Mission Statement

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)
• Consciousness-raising
• Culture assessment and survey

Equity and inclusion

• Diversity in representation throughout the organization - includes membership, committees, committee chairs, APSA Board of Governors, and leadership

Leadership development

• 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:

• Education
• 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.”

Section II - APSA pillars

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:

1. 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 [1].
   • 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
2. 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.
3. 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

Equity

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

Section III- Equity

Figure 1. Equality, Equity and Justice.6

Sec III - HIP equality vs equity

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

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."[7] 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, [8] 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.”^[9] 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.”[10]

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.”[11] 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.[12] 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,[13][14] 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.[15]

Section III - Health disparities

Figure 3. Health Disparities from Kaiser Family Foundation.¹⁶

Source: The Kaiser Family Foundation. Website accessed March 12, 2022.

Developing Common Goals and a Path Forward

The Diversity Bonus-Why Should We Care?

Success of Diverse Teams

Social category differences such as age, race, sexual orientation, religion, nationality, ethnicity and culture contribute to cognitive development.^[17] Education, training, and innate talents further enrich cognitive attributes.[18] 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.[17][18] 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.”[17][18][19][20] In addition to a wider range of information and talents, diverse teams have a higher tendency to focus on facts.[21] 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.”[22] Therein lies the diversity bonus. [18][19]

sec IV- fig 1 dec making w- team divers

Figure 1. Better decision making is achieved by increasing team diversity.⁷

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.[23] 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.[24]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.[25][26][27][28] 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. [25][26][27][28]

Patients with culturally competent practitioners are more adherent to treatment and experience improved health outcomes.[25][26][27][28][29][30] 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.[30] Language-concordant care similarly improves Hispanic pediatric surgery families’ understanding and satisfaction.[29] 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.[31] 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.[31] 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.[32]

Sec IV - Pew res ASA

Figure 2. Changing face of America, demographic distribution over time in US (Adapted from Pew Research Center and American Surgical Association).¹⁸

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.[60] 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.[61] Furthermore, ethnically-diverse teams of authors achieved more citations and high-impact publications than papers written by ethnically uniform teams of authors.[61] Female authorship increased two-fold when the senior author is female.[62] 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.[63][64][65] Black, Hispanic, and Native American researchers and full-time academic faculty lag in numbers when compared to the US population and white colleagues.[63][64][65] 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.[63] 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.[62][65] 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.[66] mentorship, training, and resources available to URM researchers are significant barriers to successful research careers.[66] Blacks and Hispanics were less likely to revise and resubmit grant applications, and Blacks resubmitted grant applications more times than any other group.[62][67] 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.[68]

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

Sec IV - fig 4

Figures 4-6. Barriers and facilitators for career and research development in under-represented minorities.⁵⁸

Sec IV fig 5

Sec IV - Fig 6

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.[69][70][71][72][73][74][75][76][77][78]
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.[69][78]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.[69][70][71][78] 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.[71]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.[69][70][71][78] Physicians in minority racial/ethnic groups were less likely to report burnout compared with non-Hispanic White physicians.[73][74] For female faculty, the major theme of gender bias in the workplace as a risk factor for burnout was prominent.[75]

1. 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.[71][72] 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%.[69][71][78]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.[69] 96% of pediatric surgeons were satisfied with their career choice.[77] Female surgeons are more likely to report less career satisfaction than their male counterparts.[77] 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.[79] Healthcare professionals throughout the developed world have markedly high rates of sickness absence, burnout, and distress compared to those working in other sectors.[80]
2. 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.[69][70][71][72][73][74][75][76][77][78] 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.[69][78]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.[69][70][71][78] 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.[71]
   Etiologic factors associated with burnout [69][70][71][72][73][74][75][78]
   1) A sense that work was “overwhelming”,
   2) A perceived imbalance between career, family, and personal growth,
   3) Perceptions that one’s career is unrewarding,
   4) Lack of autonomy

3. 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.[81][82] 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.[82][83] 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.[81][82] 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.[71][76][77][79][80][81][82][83][84][85]
   Fortunately, stress management and coping skills are learnable. In a randomized controlled trial, 126 healthcare professionals were instructed in stress management and adaptive coping.[84] 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.[86] 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.[86] Interventions aimed at addressing the well-being of healthcare workers have been categorized into three groups by the Finnish Institution of Occupational Health.[86]
   Categorization of interventions for improving well-being in healthcare workers[86]
   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)

4. 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?

Trainees

With all of this information in mind, where do APSA and the field of pediatric surgery stand? Each year, diversity among medical school students and surgical training programs continues to rise. The pace of advancement, however, is not shared equally by all minority groups.
Information on diversity in medical schools can be found here
Some important statistics to keep in mind:
· 13.4% of the U.S. population is Black, but only 7.5% of graduating medical students and 5.3% of general surgery trainees are Black.[87][88]
· The proportion of Black medical school graduates increased by only 1.0% from 2016 to 2020.[88] Hispanics makeup 18.5% of the U.S. population but only 6.7% of medical students and 9.3% of surgery trainees.[87][88]
· The proportion of Hispanic medical school graduates increased by less than 1.0% from 2016 to 2020 (4.6% vs 5.3%).[88]
· In pediatric surgery, only 6.2% of fellows are Black and only 9.9% are Hispanic.[87] The scarcity of Black and Hispanic trainees places additional stress and burden upon them.

sec V - Fig 1

Figure 1. Black and Hispanic population distribution for medical students and surgical trainees.^1-2

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.”[89] 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.[87][88] 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.[67]
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.[88]
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.[90] 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).[88]

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.[91][92][93] 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).[94]

sec V - APSA membership demogr

Figure 2. American Pediatric Surgical Association membership.⁹

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.[95] 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.[94] 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.[96]
Though demographic underrepresentation exists in many medical and surgical specialties, the gaps are beginning to narrow.[97][98][99][100][101][102][103] 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.[96] The lack of women and minorities in leadership positions limits the pool of mentors and models of experience.[104] 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.[104]
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.[105] Higher practitioner cultural competence has been shown to result in better outcomes as well as better patient adherence to treatment.[106]
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 Can I Learn More?

Bias Training

Table 1. Bias Training.[108][109][110]

Variations of Bias	Definitions:
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.[108]
Explicit Bias	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.[109]
Implicit Bias	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.[110]

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

Table 2. Mitigating Bias.[107]

Tools to Mitigate Bias:	Descriptions:
Common Identity Formation	Ask about possible common group identities (i.e., hometown, sports teams, music, movies, hobbies)
Perspective Taking	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
Counter-stereotypical Exemplars	Consider individuals you admire and respect who are from a demographic you have a bias against

Sec 6 Fig 1 - AWS implicit bias

Figure 1. AWS #HeForShe Taskforce Best Recommendations for Reducing Implicit Bias.¹¹

Microaggressions and Microaggression Training

Microaggression:
Subtle snubs, slights, and insults directed towards minorities, women, and other stigmatized groups, that communicate or engender hostility or lack of belonging [109][111]

Sec 6 fig 2 types microaggressions

Figure 2. Types of microaggressions.¹²

Sec 6 fig 3 - examples microaggressions

Figure 3. Examples of microaggressions.¹³

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

Table 3. Microaggression Assessment Tools.¹⁴

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:

Breaking the Prejudice Habit

Table 4. Adapted Frameworks for Responding to Microaggressions.[109][111]¹⁴

Framework:	Description:
Apologize	-Acknowledge responsibility -Offer to repair the issue -Express regret -Explain what went wrong -Repent for the problem -Request forgiveness
Open the Front Door	-Observe -Think -Feel -Desire
ACTION	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
X..Y..Z	"I feel X when you say Y because Z"
RAVEN	R - Redirect the conversation A - Ask probing questions V - Values clarification E- Emphasize your own thoughts and feelings N - Next steps

Reading List

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.[112][113][114][115] 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.

Sec VII- Optomizing surg care

Figure 1. Necessary considerations for optimizing surgical care of diverse patients.⁵

1. 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

   National Initiatives:	Institutional Initiatives:
   American College of Surgeons Committee on Diversity	Boston Childrens Hospital
   Association for Academic Surgery	Stanford Unviersity School of Medicine Department of Surgery
   Assocation of American Medical Colleges	University of Colorado Department of Pediatrics
   American Medical Association	University of North Carolina School of Medicine Department of Surgery

2. 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.[116][117][118] 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.[29] 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
3. 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.[29][119] 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.[120][121] 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
4. 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.
5. 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.[122] 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.
6. 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.[55]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.

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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.

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What Steps Can My Institution Take to Improve Diversity within Pediatric Surgery?

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.

Sec 8 fig 1 -Addressing disparities in academic med

Figure 1. Addressing Disparities in Academic Medicine.³

Promote cultural competence and a culture of inclusion

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

Sec 8 fig 2 - Exmp system LGBT cult compet

Figure 2. Examples of system-level LGBT cultural competence at VA Boston Healthcare System.⁴

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.

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

Sec 8 Fig 3 ASA DEI handbok Mayo model

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

Sec 8 fig 4 - UMich Cult complic

Figure 4. The “Cultural Complications” curriculum.²³

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

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

APDS DEI Toolkit

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

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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.

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What Can My Institution Do to Impact Greater Social Determinants of Health?

Primary author: Dr. Hanna Alemayehu

1. 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.[138]
   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.[138][139] 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.[140]
   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.[141][142][143] SDOH education and interventions should be incorporated into medical student and resident trainee activities and curricula as follows:[141][142][143]
   · 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
2. Research
   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.[55][144][145] 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.[146] Community engagement in medical research remains imperative, but it is not often practiced.[146][147] 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.[147] Institutional Review Boards should consider mandating plans for community engagement for all studies involving participant recruitment.
3. 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
4. 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
5. 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

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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.

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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.[148][149][150][151][152][153]²

1. 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.[153] 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.
2. 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:
   • AAP Diversity and Inclusion Statement⁸
   • University of California Statement on Diversity²
   • APSA Statement on Equity and Social Justice⁹
   • American College of Surgeons - Statement on Diversity[148]
3. 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:[150][151][152][154]
   * 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.[154]
4. 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.

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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/198.71.233.52/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.

Authors

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.

Authorship team:

• 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

Editorship team:

• 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

• APSTPD Tip Sheet for Bias MitigationDuring Fellow Selection
• Holistic Approach to Application Review
• Conducting Implicit Bias Training with the Harvard IATs
• Watch: Implicit Racial Bias in Medical School Admission, by Dr. Quinn Capers, IV.

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.

References