The recent heightened attention regarding racial inequalities has led many national medical societies, including the American Society of Plastic Surgeons, to craft public statements speaking to the need to establish an antiracist culture. Recognizing the magnitude of this national dialogue, it is important to consider this topic’s interface with the field of plastic and reconstructive surgery. It has been well documented that practitioner bias and discrimination results in diminished health and inferior medical outcomes in minority communities, relative to the majority population.1–4 Unfortunately, these disparities have been identified throughout the spectrum of medical care, with plastic surgery not being exempt.5–9 Most recently, our country has observed differences in health-related outcomes regarding the COVID-19 global pandemic. Morbidity and mortality rates confirm that black and Latinx patients disproportionately suffer and die from COVID-19 at significantly higher rates than their white counterparts.10 This, in the backdrop of the recent video-recorded killings of black men and women due to overt racism, has led to a much needed dialogue regarding the need to create a more equitable society—intolerant of racism in any form. As health systems strategize to develop this type of culture and climate, the field of plastic surgery must also do its part to embrace and employ this change. As plastic surgeons are frequently perceived as the “consultants’ consultant” due to the wide spectrum of services that our discipline renders, we arguably interact with the broadest population of physician colleagues, patients, and staff of any specialty. Therefore, we must be equipped with a better understanding and vernacular of antiracist principles to establish a more inclusive, equitable, and unbiased environment.
There is a growing consensus that to eliminate healthcare disparities, a multifaceted approach inclusive of: broadening health care access, increasing public health funding, improving diversity of the physician workforce, promoting more research in minority-focused health challenges, and ensuring cultural competency training among all providers is required. The field of plastic surgery has room for improvement in all of these arenas. There is a persistent underrepresentation of racial, ethnic, and gender diversity in the plastic surgery workforce, despite the diverse breadth of patients that necessitate and seek services. Black physicians represent 3.7% of the US plastic surgery residents and fellows, with a decreasing trend of black integrated plastic surgery residents, and <2% of plastic surgery faculty.11,12 Most plastic surgery training programs’ curricula lack implicit bias and cultural competency training when compared with other specialties (family medicine, emergency medicine, etc.).13,14 Finally, access and equitable care has come into question regarding post mastectomy breast reconstruction rates, cleft lip and palate care, and even body contouring rates regarding black and brown communities.6,8,15 Although the etiology of these disparities is complex and multifactorial, systemic and structural racism is a significant factor.
Given the current lack of literature on antiracism, microaggressions, and implicit bias training in plastic surgery, our aim is to provide a definitional framework to spark both self-reflection and discussion within the discipline to foster a more inclusive, equitable, and socially conscious practice environment. To adequately address racial and ethnic health care disparities, it is imperative that practicing plastic surgeons, trainees, and staff understand definitions to create an antiracist environment in the workplace. Our article intends to define pertinent terminology and provide strategies and approaches to promote antiracist practices.
Before exploring this relevant terminology, we should briefly comment on why historically it has proved so difficult to discuss racially charged issues. Due to our country’s less-enlightened past regarding the treatment of individuals of African descent, the overt or even implied suggestion that someone is either acting or perpetuating racist behavior is admittedly an insult.16 In response, that accused individual becomes defensive and all too frequently closes communication. This unfortunately halts any open, transparent, and healthy discussion. This article challenges all persons that have experienced a similar dynamic, to place those historical interactions aside and use this piece as a tool to help make these previously uncomfortable conversations positive and healthy for all involved. As we will discuss, most people are well-intentioned and believe in equitable and antiracist ideals. Unfortunately, some do not and others that respond or insinuate that this topic does not pertain to them because of their self-proclaimed “colorblindness” should try to understand that this perspective can also be perceived as dismissive, and stall meaningful conversation. Therefore, we strongly encourage all to read and receive this article with an open mind.
DEFINING RACISM, ANTIRACISM, AND OTHER PERTINENT TERMINOLOGY
Race is a social construct used to refer to a group of people who share physical traits and ancestry.17Racism is typically defined as discrimination, prejudice, antagonism against a person or group of people, based on their race. Racism is the practice of subordinating other races believed to be inferior. Racism is seen on multiple levels: (1) Interpersonal—occurs between individuals. These are public expressions, often involving hateful words, such as slurs, different treatment, or actions. (2) Institutional—that which is built into policies, procedures, and every day practices of institutions. This can be seen in healthcare, education, banking, the legal system, and in our very system of government representation. (3) Structural—the racism created by institutions that amplifies different treatment typically for people of color and indigenous people. (4) Cultural—pervasive images, pictures, comments, literature, movies, advertisements, and online media that portray a race as deviant or inferior. (5) Ideological—ways of thinking that are “common” in society or culture and are rooted in racial ideas, world views, and beliefs.18,19 In the clinical setting, discrimination can be seen at all of these levels.
Antiracism is defined as supporting equitable policy through actions or expressing antiracist ideas.20 It is taking an active role to examine power imbalances and promote change of a system for equity. The difference between “I am not racist” and “anti-racism” is key. The former acknowledges that racism exists, where the latter acts to resolve inequalities. As plastic surgeons or plastic surgeons in training, we need to work to understand how racism affects people of color, how the majority community can unconsciously contribute to racism, and ultimately how to dismantle the systems that have led to inequity.
White Privilege is defined as the advantages that all white people gain at the expense of people of color regardless of age, gender, or socioeconomic position.18 This does not imply that Caucasians have not had to overcome adversity or had to work hard during their life; however, it does recognize and acknowledge that Caucasians do not have to overcome false assumptions solely based on the color of their skin (that they are less intelligent, less capable, or simply “less than”). Although not all white people are wealthy or healthy, there are substantial economic and health benefits of having white skin.
Microaggressions are defined as verbal, behavioral, environmental, or body language indignities that provide racial slights toward people of color in a hostile, derogatory, or negative tone.21,22 These can be intentional or unintentional. Examples of such statements or actions include asking “where are you from?,” clutching a purse when a black or Latinx person approaches, announcing that “you have several black friends,” stating that “the most qualified person should get the job,” and saying “you people” or “you don’t act black.” These acts imply fear that people of color are given unfair advantages and lack qualifications, that the use of proper English is discordant with black race, and that a person can be immune to racist behavior by having friends of color.
Implicit Bias refers to stereotypes and attitudes that affect our decision-making, understanding, and ultimately actions in an unconscious manner.23 For instance, holding the belief that black patients can tolerate more pain than white patients, therefore resulting in inadequate pain control.23,24 There are various available references that plastic surgeons, trainees, medical students, and staff can use to evaluate their own implicit bias to develop a better understanding.25
DIRECTIONS MOVING FORWARD: STRATEGIES TO CREATE AN ANTIRACIST CULTURE IN PLASTIC SURGERY
The first step is identifying that inequities exist and acknowledging interactions that often are ignored, even if it is uncomfortable. Second, address group dynamics and name what is happening in the environment, whether it is at work or at dinner with friends. Third, examine, challenge, and interrupt discriminatory, racially charged, or other problematic behavior to promote a safe space for learning and growth.
Cultural Competency and Cultural Humility is the ability to appreciate, communicate, collaborate, and effectively interact with people from different backgrounds/culture.26–28 To become culturally competent, adjustments must be made at every level in the field of plastic surgery. When developing a diverse, equitable, inclusive, and antiracist (DEIA) work environment, consider the following strategies as a guide:
- In advertising, marketing materials (brochures, websites, and social media) should be inclusive of all racial and ethnic backgrounds.29 This should represent respectful and positive depictions to minimize stereotypes. Representation matters.
- Mandate antiracism training for all providers and staff and establish tangible DEIA action items (ie, schedule subconscious bias workshops, implement an anonymous racist reporting system, and incorporate DEIA-themed journal clubs and grand rounds). This can be incorporated at the medical school, residency, fellowship, faculty, and staff levels by allotting specific time. Emergency medicine and family medicine have seen improvements by implementing the aforementioned action items.13,14
- Regularly assess these action items to ensure accountability.
- Support research to continually evaluate the successes and failures of changes employed.
- Dismiss patients from the practice if racist language is used (zero tolerance).
- Endorse and employ a frame shift that challenges century-old ideologies that force minority populations to “fit in” rather than belong.
Allyship is a lifelong process of being consistent, trustworthy, and accountable in support of marginalized individuals or groups of people. Small actions, such as honoring underrepresented minority groups’ experiences, can have a significant impact. Recognizing personal privilege and using it to amplify the voices of marginalized groups at the patient, provider, and administrative level is critical. In the field of plastic surgery, consideration should be paid to the following:
- Review recruitment processes and update them to ensure not only the effective recruitment of diverse physicians, midlevel providers, and staff, but also methods for retention.
- Engage colleagues, trainees, staff, and patients for open and honest feedback without punitive repercussions.
- Challenge oneself to examine personal bias and call out inappropriate discriminatory behavior regardless of if it is a colleague, staff, patient, or family member.
- Promote the use of inclusive language at all times and in all settings.
- Task lea0dership at all levels to embrace diversity and foster an inclusive environment.
- Acknowledge that often underrepresented people are tasked with developing diversity initiatives and performing their job, in the midst of experiencing racism. Consider taking the time to educate oneself, rather than placing the burden on a colleague of color.
Allyship is a continuous commitment. Mistakes will inevitably be made; however if we are all receptive to feedback and open dialogue, we can achieve a socially conscious environment. With race relations currently on the forefront of national conversation, the field of plastic surgery can successfully adjust and evolve to reflect these insights. Our field can lead the way in embracing a medical climate of inclusivity, completely intolerant of racist practices or behavior.
The time is now to establish a culture and climate of antiracism in the field of plastic surgery. Fundamental steps include approaching conversations with an open mind, actively participating in continuing education, taking responsibility for actions, and growing from experiences. It is our hope that the field of plastic surgery and those that provide the care will develop a better understanding of key antiracism principles, and integrate this philosophy into their daily lives. In doing so, subsequent external policies, practices, and behaviors could assuredly follow suit to foster a society that genuinely embraces racial equity and justice. Collectively, we can cultivate an environment that allows all to reach their full potential.
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