21st Century Lens on Diversity,Equity,and Inclusion in Surgery Antiracism Symposium

Abstract

Inequities in society and health care combined with underlying structural and systemic racism have demonstrated significant consequences which have resulted in a renewed focus on the current state of diversity in health care and the field of surgery. However, efforts to combat racism and increase diversity and inclusion at all levels in the field of surgery require a comprehensive review, significant commitment, and purposeful action to achieve. These actions must include increasing diversity within training program recruitment, improving retention of minority and under-represented trainees, and implementing inclusive, transparent pathways to promotion, leadership, and involvement in scientific inquiry. This symposium brings together experts in surgery, health equity and policy to address antiracism, diversity, equity, and inclusion in a comprehensive manner ranging from workforce diversity and promotion, pipeline diversity, scholarly pursuits, social and political determinants of health.

Long-standing societal inequities in America have led to fatal and dire consequences that have caused the nation and the world to notice. The COVID-19 pandemic, the deaths of African Americans at the hands of law enforcement agents, and the rise of violence against Asian Americans have exposed structural and systemic racism that drive these societal inequities. In 2020, the American Medical Association House of Delegates adopted a new policy to “Recognize racism, in its systemic, cultural, interpersonal and other forms, as a serious threat to public health, to the advancement of health equity and a barrier to appropriate medical care”. ¹ This symposium brings together experts in surgery, health equity and policy to address antiracism, diversity, equity, and inclusion in a comprehensive manner ranging from workforce diversity and promotion, pipeline diversity, scholarly pursuits, social and political determinants of health.

Technology and health care delivery have shown substantial gains over the past several decades, yet stark health inequities remain. African Americans are twice as likely to die from COVID-19, while Hispanic Americans also demonstrated startlingly inequitable infection rates. ² Black women have higher rates of maternal mortality and infant mortality.^3,4 Recent stories of celebrity women such as Serena Williams and Beyonce have helped shine a spotlight on this stark health inequity.^5-7 Additionally, we see significant racial disparities in outcomes for breast cancer, prostate cancer, and many other diseases.^8,9 Conversely, research demonstrates that patients cared for by physicians of the same ethnicity have shown improved health outcomes, such as reducing cardiovascular disease by 20% and improving infant mortality.^10,11

In 2015, a report by the AAMC demonstrated that the number of black males graduating from medical school was less in 1978. ¹² Additionally, in 2019, Association of American Medical College data demonstrated that while African Americans comprise 13% of the nation’s population, they comprise only 5% of physicians in the United States. ¹³ Minorities suffer from lower matriculation rates and report experiencing increased microaggression and implicit bias.^14-17 These pervasive microaggressions significantly impact the well-being of residents and surgeons, leading to increased rates of burnout.^16,17 Minority trainees are also subject to higher levels of adverse actions such as dismissal. ¹⁸

Many surgical organizations have begun to examine their surgical diversity and antiracism policies and initiatives.^19-21 Butler et al evaluated presidents of the American College of Surgeons, American Surgical Association, Association of Women Surgeons, and Society of Black Academic Surgeons. The study demonstrated that the ACS and ASA cohort of presidents consisted of 87% male and 83% White members. Presidents of the Association of Women Surgeons and Society of Black Academic Surgeons attained comparable scholastic achievement. ²²

Black faculty comprise only 3% of medical faculty, while Hispanic or Latino faculty comprise 4%. ¹⁵ In 2017, there were only 11 tenured African American female surgeons and ten full professors of surgery. ²³ Additionally, at the time of this publication, there has never been an African American female chair of a department of surgery. Research by Berry et al ²³ demonstrated that from 1998 to 2017, 31 grants were awarded to fewer than 12 African American female surgeons.

In November 2020, in response to a now-retracted article in vascular surgery that targeted women physicians, the current and former editors-in-chief of JAMA issued a call to action to surgical journal editors to pursue increased diversity in the editorial process. More than 50% of the editors agreed. ²⁴

A strategy that addresses racism in surgery will require a multi-pronged comprehensive response:

1) Improvement in the pipeline for under-represented minorities ²⁵ ;

2) Antiracism curricula and training implemented in medical schools;

3) Increased diversity recruitment and retention strategies in medical school and training programs;

4) Addressing systemic and structural racism in health care and health care organizations;

5) Identifying, countering, and addressing microaggressions and implicit bias;

6) Ensuring equitable opportunities for academic progression;

7) Fairness and transparency in scientific inquiry and peer-review processes;

8) Improving diversity on editorial boards and grant review processes; and

9) Review of leadership, diversity, and inclusion processes among surgical organizations to ensure equal access to leadership opportunities

Previous experiences in American health care, such as the Tuskegee experiment and the Henrietta Lacks story, have engendered mistrust of the health system, which remains a significant problem. ²⁶ As the country provides needed preventive services with vaccination for COVID-19, this mistrust poses difficulty in achieving equitable health treatment for all communities.

The above actions and much more are needed if we plan to engender the public’s trust in health care, eliminate disparities, and provide equal opportunity for all. Comprehensively, we must strive to provide the stepping stones to combat racism in the field of surgery, and the surgical care that we provide, and thus, protect our patients and impact society now and for the future. The articles that comprise this symposium are thought-provoking and intended to lead to sustainable change.