June 2023 - Diversity, Equity, Inclusion
June 2023
EAST Monthly Literature Review
"Keeping You Up-to-Date with Current Literature"
Brought to you by the EAST Manuscript and Literature Review Committee
This issue was prepared by EAST Equity, Diversity, and Inclusion in Trauma Surgery Practice Committee Members Sahaja Atluri, MD, Ronnie Mubang, MD and Luis R. Taveras, MD.
Thank you to Haemonetics for supporting the EAST Monthly Literature Review.
In This Issue: Diversity, Equity, Inclusion
Article 1 reviewed by Sahaja Atluri, MD and Ronnie Mubang, MD
Perceptions of Equity and Inclusion in Acute Care Surgery: From the #EAST4ALL Survey. Tseng ES, Zakrison TL, Williams B, Bernard AC, Martin MJ, Zebib L, Soklaridis S, Kaafarani HM, Zarzaur BL, Crandall M, Seamon MJ, Winfield RD, Bruns B; and the Equity, Quality, and Inclusion in Trauma Surgery Practice Ad Hoc Task Force of the Eastern Association for the Surgery of Trauma. Ann Surg. 2020 Dec;272(6):906-910.
Article 2 reviewed by Sahaja Atluri, MD and Ronnie Mubang, MD
General surgery residency and action toward surgical equity: A scoping review of program websites. Byrd JN, Huynh KA, Aqeel Z, Chung KC. Am J Surg. 2022 Jul;224(1 Pt B):307-312.
Article 3 reviewed by Luis R. Taveras, MD and Jane R. Cowan, MD, MPH
Diversity, equity and inclusion in acute care surgery: a multifaceted approach. Strong BL. Trauma Surgery Acute Care Open. 2021 Mar 31;6(Suppl 1):e000647.
Article 4 reviewed by Luis R. Taveras, MD and Jane R. Cowan, MD, MPH
Why Diversity Programs Fail, And What Works Better. Dobbin F, Kalev A. Harvard Business Review. 2016 July-August.
Article 1
Perceptions of Equity and Inclusion in Acute Care Surgery: From the #EAST4ALL Survey. Tseng ES, Zakrison TL, Williams B, Bernard AC, Martin MJ, Zebib L, Soklaridis S, Kaafarani HM, Zarzaur BL, Crandall M, Seamon MJ, Winfield RD, Bruns B; and the Equity, Quality, and Inclusion in Trauma Surgery Practice Ad Hoc Task Force of the Eastern Association for the Surgery of Trauma. Ann Surg. 2020 Dec;272(6):906-910.
As the field of surgery grows, so does its efforts to increase diversity, equity, and inclusion (DEI) within the field. While multiple surgical societies have created programs to tackle this endeavor, the Eastern Association for the Surgery of Trauma (EAST) created an Equity, Quality, and Inclusion Ad Hoc Task Force in 2018 to increase awareness on workplace best practices as well as provide education regarding privilege, inequity, bias, and exclusion within the field of surgery. In order to show how DEI is perceived within the field of surgery, this study utilized a survey to collect baseline data on the state of the field of Acute Care Surgery. The survey had three objectives: to examine demographics of acute care surgeons, the exclusionary or biased behaviors witnessed and experienced by acute care surgeons, and the environments in which those behaviors are encountered. The survey assessed these three objectives through issues experienced within the last 12 months via yes/no, Likert scaled, free text questions and validated the survey using a modified Collingridge method. The survey demographics found that most of the respondents identified as white, non-Hispanic (71.2%), male (58.4%), heterosexual or straight (87.3%), and Christian (53.3%). In regard to general questions about equity and inclusion, the majority of respondents reported feeling that their workplace included all types of people (70.9%) and this was more likely to be reported by white, non-Hispanics. Furthermore, when asked about race and ethnicity issues, 40.1% of respondents noted observing or experiencing some form of inequity and females were noted to observe/experience such inequity more than their male counterparts. In regard to questions about sexual orientation and identification issues, 19.2% of respondents noted observing or experiencing some form of inequity. Females were more likely than males to experience prejudice. When asked about environments and speaking out amongst the respondents that faced inequity and exclusion of any kind, they reported an increase in the frequency of reoccurrence of these negative behaviors at the workplace. In response to being asked about unfair treatment, 28% of female respondents reported experiencing unfair treatment to male counterparts but were also more likely than male counterparts to report such treatment.
This survey is the first of its kind to expose the mindset of acute care surgeons on diverse and intersectional issues of equity and inclusion within the workplace. While many respondents clearly value DEI, it is far more prevalent in the workplace than expected. This survey expanded on the issues of gender, racial, ethnic biases and sexual harassment as serious yet prevalent items within the Acute Care Surgery realm. Interestingly, the respondents noted that these issues occur more frequently in the workplace than at conferences within the same profession. This raises the question of why DEI programs at workplaces are not adequate enough on addressing the aforementioned issues and, how come conferences are being portrayed as safe spaces to further address issues of DEI. The limitations of this study include low response rates when compared to similar survey studies sent in other surgical organizations which can further translate to lowered response rates from marginalized groups. This could potentially hinder this survey’s ability to detect issues of intersectionality. Recently, commentary published in JAMA noted that intersectionality is an important component of DEI discussions. Having long-term DEI solutions that remove barriers and ensure equity and inclusion for all will potentially help attract bright scholars to the field of Acute Care Surgery, thus enhancing patient care.
Article 2
General surgery residency and action toward surgical equity: A scoping review of program websites. Byrd JN, Huynh KA, Aqeel Z, Chung KC. Am J Surg. 2022 Jul;224(1 Pt B):307-312.
In the United States healthcare system, minority patient populations, experience higher rates of disparities within their care which range from higher rates of traumatic injury, later-stage cancers, and later presentation of surgical diseases. These disparities were further exacerbated by the COVID-19 pandemic. While most recognize the importance of identifying and acting on root causes of inequity, it is difficult to implement long-term solutions for them. In a 2016 American College of Surgeons survey, 37% of practicing surgeons agreed disparities exist in health care, while only 12% of surgeons thought disparities were present within their own practices. To explore the current state of Diversity, Equity, and Inclusion (DEI) efforts made by Accreditation Council for Graduate Medical Education (ACGME)-accredited general surgery residency programs, this study considered DEI statements, didactic and immersive curricula, and program steps taken to include DEI-focused research. The study team obtained a list of ACGME-accredited general surgery residency programs in December 2020. Inclusion criteria were allopathic and osteopathic general surgery residency programs whereas any program with pre-accreditation status for the 2020-2021 academic year was excluded. General surgery residency program websites were examined by 3 researchers, and each website had two assigned researchers who created a codebook to quantify the results. The review included seven key elements to determine common advocacy approaches among programs: mention of DEI, discussion of underserved or vulnerable patient populations, mention of advocacy, policy, or change efforts, community engagement initiatives, didactic sessions on disparities, resident-led initiatives, and spotlight on disparity-focused research. The researchers reviewed: ongoing or new actions taken by surgical departments, surgical program websites, resident spotlights, DEI-focused publications, and surgical disparity advocacy. 326 programs were reviewed, one quarter or less programs mentioned any of the seven elements. Furthermore, the most common element present was the existence of a DEI statement, seen in 17% of programs, while the least common was resident-led initiatives, seen at one program. Of the programs reviewed, 20 programs discussed their community-driven DEI work on their website. It is important to note that 6 of these 20 are urban safety-net hospitals. Notably, academic program websites were more detailed in explaining their DEI efforts than community programs.
The primary purpose of this study was to identify DEI efforts in the field of surgery through assessment of surgical residency programs via their websites. It is important to recognize that this area requires continued growth and effort. Although every program is unique in its approach towards tackling these issues, observing disparities does not necessarily translate to acting on such disparities to intervene on underlying outcomes. As the surgical field grows, so does the importance of DEI efforts within the field – trainees look for programs where issues of structural racism are recognized and openly discussed. As programs look ahead, they should consider DEI-focused academic-community partnerships aimed at finding innovative solutions to affect underlying outcomes. Limitations of this study include utilizing website data which may be limited and outdated. Websites of programs don’t necessarily reflect recent initiatives. Another limitation is that website information may not translate to the actual experience a resident has at that institution. Words may not be representative of actions taken by surgical residency programs. Even though the path towards surgical equity is arduous, a shared responsibility of acting on DEI disparities lies in the hands of both the surgeons and the trainees.
Article 3
Diversity, equity and inclusion in acute care surgery: a multifaceted approach. Strong BL. Trauma Surgery Acute Care Open. 2021 Mar 31;6(Suppl 1):e000647.
While racial and gender diversity in medicine has improved, American general surgery residency lags behind other fields. Programs to improve education, training and mentorship for underrepresented minority pipeline trainees can partially ameliorate inequities they have faced. Acute care surgeons could develop such pipeline programs encompassing different education levels to increase diversity in our workforce.
The presence of minority faculty correlates with increased diversity of residents. General surgery residency has an approximately 18% attrition rate, with evidence of racial disparity, in line with evidence of differential feelings of belonging by racial minority residents. Acceptance of a diverse group of residents falls short of the goal of retaining them through the completion of ACS training programs; the creation of an environment based on trust and support is necessary to prevent the gradual loss of these trainees through their training and beyond. Additionally, unconscious racial bias has been found in healthcare workers including ACS providers, which can be mitigated by working in a diverse workplace. The effects of implicit bias affect at least the patients’ perceptions of care. Furthermore, disparity in racial minority representation in academic surgery, particularly in leadership, has persisted or worsened from 2000 to 2015, with higher promotion rates for Whites than all other races. ACS patients are racially diverse and often disadvantaged, particularly victims of violence. Reduction of bias in ACS providers and leaders may improve the diversity of departments, contributing to improved patient care environments. Specifically, promotion processes should be transparent to reduce potential bias that limits the recruitment and career advancement of traditionally underrepresented racial groups.
There are no simple solutions for optimizing diversity, equity and inclusion in acute care surgery; the disparities in the field are a reflection of broader societal systemic racism. There are methods to combat these problems; however, our training does not typically supply the skills needed. ACS programs to reduce violent re-injury have shown success; programs to reduce racial bias and confront systematic racism in our profession have the potential to similarly produce meaningful change.
Article 4
Why Diversity Programs Fail, And What Works Better. Dobbin F, Kalev A. Harvard Business Review. 2016 July-August.
After several costly and high-profile discrimination lawsuits, many institutions expanded mandatory training programs which have resulted in limited improvements in diversity. This training has not been shown to change behavior and can spark backlash and increased racial animosity. Conversely, offering voluntary training can reinforce even weak commitments to diversity and has resulted in increases in minority hiring and promotion. Mandatory training can be framed as remedial or punitive, an effort to control thought and behavior; voluntary courses imply the training will increase a trainee’s skills. Similarly to the mandatory training programs, other frequently used strategies have shown to have poor outcomes, such as hiring tests, performance ratings informing salary and promotion decisions and grievance systems.
In general, involving people in efforts to increase diversity improves their opinions of those efforts; they resolve the cognitive dissonance between their beliefs and actions by changing one or the other. For example, asking managers to find and recruit from underrepresented groups on college recruitment trips increased the commitment of those managers to diversity. Similarly, assigning \ minority mentees to mentors ambivalent to diversity programs led to increased opportunities and advancement for the mentees and to belief from mentors that their mentees merited those achievements. Moreover, both recruitment campaigns and formal mentorship programs can increase diversity in leadership roles. Coca-Cola executives in a mentorship program open to all races (but as with many such programs, popular with minorities: 36% of mentees were African American) increased overall and managerial diversity. As Dr. Strong stated in her article, the unconscious racial bias can be broken down simply by working side-by-side with minorities in a diverse workforce; for instance, white soldiers who fought in integrated US military units in World War II had less racial animus than those in segregated units. Finally, social accountability, via the scrutiny of diversity task forces, diversity managers or public self-tracking of statistics, improves hiring, retention and promotion of diverse candidates. For example, at a particular firm, disparities in the amount of raises for African American versus white workers disappeared when each unit’s average raises and performance ratings by race and gender were publicly posted. The knowledge that discriminatory or inequitable decisions will be noticed causes actors to pay closer attention to their choices, making their unconscious bias visible to them—and therefore possible to counter—before they act.
Synthesis:
Acute care surgery suffers from systemic bias while serving diverse and disadvantaged patients. Increased diversity in academic surgery has a positive local effect on the diversity of residency pipelines and reduces implicit bias. Examples from studies of diversity efforts in business show that recruitment, formal mentorship and social accountability yield measurable improvements. Such programs could be methods to increase the diversity of acute care surgery, reduce bias, and improve our ability to care for our patients.
Have you checked out EAST's Landmark Paper Resource?
Mark Your Calendar for the 37th EAST Annual Scientific Assembly
January 9-13, 2024 at the Signia by Hilton Bonnet Creek in Orlando Florida.
It's Membership Renewal Time - Sign in to your Profile to check
your renewal status and pay your 2023 dues.
This Literature Review is being brought to you by the EAST Manuscript and Literature Review Committee. Have a suggestion for a review or an additional comment on articles reviewed?
Please email litreview@east.org. Previous issues available on the EAST website.