to optimize surgical care of diverse children and their families in order to reduce and ultimately eliminate disparities in care for these vulnerable populations.
- Increase your awareness
Educating yourself on surgical disparities in care, the backgrounds of your diverse patients, and the social determinants of health that may promote or undermine their health is a key first step. We cannot optimize care if we don’t understand the problem. Implicit biases must also be recognized and remedied, as described in the sections above. Part of this process includes avoiding assumptions about cultures or customs with which you are less familiar. Participation in local, regional, or national “Diversity, Equity, and Inclusion” initiatives (Table 1) can be highly educational, even if these groups seem uncomfortable for you at first, or you are your only partner participating in them.
Table 1. Examples of diversity, equity and inclusion initiatives
Stanford Unviersity School of Medicine Department of Surgery
University of North Carolina School of Medicine Department of Surgery
- Practice and promote culturally competent care
Pediatric surgeons should provide and champion culturally dexterous and compassionate care toward diverse children. We must recognize that diverse communities may have a strong distrust of the healthcare system based on decades of institutional racism and unequal treatment. We must work to regain their trust and improve comfort by providing culturally competent care and hiring staff from diverse backgrounds when possible. Promote yourself as an ally to diverse community members. If you do not speak the primary language of your patient or their family, consider learning basic words or phrases to initiate or close encounters with them, and prioritize the use of trained interpreters and cultural brokers where possible. Your inpatient and outpatient teams should be able to quickly and reliably access professional interpreters, as language-concordant care is a proven means to improve patient satisfaction and clinical understanding. Consider the use of clinical tools to help you provide culturally competent care, especially in unfamiliar situations. For example, the use of the four tools to mitigate Implicit Bias, described in section VI of this Toolkit, can be used in a myriad of clinical and patient care contexts. Another example is this toolkit for collecting data on sexual orientation and gender identity in the clinical setting, allowing you to optimize the care of LGBTQ patients in an efficient, respectful, and validating manner.10
- Utilize additional resources and technology to optimize patient education and shared decision-making
Some families may have lower health literacy and require additional resources and time to ensure a thorough understanding of their child’s disease. All printed and online information should be available at an appropriate health literacy level and in their primary language. Virtual visits should be strongly considered for clinical encounters that do not require a physical exam; transportation limitations or lost income from shift-work jobs can add significant stress for many families. You can also consider involving social workers early on to coordinate multidisciplinary visits with consulting physicians for appropriate informed consent. For providers at smaller hospitals where social workers may not have the same connections to robust outpatient resources as they might at larger academic centers, providers should consider establishing out-of-hospital relationships with regional or national nonprofit organizations.
· Children’s Burn Foundation is one example of a nonprofit organization that can offer significant post-burn outpatient resources to children and their families whose lives have been impacted by burns.14
· The robust Family Support Services program offered by Children‘s National is an institutional example, which includes a Parent Navigator Program to assist families of children with chronic medical conditions and special health care needs, including transportation and respite.15
- Emphasize family-centered care by identifying expectations for postoperative recovery
If the child’s surgical disease or operation(s) may result in prolonged hospitalization, emphasize this to families early on so that they can prepare accordingly. Taking time off from work or enlisting the help of other caregivers can be overwhelming, especially for families of lower socioeconomic backgrounds. Instead of putting the burden on them to ask for additional resources, consider providing help to all families, or involving social workers early to mobilize resources for these families (e.g., lodging at a local Ronald McDonald House chapter,16 transportation to and from the hospital, or food assistance within or near your hospital). Ensure your inpatient staff can be flexible and accommodate caregivers’ schedules for updates. Interpreter services should be present on rounds or during updates so that all questions can be answered. Post-discharge, families may require additional follow-up appointments to ensure optimal care is being provided in the outpatient setting.
- Strengthen local resources and empower low-volume hospitals in the context of differential access to care
The delivery of pediatric surgical care is transitioning to high-volume regional centers, which will likely increase disparities in surgical care for diverse families. If you practice at a high-volume regional center where consultations and/or referrals from particular communities are common, consider establishing a local connection to investigate the needs of local providers and their patients; optimizing outreach in a mutually respectful manner is critical.
· Surgeons at Boston Children’s Hospital provide surgical care (clinic and operations) at South Shore Hospital in order to provide care for patients in the community relieving the burden and expense of travel and difficulty navigating the larger medical complex of Boston Children’s Hospital.18
· Connecticut Children’s has developed the CLASP program (Connecticut Children’s Leaders in Advanced Solutions in Pediatrics) to provide referral guidelines to pediatric primary care providers, with the goal of bringing competent care closer to where patients and their families live.19 This can minimize the burden of unnecessary travel time and the stress of navigating an unfamiliar health care setting while empowering local resources.
For low complexity cases, consider performing preoperative workups or consultations virtually. Clinics can also be organized so that you or a partner intermittently travels to see the patients in their communities. If travel to your regional center is deemed imperative, resources could be organized and standardized through your hospital to support families throughout their stay.
- Participate in research or advocacy initiatives to reduce surgical disparities in care
Individually, we can try to optimize care for our patients in our respective communities by following the above steps. However, widespread optimization of care for diverse communities will only occur with a national-level movement that includes national-level policy change. This will require broad multidisciplinary support on a foundation of convincing data. In 2016, the National Institutes of Health and the American College of Surgeons set a national agenda for surgical disparities research.21 They concluded that research and funding priorities should prioritize patients’ care perspectives, workforce diversification and training, and systematic evaluation of health technologies. Pediatric surgeons must engage in this agenda to optimize care for diverse patients both locally and nationally.
Widespread optimization of care for diverse communities will only occur within a national-level movement that includes national-level policy change.
Optimize Surgical Care Section References:
1. Hills-Dunlap J, Melvin P, Graham D, Kashtan M, Anandalwar S, Rangel S. Association of Sociodemographic Factors With Adherence to Age-Specific Guidelines for Asymptomatic Umbilical Hernia Repair in Children. JAMA Pediatr. 2019;173(7):640. doi:10.1001/jamapediatrics.2019.1061
2. Smink D, Fishman S, Kleinman K, Finkelstein J. Effects of Race, Insurance Status, and Hospital Volume on Perforated Appendicitis in Children. Pediatrics. 2005;115(4):920-925. doi:10.1542/peds.2004-1363
3. Lin Y, Pan I, Harris D, Luerssen T, Lam S. The Impact of Insurance, Race, and Ethnicity on Age at Surgical Intervention among Children with Nonsyndromic Craniosynostosis. J Pediatr. 2015;166(5):1289-1296. doi:10.1016/j.jpeds.2015.02.007
4. Nelson C. Evidence of Variation by Race in the Timing of Surgery for Correction of Pediatric Ureteropelvic Junction Obstruction. Journal of Urology. 2007;178(4):1463-1468. doi:10.1016/j.juro.2007.05.167
5. American College of Surgeons. Diversity Resources. https://www.facs.org/about-acs/governance/acs-committees/committee-on-diversity-issues/diversity-resources/. Accessed Mar 12, 2022.
6. Armstrong K, Rose A, Peters N, Long J, McMurphy S, Shea J. Distrust of the health care system and self-reported health in the United States. J Gen Intern Med. 2006;21(4):292-297. doi:10.1111/j.1525-1497.2006.00396.x
7. Armstrong K, McMurphy S, Dean L et al. Differences in the Patterns of Health Care System Distrust Between Blacks and Whites. J Gen Intern Med. 2008;23(6):827-833. doi:10.1007/s11606-008-0561-9
8. Dean M, Victor E, Guidry-Grimes L. Inhospitable Healthcare Spaces: Why Diversity Training on LGBTQIA Issues Is Not Enough. J Bioeth Inq. 2016;13(4):557-570. doi:10.1007/s11673-016-9738-9
9. Dunlap J, Jaramillo J, Koppolu R, Wright R, Mendoza F, Bruzoni M. The effects of language concordant care on patient satisfaction and clinical understanding for Hispanic pediatric surgery patients. J Pediatr Surg. 2015;50(9):1586-1589. doi:10.1016/j.jpedsurg.2014.12.020
10. Do Ask, Do Tell. Fenway Health. https://doaskdotell.org/ehr/toolkit/. Accessed March 21, 2022.
11. O’Toole J, Alvarado-Little W, Ledford C. Communication with Diverse Patients. Pediatr Clin North Am. 2019;66(4):791-804. doi:10.1016/j.pcl.2019.03.006
12. Marcin J, Shaikh U, Steinhorn R. Addressing health disparities in rural communities using telehealth. Pediatr Res. 2015;79(1-2):169-176. doi:10.1038/pr.2015.192
13. Utidjian L, Abramson E. Pediatric Telehealth. Pediatr Clin North Am. 2016;63(2):367-378. doi:10.1016/j.pcl.2015.11.006
14. Children’s Burn Foundation. https://www.childburn.org/. Accessed March 21, 2022.
15. Family Support Services | Children’s National. https://childrensnational.org/visit/resources-for-families/family-services. Accessed March 21, 2022.
16. Find a Chapter | Ronald McDonald House Charities. Rmhc.org. https://www.rmhc.org/find-a-chapter. Accessed March 21, 2022.
17. Salazar J, Goldstein S, Yang J et al. Regionalization of Pediatric Surgery. Ann Surg. 2016;263(6):1062-1066. doi:10.1097/sla.0000000000001666
18. South Shore Hospital | Boston Children’s Hospital. Childrenshospital.org. https://www.childrenshospital.org/about-us/locations/south-shore-hospital. Accessed March 21, 2022.
19. Co-Management - Connecticut Children’s. Connecticut Children’s. https://www.connecticutchildrens.org/co-management/. Accessed March 21, 2022.
20. Haider A, Dankwa-Mullan I, Maragh-Bass A et al. Setting a National Agenda for Surgical Disparities Research. JAMA Surg. 2016;151(6):554. doi:10.1001/jamasurg.2016.0014
21. National Institutes of Health. NIH Launches Research Program To Reduce Health Disparities In Surgical Outcomes. 18 April 2016. https://www.nih.gov/news-events/news-releases/nih-launches-research-program-reduce-health-disparities-surgical-outcomes. Accessed March 21, 2022.
What Steps Can My Institution Take to Improve Diversity within Pediatric Surgery?
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.
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.2
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:
Michigan Medicine Department of Surgery – Michigan Promise
Nationwide Children’s Hospital – Everything Matters
Seattle Children’s Pediatrics Residency
Stanford Medicine Pediatrics Residency
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.3 Involvement in numerous diversity committees can contribute to this phenomenon.
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
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.
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.
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. 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. 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.8
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. Structural racism has contributed to the overrepresentation of URM students in underperforming schools. Observed differences in test performance may also reflect stereotype threat. 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. 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. 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].15
“Mentors give you perspective. Sponsors give you opportunities.”
Faculty from under-represented groups suffer from a lack of mentorship, low institutional expectations, and isolation. 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.
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.
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.
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.
“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.”2
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.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 2018.22
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.23 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.
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.
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.
Improve Diversity Section References:
1. Carnes M, Handelsman J, Sheridan J. Diversity in academic medicine: the stages of change model. J Women Health (Latchet). Jul-Aug 2005;14(6):471-5. 30.
2. Khatrichettri N. How do we write better diversity statements? AACU. Fall 2021. https://www.aacu.org/article/how-do-we-write-better-diversity-statements. Accessed Feb 22, 2022.
3. Rodríguez JE, Campbell KM, Pololi LH. Addressing disparities in academic medicine: what of the minority tax? BMC Med Educ. 2015;15(1):6. https://doi.org/10.1186/s12909-015-0290-9
4. Ruben MA, Shipherd JC, Topor D, et al. Advancing LGBT health care policies and clinical care within a large academic health care system: a case study. J Homosex. 2017;64(10):1411-1431. doi: 10.1080/00918369.2017.1321386.
5. Deas D, Pisano ED, Mainous AG 3rd, Johnson NG, Singleton MH, Gordon L, Taylor W, Hazen-Martin D, Burnham WS, Reves JG. Improving diversity through strategic planning: a 10-year (2002-2012) experience at the Medical University of South Carolina. Acad Med. 2012 Nov;87(11):1548-55. doi: 10.1097/ACM.0b013e31826d63e0. PMID: 23018331.
6. Rojek A, Khanna R, Yim J, et al. Differences in Narrative Language in Evaluations of Medical Students by Gender and Under-represented Minority Status. . J Gen Intern Med 2019;34:684-91
7. Capers Q 4th, Clinchot D, McDougle L, Greenwald AG. Implicit Racial Bias in Medical School Admissions. Acad Med. 2017 Mar;92(3):365-369. doi: 10.1097/ACM.0000000000001388.
8. Halem J. Everyday bias at work – APSA Diversity, Equity and Inclusion Committee video presentation 2020. https://videolibrary.globalcastmd.com/everyday-bias-at-work. Website accessed May 3, 2022.
9. Veloski JJ, Callahan CA, Xu G, Hojat M, Nash DB. Prediction of students’ performances on licensing examinations using age, race, sex, undergraduate GPAs, and MCAT scores. Acad Med. 2000;75(10)(suppl):S28-S30. https://doi.org/10.1097/00001888-200010001-00009
10. Laurencin CT, Murray M. An American crisis: the lack of black men in medicine. J Racial Ethn Health Disparities. 2017;4(3):317-321. https://doi.org/10.1007/s40615-017-0380-y
11. Walton GM, Spencer SJ. Latent ability: grades and test scores systematically underestimate the intellectual ability of negatively stereotyped students. Psychol Sci. 2009;20(9):1132-1139. https://doi.org/10.1111/j.1467-9280.2009.02417.x
12. Wursu MH, Tepperberg S, Weinberg JM, Saper RB. Matching our mission: a strategic plan to create a diverse family medicine residency. Fam Med. 2019;51(1): 31-36.
13. Lee TC, Reyna C, Shah SA, Lewis JD. The road to academic surgical leadership: Characteristics and experiences of surgical chairpersons. Surgery. 2020 Oct;168(4):707-713. doi: 10.1016/j.surg.2020.05.022. Epub 2020 Jul 11. PMID: 32660864; PMCID: PMC7541787.
14. Sambunjak D, Straus SE, Marusic A. A systematic review of qualitative research on the meaning and characteristics of mentoring in academic medicine. J Gen Intern Med. 2010;25:7278.
15. Association of Program Directors in Surgery, APDS Toolkit. https://apds.org/program-directors/apds-diversity-and-inclusion-toolkit/. Website accessed May 3, 2022.
16. Villwock JA. Meaningfully Moving Forward Through Intentional Training, Mentorship, and Sponsorship. Otolaryngol Clin North Am. 2021 Apr;54(2):xxi-xxii. doi: 10.1016/j.otc.2021.01.003. Epub 2021 Feb 16. PMID: 33602517.
17. DiBrito SR, Lopez CM, Jones C, Mathur A. Reducing Implicit Bias: Association of Women Surgeons #HeForShe Task Force Best Practice Recommendations. J Am Coll Surg. 2019 Mar;228(3):303-309. doi: 10.1016/j.jamcollsurg.2018.12.011. Epub 2019 Jan 4. PMID: 30611895; PMCID: PMC7170165.
18. Pololi L, Cooper LA, Carr P. Race, disadvantage and faculty experiences in academic medicine. J Gen Intern Med, 25 (2010), pp. 1363-1369
19. Beech BM, Calles-Escandon J, Hairston KG, et al. Mentoring programs for underrepresented minority faculty in academic medical centers: A systematic review of the literature. Acad Med, 88 (2013), pp. 541-549
20. Youmans QR, Essien UR, Capers Q 4th. A Test of Diversity - What USMLE Pass/Fail Scoring Means for Medicine. N Engl J Med. 2020 Jun 18;382(25):2393-2395. doi: 10.1056/NEJMp2004356. PMID: 32558468.
21. Millo L, Ho N, Ubel PA. The Cost of Applying to Medical School - A Barrier to Diversifying the Profession. N Engl J Med. 2019;381(16):1505-1508.
22. American Surgical Association Task Force on Equity, Diversity, and Inclusion. https://americansurgical.org/files/2018/Equity.pdf. Accessed May 5, 2022.
23. Harris C, Dossett L, Dimick J, Jobin C, Cooper L, Chipman A. Cultural Complications Curriculum. https://www.culturalcomplications.com/. Accessed May 5, 2022.
What Can My Institution Do to Impact Greater Social Determinants of Health?
Primary author: Dr. Hanna Alemayehu
- Medical student / trainee education
Medical student education in both the pre-clinical years and during clerkships must integrate social determinants of health (SDOH) in all aspects of their curriculum.
Institutions must shift their educational mandate to training ‘doctor-citizens’ who are engaged in social justice work, which will depend on embracing and examining politicized issues. Educators who participate in activism and equity work should be given space in the curriculum to discuss this work in legitimized ways, and its value should be acknowledged in the traditional methods within academia.
The danger of teaching knowledge without tools for intervention must be acknowledged; this does not reduce health inequities and may worsen them.
Multi-pronged approaches including didactic training, mentorship, collaborative longitudinal service and advocacy projects with community partners, career seminars, and research have shown promise over isolated didactics or lectures. SDOH education and interventions should be incorporated into medical student and resident trainee activities and curricula as follows:
· Include training of and implementation of SDOH screening tools in the Medical Student-Run Volunteer Clinics and/or Chief Resident Clinics
· Volunteer social workers should be present at each clinic
· Volunteers should be aware and have access to community resources available to patients and their families
· Clinic student /resident leadership should collaborate with community organizations to build relationships that can be of value to patients and their families
· Some pre-clinical curricula should include longitudinal shadowing or clinical opportunities; these can be used as a basis for faculty-mentored medical student projects that identify opportunities for best practices in terms of SDOH in the clinic, with opportunities to provide recommendations for interventions/implementation at the culmination of the opportunity
Research has focused on identifying SDOH and on SDOH program implementations; however, there are few data on changes in patient outcomes or metrics to measure SDOH impact. More work is required to determine the best practices for identifying and measuring changes in outcome after interventions on SDOH either on a population level or even within a small cohort. Community engagement in research is “a process of inclusive participation that supports mutual respect of values, strategies, and actions for authentic partnership” of people affiliated by geographic location, shared interest, or similar circumstances to address issues affecting community wellbeing. Community engagement in medical research remains imperative, but it is not often practiced. Not only is there an ethical mandate for researchers to respect the communities they function within, but specific approaches to community-engaged research can build trust between researchers and communities, encourage participation among under-represented groups, and enhance the relevance and uptake of research findings. One of the biggest challenges continues to be the lack of consensus on how to engage the community and the lack of metrics to measure success. Institutional Review Boards should consider mandating plans for community engagement for all studies involving participant recruitment.
- Interdisciplinary institutional collaboration
As institutions begin to focus on their neighborhoods and how to address SDOH within their patient catchment area, reliance on a diversity of expertise, experience, and knowledge of the different fields of academia within the institution becomes paramount.
In addition to community engagement and input, the advantage of the concentration of multi-disciplinary expertise found at higher learning institutions cannot be overstated. For example, as problems of food insecurity are tackled, expertise from the School of Agriculture or Urban Planning becomes vital.13
Institutions can host symposia to identify and implement collaborative frameworks that are mutually beneficial to the institutional disciplines, as well as the neighborhoods and ultimately the patients. They can also act as a foundation for activities of professional organizations, such as the Michigan Impacting HOPE Collaborative Symposium.14
- Start small, go big: Practical steps
Providers beginning to delve into the concept of SDOH and how to address them may feel powerless or overwhelmed. Similarly, departmental leadership, or even hospital system leadership, may recognize the benefit of addressing SDOH in their communities, but not know how and where to start. The following is a list of concrete steps that start small and at the individual level and scale up to the clinic, division, departmental, and institutional levels.15-19
· Individual providers can make the commitment to perform SDOH screening for every patient and refer to social work as needed.
· Individual providers can make the commitment to educate themselves on community resources available to patients
· Individual providers can make the commitment to discuss and address SDOH with every student/trainee on their service
· Individual providers can advocate for coverage changes at the CMS state level or contact their state legislators to advocate for specific needs
· Clinics or divisions should provide after-hours access to patients whose jobs or childcare commitments do not allow visits during regular work hours
· Clinics should have access to social workers and listings of available community resources for referral
· Clinics can make healthy snacks a priority over stickers and candy
· Clinics can organize a book exchange program
· Divisions and departments can partner with community leaders to determine specialty-specific needs within the community for preventative health
· Divisions and departments should acknowledge and reward social equity work in traditional academic ways such as within the promotion rubric or with protected time
· Institutions can implement SDOH Screening within the medical record system for every patient encounter and ensure the social work resources are robust enough to intervene for every patient that screens positively
Institutions can identify as anchor institutions and activate a strategic plan with more details described below
- Anchor institutions
Institutions and health systems can and should identify as medical anchors, especially as they have increasing footprints in their communities and neighborhoods.15 Once they self-identify as med anchors, a strategic plan should be developed and implemented after careful community engagement and SDOH evaluation to determine the needs. Specific engagement strategies may include, but not be limited to the following:16-19
· Allocate a specific percentage of capital improvement project costs for community health initiatives
· Job programs/employment commitment in terms of real percentage (with focus on the job training in the community with local community groups)
· Promotions program with experience/institutional longevity vs. educational requirements
· Purchasing and procurement practices that focus on the local economy and businesses owned by women and minorities
· Investment and place-based investing: devote a certain percentage of endowment or operating dollars into community impact projects/development
· Implementing healthy nutrition standards for food for meetings and events (requiring locally sourced or locally owned businesses to be used), initiating on-site farmer’s market
“Social accountability demands that medical institutions must be held accountable to society to ensure that societal needs are being met through research, education, and service provision.”16
"Some sociologists advocate moving people out of the neighborhood. But why don’t we transform the neighborhood, so everyone wants to come into it?” (Dr. Victor Garcia - Cincinnati Children’s)19
Social Determinants of Health Section References:
1. Skochelak, Susan E. MD, MPH; Stack, Steven J. MD Creating the Medical Schools of the Future, Academic Medicine: January 2017 - Volume 92 - Issue 1 - p 16-19. doi: 10.1097/ACM.0000000000001160.
2. Patel, N.A. Health and Social Justice AMA J Ethics. 2015; 17(10):894-896. Doi:10.1001/journalofethics.2015.17.10.fred1-1510.
3. Sharma, Malika MD, MEd; Pinto, Andrew D. MD, MSc; Kumagai, Arno K. MD Teaching the Social Determinants of Health: A Path to Equity or a Road to Nowhere? Academic Medicine: January 2018 - Volume 93 - Issue 1 - p 25-30 doi: 10.1097/ACM.0000000000001689.
4. Song AY, Baylor College of Medicine Committee on the Social Determinants of Health. Poythress EL, Bocchini CE, Kass JS. Reorienting orientation: introducing the social determinants of health to first-year medical students. MedEdPORTAL. 2018;14:10752. https://doi.org/10.15766/mep_2374- 8265.10752.
5. Martinez IL, Artze-Vega I, Wells AL, et al. Twelve tips for teaching social determinants of health in medicine. Med Teach. 2015 Jul;37(7):647-652. doi:10.3109/0142159X.2014.975191. Epub 2014 Nov 6. PMID: 25373885.
6. Kasper J, Greene JA, Farmer PE, Jones DS. All Health is Global Health, All Medicine is Social Medicine: Integrating the Social Sciences into the Preclinical Curriculum. Acad Med. 2016 May; 91(5): 628-32. Doi: 10.1097/ACM. 0000000000001054. PMID: 26703416.
7. Alcántara C, Diaz SV, Cosenzo LG, Loucks EB, Penedo FJ, Williams NJ. Social determinants as moderators of the effectiveness of health behavior change interventions: scientific gaps and opportunities. Health Psychol Rev. 2020 Mar;14(1):132-144. doi: 10.1080/17437199.2020.1718527. PMID: 31957557.
8. Akbilgic O, Shin EK, Shaban-Nejad A. A Data Science Approach to Analyze the Association of Socioeconomic and Environmental Conditions with Disparities in Pediatric Surgery. Front Pediatr. 2021 Mar 12;9:620848. doi: 10.3389/fped.2021.620848. PMID: 33777865; PMCID: PMC7994338.
9. Haider AH, Dankwa-Mullan I, Maragh-Bass AC, Torain M, Zogg CK, Lilley EJ, et al. Setting a national agenda for surgical disparities research: recommendations from the National Institutes of Health and American College of Surgeons Summit. JAMA Surg. (2016) 151:554–63. 10.1001/jamasurg.2016.0014
10. Ahmed SM, Palermo AG. Community engagement in research: frameworks for education and peer review. Am J Public Health. 2010;100(8):1380-1387. doi:10.2105/AJPH.2009.178137
11. MacQueen KM, Bhan A, Frohlich J, Holzer J, Sugarman J; Ethics Working Group of the HIV Prevention Trials Network. Evaluating community engagement in global health research: the need for metrics. BMC Med Ethics. 2015 Jul 1;16:44. doi: 10.1186/s12910-015-0033-9. PMID: 26126899; PMCID: PMC4488111.
12. Holzer JK, Ellis L, Merritt MW. Why We Need Community Engagement in Medical Research. Journal of Investigative Medicine 2014; 62:851-855.
13. Cabannes, Y., & Marocchino, C. (Eds.). (2018). Integrating Food into Urban Planning. UCL Press. https://doi.org/10.2307/j.ctv513dv1. Accessed May 5, 2022.
14. Michigan Hope Collaborative Symposium 2021. From: https://www.youtube.com/watch?v=_1tLAvDoRQ0. Accessed May 5, 2022.
15. Center for Disease Control. At-a-Glance: 10 Essential Public Health Services and How they can Include Addressing Socialt Determinants of Health Inequities. From: https://www.cdc.gov/publichealthgateway/publichealthservices/pdf/ten_essential_services_and_sdoh.pdf. Accessed May 5, 2022.
16. Howard K. Koh, Amy Bantham, Alan C. Geller, Mark A. Rukavina, Karen M. Emmons, Pamela Yatsko, and Robert Restuccia, 2020:Anchor Institutions: Best Practices to Address Social Needs and Social Determinants of Health American Journal of Public Health 110, 309_316, From: https://doi.org/10.2105/AJPH.2019.305472
17. Johnson SR. In depth: Hospitals tackling social determinants are setting the course for the industry. 2018. From: https://www.modernhealthcare.com/article/20180825/NEWS/180809949/in-depth-hospitals-tackling-social-determinants-are-setting-the-course-for-the-industry. Accessed May 5, 2022.
18. Sokol, E. (2020) EHR Intelligence. Integrating Social Determinants of Health into the EHR. From: https://ehrintelligence.com/features/integrating-social-determinants-of-health-into-the-ehr. Accessed May 5, 2022.
19. Garcia, V. TEDxCincy-Health, and Prosperity for All. (2011) From: https://www.youtube.com/watch?v=j-JYDZteE-M. Accessed May 5, 2022.
What Can My Professional Organization Do to Drive Diversity, Equity, and Inclusion?
Primary author: Dr. Morgan Richards
Although it is important for individuals to take steps to incorporate diversity, equity, and inclusion in their everyday practice, it is imperative that professional organizations also formalize these concepts into their working models. When organizations 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. There are many ways by which organizations may prioritize diversity, equity, and inclusion.2
- Determine stakeholders
It is critical for an organization to first identify its stakeholders. Identifying stakeholders consists of determining who is affected by the organization as well as who may influence the direction of the organizational efforts. This includes, but is not limited to employees, board members, and community members. Methods for determining stakeholders include a survey of the membership, specifically asking about demographic factors that relate to diversity. Professional organizations may not know the makeup of their membership unless a formal survey to determine this information is created, distributed, and collated. Surveys will help to determine how those stakeholders identify and also allow an organization to broaden its reach by discovering underrepresented subgroups. Surveys should be strongly vetted by under-represented groups to ensure minority groups feel accepted and important. For example, if a person were of a non-conforming gender, but the survey only gave options for the male and female gender, this would actually cause feelings of isolation and exclusion rather than the intended effect. Once stakeholders are identified, they will be assets to the organization as they may have a vested interest in promoting the visibility and representation of minority groups.
- Develop an organizational diversity statement
These diversity statements emphasize the value of diversity, the active promotion of diversity within the organization and among stakeholders, and the commitment to work to eliminate sources of exclusion within their respective communities.8-10 Examples include:
- Educate your Board of Directors and members
The promotion of diversity, equity, and inclusion within an organization demonstrates to employees its values and promotes productivity in these areas. The criteria by which people within an organization find professional advancement are the strongest indicators of that organization’s values. This goes beyond diversity statements or press releases. A professional organization that actively seeks out hires, and promotes diverse opinions, backgrounds, and identities is leading with action. It sends a message to members that inclusion is more than an abstract idea. Some methods for educating leaders and organizational membership include:
* Publishing diversity, equity, and inclusion related literature
* Holding membership accountable for reading such literature reviews
* Promoting sessions related to these concepts at annual meetings. For example, the Journal of Pediatric Surgery has published a white paper outlining APSA’s commitment to the principles of diversity, equity, and inclusion.
- Practical steps to ensure equity and inclusion
When there is an imbalance of representation, not only does this need to be corrected but also those in positions of power require ongoing implicit bias training. It is also helpful to ensure diversity, equity, and inclusion within other committees so that decisions, policies, and biases may be held accountable. Professional organizations should commit to steps that correct this imbalance of representation and further a culture of inclusion:
- Implement a training curriculum for the Board of the organization as well as the Diversity Committee with predetermined sessions at select intervals to be ongoing annually – including but not limited to implicit bias training, bystander training, microaggressions training, etc. As an example, this is the APSA Board of Governors’ Implicit Bias Training Guide.14
- Include a representative member from the organization’s Diversity Committee to participate in all other major committee meetings to ensure the lens of equity is used in all organizational activities
Annual review of organizational policies and procedures (including related to membership, committee election, leadership election etc.) by the organization’s Diversity Committee.
Inclusion of the Rooney Rule or equivalent in the organizational leadership selection process. Initially implemented by the National Football League (NFL) in 2002 after recognition of biases in hiring practices for senior coach positions, this rule requires the organization to interview at least one under-represented minority applicant for available leadership positions in order to decrease the potential for decision-maker bias. Other sports organizations and medical organizations (eg., APSA) have integrated the Rooney rule into nominations for committees and leadership positions.15
It is imperative that professional organizations do not assume that diversity, equity, and inclusion have been achieved once a diversity statement has been created or a committee has been formed.
Professional Organization Section References:
1. Lightfoote JB, Deville C, Ma LD, Winkfield KM, Macura KJ. Diversity, Inclusion, and Representation: It Is Time to Act. J Am Coll Radiol. 2016 Dec;13(12 Pt A):1421-1425. doi: 10.1016/j.jacr.2016.08.008. Epub 2016 Oct 25. PMID: 27793506.
2. University of California Regents Policy 4400: Policy on University of California Diversity Statement, (2007, amended 2010). University of California Statement on Diversity, From: https://diversity.ucdavis.edu/uc-statement-diversity. Accessed May 5, 2022.
3. Pierce AE, Moreno-Walton L, Boatright D, Moll JL, Hicks MN, Druck J, Lopez BL, Oral E, Heron SL. Advancing Diversity and Inclusion: An Organized Approach Through a Medical Specialty Academy. AEM Educ Train. 2019 Dec 31;4(Suppl 1):S40-S46. doi: 10.1002/aet2.10427. PMID: 32072106; PMCID: PMC7011409.
4. Sepulveda KA, Paladin AM, Rawson JV. Gender Diversity in Academic Radiology Departments: Barriers and Best Practices to Optimizing Inclusion and Developing Women Leaders. Acad Radiol. 2018 May;25(5):556-560. doi: 10.1016/j.acra.2017.08.018. Epub 2018 Feb 3. PMID: 29398435.
5. Powderly WG. The Importance of Inclusion, Diversity, and Equity to the Future of the Infectious Diseases Society of America. J Infect Dis. 2019 Aug 20;220(220 Suppl 2):S82-S85. doi: 10.1093/infdis/jiz197. PMID: 31430378.
6. Satiani B, Vaccaro PS, Go MR. Diversity in membership and leadership positions in a regional vascular society. J Vasc Surg. 2010 Apr;51(4 Suppl):47S-52S. doi: 10.1016/j.jvs.2009.09.063. PMID: 20346339.
7. Varvasovsky Z, Brugha R. How to do (or not to do) a Stakeholder Analysis. Health Policy and Planning, 2000; 15(3): 338-345. https://doi.org/10.1093/heapol/15.3.338. From: https://academic.oup.com/heapol/article/15/3/338/573312?login=true. Accessed May 5, 2022.
8. AAP Diversity and Inclusion Statement. Pediatrics. 2018;141(4):e20180193. AAP Diversity and Inclusion Statement
9. APSA Statement on Equity and Social Justice. American Pediatric Surgical Association, APSA Governors and APSA Diversity, Equity and Inclusion Committee, 2020. https://secureservercdn.net/126.96.36.199/ppf.e7e.myftpupload.com/wp-content/uploads/2020/10/Statement-on-Equity-and-Social-Justice-060320.pdf. Accessed May 5, 2022.
10. American College of Surgeons Statement on Diversity, 2018. From: https://www.facs.org/about-acs/statements/104-diversity. Accessed May 5, 2022.
11. Morrison Z, Reyes-Ferral C, Mansfield S et al. Diversity, Equity and Inclusion: A strategic priority for the American Pediatric Surgical Association. JPS, 2021;56(4): 641-647.
12. Ped Surgery Library. Not a Textbook. Diversity, Equity and Inclusion Committee. From: https://www.pedsurglibrary.com/apsa/view/PedSurg%20Resource/1884035/all/Diversity__Equity_and_Inclusion_Committee. Accessed May 5, 2022.
13. APSA Diversity, Equity and Inclusion Committee Literature Reviews. https://apsapedsurg.org/research/publications/cancer-committee-literature-reviews/diversity/. Accessed May 5, 2022.
14. APSA Board of Governors’ Implicit Bias Training Guide. (2022) From: https://youtu.be/3W_ZQHbjfGw. Accessed May 5, 2022.
15. Collins, B.Tacking Unconcious Bias in Hiring Practices: The Plight of the Rooney Rule (2007); From:https://www.nyulawreview.org/wp-content/uploads/2018/08/NYULawReview-82-3-Collins.pdf. Accessed May 5, 2022.
This APSA Diversity, Equity, and Inclusion Toolkit Sections were written by members of the inaugural APSA Diversity, Equity, and Inclusion Committee and revised over the course of several years prior to publication in the spring of 2022. The following members were instrumental to its inception, creation, revision, and publication.
- Dr. Hanna Alemayehu
- Dr. Erika Newman
- Dr. Cynthia Reyes-Ferral
- Dr. Kathryn Martin
- Dr. Numa Perez
- Dr. Hira Ahmad
- Dr. Sara Mansfield
- Dr. Kate Ott
- Dr. Tolulope Oyetunji
- Dr. Deborah Loeff
- Dr. Stephen Shew
- Dr. Jonathan Hills-Dunlap
- Dr. Richard Wood
- Dr. Morgan Richards
- Dr. Zach Morrison
- Dr. Tolulope Oyetunji
- Dr. Carmen Ramos
- Dr. Stephen Shew
- Dr. Dana van der Heide
- Dr. Irving Zamora*
Strategies for Equity in Pediatric Surgery Fellow Selection
DEI Committee Publications
- Morrison ZD, Reyes-Ferral C, Mansfield SA, Alemayehu H, Bowen-Jallow K, Tran S, Santos MC, Bischoff A, Perez N, Lopez ME, Langham MR Jr, Newman EA; Diversity, Equity, and Inclusion Committee of the American Pediatric Surgery Association. Diversity, Equity, and Inclusion: A strategic priority for the American Pediatric Surgical Association. J Pediatr Surg. 2021 Apr;56(4):641-647. doi: 10.1016/j.jpedsurg.2020.11.011. Epub 2020 Dec 8. PMID: 33309300.
- Waldhausen J, Barksdale E, Vacanti J, Langham M, Arca M, Dillon P, Hayes-Jordan A, Reynolds E. The APSA Board of Governors enthusiastically endorses the position paper ``Diversity, Equity, and Inclusion: A Strategic Priority for the American Pediatric Surgical Association’’. J Pediatr Surg. 2021 Apr;56(4):648. doi: 10.1016/j.jpedsurg.2020.10.024. Epub 2020 Oct 31. PMID: 33223224.
- Perez NP, Ahmad H, Alemayehu H, Newman EA, Reyes-Ferral C. The impact of social determinants of health on the overall wellbeing of children: A review for the pediatric surgeon. J Pediatr Surg. 2022 Apr;57(4):587-597. doi: 10.1016/j.jpedsurg.2021.10.018. Epub 2021 Oct 29. PMID: 34893308.
- Morrison Z, Perez N, Ahmad H, Utria A, McCulloh C, Lopez M, Reyes-Ferral C, Newman E, Martin K; American Pediatric Surgical Association’s Diversity, Equity and Inclusion Committee. Bias and discrimination in surgery: Where are we and what can we do about it? J Pediatr Surg. 2022 Feb 20:S0022-3468(22)00174-9. doi: 10.1016/j.jpedsurg.2022.02.012. Epub ahead of print. PMID: 35307193.
- Mansfield SA, Morrison Z, Utria AF, Reyes C, Garcia AV, Stallion A; Diversity, Equity, and Inclusion Committee of the American Pediatric Surgery Association. Improving pathways to eliminate underrepresentation in the pediatric surgery workforce: A call to action. J Pediatr Surg. 2022 Feb 19:S0022-3468(22)00172-5. doi: 10.1016/j.jpedsurg.2022.02.010. Epub ahead of print. PMID: 35304026.
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