“It's good to see one of us in the white coat. It's rare and I am so proud of you.”
Such intimate acknowledgments are seemingly commonplace between minority patients and providers and reflect the lack of diversity of our healthcare workforce. Diversity refers to having a workforce that reflects different types of people (such as by race, ethnicity, gender identity, socioeconomic background, and disability status). Inclusion moves beyond satisfying quotas—it speaks to an environment in which those in the workforce feel acknowledged, respected, and valued.
The American Association of Medical Colleges traditionally reports groups under-represented in medicine as Hispanic, Black, Native Americans, and Alaska Natives. These groups comprise 33.2% of the US population, and yet, there were only 9.1% of gastroenterology (GI) fellows and 10% of GI faculty in 2018–2019 (1–3). Other under-represented groups in GI that are not reflected in these statistics include lesbian, bisexual, gay, transgender and queer individuals, people living with a disability, and veterans (Figures 1 and 2).
This lack of representation is problematic because diversity in medicine has been shown to improve access to care for underserved communities and positively influence healthcare delivery, patient outcomes, and public policy (4,5). For example, patient-physician racial concordance has been linked to greater receipt of preventive care services, and gender concordance has been associated with decreased mortality among women with acute myocardial infarction (6,7).
In support of diversity and inclusion in academia, the National Institutes of Health has allocated resources toward diversity supplements for researchers from under-represented groups. In addition, the Accreditation Council for Graduate Medical Education appointed their first Chief Diversity and Inclusion Officer in 2019, recognizing the impact that this role can have on the environment for medical trainees.
Furthermore, many medical subspecialty leaders are embracing the opportunity to support diversity and cultivate cultures of inclusion. A recent article in the Journal of Infectious Diseases outlines recommendations for achieving equity in the infectious disease workforce (8). Our cardiology colleagues have followed suit. At a national level, the American College of Cardiology has developed a strategic plan around 3 diversity and inclusion objectives: (i) enhancing a culture of inclusion, (ii) implementing programs for accountable execution, and (iii) engaging and leveraging all available talent at the College (9). On a local level, some cardiology fellowship programs have revised the recruitment process to make diversity a priority, and in the case of The Ohio State University, improvements in diversity with the fellowship classes have been sustained (10).
In a similar fashion, GI professional societies have committees aimed at fostering a culture of diversity and inclusion among their membership. Some have created programs for under-represented minorities to enrich the pipeline to GI careers including: the American College of Gastroenterology (ACG) Prescriptions for Success program for high school students, the ACG Summer Scholars Program which provides research opportunities for promising medical students, and the American Gastroenterological Association FORWARD program which is aimed at bolstering the career advancement of minority physician scientists. Furthermore, in 2017, for the first time in the history of these organizations, the presidents of the American Gastroenterological Association, the ACG, the American Society of Gastrointestinal Endoscopy, and the American Association for the Study of Liver Diseases were women.
Yet, despite these efforts and successes, the face of GI does not mirror that of our nation. We need a level of gender diversity and minority representation that is better aligned with the demographics seen both domestically and internationally (11,12). So what does it require to enhance diversity and inclusion in GI? It demands an environment in which all people feel valued and those from minority groups are in roles and spaces in which they can influence practice and policy decision-making. Such an environment recognizes and mitigates implicit biases, actively addresses racism and the structural forces that produce inequities, and cultivates GI practices and, to a larger extent, health systems that reflect the increasing diversity of the society that we live in today.
Outlined here are critical steps to make sustainable strides in improving diversity and inclusion within the GI field.
- Create and support pipeline programs at the earliest stages of education. These programs offer mentorship, summer research with potential to publish, and shadowing opportunities. These experiences are pivotal for under-represented students in medicine—working intimately with and readily seeing a diverse population of clinicians, researchers, and patients is invaluable for many who do not see people who look like them in these professional positions.
- Incorporate holistic review and implicit bias training in recruitment selection committees. Individuals involved in the recruitment of fellows and/or faculty should undergo implicit bias training to both confront prejudices that may impede their ability to select diverse candidates and to allow for candidates to be evaluated wholly. In addition, there should be faculty from under-represented groups intimately involved in the selection process to create a diverse pool of fellow applicants to interview and to create final program rank lists.
- Encourage mentorship and sponsorship. Coaches, mentors, and sponsors are pivotal to professional success. Coaches provide basic skill building. Mentors offer career guidance and advice. Sponsors are typically senior leaders who both publicly and privately provide endorsement, recommendations for key positions, promotions, and other appointments. It is imperative that under-represented trainees and faculty, in particular, have mentors guiding them through career choices and sponsors advocating for equal pay, committee appointments, promotions, and their overall career success.
- Use mandatory implicit bias training for GI faculty, trainees, and staff. Too often minorities are subject to microaggressions, expectations of lesser performance from peers and staff, or racism. These experiences can result in imposter syndrome, isolation, and burnout (13). Implicit bias training is paramount to fostering inclusivity.
- Cultivate a diverse and inclusive cadre of leadership. It is essential for prospective students, postgraduates, and trainees to see people with a shared experience and who look like them in leadership. Furthermore, diversity in leadership and teams within organizations is associated with greater innovation and better financial performance. Representation matters!
There is also a role for social media in promoting diversity and inclusion within gastroenterology. In April 2019, the ACG launched its #DiversityInGI social media campaign to accomplish this. They subsequently partnered with the North American Society of Pediatric Gastroenterology, Hepatology & Nutrition to enhance the campaign's reach and impact that now has international support from colleagues in Europe and the Middle East.
Nonetheless, although we have made progress toward improving diversity and inclusion in gastroenterology, bigger strides are overdue. In addition, as gastroenterologists from under-represented groups, we long for the day when there is equity in leadership opportunity, research funding, pay, and academic promotion. We know this day is on the horizon.
CONFLICTS OF INTEREST
Guarantor of the Article: Darrell Gray, MD, MPH, FACG.
Specific author contributions: A.A.Y.: drafting of the manuscript and revisions; S.B.: drafting of the manuscript and revisions; D.G.: drafting of the manuscript and revisions.
Financial support: None to report.
Potential competing interests: None to report.
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