THE GOAL IS RIGHT AND THE TIME IS RIGHT
OUR CALLING and what it entails is at the core of our profession and is, indeed, the right thing for us to do. We have long recognized the inherent good of committing to equity, diversity, and inclusion. In 2004, an IOM report identified the urgent need for increased diversity in Medicine.4 The report proposed that diverse healthcare providers would lead to improved access to care for minorities, permit better communication with patients, and produce greater patient-centered care. Now is the right time to confirm our commitment to address this need to move forward and become the leaders for change. A unique and enduring concept of the discipline of surgery is the legacy of critically identifying problems and working to eradicate or improve areas where we fall short. Surgeons have traditionally treated all patients equally and respectfully. In contrast to the many areas where surgery has blazed new trails, surgery has been slow to ensure equity, and embrace diversity whether, sex, race, ethnicity, sexual orientation, or other individual metrics within surgery.
It is time to move beyond recognizing the absence of diversity in the surgical family and identify the goals and behaviors that can achieve greater diversity and inclusion. We need to extend to each member of our surgical family the same considerations with which we have traditionally treated our patients. In the Fellows Pledge of the College, each Initiate declares that “I pledge to pursue the practice of surgery with honesty and to place the welfare and the rights of my patient above all else. I promise to deal with each patient as I would wish to be dealt with if I were in the patient's position, and I will respect the patient's autonomy and individuality.”5 In fact, in recognition of our current highly diverse society, this tenet based on the Golden Rule has been revised to the Platinum Rule, where we, in fact, deal with our patients not only as we would wish to be treated ourselves but as they based on the entirety of their own unique intersectionality want to be treated. Equity for all is an intrinsic ethical value and a human right, which mandates diversity and inclusion within the community, adding both intrinsic and extrinsic value to the community.
Just as surgeons have committed to the benefits of adapting to new techniques and technologies that benefit our patients, we must also adapt our behaviors to improve equity and thus better our surgical community and our society. Although we cannot alone change the culture in which we live and practice, we can be catalysts to greater equity in society, which will improve us all. Surgery departments should reflect the broader community or society in which we practice.
The American Association of Medical Colleges (AAMC) has adopted the definition: “Under-Represented in Medicine (URiM) means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.”6 Academic surgery should lead by example through making concerted efforts to increase diversity and inclusion. Creating and dispersing knowledge that optimally serves the public good is only possible in an environment in which a broad range of perspectives can be voiced and explored. Increased diversity and inclusion in surgery will lead to a greater appreciation of differing points of view about what is best for the increasing diversity and intersectionality of our patient populations. Innovation and creativity depend on and increase with diversity. Diversity is crucial to our success. Diversity will help us toward breaking down the implicit and explicit biases that have perpetuated the under representation of women and URiM in so many facets of surgery. Diversity and inclusion in surgery will further facilitate recruitment and retention, make patients more comfortable with their care, break down barriers to our diverse patient communities, and produce leadership by example in our academic communities.
In addition, these changes are supported by significant extrinsic benefits. There is increasing documentation from the business and financial spheres that “more diverse” companies, both sex and ethnic, are on the whole more profitable. Groups perform better than the best individuals, and the more diverse the team the better the overall function. In industry, groups with more differing viewpoints and perspectives have the best result7 (Fig. 8). Furthermore, we have learned from the analogies with the airline industry and others that horizontally integrated teams have enhanced performance and safety. Similarly in medicine, our overarching goal is to produce better results and enhance patient outcomes and satisfaction.
WHERE ARE WE CURRENTLY?
How have we done? One can point to definite successes and progress in society, medicine, academic surgery, and the ASA. The Accreditation Council for Graduate Medical Education reports that for the first time, the entering medical school class of 2017 will have more women than men.8 Within the ASA, we continue to increase our gender and URiM populations among the membership. Of the 7 major chairs of surgery filled last year, 5 of the 7 were filled by excellent female candidates. There are at last count 21 sitting chairs of surgery held by women. And, the number in the American Surgical is likely to grow by 2 or 3 as a result of the new membership vote at the upcoming business meeting (Fig. 9). Of the 101 applicants to the ASA this year, 27 (27%) were women and of the final list recommended for admission, 21 (34%) of the 62 were women. Similarly, we are encouraged by the increasing involvement of URiM in academic surgery and the ASA.
Before we accept the current progress as adequate, we should, however, look at other aspects. When you enter the executive session tomorrow look around and see whether half the members in the room consist of women or an appropriate proportion of URiM are present to match our greater society. There are 136 women (8.5%) of the total 1594 ASA membership and 73 (16%) of the 449 active members. Less thoroughly explored is how well represented African American, Hispanic, Lesbian, Gay, Bisexual, Transgender, Queer/Questioning (LGBTQ), and others from URiM are in academic surgery. On this graph, composites of the current status of women in academic surgery were presented recently by the Surgical Women's group of my home department at their annual Grand Rounds. As you can see while the number of male and female entrants into academic surgery nationally is very similar, rate of progression through the ranks rapidly leads to an obvious disparity in success over time on faculty. Admittedly, this growth and progression though the ranks require a prolonged lag time and will require significant time to correct, despite our current best intentions and efforts. And, while that is true, one interesting statistic shown here, is that at our current rate of correction, it will require 121 years to rectify the imbalance and level the field9 (Fig. 10). And with the less well represented URiM in the pipeline the overall imbalance will require even more effort for the academic community to reach a mirror image of the diversity in our society. In addition, an easily obtained and objective monitor of this ongoing inequity is the assessment of reimbursement matched to rank, Relative Value Units, or other benchmarks. Recently, the latest self-reported poll on physician incomes revealed that across the profession of physicians, salaries for women are on average 27.7% less ($105,000) than their male counterparts. Disturbingly, this gap has not narrowed and, in fact, has increased from the 26.5% ($91, 284) differential reported for 2016.10
What can or should the surgical academic community do and how should the American Surgical Society provide support and leadership to help the academic departments achieve equity, diversity, and inclusion? We need to commit to meeting the challenge of creating an environment that supports free and critical inquiry, recognizing that such inquiry is not always comfortable or easy for any of us. I recognize that I am uncomfortable considering the breadth and nuances of these challenges. I do not hold myself as an expert or established leader in this field. However, I take on the challenge to openly discuss and commit to the vast and rapid changes in societal expectations as a necessity and inherent right thing to do. There are those who are true leaders in this movement in the audience and to them I give great thanks for assisting me in providing this address. I ask for your consideration and thoughtful input as we move forward as leaders pursuing OUR CALLING.
This is a complex problem and requires a multiplex response to be truly successful. For ease of assimilation, the approaches and opportunities available can be delineated though each phase of the academic process. The required resources and access may not be available to every department but without a sustained and broad-based concerted effort measureable success is unlikely. In addition, one must recognize that the department of surgery can only control limited aspects of some avenues that should be pursued. Every department can, however, make an impact, and if persistent, even lead in the changes required for success. Along the continuum of a single recruit many interventions can be identified. These may be divided into (1) Outreach and Recruitment; (2) Onboarding, Support, Education, and Promotion; (3) Transparency and Creation of a Safe Optimal Environment; and (4) Leadership, Persistence, and Resilience (Fig. 11).
Of the multitude of concepts to pursue, an increasingly recognized challenge is to understand the individuality of each of us and each of our communities (Fig. 12).11 There is an ongoing need to increase the overall “cultural competence” of physicians. Our actions are driven by our cultural and daily experiences over our lifetimes. We are the product of what we have been taught, explicitly and implicitly, along with the summation of experiences with our greater human family. A result of these imprinting experiences is an often subconscious mind's view of the world and those around us. One obvious result is the comfort we all feel by being surrounded by those who “look like us” and, on the faculty level, we are attracted to mentor, based on our similar backgrounds and cultures. To accept fully those “who are different from us” requires the recognition of our implicit biases and a willingness to accept and address these biases. A challenge that may come with uncomfortable feelings and require intentional effort, until our responses, when we are faced with daily decisions, become balanced, and unbiased.
The demographics of the United States is changing and has become greatly more racially and ethnically diverse than in the past. To change the persistent existing disparities in the work force, we must understand why there are fewer women and URiM surgeons in our departments. Although factors involved, such as access and diversity of candidates, will vary with local culture and politics, many departments and institutions have not openly assessed their own level of diversity. Our traditional attitudes and stereotypes affect our understanding, actions, and decisions. There are online exercises, that can give one insight into our own biases that impact how we approach trainees, faculty candidates, and colleagues.12 This is a first critical step to identify and use tools needed to mitigate the impact of these biases.
Common daily expressions of implicit biases frequently produce microaggressions. The term microaggression was coined in 1970, to describe often subtle insults and dismissals by non-black Americans toward African Americans. Categorized into 3 forms: microassault, microinsult, and microinvalidation, they are brief everyday exchanges that send denigrating messages to select individuals based on various components of their intersectionality.13 These go well beyond race into potentially all facets of intersectionality from social status, religion, sex, ethnicity, and sexual orientation14 (Fig. 13). We need to move beyond mere recognition that in addition to explicit bias, implicit biases exist and proactively strive to create an environment that promotes safety, advocacy, equity, and inclusion for all.
Recognition and Change
And, how do we achieve these goals? We need to fully exploit OUR CALLING. The leadership of academic surgery can enable us to reach these goals. There are many avenues that contribute to this potential. To affect this change requires a series of definable steps: (1) precontemplation, the current status quo is accepted; (2) contemplation, when recognition of lack of equity and diversity is identified and preparation, where specific plans to improve diversity are formulated; (3) action, when specific conscious behavioral changes to improve diversity are implemented and lastly; (4) maintenance, with ongoing monitoring to document success, and share the success in diversity of hires, retention and promotion, invited speakers, development of diversity committees, and composition of key committees (Fig. 14). This public display of transparency will not only benefit the growth of success for the department but will influence and benefit other departments and the entire institution.
How do we enhance our equity, diversity, and inclusivity on a department level? Chairs of Departments of Surgery face many challenges in the recruitment of women and URiM faculty. To successfully overcome these difficulties, organizational changes to address areas of concern and delineating areas of focus to facilitate recruitment is crucial. Creating an environment in which diversity is valued and support for women and URiM faculty is present is the basis of change. The first step to creating this environment is recognition that there is a problem. A simple start is to count the number of women and URiM faculty in your department. Do the numbers approach the percentage in your community? There are also tools to characterize the degree of diversity and inclusion, such as the Diversity Engagement Survey.15 A baseline assessment of the current status of women and URiM is critical to make the case for change, design individualized interventions, and allow for measurement of progress. Measurement and data drive accountability and accountability drives behavioral changes16 (Fig. 15). Buy in from the leadership is essential for success. Many institutions have created an Office of Diversity and Inclusion to coordinate all diversity efforts across the entire institution. The Office is usually led by a Dean or Officer of Diversity and Inclusion to enhance and coordinate staff, faculty, residents, and medical students’ efforts and activities in the process. Activities include women and URiM networking events, diversity awards, pipeline efforts with high schools and colleges, transparency of recruitment results, focused activities on dedicated Web sites, and additional committees to enhance the environment and advancement.
The Chair of Surgery should be a leader in these institutional initiatives and support Surgical Department faculty involvement. In addition, parallel activities need to occur in the department. Advocacy for Diversity, explicit education of all faculty to create a supportive environment and recognizing a primary role in supporting women and UriM faculty in career development. A vice chair or diversity officer to support the Chair and Division Chiefs focuses on these goals. Overt identification of recruitment opportunities as a 5-year plan should direct recruitment efforts to fill identified upcoming and current needs of the department. These needs can then inform attendance and identification of potential candidates at meetings and conferences, particularly minority and women-focused events. Importantly, the process of recruitment should specifically address hurdles and biases. The Diversity Officer should be a member of search committees for Chiefs of Services. Search Committees need adequate women and URiM faculty both for a bias free process and to provide evidence to the recruit of departmental commitment. If necessary, appropriate representation should be solicited from other departments. The search committee should understand the goals and needs of the department to enhance diversity and training such as the AAMC Unconscious Bias online video course for all members should be provided to create a search process free of interview and selection bias.17 A standardized interview process is required with vetted interview questions by the Diversity committee. All positions should be advertised through the AAMC Group of Diversity and inclusion of minority and women in medicine society websites. Remember to build on diversity successes. Recruitment of diversity will be rapidly recognized, enhance the reputation of the department, and will lead to more women and URiM applicants (residents, fellows, and faculty candidates).
Onboarding and Support
Onboarding should be extensive with orientation into the expectations, description of resources for mentoring, promotion and diversity support, and guidance to not only how to identify but also correct any deficiencies that will impede advancement of the faculty member. There is a frequent lack of knowledge in negotiation skills, which should be provided to both young faculty and our residents during their training. Focused mentorship and mentors, both in the same specialty and outside the specialty, along with advanced educational training programs in basic science, clinical outcomes research, or administrative leadership are frequently necessary.
The transition from resident or fellow to faculty is challenging and each comes with varying strengths and deficiencies. The ability to succeed in all “4 legs of the modern academic stool: clinical, research, teaching, and administrative roles” is unlikely to be realized (Fig. 16). Reality in expectations and need to define one's niche and focus for greatest success often requires assistance for insight into the realities of modern day academic medicine. The increasing self-selection by residents for additional training and fellowships is beneficial but still may not be sufficient for one to be fully independent at the outset. With the reduction in work hours there is a reduction in experiential knowledge and senior support and availability is often required for junior faculty development and patient safety. The department of today must provide outcomes monitoring, mentorship, and educational resources to provide training and support for optimal patient care.
To support and provide an optimal environment for success, similar to institutional efforts, activities should occur in the department and not merely rely on the broader institutional events. An overall commitment to transparency and dissemination of diversity and inclusion activities and progress regarding the department is crucial. Examples of departmental activities are an annual diversity lecture, Women in Surgery and URiM faculty groups, support of involvement in the Association of Women in Surgery, the Society of Black Academic Surgeons, and the Society of Asian Academic Surgeons with institutional membership and sending faculty, residents, and students to appropriate meetings. Commitment to diversity in the department should be transparent and highlighted. At the University of Washington, the Department of Surgery A + P criteria were recently revised by input from our Diversity Committee to explicitly recognize faculty efforts and activities directed to enhancing diversity and inclusivity in support of promotion. Compensation should be determined by objective criteria known to all. If equality in pay is not achieved the basis for the disequity should be transparent and based on objective criteria.
Recognition of family and child rearing needs, from parental leave policies that include both mothers and fathers, to lactation stations, to off hour child care support help create a caring environment. In addition, with the increasing work expectations and regulatory demands on the young surgeon, additional tools, to develop life-work balance and wellness decision making, are needed to choose a more content and complete existence and optimize academic success and ensure high-level patient care. These tools of survival are often not provided during medical school and residency training and need to be readily available within out academic departments and institutions for all.
A major identified barrier to career satisfaction and success for women and URiM is the absence of mentorship. This inequitable availability of mentorship produces a significant impact leading to frustration and often early departure of quality faculty from the academic setting. Along with lack of equal mentorship is the absence of role models for both optimal recruitment and retention. How often do we relate to the great role models in each of our academic lives that not only attracted us to our specialty during medical school and residency but also provided the mentorship and guidance that added so much in our careers in attaining success and happiness?
As has been reported repeatedly in surveys, one of the best ways to recruit and support diversity in our departments is through not only the presence of diversity on the faculty but even greater is evidence of success and promotion of the diversity population to positions of leadership and authority in the departmental structure. Mentorship to include sponsorship by senior faculty for positions on departmental committees, membership in academic societies, and leadership organizations such as the ASA, ACS, American Board of Surgery, and other major leadership groups is critical to maintain involvement and career success. Mentorship opportunities and involvement/inclusion in the department activities are very important to recruit and encourage more women and URiM to remain in surgery and in particular academic surgery. These success stories and role models will do much to attract and produce great benefits by further increasing diversity in our departments.
A Safe and Inclusive Environment
A major goal of current efforts to enhance equity, diversity, and inclusion is to provide a welcoming and safe environment for all members of our academic community. Creating a safe environment requires that each person be treated with respect. Bullying, harassment, and sexual harassment are destructive to the functioning and achievements of the academic family. Medicine and surgery in particular, has traditionally engaged a hierarchical system from the educational to the practice environment. Unfortunately, historically, empowered holders of leadership in surgery have not always used their authority to emulate positive behaviors or set high standards. Some consider our profession as too often utilizing intimidation, harassment, and bullying to the detriment of the less empowered. Those so treated frequently sense fear, humiliation, and anxiety. In addition, those affected are often fearful of voicing complaints due to potential retribution. The outcome can be the loss of these members from the environment and even the profession itself. In addition, the negative impact on the environment impacts patient care, leading to flawed team performance and impaired patient safety. And, although any vulnerable group can be affected, most commonly the targets are minority groups including women, racial, ethnic, LGBTQ, religious faiths, or national origin.
Microaggressions, the everyday verbal, nonverbal, and environmental slights, snubs, or insults, whether intentional or unintentional, can communicate a hostile, derogatory negative message to individuals based solely upon their marginalized group membership. Recognition is critical to addressing the problem.18 Many of these slights may not be initially obvious. An example is the category of “alien in one's own land” expressed by members of the dominant culture calling out others based on physical traits: “Where are YOU from?” or “Where were you born? “These directed inquires send a message to the individual that you are different, a foreigner, and less welcome. Certainly, the context of the question is pertinent, the relationship to the individual and the generality of the inquiry to all present change the intent and impact. But these subtle daily interactions can have significant cumulative impact. And there are numerous other similar examples. To begin to understand the problem, I recommend you read and complete the exercise in “Recognizing Microaggressions and the Message They Send.”
Harassment can be used to discredit a person, challenge one's professional status, or be sexual in nature. It is an act of systematic and/or unwanted actions, including threats and demands. Harassment is more common in hierarchal empowered professions, such as the entertainment industry, management, and medicine. A recent review of training programs found a higher incidence in surgery compared to other specialties. Verbal harassment was reported in one meta-analysis by 63% and physical harassment by 15%.19 In addition, bullying of junior doctors in a recent UK survey was common, and most had been bullied by senior doctors. In addition, harassment is not always recognized and there is a need to improve situational awareness and provide tools to educate and mitigate behaviors. Another use of harassment is to question an individual's competence and accomplishments to discredit the individual, often with the goal to push the person out. An important challenge for leadership is to define the line between “high professional expectations and harassment.” In response to their surveys the Royal Australasian College of Surgeons and the Royal College of Surgeons Edinburgh have both initiated major educational campaigns and also apologized for discrimination, bullying, and sexual harassment.20,21 As our workforce demographic has changed and as our society has established rules for sex-based discourse, there is need to ensure that the environment of surgery is renewed to eliminate sexual harassment and bullying. Periodic surveys of the environment are necessary to assure that the behavior is not ignored. Explicit policies of expectations and safe avenues for reporting should exist. Clear expectations from leadership are required.
At the Friday night banquet, the ASA invites you to participate in the recognition of those who have felt disrespected, harassed, excluded, or discriminated against in the surgical community (Fig. 17).22 To demonstrate our present and future commitment to inclusivity and respect for all, ribbons will be available at the banquet for all attendees to wear as a symbol of support. I welcome you to join in this support.
Assessment and Resilience
Continuous ongoing self-assessment is key to achieving tractable success in diversity and inclusivity. Recognition of explicit and more importantly implicit bias and development of emotional intelligence are necessary to mitigate the impact. The challenges of successful promotion and retention are infrequently due to overt discrimination but rather unrecognized subtle organizational culture that predominantly affects women and URiM. The ideal academic department provides equal access to knowledge, opportunities, resources, recognition, and leadership roles for each member, while supporting the whole person and their life balance.
As we apply our industry, inquisitiveness, and compassion to the challenges of current change in demographics and societal expectation, surgery and the surgeon will again produce the changes needed to lead in medicine and in society.
OUR CALLING brings to us the best and brightest future stars and leaders. This organization is living proof of the continuous evolution and constant infusion of the new leaders in academic medicine. The outlook is indeed encouraging. Hopefully, these thoughts derived in part from the Ensuring Equity, Diversity, and Inclusion in Academic Surgery work product created by a cadre of dedicated thoughtful members will help to stimulate and encourage the process. OUR CALLING is to help ensure success for our students, residents, fellows, junior faculty, and peers. We are here because of this calling and we accept it willingly. Our challenge is to recognize the evolution of our society and the corresponding changes needed in our academic families. To reach and maintain our goals we need to create and produce a sustained system of assessments, directed programs, and evidence-based outcomes and benchmarks with informed constant modifications to key success for all in our community.
I have great confidence our surgical academic families will achieve true equity, diversity, and inclusion and we will greatly enhance our ultimate goal of doing what's right for our patients by providing an ideal environment for our faculty to produce optimal care.
1. Copeland EM. Presidential address
: the role of a mentor in creating a surgical way of life. Bull Am Coll Surg
2. Kibbe RM, Patti MG, Pellegrini CA, Townsend CM. Hoyt DB, Ko CY. Mentoring and coaching. Optimal Resources for Surgical Quality and Safety
. Chicago, IL: American College of Surgeons; 2017. 316–331.
3. Lillemoe KD. Presidential address
: surgical mentorship: a great tradition, but can we do better for the next generation? Ann Surg
4. IOM (Institute of Medicine). In the Nation's Compelling Interest: Ensuring Diversity
in the Health-care Workforce. Washington, DC: The National Academies Press; 2004.
7. Hunt V, et al. Diversity Matters
. McKinsey & Company; 2015.
9. Abelson, et al. The climb to break the glass ceiling in surgery: trends in women progressing from medical school to surgical training and academic leadership from 1994 to 2015. Am J Surg
10. Doximity. 2018 Physician Compensation Report. March 2018. Available at: www.doximity.com
. Accessed April 13, 2018.
13. Pierce C. Barbour F. Offensive mechanisms. The Black Seventies
. Boston, MA: Porter Sargent; 1970. 265–282.
14. Lee KP, Kelz RR, Dubé B, et al. Attitude and perceptions of the other underrepresented minority in surgery. J Surg Educ
18. Garibay JC. Diversity
in the Classroom, UCLA Diversity
and Faculty Development, 2014. adapted from Sue, Derald Wing, Microaggressions in everyday Life: Race, Gender, and Sexual Orientation. Wiley & Sons; 2010.
19. Fais N, Soobiah C, Chen MH, et al. Harassment and discrimination in medical training: a systematic review and meta-analysis. Acad Med
22. Kelly B. Worth Repeating: More than 5,000 Classic and Contemporary Quotes. Kregel Academic & Professional (May 28, 2003). pp 263.
Keywords:Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
academic surgery; diversity; equity; inclusion; presidential address