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EQUITY AND SOCIAL JUSTICE

Of Capes and White Coats

Championing Diversity and Inclusion in Medicine

Moreno, Natalie A. BA

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doi: 10.1097/SLA.0000000000004524
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5:00 am. After glancing at my patients’ vitals, I finalize my assessments and tuck the pen and patient list into my scrub pockets. I take a sip of homemade coffee fused with piloncillo and cinnamon bagged by a vendor in Guadalajara. Awake and ready for surgery rounds, I am about to head out of the call room when I turn around. First, I don my white coat then stand in front of a mirror. Dark, undulating hair covers half of the coat. I pull my hair back into a sleek bun, straighten the coat collar, smooth the sleeves, and stand straight. Face and coat now more visible, I walk out the door.

As a Hispanic woman, a number of reasons explain why I am meticulous about how I present myself. Often, I am the only minority and female rounding on a team. During one such time, a patient called my tall, male peer Clark Kent. Another patient called me Margarita. At first, I dismissed it with a chuckle to save face, but a hidden inuendo lurks beneath these monikers, and it must be understood. Clark Kent is a quintessential savior who leads an insurmountable alliance. Margarita is an alcoholic beverage.

This anecdote sounds amusing and harmless at first, but between the lines rests implicit bias that underrepresented in medicine (URiM) individuals face regularly. The message is that many believe we can only fit within a limited spectrum of roles, and these are backstage—not at the forefront of excellence. An example of this occurred when I was in college. It was during a record-breaking snowmageddon that forced my university to close for 1 week, leaving students to study in their dorms. During a break I sat in the common living space with floormates, one of whom made a statement that I will never forget. “What we need is a bunch of Mexicans to come and shovel up this mess.” I was nearly rendered speechless. “You do realize I am Mexican?” Without hesitation he asked why I was not outside shoveling the snow.

This depreciation of minorities echoes what other URiM individuals experience, now amplified by the most recent loss of Black and Hispanic lives. As Blacks and Hispanics serve on the wards, they remember Breonna Taylor, a 26-year-old emergency medical technician, Vanessa Guillen, a 20-year-old soldier, and Andres Guardado, an 18-year-old security guard, each of whom were killed by authorities whose duties are to serve and protect. What we recognize is that these individuals were not protected by their service to society. And likewise, our white coats will not protect us. For far too many, our most salient features are our skin, hair, and the names on our IDs. Others who do see our white coats behave as though we are in costume, not uniform. These incidents, exponentiated by the news flood of disregard for minority lives, highlight only a few people who reduce the white coat to a costume when a URiM person dons it because they believe we do not offer anything of value. And this is why we yet attempt to make our white coats our most conspicuous feature as possible.

The backwash of bias is not isolated to providers who are URiM. Our physician body must be inclusive to care for a diverse patient population. This is congruent with a recent illustration that went viral as COVID-19 surged in March. The scene depicted Clark Kent and his alliance inviting a doctor to their team. All of the heroes, each with unique stories and abilities, collectively said: “Welcome to the club.” As this shows, heterogeneity empowers teams to formulate solutions during crises. Medicine is no exception, as it enriches the intellectual swath1 needed to heal communities through research and clinical practice. This is why diverse teams publish more evidence-driven manuscripts than homogenous counterparts.1 Diversity in medicine also increases the likelihood that minorities are to get preventive care2 and adhere to physician recommendations.3 Thus, welcoming all doctors to the table further enables us to safeguard our patients. For these reasons, institutional efforts aimed at changing medicine's social fabric by unraveling systemic racism4 bring me hope.

However, inclusive practices must be upheld by sustainable strategies to implement change. To date, over 300 articles have been published on the lack of Black and Hispanic doctors in the past 2 decades.5 One might ask why homogeneity persists in spite of the advocacy-driven literature. It is said that an academic chair is among the most influential figures in healthcare systems, yet there are only 4 black surgery chairs aside from those at historically black colleges and universities,5 and only 3% of academic chairs who are women of color.6 Only 5% of medical graduates are Hispanic6 and there are fewer Black males in medicine today than in the 1970s.5 Numbers do not lie. Our physician body is not diversified because there are not enough URiM leaders. Furthermore, asking URiM faculty to spearhead diversity and inclusion without support perpetuates the stalemate because it divests the time they need for other opportunities to advance. As Dr. Paris Butler said, excellence is not enough.5 We just do not have the bandwidth to do this without the rest of our physician workforce. So as a minority woman applying into academic surgery, I propose the following next steps to diversify our leadership.

Identify URiM student barriers and raise awareness among surgeons. Underrepresented individuals endure the pressure of representing their demographic9 and lack the social capital to navigate the hidden curriculum,10 which is the summation of nuanced socialization processes necessary to have a successful trajectory. These hurdles combined, there is a barrier to this imperative knowledge transfer throughout medical school and beyond. To raise awareness, I recommend conducting a mentorship-needs evaluation. Questions should ask about barriers encountered in previous mentoring relationships, including race, ethnicity, sex, and socioeconomic background. They should also garner student perspectives on how to address these barriers in the mentoring relationship. Data collected should be presented during surgery grand rounds followed by a panel of URiM volunteers at various levels of training, from student-doctors to attendings. This should be presented during grand rounds since although not all surgeons will have URiM mentees, they will have URiM students.

Establish a surgical mentorship program to usher in more URiM leaders in academic surgery. Mentorship compensates for disadvantages URiM students face7,8 and increases the likelihood that they will pursue academic medicine.9 This will promote the sustainable, diverse medical leadership we need. To accomplish this, I recommend appointing a resident or attending to serve as a liaison between the surgery department and URiM student organizations. The liaison will email interest forms to URiM student organizations and to faculty in the surgery department annually to match mentors with mentees. Faculty interested in mentoring URiM students must certify that they have attended or seen a recorded session of the aforementioned grand rounds to optimize the mentor-mentee relationship. Matched mentors and mentees will determine meeting frequency according to availability and student needs. Mentors will instruct mentees on OR etiquette and on how to build an effective CV in line with student goals. They will also provide guidance with ERAS applications and offer mock interviews for residency (see Fig. 1).

FIGURE 1
FIGURE 1:
Increasing URiM leadership in academic surgery.

Lastly, strive for URiM representation in academic leadership as this will increase an institution's capacity to promote inclusion. It is important to realize that while some acknowledge the pervasiveness of systemic racism in what they call history, others of us call it our story, and that informs us of what needs mending in medical education and healthcare systems. Our physician body thus must elevate minority faculty who are just as qualified and lead with them on all endeavors. Sharing the responsibility of creating an equitable environment is imperative as this will empower URiM to advance. To continuously diversify leadership, programs should also interview and construct a rank list that is at minimum representative of the applicant pool to ensure that no one is excluded.

As I step out of the call room with my white coat on, I do so in uniform, ready to serve patients alongside fellow champions. My hope is that we continue to dismantle barriers to inclusion and strengthen the alliances between URiM and the majority in medical communities. With recruitment, representation in leadership, and a shared understanding of the barriers URiM individuals experience, we can foster a more inclusive environment. I look forward to the day we are all welcomed for our differences, which are the linchpins that will empower us to care for a diverse patient population. With understanding and intentional collaboration, let us move forward to value and establish the inclusivity long overdue.

Acknowledgments

Thank you, Dr. Michael Englesbe, Dr. Justin Dimick, and Dr. Erika Newman, for your support while drafting this piece.

REFERENCES

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9. Roberts SE, Shea JA, Sellers M, et al. Pursuing a career in academic surgery among African American medical students. Am J Surg 2019; 219:598–603.
10. Kalter L. Navigating the Hidden Curriculum in Medical School [AAMC web site]. Available at: www.aamc.org/news-insights/navigating-hidden-curriculum-medical-school Updated July 30 2019. Accessed June 20, 2020.
Keywords:

diversity, equity, and inclusion; surgical education; medical education

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