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#EAST4ALL

An introduction to the EAST equity, quality, and inclusion task force

Bonne, Stephanie MD; Williams, Brian H. MD; Martin, Matthew MD; Kaafarani, Haytham MD; Weaver, William L. MD; Rattan, Rishi MD; Byers, Patricia M. MD; Joseph, D'Andrea K. MD; Ferrada, Paula MD; Joseph, Bellal MD; Santos, Ariel MD; Winfield, Robert D. MD; DiBrito, Sandra MD, PhD; Bernard, Andrew MD; Zakrison, Tanya L. MD

Journal of Trauma and Acute Care Surgery: July 2019 - Volume 87 - Issue 1 - p 225–233
doi: 10.1097/TA.0000000000002360
CURRENT OPINION
Free
EAST Journal Club

From the Division of Trauma and Surgical Critical Care (S.B.), Rutgers New Jersey Medical School, Newark, New Jersey; Section for Trauma and Acute Care Surgery (B.H.W., T.L.Z.), The University of Chicago Medicine, Chicago, Illinois; Trauma and Emergency Surgical Service (M.M.), Scripps Mercy Medical Center, San Diego, California; Trauma, Emergency Surgery and Surgical Critical Care (H.K.), Harvard Medical School, Boston, Massachusetts; Retired Chair of Surgery for the Veteran's Administration Hospital (W.L.W.), Fayetteville, North Carolina; Division of Trauma and Surgical Critical Care (R.R., P.M.B.), University of Miami Miller School of Medicine, Miami, Florida; Trauma and Acute Care Surgery (D.A.K.J.), New York University Winthrop Hospital School of Medicine, Mineola, New York; Division of Acute Care Surgical Services (P.F.), Virginia Commonwealth University School of Medicine, Richmond, Virginia; Trauma, Critical Care, Burn and Emergency Surgery (B.J.), University of Arizona College of Medicine, Tucson, Arizona; Trauma, Acute Care Surgery and Surgical Critical Care (A.S.), Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas; Division of Acute Care Surgery, Trauma, and Surgical Critical Care (R.D.W.), University of Kansas Medical Center, Kansas City, Kansas; Department of Surgery (S.D.B.), The John Hopkins University School of Medicine, Baltimore, Maryland; and Acute Care Surgery, Trauma and Surgical Critical Care (A.B.), University of Kentucky College of Medicine, Lexington, Kentucky.

Submitted: February 9, 2019, Revised: April 18, 2019, Accepted: April 28, 2019, Published online: May 1, 2019.

Presented at the 32nd Eastern Association for the Surgery of Trauma Annual Scientific Assembly, January 15–19th, 2019, in Austin, TX.

Address for reprints: Stephanie Bonne, MD, Rutgers New Jersey Medical School 150 Bergen Street, M-228 Newark, NJ 07103; email: Stephanie.bonne@rutgers.edu.

Online date: May 2, 2019

“Not everything that is faced can be changed, but nothing can be changed until it is faced.” -James Baldwin, 1962

There is an oft-quoted aphorism: “Justice will not be served until those who are unaffected are as outraged as those who are.” As we made our way from all corners of the country to the 2018 EAST Annual Scientific Assembly, there was no shortage of outrage blasting from every airport television. The #MeToo hashtag was omnipresent, shining a spotlight on horrifying and all too common issues around sexual abuse and the associated issues of gender bias, discrimination, and unequal pay. Another black community was mobilizing in response to an apparently unjustified shooting death, while racial, ethnic, sexual orientation biases and the lack of inclusion continued to plague our profession. There was enough clear evidence of injustice for all to be outraged, but the heavy lifting was still being done by the “affected.” The rest of us largely remained silent, or at least emotionally detached. On the cover of the newspaper was another man in a position of power accused of years of sexual assault, finally being held accountable. Similar to countless other stories, except that this man was a physician. A surgeon. One of “us” was accused of sexually assaulting multiple patients while at their most vulnerable states, and then protected and allowed to continue this pattern of behavior for years after the first allegations were reported, protected by other doctors, surgeons, administrators, by “us.”

This may have been the final spark for the “unaffected” to be outraged, to transition from coolly and intellectually supportive to emotionally and personally invested. A conversation started within the EAST leadership, initially with caution and trepidation, but increasingly with understanding and urgency. We listened to heartbreaking stories that we had not heard before—because we had never asked. The newly elected EAST President, Dr. Andrew Bernard, made the decision that this would be the priority of his term, that this fell within the core guiding principles and purposes of our organization.

It was #TimesUp on turning a blind eye or offering the most tepid and purely symbolic understanding and support. Our commitment had to go beyond retweeting a hashtag, wearing a ribbon or changing our online profile picture. We were already somewhat behind, as other surgical organizations had initiated surveys, programs, and publications aimed at improving equity. However, this had to happen in our specialty of trauma and acute care surgery, and we believed that EAST was the right organization and had the right culture to carry this forward. We readily admitted that strategy is easy and execution is hard, and that we, as leaders, may not know the best way forward, but we could call upon the incredibly broad and deep experience of our members. The EAST Equity, Quality, and Inclusion Task Force was created, representing the first task force of its kind in the world of trauma and acute care surgery. We selected two co-chairs, and then assembled a “radically inclusive” group of task force members. This included a group that was not only diverse in race, gender, ethnicity, and sexual orientation, but also diverse in age, politics, and ideology. #EAST4ALL was born.

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Defining Implicit Bias

While stories of explicit bias abound in our field, implicit bias affects us all. Whereas it is easy to distance oneself from explicit bias, each and everyone one of us has unconscious biases. Thus, we all have a responsibility to acknowledge implicit bias and its effects and take ownership of finding solutions.

Unconscious biases are implicit preferences for a particular group based on a particular trait, such as race, gender, religion, sexual orientation, age, accent, or appearance. Such implicit biases are documented in in stigmatized groups demonstrating preferences for people outside of their groups.1 It is important to note that implicit bias is distinct from explicit bias and is not pathologic. Rather, it is a side effect of normal cognitive shortcuts humans use for efficiency in complex social interactions. Regardless, these unconscious biases still affect how we perceive and interact with people.

While most providers will report that they do not believe their biases, explicit or implicit, affect patient care, studies have instead found that implicit bias is a key determinant to patient outcomes.2 Providers hold similar unconscious stereotypes to the general population, and biases are noted as early as first-year of medical school.3 These biases influence clinical decisions despite occurring outside of conscious awareness.4

Additionally, there is a growing body of evidence that implicit biases also affect how we interact with colleagues and trainees. For example, men introduce male speakers by professional honorifics more often female speakers, who are introduced more often by their first name. Women introducing speakers do not demonstrate this difference.5 Surgery resident evaluations often differ by gender, with men often receiving superlative, positive, future-forward phrasing and women more often receiving comments on their docility, such as “always smiling,” “pleasant,” “never seems to get angry or upset,” or “no fuss.” Such gendered differences in surgical evaluations persist across specialties, evaluators, and postgraduate years.6

Individuals can assess their own biases with validated tools such as the Implicit Association Test, available freely online at http://implicit.harvard.edu. One may wish to pretend that such biases do not exist; however, such stereotype suppression has been found to have a detrimental rebound effect. Indeed, it is important to eschew pathologizing implicit bias or creating feeling of shame as these are unconscious preferences that we all have. Rather than focusing on political correctness, we all need to work to create a non-threatening environment focused on providing the best possible care to our patients and best possible environment for our colleagues and trainees to succeed.7

Several solutions have been studied in academic medical settings with success. Awareness of implicit bias is critical.8 Acknowledging biases allows for creation of solutions to combat bias. Gender, race, country of origin, institutional reputation, and attractiveness biases can all be counteracted by removing names and pictures from the residency application process. In situations where implicit bias may affect evaluation, compensating by making extra effort to focus on individual rather than group attributes can lessen the effect of implicit bias. Finally, empathy-building exercises are essential to reducing implicit bias, by increasing one's exposure to dissimilar groups.

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Childbearing and Family Concerns in Surgery

“I was the first woman faculty member in our department. My first pregnancy became evident 18 months into my position and I worked with full call until my term delivery. It went smoothly; I had accumulated 2 months of sick and vacation time for “maternity leave.” My clock was ticking and I became pregnant 12 months later. It was not well received by my leadership. I had to borrow time against the coming year to get 2 months off. Midway through the sixth month, I developed severe incapacitating nausea whenever I wore a surgical mask. Nasal cannula oxygen relieved this symptom and was required from that point forward with every case. The anesthesiologist used to have to set up two sources of oxygen for each case – one for the patient and one for me. Why did not I respond to my body's call for help? It was denial and the fear of failure.

“My son was born prematurely at 32 weeks with a respiratory arrest. He was extremely weak at eight weeks and not ready for daycare. I asked for an additional two weeks off as he was just beginning to fill out, but this was denied, and I was told that I would have to take a leave of absence or leave the university. My son started day care at eight weeks, contracted pneumonia, and was hospitalized for two weeks. Thankfully, at this point, I was allowed to take off. Why was I willing to ‘hope for the best’ when it came to my baby? Again, it was denial and fear of failure. My son suffered many developmental delays consistent with hypoxic injury and required physical, occupational, play, speech, tongue, and eye muscle therapy to become the person he is today.”

“I am dismayed that young women surgeons continue to feel that they need to demonstrate ‘survival of the fittest,’ and ‘pave the way for future women.’ They continue to carry guilt and apology for being pregnant or having children. If we continue to take on feelings of inadequacy due to our gender, we are enabling gender bias. Accommodations should be expected, with no apologies, as these life cycles in no way diminish our value. As Dr. Andy Peitzman stated this morning, we make our choices—and there are consequences. I worked hard for the next 18 years dealing with them.”

The demands of a surgical career whether one is a resident, a solo surgeon in private practice, or an attending at a teaching hospital are quite different that those of most other professions rendering much of the advice targeting working women during their pregnancies irrelevant. Women surgeons must manage their work obligations throughout their pregnancies. Issues include workplace exposures (e.g., radiation, needlesticks, chemotoxic agents, ergonomics), managing appropriate time off, and arranging clinical coverage, and practical tips for a healthy pregnancy and post-partum period.

The concerns of women surgeons attempting healthy pregnancies are numerous. Data on pregnant physicians indicate that miscarriage, placental abruption, and intrauterine growth retardation are the most common fetal complications in pregnant physicians.9 The most common maternal complication is maternal hypertension. These complications occur in physicians in higher rates than in the normal population, particularly in those with more than 6 call nights per month or more than 8 hours of operating time per week. Similarly, fertility is sharply affected in surgical careers, with 32% of women surgeons reporting fertility difficulty, as compared to 10% in the general population.10

The concerns for women physicians go beyond the physical complications of pregnancy. Maternity leaves can complicate academic advancement for women in medicine and surgery. Time away from clinical practice and research causes a loss of precious teamwork dynamics and “social capital” built with trainees and partners.11 Time off for maternity or birth complications may lead to the appearance of a “baby gap” on a CV that may lead to slower advancement or more difficulty in attaining leadership positions for women.12 Pausing the tenure clock is one way that academic women can be supported, but even those who pause their tenure clock see a sustained decrease in academic productivity after having taken time off.13 Finally, the implicit bias that women face is still prevalent in the surgical workforce. Women who choose to have families are seen as “less serious” about their careers or “more distracted” by colleagues.

The management of the complexities of health pregnancy and birth, and the navigation of the complex balance between family and a demanding career is a frequent topic of conversation among women physicians. This has compelled the formation of Internet support groups, mentorship programs, and attention directed toward these issues.14 As Dr. Matthew Martin stated in reference to starting the #EAST4ALL task force: “The women are having a very different conversation in the hallway at these meetings.” Survey data suggests that the perceived unsupportive culture of childbearing women in surgery has led to a decrease interest in the field among medical students, but interestingly, not increased attrition once women are in the field.15 Anecdotal evidence suggests that male surgeons may face similar challenges when applying for paternity leave however clear evidence on the topic is currently lacking.

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Microaggressions and Macroaggressions

“Microaggressions are verbal and nonverbal, intentional or unintentional, that communicate hostile, derogatory, or negative messages. Macroaggressions are more obvious and often intentional aggressions. This has been my personal experience with these challenges:”

“‘We need a white face for that project.’ This was said to me, regarding a project that I created and developed. After the project became successful, some people thought they could take over it. With the support of mentors and sponsors I was able to keep the leadership role. Furthermore, I was able to integrate those that wanted to take over and now they help on a section of this important project, very successfully.”

“‘You would not enjoy that role, you are too Latina for it anyway.’ This was said to be about a leadership opportunity that I deserved. It was told to me by a mentor at the time. I did not obtain this leadership position at that particular time. However, I was able to find strategies to secure a different role, and now I oversee the person that took over the role that I wanted initially.”

“‘You can't be a great wife, mother and surgeon at the same time.’ This was said to me as a challenge for wanting to grow on leadership roles by someone on a position of management above me. I am a mother, I am a surgeon and a wife. And I try to balance these roles constantly. To my patients I am a great surgeon, to my husband I am a great wife and to my son I am in his own words ‘the best mom he ever had.’”

“‘Your heels make you look like you don't work hard enough.’ I wear heels. I work hard. I don't have to prove to anyone about any correlation between fashion and effort.”

“Reaching leadership roles is often based on decisions that others take for you; meaning, you can only be a great leader if you are given the opportunity to serve in that role. Some of these decisions are made based on stereotypes, that although they are not purposefully poorly intentioned, they can stagnate academic growth. Finding yourself in an environment where people surrounding you display these behaviors can be discouraging. This is especially disappointing when the aggressors are people that are in positions of power and are supposed to help those under them.”

“Strategies exist to work around the issues of unconscious bias. First, avoid isolation: Talking about our issues decreases the emotions around them and help us find a feasible solution. You also might find allies by allowing your story to be heard. Second, do not give away your power. Understand that everything we do is a choice, including the amount of influence that we grant to the comments we hear and those people that make the statements. Ultimately how we allow ourselves to feel and react are issues completely under our control. Leading ourselves is the hardest but most important task when expanding our sphere of influence. Next, focus on developing yourself and others. One of the long-term solutions for breaking stereotypes is leading by example. By becoming successful you will contribute tremendously to changing these stereotypes and to create path of success for those behind you.”

“Finally, build a base of allies. I consider myself lucky to have been able to build a base of mentors. This group is very diverse regarding gender, ethnicity and age. A successful mentor-mentee relationship is never passive, the mentee needs to be aggressive in reaching out and asking for what he or she needs. I have learned tremendously from mentees as well who, with time, have become part of my work family.”

Microaggressions, that is, comments and actions that are subtly, and often unintentionally, hostile, or demeaning to a member of a minority or marginalized group are a result of the unconscious biases we all have. They are small, invisible and often unintentional messages (“incessant cuts”) that communicate to a person that they are not as important. Some can be overtly hostile microassaults, or subconscious microinsults. Microinvalidations are verbal statements that deny, negate or undermine the experience of discrimination for members of a target group, for example, by telling them that they are “being too sensitive.” Microaggressions of different types are not harmless. Studies have demonstrated the profound, negative impact that microaggressions have on mental and physical health, leading to chronic “microtraumas.” Recognizing the presence of microaggressions in ourselves and in others is an important first step, as everyone commits microaggressions. Pointing out that the behavior was personally hurtful while dropping defensiveness in receiving feedback is the first step. Owning up to a microaggression, apologizing and listening deeply is a way to communicate gratitude for education received from an offended colleague, peer, trainee or even friend. (https://advancingjustice-la.org/sites/default/files/ELAMICRO%20A_Guide_to_Responding_to_Microaggressions.pdf.)

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Gender Bias in Surgery

“A 45-year-old black female trauma surgeon is the associate director of trauma and in line for advancement to Trauma Medical Director, is informed that the job has been assigned to a 42-year-old nonpublished white male who was previously in private vascular practice.

Bias exists. It is real and not always implicit. In fact, it is often quite clear.”

Figure 1 is from a study cited in Dr. Caprice Greenberg's 2017 presidential address at the Association for Academic Surgeons entitled “Sticky floors and glass ceilings.”16 It demonstrates that as we advance academically the professional gap between the genders grow. In one study on sexual harassment, 30% of women in academic medicine vs. 4% of men encountered unwanted sexual comments, attention, or advances by a superior or colleague. Another 70% reported gender bias. When asked, 66% of women reported gender bias in professional advancement.

Figure 1

Figure 1

The difference extends to pay gaps. In one study, until the age of 35 years, women made 90% of men's earnings. However, this decreased further to 76% to 81% after the age of 35 years.17 Although physicians, and in particular surgeons, are listed in the top 10% of earners, we are also the group with the largest pay gap based on gender.18 The first step is recognizing that bias exists. The intent is not to make one feel uncomfortable or to blame or to make one feel responsible. This is about making us accountable so that we understand that it exists and we have the power to change it.19

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Race and Ethnicity Bias in Surgery

“The good thing about being retired is that I don't have to worry about what I say. And for a long time, I have really thought about the isms of life: racism, sexisms, classism, elitism, and I've lived through most of it, been a victim of it, and witnessed a lot of it. But here I'm not going to tell you all the different stories because we would be here all day and all night, but I want to tell you some things I think I've learned in over 70 years of being on this planet: some things that will help us move forward and some things that will give us hope. First, I'm going to tell you something that's old: wisdom that comes from Frederick Douglas: he said “power concedes nothing without a demand, it never did and never will.” What we are dealing with is a power structure. No child is born is racist, no child is born sexist, classist or elitist.”

“I want to tell you a story about Dr. Martin Dalton. Dr. Dalton was chair at Mercer University in Macon, Georgia. He turned out to be probably the most beneficial ally in my career and my life. Dr. Dalton nominated me for president of the Georgia Chapter of the Georgia Surgical. I said “what's the Georgia Surgical?” It was an organization that was formed because the American College of Surgeons chapter was informed that they had to integrate in 1954 and they said rather than integrate, they'd form a different organization. Dr. Dalton named me as president of that organization. Not only that, but he changed his program. He had me come down for every year, for every meeting. I asked, “Why do you keep inviting me over and over again?” and he said “it's important that my students and my residents see a black man that is head of a department of surgery, and someone that I respect and admire. It's important that they see it. Not only my residents, but my faculty.” He went on to not only do those things for me, but also to make sure that I was a part of the American Surgical. Those were things that when they happened just weren't done. He was very important to me.”

“Now, when I asked Dr. Dalton where that comes from, he said, ‘You know, when I went to medical school and residency, there was not one black person in my class, not one woman in my class. In fact, I've never been to school in my life with a person of color.’ He said ‘That's not the type of world I want to leave, so I am proactively changing it.’ And he did. He got women into his residency program, African Americans into his residency program, and foreign medical graduates into his program.”

“Change can be made from the top, but it has to take someone who is courageous enough to make that change. And we can say that ‘Well, no matter what we do, it's all going to remain the same.’ Or we can say, like Dr. Dalton, that there will be change. “What I would say to this group, is that remember what Frederick Douglas said: “Power concedes nothing without demand, and never did.” Keep on demanding. You have to keep on demanding and fight for the rights of not only yourself, but others, because one person of one person can make a difference, all people can make a difference.”

“I said earlier, I feel like whenever we have these type of sessions, you are talking to the choir, or preaching to the choir. I think that the congregation has grown and that it's more than just the choir. I've been in surgery a long time, but I can honestly say that I have never felt prouder of any organization as I do of EAST, that this moment.”

Racial and socioeconomic disparities exist in all areas of medicine. Trauma surgery is not an exception. In 2003, the Institute of Medicine published a report “Unequal Treatment” (See Fig. 2) showing that racial disparities exist in healthcare due to three main factors, which are patient, provider, and systemic-level factors.20 They found that these disparities are more than just related to barriers in access to care. The report emphasized the importance of understanding and addressing each of these potential roots of bias and disparities to optimize both the system and the well-being of patients and providers within that system.

Figure 2

Figure 2

Trauma is thought to be immune to disparities because of its emergent nature and the apparent universal access to trauma centers. However, minorities, which largely but not exclusively include African-Americans, Asians, and Hispanics, have worse outcomes than their white counterparts.21 Studies have demonstrated that minority groups receive better care if their physicians are from similar backgrounds.22 Racial diversity in our profession can potentially address the health inequalities that we are experiencing. However, even with diversity initiatives, there has been a dramatic decline in the absolute number of African American men that matriculate to US medical schools from 1978 to 2014, with this particular demographic representing only 2% of male full-time faculty at medical schools.23 It is also notable that the acceptance rate of African American men into medical school is only 41%, the lowest rate across all genders and ethnicities.22 Addressing the patient and systemic factors will require a gargantuan effort whereas focusing more on provider factor may just require some degree of introspection and understanding. Unconscious preference for white and upper-class persons seemed to be prevalent among trauma and acute care surgeons. Seventy-four percent of EAST members who completed the Implicit Association Test (IAT) demonstrated this bias, which is no different than the IAT scores of the general population. Statistically, the bias detected did not seem to significantly affect clinical decision making.24 Interestingly, diversity in trauma care providers mitigates this implicit bias for race and class to a certain extent.25 Knowing that unconscious bias exists within us can be an opportunity for introspection, awareness of the problem, and a call for action to find appropriate solutions.

Delivering trauma care is a team effort. Any perception of implicit bias and micro or macro-aggression can have a direct or indirect effect on the care of the critically ill or injured patient. Qualitative data in trauma research has begun to explore the experiences of African American trauma patients in the trauma bay: “They were judgmental of me because I have tattoos; I am black.”26 Conversely, inequity is sometimes experienced from members of the trauma team, and can arise from trauma patients themselves. There are personal instances when patients request “if there is any other doctor” or more explicitly “Is there a white surgeon?” The inequity experienced by the provider is seldom heard due to the need to avoid conflict which can cause disruption to patient care. Raising the issue of the perceived inequity can be misconstrued as being too sensitive, difficult to work with, or playing the “race card.” The perception of exclusion triggers a sense of doubt, loss of morale and confidence, depression and burnout which can be detrimental to the care of the injured patient, as well as provider. Multiple resources have in fact been developed to aid health care professionals in dealing with patient-generated, structural or systemic racism that lead to personal and patient harm.27–29

Trauma system may provide universal access to some level in the Unites States but disparities occur and we have to identify the sources and mitigate the differences in the continuum of trauma care. Preventing racism and exclusion felt by health care providers will prevent burnout and harm. Trauma systems, providers, and patients must continue to evolve as compassionate organizations and human beings providing equally for all.

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It's Not Just Race and Gender: The Effects of Religious or Country of Origin Bias

[Bi-smi llāhi r-raḥmāni r-raḥīm]” is an Islamic phrase which means “In the name of God, the Most Gracious, the Most Merciful.” This is the same phrase I have started each operation with since being a resident. It's simply another way to ask for God's help and protection during the operation. These words are used by Muslims in various contexts, mainly as an opening before each action to receive blessings from God. The scrub nurse assisting in the operating room that day seemed upset when she heard these words and reported the incident to the hospital's human resource office as being “harmful to the patient.” The resultant action was that same nurse was allowed to avoid operating with me for the next 10 years. These 10 years passed without an explanation or justification.

“The number of religious bias incidents I have personally experienced are too numerous to count. Although I am an American born Muslim, I am not a terrorist. Frequently during clinical experiences and in person, I am referred to as a “terrorist.” I have had patients request “a doctor from America.” This usually results in laughs from colleagues, including myself, to minimize its impact. This hit home most recently during an EAST Annual Scientific Assembly a few years back at Disney World, which I was attending with my wife. A disagreement with another family in-queue led to them calling us “terrorists” claiming that we should be sent back to our country. Bringing this to the staff at the resort resulted in threats from management to ban us from the park because we were angry at the lack of response to such words.”

A search for articles on religious discrimination reveals nearly all papers only written about Islam. Discrimination is not only a human and civil rights violation, but also has an adverse influence on health and health outcomes, including mental health. A significant minority of Muslim clinicians experience religious discrimination in their workplace. Various discriminatory behaviors have been described by Muslim physicians, which included racial slurs, jokes, or patients explicitly requesting a non-Muslim doctor. One study showed that 24% of members of the Islamic Medical Association of North America reported experiencing religious discrimination frequently in their career, and 14% are currently experiencing religious discrimination in their workplace. Additionally, they reported that religion was the most important factor associated with an increased odds of discrimination (OR: 3.9, p < 0.01). Moreover, a cross-sectional study by Martin30 demonstrated that 28% of Muslims reported perceived religious discrimination in the health care setting. Discriminatory behaviors reported in this study varied widely and are illustrated in Figure 3.

Figure 3

Figure 3

“Walking hopeful into my first residency interview, the interviewing surgeon, sitting in a chair, continues flipping my file and does not look up or return my greeting. After two long and awkward minutes, she says: “I don't understand. You are an ‘IMG’. That puts you way at the bottom of my list. Why should I waste my time?’”

Bias against the country of origin in surgery often takes the shape of bias against International Medical Graduates (IMGs). Despite numerous reports suggesting that IMGs are a key component of the success and sustainability of success of American surgery, discrimination against IMGs continues to be tolerated. Every IMG can easily recall similar stories of direct stereotyping and discrimination whether pre-match or during residency years.31 As importantly, this discrimination goes beyond the individual discrimination and is institutionalized. It is no secret to any surgeon that the reputation of residency programs is negatively affected by the presence of IMGs; as such, the residency applications of many IMGs are screened upfront without being individually reviewed. When program directors are asked, more than 70% admit that IMGs are discriminated against, and almost a quarter report being coerced into ranking less qualified US medical graduates ahead of IMGs.32 Moreover, the limitations the J-visa imposes on IMGs cannot be overstated. With a 7-year total training limit, academically oriented IMGs simply cannot pursue research during residency, putting them at a disadvantage.33,34 With a 3-year underserved areas waiver requirement after training, the academic career of many IMGs is unfortunately dead before it starts. The discrimination against IMGs, the unkindest cut of all, it is simply not right.32

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The Burden of Being “the Only One Like you” in the Room

“When I applied for general surgery residency nearly a decade ago, I planned to couples match with my girlfriend. I wanted to train at program that would accept me for the candidate I was, regardless of my sexual orientation, so I thought it was important to write her name- Kathryn- which is not androgynous by any means- on the first page of my application as my “match” partner- and to be very up front. Apparently, this was not common, and honestly, it still isn't.”

“On the interview trail, many interviewers clearly heard I was planning to couples match, and asked me point blank “What does your husband do?” I found this at once comical and alarming- so many assumptions crammed into this one short sentence. This happened so often that I had to come up with a “prepared” answer that would clear the confusion, fix the awkwardness, and keep the interview moving forward. I said something like “my PARTNER is applying into pediatrics, and SHE has an interview here next week.”

“Between then and now, laws changed allowing us to get married. My wife had a child while I was a third year resident and I was given 1-week paternity leave just like anyone else. Our family Christmas card is posted every year alongside the others in our departmental office. We are treated exactly the same, which is not interesting to talk about, but which speaks volumes of the evolution of our surgical culture. Sure-attendings, nurses, everyone who is curious, asks me questions about how we had our kids. And I go into as much detail as they want to hear, because I feel like people asking about where we got our sperm and how we chose our donor shows that they are interested in learning about people whose experience is foreign to their own. Normalizing my situation, my family, my life, in front of other residents and students, helps everyone to feel more comfortable in the long run.”

“I realize that the next big transition, moving from being a trainee to a fully-trained and hopefully equally-compensated surgeon, is a tough one. But I intend to keep being myself, demanding equity when I must and otherwise keeping the confusion and awkwardness to a minimum, so I can focus on being an excellent surgeon and teacher.”

Sexual and gender minority individuals are those who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ), with 4.5% identifying as LGBTQ and 0.6% as transgender in the United States (https://en.wikipedia.org/wiki/LGBT_demographics_of_the_United_States). As other minorities, LGBTQ individuals are subject to stigma-related stress and exclusion from society. Chronic exposure to such stigma yields anxious anticipation of future rejection, internalized heterosexism, and stress associated with identity concealment, even among surgeons. General surgery and other surgical specialties historically in the United States have been considered to be the least welcoming to sexual minorities. A 1998 study noted that surgeons were particularly likely to discourage surgical minorities from entering their specialty.35 A 2014 cross-sectional online survey of LGBTQ general surgery residents in the United States found that 21% experienced targeted homophobic remarks from fellow residents and 12% from surgical attendings, with none reporting the event to supervisors.36 It remains unclear whether this hostile culture has improved at all for trainees or surgical colleagues alike, representing a significant gap in the literature.

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Equity and Inclusion Are About Providing Optimal Care

“As a straight white male growing up in a well-to-do family, I have seldom faced discrimination; what do I add to this discussion? First, the anecdotes shared previously were shared by friends and colleagues. Knowing that they have been treated this way evokes embarrassment and infuriation, so I stand in solidarity with them in ending these injustices. But this is not solely a matter of being “right”; it's about providing optimal care.”

“While trauma surgeons are highly skilled, none can do the job alone; we work as part of a diverse, highly functioning team comprised of people with different backgrounds and skill sets. We understand this best in the trauma bay, where a multidisciplinary team converges to provide care to the injured, respectful that everyone has something to contribute. If even one person is missing, we can fill in the gaps, but it's never optimal.”

“What's true in the trauma bay is true for our specialty. We have an important job to do and we need everyone's contributions. When we fail to be inclusive and equitable, we're settling for less. None among us would knowingly accept this; we work too hard and care too much about our patients to allow it. So, until we have achieved zero preventable deaths, we can do better: let's open our minds, challenge ourselves to identify and combat our biases, and welcome everyone to the table as a collective of equals. Our specialty, our peers, and the patients whom we serve, deserve this.”

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What Is Next?

This plenary session represents the beginning of a discussion that is long overdue, one that is essential to the future of our specialty. The history and founding of EAST created a space for the inclusion of the junior trauma surgeon. This paralleled the founding of the American College of Surgeon in 1914 which recognized equity as an important tenet of quality when caring for the surgical patient. More urgently, exclusion and discrimination very clearly exist today. These are epitomized with the pressing yet unchanging injustice of racial and gender pay disparity and the lack of adequate parental (maternity and paternity) leave for internal and external reasons. This concerns our collective health and well-being.

Multiple toolkits, literature, resources and task forces already exist dealing with “diversity,” “equity,” “implicit bias” and “inclusion” in surgery and critical care. While some of the sentinel, peer-reviewed white papers or best practice recommendations have been published with the contributions of trauma surgeons, no such guidelines or recommendations have been created by a trauma surgery organization to date. EAST, again, is the logical organization to spearhead such an initiative. Discussing equity, quality and inclusion has nothing to do with division, it's about cohesion. An attack against one of us is an attack against the EAST family. It is about bringing the best out of each one of us. A diversity of people leads invariably to a diversity of ideas, but only if all feel valued and included. Diversity of ideas will lead to further and deeper scientific inquiry, novel surgical approaches or injury prevention programs, a challenge to dogma and may lead to improved patient outcomes. The burden of equity is not on women or surgeons of color. It's on the people in power and anyone with a voice. We need mentors, sponsors & allies. We need those in power to speak up, we need all of us to speak out. This involves all of us.

Our plan is to explore the following over the next 3 years: (1) How do we treat each other? (2) How do we treat our patients? (3) How do we see the future of trauma surgery? We will accomplish this with four workgroups:

  1. Assessment and research: assess our culture of equity and inclusion in trauma surgery through surveys, disseminate results, and create white papers.
  2. Education: share knowledge about equity and inclusion with our membership, through plenary sessions and workshops, while operationalizing solutions.
  3. Guidelines and Processes: develop an EAST equity toolkit and novel practice management guidelines to be resources for members for legitimate paternity and maternity leave, transparent pay parity; navigation through discriminatory events, and support for community, academic and military surgeons, trauma nurses and trainees of all levels.
  4. Mentorship, dialogue, and collaboration: identify equity mentors and sponsors in trauma surgery with experience accessing tools to challenge and navigate discrimination or difficult workplace situations to achieve professional excellence.

Our recently released survey on equity and inclusion for the EAST membership is the first necessary step to understand the culture of our workplaces, our profession and our organizations. This will help us answer the question of “how do we treat each other?” to learn what is needed to support the development of each and every one's potential for academic, professional and surgical growth. The products of our workgroups will provide specific language to address issues of discrimination, bias, micro and macroaggression while depathologizing the individual and rather identifying harmful behaviors that are modifiable. They will also provide pathways to establish such necessary tools for growth and equity for all, including legitimate parental (maternity and paternity) leave, and the elimination of any discriminatory pay gap. We will provide resources for individuals experiencing workplace hostilities or for those who bear witness. Toolkits for divisional, departmental and association leaders will be created to help our leaders in trauma to foster a space where we can all thrive and invite the next generation of talent to join us.

These are the stories of our colleagues who epitomize the types of role models we celebrate in EAST. We are surgeons, scientists, educators, mentors, and leaders. We also represent the intersection of gender, race, ethnicity, and sexual orientation. From these stories, we acknowledge that inequities in the treatment of our colleagues have a profound impact that we must acknowledge and eradicate.

The dignity and respect we afford our patients must be extended to each other. The leadership of EAST has taken a bold step in the pursuit of equity, quality, and inclusion. It is a seminal moment that has excited newer members and reignited the passion in some older members. While this is the beginning of a new journey for EAST, the stories of our colleagues show that this is merely the continuation of a journey many have endured the entirety of their careers. The members of the Equity, Quality, and Inclusion Task Force look forward to working with you to realize a future that is truly an #EAST4ALL.

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AUTHORSHIP

S.B., B.W., H.K., R.R., D.J., B.J., A.S. participated in the literature search. S.B., B.W., A.B., T.Z. participated in the design. B.W., M.M., H.K., W.W., P.B., P.F., B.J., R.W., S.D. participated in the data collection. S.B., B.W., A.B., M.M., T.Z. participated in the data interpretation. S.B., B.W., M.M., H.K., W.W., R.R., P.B., D.J., P.F., B.J., A.S., R.W., S.D., A.B., T.Z. participated in the writing. S.B., T.Z., M.M. participated in the critical revision.

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ACKNOWLEDGMENTS

We would like to thank all members of the East Equity, Quality, and Inclusion Task Force as well as EAST Executive Director, Christine Eme. As the #EAST4ALL Task Force, we would also like to thank Dr. W. Lynn Weaver and his wife Ms. Kay Weaver for their support and contributions to this endeavor and for leaving a lasting legacy of equity in surgery.

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DISCLOSURE

The authors declare no funding or conflicts of interest.

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REFERENCES

1. University H. Project Implicit. 2018. https://implicit.harvard.edu/implicit/ (Accessed Feb 12, 2019).
2. Santry HP, Wren SM. The role of unconscious bias in surgical safety and outcomes. Surg Clin North Am. 2012;92(1):137–151.
3. Haider AH, Sexton J, Sriram N, et al. Association of unconscious race and social class bias with vignette-based clinical assessments by medical students. JAMA. 2011;306(9):942–951.
4. Burgess DJ, Fu SS, van Ryn M. Why do providers contribute to disparities and what can be done about it? J Gen Intern Med. 2004;19(11):1154–1159.
5. Davids JS, Lyu HG, Hoang CM, Daniel VT, Scully RE, Xu TY, Phatak UR, Damle A, Melnitchouk N. Female representation and implicit gender bias at the 2017 American Society of Colon and Rectal Surgeons' Annual Scientific and Tripartite Meeting. Dis Colon Rectum. 2019;62(3):357–362.
6. Gerull KM, Loe M, Seiler K, McAllister J, Salles A. Assessing gender bias in qualitative evaluations of surgical residents. Am J Surg. 2019;217(2):306–313.
7. Burgess D, van Ryn M, Dovidio J, Saha S. Reducing racial bias among health care providers: lessons from social-cognitive psychology. J Gen Intern Med. 2007;22(6):882–887.
8. Girod S, Fassiotto M, Grewal D, Ku MC, Sriram N, Nosek BA, Valantine H. Reducing implicit gender leadership bias in academic medicine with an educational intervention. Acad Med. 2016;91(8):1143–1150.
9. Behbehani S, Tulandi T. Obstetrical complications in pregnant medical and surgical residents. J Obstet Gynaecol Can. 2015;37(1):25–31.
10. Phillips EA, Nimeh T, Braga J, Lerner LB. Does a surgical career affect a woman's childbearing and fertility? A report on pregnancy and fertility trends among female surgeons. J Am Coll Surg. 2014;219(5):944–950.
11. Flynn T, Bonasera L. Pregnancy and parenthood in residency. Virtual Mentor. 2003;5(9).
12. Bhattacharjee Y. Higher education. Princeton resets family-friendly tenure clock. Science. 2005;309(5739):1308.
13. Bhattacharjee Y. Academic careers. Family matters: stopping tenure clock may not be enough. Science. 2004;306(5704):2031–2033.
14. Lewin MR. Pregnancy, parenthood, and family leave during residency. Ann Emerg Med. 2003;41(4):568–573.
15. Brown EG, Galante JM, Keller BA, Braxton J, Farmer DL. Pregnancy-related attrition in general surgery. JAMA Surg. 2014;149(9):893–897.
16. Greenberg CC. Association for Academic Surgery presidential address: sticky floors and glass ceilings. J Surg Res. 2017;219:ix–xviii.
17. Laine C, Turner BJ. Unequal pay for equal work: the gender gap in academic medicine. Ann Intern Med. 2004;141(3):238–240.
18. Morris M, Chen H, Heslin MJ, Krontiras H. A structured compensation plan improves but does not erase the sex pay gap in surgery. Ann Surg. 2018;268(3):442–448.
19. Desai T, Ali S, Fang X, Thompson W, Jawa P, Vachharajani T. Equal work for unequal pay: the gender reimbursement gap for healthcare providers in the United States. Postgrad Med J. 2016;92(1092):571–575.
20. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC; 2003.
21. Haider AH, Hashmi ZG, Zafar SN, Hui X, Schneider EB, Efron DT, Haut ER, Cooper LA, MacKenzie EJ, Cornwell EE 3rd. Minority trauma patients tend to cluster at trauma centers with worse-than-expected mortality: can this phenomenon help explain racial disparities in trauma outcomes? Ann Surg. 2013;258(4):572–579; discussion 579–81.
22. van Ryn M. Research on the provider contribution to race/ethnicity disparities in medical care. Med Care. 2002;40(Suppl 1):I140–I151.
23. Haider AH, Weygandt PL, Bentley JM, Monn MF, Rehman KA, Zarzaur BL, Crandall ML, Cornwell EE, Cooper LA. Disparities in trauma care and outcomes in the United States: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2013;74(5):1195–1205.
24. Haider AH, Schneider EB, Sriram N, et al. Unconscious race and class bias: its association with decision making by trauma and acute care surgeons. J Trauma Acute Care Surg. 2014;77(3):409–416.
25. Zebib L, Strong B, Moore G, Ruiz G, Rattan R, Zakrison TL. Association of Racial and Socioeconomic Diversity with implicit bias in acute care surgery. JAMA Surg. 2019.
26. Kaufman EJ, Richmond TS, Wiebe DJ, Jacoby SF, Holena DN. Patient experiences of trauma resuscitation. JAMA Surg. 2017;152(9):843–850.
27. Joseph K, Turner P, Barry L, et al. Reducing the impact of violence on the health status of African-Americans: literature review and recommendations from the Society of Black Academic Surgeons. Am J Surg. 2018;216(3):393–400.
28. Paul-Emile K, Smith AK, Lo B, Fernandez A. Dealing with racist patients. N Engl J Med. 2016;374(8):708–711.
29. Hardeman RR, Medina EM, Kozhimannil KB. Structural racism and supporting black lives—the role of health professionals. N Engl J Med. 2016;375(22):2113–2115.
30. Martin MB. Perceived discrimination of Muslims in health care. J Muslim Mental Health. 2015;9(2):41–69.
31. Kaafarani HM. International medical graduates in surgery: facing challenges and breaking stereotypes. Am J Surg. 2009;198(1):153–154.
32. Moore RA, Rhodenbaugh EJ. The unkindest cut of all: are international medical school graduates subjected to discrimination by general surgery residency programs? Curr Surg. 2002;59(2):228–236.
33. Itani KM, Hoballah J, Kaafarani H, Crisostomo AC, Michelassi F. Could international medical graduates offer a solution to the surgical workforce crisis? Balancing national interest and global responsibility. Surgery. 2011;149(5):597–600.
34. Kaafarani H, Möller MG, Prabhakaran S, Melis M. Addressing workforce issues with foreign medical graduates. Bull Am Coll Surg. 2010;95(7):27–32.
35. Ramos MM, Tellez CM, Palley TB, Umland BE, Skipper BJ. Attitudes of physicians practicing in New Mexico toward gay men and lesbians in the profession. Acad Med. 1998;73(4):436–438.
36. Lee KP, Kelz RR, Dube B, Morris JB. Attitude and perceptions of the other underrepresented minority in surgery. J Surg Educ. 2014;71(6):e47–e52.
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