In October 2017, the leadership of the American Surgical Association (ASA) identified increasing diversity in the surgical workforce as a priority of the Association and approved the preparation of a handbook to aid departments of surgery in achieving this aim. A call for volunteers was extended to the ASA membership, and a roster of contributing authors was selected, led by Dr Ronald Maier. Over 3 months, the committee compiled a comprehensive document entitled: Ensuring Equity, Diversity, and Inclusion in Academic Surgery. The aim of this document is to serve as a practical reference for surgical departments and institutions as they work to address this critical issue. The following is a summary of the handbook, which can be downloaded in full at: http://www.americansurgical.org/equity/.
Ensuring Equity, Diversity, and Inclusion: An Academic Surgery Imperative
The demographics of the United States are changing and the country is becoming more racially and ethnically diverse.1 In 2003, the Association of American Medical Colleges (AAMC) adopted the following definition: “Under-Represented in Medicine (URiM) means those racial and ethnic populations that are under-represented in the medical profession relative to their numbers in the general population.”2 Evidence from the AAMC and the Accreditation Council for Graduate Medical Education (ACGME) shows far fewer women and URiM faculty in surgery departments than in the general population.3 Women and racial/ethnic minorities have had fewer opportunities to enter academic surgery and they encounter more academic career challenges than their white male counterparts. Less data are available for the lesbian, gay, bisexual, transgender (LGBT) community or disabled surgeons, but few success stories can be identified.
The need to increase diversity in health care and surgery is compelling. In 2004, the Institute of Medicine (IOM) specifically addressed the urgency of enhancing diversity in the health care workforce, citing shifting US population demographics and the importance of more ethnic/racial diversity among health care professionals.4 The IOM report suggested that more diverse health care providers would lead to improved access to care for minorities, permit better communication with patients, and greater patient-centered care around health care decision-making. Those assertions are strongly supported by other studies showing that patients have better communication and more participatory decision making with providers of the same race/ethnicity or gender.5
Another key component to ensure equity in health care is increasing the overall “cultural competence” of physicians, through understanding each patient's unique health beliefs and accounting for these beliefs while providing patient care. Cultural competence has been shown to result in better health outcomes for the patient and the health system, while providing fair and equitable healthcare regardless of race/ethnicity, ethnicity, gender, or culture.6 Thus, there is a strong mandate to increase the diversity of the surgical workforce, and a need to establish best practices to help implement this change.
Recognizing Individual and Organizational Barriers to Diversity and Inclusion
A necessary first step to improving diversity and inclusion requires defining terms and characterizing individual or institutional baselines in order to identify targets for positive change. Efforts to improve diversity and inclusion must be based on accurate and current information that assesses institutional leadership, identifies problems in the institution's culture and practices, elicits input from stakeholders, and facilitates evaluation of results. Individuals and institutions may manifest unique obstacles to diversity and inclusion that reflect local contextual factors. A baseline assessment is critical to make the case for change, design individualized interventions, and allow for measurement of progress. Clearly, buy-in from leadership at all institutional levels is essential.
A number of tools are available to characterize the degree of diversity and inclusion in the workplace. For example, 8 engagement and inclusion factors can be evaluated using the Diversity Engagement Survey (DES).7 Identifying concrete measurements helps to address specific organizational level barriers that can be targeted for improvement. Measurement drives accountability and accountability drives behavioral changes. The choice of which metrics to use will need to be based to a large degree on institutional priorities, previous experience, and assessment of known or hypothesized barriers. The Workforce Diversity Network also reported metrics that assess diversity and inclusion8 and the NIH Scientific Workshop Diversity Office (SWO) also offers validated toolkits to enhance diversity.9
Ethics of Diversity
A unique and enduring aspect of surgery is the legacy of critically identifying problems and working to eliminate or improve areas where we fall short. The surgeon's goal has traditionally been to treat all persons equally and respectfully, whether they be our patients, our students and trainees, or our colleagues. Surgery now needs to apply this same critical appraisal to recognize that both explicit (conscious) and implicit (subconscious) biases can stand in the way of increased diversity and inclusion. Academic surgery has a duty to catalyze change in the broader community; to expect diversity and demand inclusion. Increased diversity and inclusion in surgery will lead to a greater incorporation of differing points of view about what is best for patients, and this will go a long way toward breaking down the implicit and explicit biases that perpetuate under-representation of many groups in surgery. The ethical and moral imperative supporting greater diversity and inclusion is self-evident, but addressing our past deficiencies will also produce objective tangible benefits such as those shown below.
Evidence suggests that the performance of groups of humans working across multiple tasks is positively correlated with the proportion of females in the group.10 Numerous studies have shown that groups perform better than the best individuals, and groups with more differing viewpoints and perspectives achieve the very best results.10,11 There is growing evidence that a diversity of opinion leads to better outcomes12 and fosters innovation and creativity across a variety of disciplines.13 For departments of surgery, more viewpoints and skills will enhance both surgical outcomes and patient satisfaction. There is also a compelling business case for supporting equity and inclusion. Companies that prioritized employee diversity had greater profitability14 and those with 30% or more women in the corporate leadership (CEO, the board, and other C-suite leaders) had higher net margins than companies that lacked female representation at this level.15 In aggregate, there are compelling ethical and pragmatic reasons to support greater diversity in the surgical workforce.
Recruitment and Retention of Diversity: Impacting Change
Recruitment is facilitated in an institutional and departmental environment where diversity is valued and supported for URiM faculty.16,17 Many institutions have established Offices of Diversity and Inclusion to coordinate such efforts. Institution-wide seminars, workshops, and conferences that focus on diversity and inclusion can highlight availability of resources for mentoring, career advancement, and promotion of well-being and work-life balance. Creation of URiM or women's councils can develop programs to facilitate career progression of female and URiM faculty and enhance their capacity to become institutional leaders.
Beyond recruitment, the creation of a caring environment that addresses family needs helps to attract and retain faculty, including women and URiM.18 Establishing parental leave policies that include both mothers and fathers, providing time off for both parents after birth, adoption, or surrogacy, lactation facilities for mothers through the institution, and assistance with childcare are examples of such efforts.19 The Urban Universities for Health Metric tool kit20 provides resources to establish baseline measures, record progress over time, improve internal reporting, develop strategic plan metrics, and set long-term goals.
Success in Academic Surgery: Faculty Focus
Departmental support is crucial to provide a solid foundation in academic surgery for new faculty.21 Four elements to consider when starting a new position include clinical service, education, administrative, and research roles. New faculty should attend departmental onboarding events to meet departmental leaders, understand departmental policies, and familiarize themselves with the resources available to help with research. These sessions also provide an opportunity to understand the institutional promotion pathways, the culture of their new environment, and the department's compensation policies.22 A mentor or a mentorship team is essential to academic success and identification of a mentor that is a good fit is very important. Mentorship is critical for the career development of the new faculty member. It is best if the mentor is chosen by the faculty member after a period of onboarding. The mentor may be in the same division or department, but some faculty may find excellent mentors in other departments or divisions. A mentoring team comprised of multiple faculty is particularly helpful for the developing surgical scientist.
“Life balance,” better described as “life integration,” is a concept that includes prioritizing between work (career and ambition) on the one hand and life (health, leisure, family, and spiritual development) on the other hand.23Wellness is the active process through which people choose a more successful and complete existence. Female surgeons from all specialties exhibited significantly higher levels of burnout and compassion fatigue than male surgeons.24 Maternity and paternity leave policies for every institution should be part of the initial orientation along with delineating institutional support resources to address challenges of child care.
Creating a Culture of Respect, Equity, and Inclusion
An equitable, inclusive environment requires that each person be treated with respect. Surgery has traditionally had a hierarchical system, although recent evidence suggests that a more horizontal team approach to management creates better performance. Regrettably, surgeons have not always used their authority position to emulate positive behaviors or model standards of inclusion for the team. Medical students, residents, and less empowered members of the surgical team (nurses, pharmacists, etc) can manage such a construct, but only when coupled with humility and respectful treatment of the team.
Growing evidence shows that bullying, sexual harassment, and microaggression not only harm the victim but also undermine culture and reduce both the quality of care and patient safety. These behaviors most typically impact vulnerable groups, such as women, racial minorities, LGBT individuals, and persons of certain religious faiths or national origin. Every surgical department should assess the prevalence of these unacceptable behaviors within their environments.
There should be a recognition that marginalized and nonmajority populations are the most vulnerable, and we must educate surgeons about the types of behavior that constitute bullying and ways to intervene and eliminate the behavior. By addressing harassment, we achieve the goal of creating a work environment that is safe and supportive for all who work in the profession and in our surgical community. A “stop the line” policy to ensure that witnesses to bullying or sexual harassment are either empowered to speak up or are provided with an explicit pathway for reporting concerns to leadership is essential to creating an inclusive, tolerant work environment.
Initiatives for Faculty Leadership Development, Retention, and Promotion
Leadership development is integral to faculty retention and engagement in departmental activities. There are many leadership roles that either exist or can be created to provide leadership opportunities for those at all levels. Principles for leadership development include identifying opportunities and naming roles, having a single role for a single person, and using finite terms of appointment to allow for development and progression. Formal leadership courses are offered by the AAMC for early and mid-career faculty as well as by the Association for Academic Surgery. Naming a departmental “diversity champion” is an opportunity for an explicit statement of the importance of equity in the life of the department. Making this a senior leadership role makes an even stronger statement.
Leadership does not refer only to rank but can also mean involvement in a variety of regional and national surgical societies. Once faculty become members, specific committees and leadership opportunities within these societies can be targeted. In addition, departments should support faculty membership in the Association of Women Surgeons (AWS), Society of Black Academic Surgeons (SBAS), and Society of Asian Academic Surgeons (SAAS), along with scholarships or sponsorships for medical students, residents, and faculty to attend their annual meetings. Such efforts speak volumes about the departmental commitment to value diversity. Departmental URiM faculty members can also be encouraged to join national organizations that provide mentorship, such as the National Mentoring Research Network (NMRN)25 or the National Medical Association (NMA).26
Once measures have been implemented to address the practical and moral imperative of increasing diversity and inclusion among health care providers, there is a need for continuous vigilance and self-assessment in order to track progress, identify areas in need of improvement, and to provide benchmarking measures against other institutions. The responsibility for continuous assessment falls upon individuals at all levels of the institution—starting from the individual surgeon and extending to the department leadership, to the institution and the medical center. At each assessment level, there are differing opportunities for evaluation and impact. Regardless of when and at what level the assessment occurs, the metrics used for evaluating progress must engage key stakeholders and involve methodology and evidence-based tools that promote broad engagement.
Ongoing assessment is part of creating and maintaining a diverse, inclusive work environment. Practical and validated tools have been published by leaders in the field, including Stanford University,27 the University of Washington,28 and the University of Wisconsin.29 As academic surgical departments invest resources to create greater workforce diversity, ongoing assessment should also be an important component of these diversity initiatives.
Service and Altruism
Service and altruism embody our responsibility to create a diverse, inclusive, and equitable health care system locally, nationally and globally. In 2008, the Liaison Committee for Medical Education30 adopted a new standard to encourage all medical schools to increase student community engagement during their medical education.30,31 Graduate medical education and academic surgery have embraced health disparities research as a way to address disparate outcomes and lack of access for various unique populations within the US.32 Academic departments are also increasingly expanding into international sites through resident clinical rotations, research activities, and faculty projects in education, research, and capacity building.
Our academic mission requires that we continue to attract diverse trainees to our specialty and early outreach helps students from diverse backgrounds consider careers in the biomedical sciences.33 Participation in community outreach to medically underserved areas through service, education, and research is a vital role for academic faculty. Faculty participating in these programs model service and altruism to trainees, while contributing to their own professional development.
The growing interest in global surgery outreach has created new and more enriching opportunities for students, residents, and faculty. The ASA Working Group on Global Surgery recommended that department-supported programs should not only deliver care, but also need to increase capacity, educational opportunities, develop research into disease patterns, treatment, and prevention. Departments must take a leadership role in supporting the professional development of international faculty. Examples include the exchange scholarships offered by the ACS34 or the Women Surgeons in Low & Middle Income Countries Award from the AWS.35
Surgeons and the discipline of surgery have a tradition of leadership in medicine and within society. We must harness this privileged position to address the significant deficiencies within our field in the areas of diversity, equity, and inclusion. References and tools are available and the use of validated metrics is an essential component of measuring progress. More diverse departments, residencies, clinics, and universities will improve our care, enhance our productivity, augment our community connections, and achieve our most fundamental ambition, doing good for our patients (Table 1).
The following individuals added critical insights to the work product of the ASA Equity, Diversity, and Inclusion Task Force by reviewing and critiquing the drafts and final documents.
R. Daniel Beauchamp, MD
John R Benfield, MD
Eileen M. Bulger, MD
Francisco G. Cigarroa, MD
Mary T. Hawn, MD, MPH
K. Craig Kent, MD
Mary E. Klingensmith, MD
M. Margaret Knudson, MD
Rosemary A. Kozar, MD, PhD
Scott A. LeMaire, MD
David W. McFadden, MD
Kenric M. Murayama, MD
Dmitry Oleynikov, MD
Aurora D. Pryor, MD
Mark Puder, MD, PhD
Patricia L. Roberts, MD
David A. Rothenberger, MD
William P. Schecter, MD
Martin A. Schreiber, MD
Douglas P. Slakey, MD, MPH
David I. Soybel, MD
David A. Spain, MD
Allan Tsung, MD
Sharon M. Weber, MD
3. Julien JS, Lang R, Brown TN, et al. Minority underrepresentation in academia: factors impacting careers of surgery residents. J Racial Ethn Health Disparities
5. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA
6. Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and healthcare quality. J Natl Med Assoc
7. Person SD, Jordan CG, Allison JJ, et al. Measuring diversity
in academic medicine: the Diversity
Engagement Survey. Acad Med
10. Jagsi R, Griffith KA, Stewart A, et al. Gender differences in salary in a recent cohort of early-career physician-researchers. Acad Med
11. Hoogendoom S, Oosterbeek H, Van Pragg M. The impact of gender diversity
on the performance of business teams: evidence from a field experiment. Manag Sci
16. Nattinger AB. Promoting the career development of women in academic medicine. Arch Intern Med
17. Singer M. Beyond bias and barriers. Science
18. Cohen JJ, Gabriel BA, Terrell C. The case for diversity
in the health care workforce. Health Aff (Millwood)
19. Shollen SL, Bland CJ, Finstad DA, et al. Organizational climate and family life: how these factors affect the status of women faculty at one medical school. Acad Med
21. Valsangkar NP, Zimmers TA, Kim BJ, et al. Determining the drivers of academic success in surgery: an analysis of 3,850 faculty. PLoS One
22. Sanfey H, Crandall M, Shaughnessy E, et al. Strategies for identifying and closing the gender salary gap in surgery. J Am Coll Surg
23. Covey S. The Seven Habits of Highly Effective People. New York: Simon and Schuster; 1989.
24. Wu D, Gross B, Rittenhouse K, et al. A preliminary analysis of compassion fatigue in a surgeon population: are female surgeons at heightened risk? Am Surg
25. Network NMR. National Research Mentoring Network (NRMN). Available at: https://nrmnet.net/
31. Goldstein AO, Bearman RS. Community engagement in US and Canadian medical schools. Adv Med Educ Pract
32. Haider AH, Dankwa-Mullan I, Maragh-Bass AC, 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
33. Winkleby MA. The Stanford Medical Youth Science Program: 18 years of a biomedical program for low-income high school students. Acad Med
34. Fong Y, Early K, Deane SA, et al. American College of Surgeons International scholarship programs: 40-year history of support for International Surgical Education
. J Am Coll Surg
2010; 211:279–284. e1-8.