Diversity, Inclusion, and Equity Toolbox

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Diversity, Inclusion, and Equity Toolbox APDS Diversity and Inclusion Committee

1.  Background: Defining the Problem

AAMC definition (3/19/04): “Underrepresented in medicine means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.” 

Adopted by the AAMC’s Executive Council on June 26, 2003, the definition helps medical schools accomplish three important objectives:

• a shift in focus from a fixed aggregation of four racial and ethnic groups to a continually evolving underlying reality. The definition accommodates including and removing underrepresented groups on the basis of changing demographics of society and the profession,
• a shift in focus from a national perspective to a regional or local perspective on underrepresentation, and
• stimulate data collection and reporting on the broad range of racial and ethnic self-descriptions.

Underrepresented in Medicine (URiM): Groups that have been traditionally disadvantaged, underrepresented, or inadequately supported in medical training

1. 1. Who are URiM? Minorities underrepresented in medicine (URiM) are considered to be those identifying as Black or African American (AA), Hispanic, Latino or of Spanish origin (HLS), American Indian or Alaskan Native (AIAN), or Native Hawaiian or Pacific Islander (NHPI)
   2. Diversity: experiences, attributes, and metrics
   3. What are potential areas for diversity: racial/ethnic; socioeconomic; experiences with the medical community; interactions with a diverse or disadvantaged community; rural versus urban childhood; members of the armed forces; multiple language fluency; immigrant status; gender; and sexual orientation and sexual diversity

The 2003 Institute of Medicine report on racial and ethnic disparities in health care initiated a focus on increasing participation of URMs as health care providers to change the inequity in care for people who are racial or ethnic minorities.

“Racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factors, such as patients’ insurance status and income, are controlled… The healthcare workforce and its ability to deliver quality care for racial and ethnic minorities can be improved substantially by increasing the proportion of underrepresented U.S. racial and ethnic minorities among health professionals.”

Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care; Smedley BD, Stith AY, Nelson AR, editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington (DC): National Academies Press (US); 2003. Available from: https://www.ncbi.nlm.nih.gov/books/NBK220358

While racial makeup of medical students and faculty is collected and reported, little is known about racial diversity in residency because all data is self-reported and optional. We have statistics regarding gender, but relative absence of data on underrepresented trainees (e.g., ethnicity, gender, sexuality, or socioeconomic status).

2.  Current State of Affairs

The current state of racial diversity in academic surgery demonstrates that Blacks and Hispanics continue to be underrepresented in surgery:

“In 2014–2015, Blacks represented 12.4% of the U.S. population, but only 5.7% graduating medical students, 6.2% general surgery trainees, 3.8% assistant professors, 2.5% associate professors and 2.0% full professors….

“In 2014–2015, Hispanics represented 17.4% of the U.S. population but only 4.5% graduating medical students, 8.5% general surgery trainees, 5.0% assistant professors, 5.0% associate professors and 4.0% full professors. There has been modest improvement in Hispanic representation among general surgery trainees (0.2%/year, p < 0.01), associate (0.12%/year, p < 0.01) and full professors (0.13%/year, p < 0.01).”

Data below from: Abelson JS, Symer MM, Yeo HL, Butler PD, Dolan PT, Moo TA, Watkins AC. Surgical time out: Our counts are still short on racial diversity in academic surgery. Am J Surg. 2018 Apr;215(4):542-548. doi: 10.1016/j.amjsurg.2017.06.028. Epub 2017 Jul 1. (not open access)

How do we define diversity, inclusion, and equity-related terms

Embrace a common language (vocabulary guide) (Race Reporting Guide, Race Forward, 2015) http://raceforward.org/reporting-guide

Diversity: “There are many kinds of diversity, based on race, gender, sexual orientation, class, age, country of origin, education, religion, geography, physical, or cognitive abilities. Valuing diversity means recognizing differences between people, acknowledging that these differences are a valued asset, and striving for diverse representation as a critical step towards equity” (Race Forward, 2015).

Equity: Refers to “fairness and justice and focuses on outcomes that are most appropriate for a given group, recognizing different challenges, needs, and histories. It is distinct from diversity, which can simply mean variety (the presence of individuals with various identities). It is also not equality, or ‘same treatment,’ which doesn’t take differing needs or disparate outcomes into account. Systemic equity involves a robust system and dynamic process consciously designed to create, support and sustain social justice” (Race Forward, 2015).

Inclusion: “Being included within a group or structure. More than simply diversity and quantitative representation, inclusion involves authentic and empowered participation, with a true sense of belonging and full access to opportunities” (Race Forward, 2015).

Cultural Competency: Taking responsibility for learning about the cultures of others with whom we work, teach, and serve and using this knowledge as a basis for interaction.

Example of a Diversity and Inclusion glossary – Indiana University Southeast https://www.ius.edu/diversity/resources/diversity-glossary.php

What is the goal for diversity efforts?

2. 1. • Create a physician workforce that at least reflects the general population of the US and specifically the local population of the training program
      • Develop an environment where differences are embraced and supported so that all participants have an equal opportunity for success

3.  The Value of Diversity

Why is diversity important?

Dr. Quinn Capers OHSU, One Minute Professor – Diversity (video) One minute video on the importance of diversity in medicine https://www.youtube.com/watch?v=w1KKNF2_w6A

AAMC Webinar: Power of Diversity (video) (83 min)

https://www.aamc.org/what-we-do/mission-areas/diversity-inclusion/learning/webinar-power-of-diversity

Scott E. Page, Ph.D., a leading scholar in the role diversity plays in organizations and society, and AAMC Chief Diversity Officer Marc Nivet, Ed.D. discuss the importance of diversity and inclusion in academic medicine, the value diversity and inclusion adds to medical education and health care, and how diversity influences the complex system of health care.

Diversity correlates with better financial performance in business ¹

Diversity helps improve organizational performance¹

https://www.mckinsey.com/~/media/…

4.  How can we make an impact?

Guidelines from Surgical Societies to promote diversity, inclusion, and equity

American Surgical Association’s Handbook: Ensuring Equity, Diversity, and Inclusion in Academic Surgery (Handbook)https://americansurgical.org/equity/

Living document designed to identify issues hurdles and develop a set of solutions and benchmarks to aid the academic surgical community in achieving these goals. “Surgery needs to identify areas for improvement [in diversity, equity, and inclusion] and work iteratively to address and correct past deficiencies. This requires honest and ongoing identification and correction of implicit and explicit biases. More diverse departments, residencies, and universities will improve our care, enhance our productivity, augment our community connections, and achieve our most fundamental ambition – doing good for our patients. To address these needs.”

Program and Sponsoring Institution’s Leadership to Promote Diversity, Inclusion, and Equity

As an ACGME requirement, residency programs must state their individual and their sponsoring institution’s commitment to diversity.

ACGME Core Common Program Requirements in Surgery (2019): “The program, in partnership with its Sponsoring Institution, must engage in practices that focus on mission-driven, ongoing, systematic recruitment and retention of a diverse and inclusive workforce of residents, fellows (if present), faculty members, senior administrative staff members, and other relevant members of its academic community.”

Diversity, inclusion, and equity statements are important for defining the program’s mission and vision related to these topics. Ideally, the residency program’s statement should reference the supporting institution’s diversity and inclusion efforts.

Examples of “best practices” for tools to achieving diversity, inclusion, and equity can be identified outside of medicine in higher education and business.

• 10-question Diversity and Inclusion “pulse check” (interactive assessment) to determine whether your organization is ready to leverage diversity and engage every employee http://www.basicdiversity.com/pulse_check.html

• Diversity and Inclusion Pulse: 2017 Leader’s Guide, Russell Reynolds Associates (report) surveyed 2,167 executives internationally to understand how companies align themselves around diversity and inclusion. Insights are compiled into the following handbook (excerpt below): https://www.russellreynolds.com/en/Insights/thought-leadership/Documents/Diversity%20and%20Inclusion%20Pulse.pdf

Multiple academic and community general surgery residency programs have excellent diversity statements and robust programs. While not an exhaustive list, multiple examples are below.

• “Michigan Promise” Aims to Diversify, Strengthen Surgical Field

https://labblog.uofmhealth.org/industry-dx/michigan-promise-aims-to-diversify-strengthen-surgical-field

• University of Washington Department of Surgery Council on Promotion of Diversity and Inclusion

https://www.uwsurgery.org/wp-content/uploads/2018/05/surgsynopsis_spr2018_diversityinclusive.pdf

• UCSF surgery residency web site includes a diversity tab, and references UCSF’s “Differences Matter” program https://surgery.ucsf.edu/about-us/diversity-equity-and-inclusion.aspx
• Brigham and Women’s surgery residency references the health systems’ Center for Diversity and Inclusion and a video on “Training at a Harvard Hospital.” https://www.brighamandwomens.org/surgery/for-medical-professionals/general-surgery-residency

• Stanford University has a Vice Chair of Diversity in the Department of Surgery, diversity statement, and links to surgery-specific “diversity programs.” http://med.stanford.edu/gensurg/education/residencyProgram/Diversity.html

• Tulane University Department of Surgery Vision includes diversity https://medicine.tulane.edu/departments/clinical-sciences/surgery

• Boston Medical Center General Surgery Residency website links to institution diversity and inclusion office https://www.bumc.bu.edu/surgery/training/residency/

• University of Wisconsin School of Medicine highlights diversity strategy, definition, and goals https://www.med.wisc.edu/about-us/diversity/strategy-definition-and-goals/

• Hennepin Healthcare general surgery residency program website highlights a diverse training experience https://www.hennepinhealthcare.org/medical-education-training/residency-programs/surgery-residency/

• Carolinas Medical Center has a robust diversity program linked to the surgery residency page https://atriumhealth.org/education/graduate-medical-education/physician-residencies/surgery/diversity

• University of Arizona, Tucson, Department of Surgery has a robust diversity page https://surgery.arizona.edu/about/diversity-inclusion

• MUSC residency program “aims” include diversity https://medicine.musc.edu/departments/surgery/education/residency-and-fellowship/general-surgery-residency-program

Recruit champions of diversity – include “The White Guy”

“History will have to record that the greatest tragedy of this period of social transition was not the strident clamor of the bad people, but the appalling silence of the good people.”

Martin Luther King, Jr

“When you’re accustomed to privilege, equality feels like oppression.” Unknown

Adapted from “The Role of the White Guy in Diversity and Inclusion” by Dr. Dan Dent, General Surgery Residency Director, University of Texas, San Antonio (presented at the Diversity and Inclusion panel, APDS 2019)

White men have traditionally had power and opportunity in surgery. This is the group most poised to help strengthen the field of surgery through inclusion of other types of people and ideas. They are the people most able to sponsorwomen and URiM groups by recommending them for inclusion on a committee, panel, presentation, project, or award.

It is not enough just to not be the enemy. White men can be excellent allies (See ally section below). To be an ally, you cannot keep quiet when you see discrimination, inequality, or microaggressions – you must speak up.

Recognize diversity and inclusion is good for all people. It is NOT about giving opportunities to people who are undeserving or denying opportunities for YOU. It is about identifying those who are deserving through non-traditional means.

Additional resources:

Inclusive Excellence Toolkit – The University of Denver: Designed by staff of the CME to assist offices, departments, and colleges at DU in implementing Inclusive Excellence. Specifically, it is intended for staff, students, Deans, Vice Chancellors, managers, directors, chairs of committees, and other individuals who want to begin the discussion, exploration, and practice of embedding inclusiveness throughout their areas of responsibility. https://www.du.edu/gsg/media/documents/InclusiveExcellenceToolkit-DUCME3-09.pdf

Race Forward’s “Ready for Equity in Workforce Development: Racial Equity Readiness Assessment Tool.” Designed as a guide for workforce development organizations and practitioners to evaluate their programs, operations, and culture in order to identify strength areas and growth opportunities. Use this toolkit to familiarize themselves with various prac­tices and policies that support institutional racial equity, evaluate their current efforts, and plan action steps.

https://www.raceforward.org/practice/tools/workforce-development-racial-equity-readiness-assessment

Increase the pipeline

“Increasing the pipeline” describes efforts to increase the number of candidates underrepresented in Medicine (URiM) applying to general surgery residency programs, to poise these candidates for success, and to attract URiM candidates to your program. This section outlines attainable methods that residency programs can work to increase the “pipeline” of exceptional students from backgrounds underrepresented in medicine who are interested in surgery.

1. Outreach and partner with medical school, undergraduates, high schools, and URiM organizations

• Volunteer to participate (run a suturing workshop, serve on a panel, participate in a “residency fair” forum) in local/regional meetings; recruit applicants and showcase your program
• Partner with diverse medical school groups to mentor and sponsor members interested in surgery. Listed below are medical student-specific groups and surgical groups representing diverse interests.

Latino Medical Student Association https://lmsa.site-ym.com/ National organization founded to represent, support, educate, and unify US Latino(a) medical students

Association of Native American Medical Students (ANAMS) http://www.anamstudents.org/ Student organization representing Native American graduate health professions students in the US and Canada. Goals include providing support and a resource network for all Native Americans currently enrolled in various allied health professions schools. ANAMS strives to increase the number of Native American students in medicine and other health professions. Exposure and recognition on a national level throughout the medical community is what we continue to promote.

Student National Medical Association (SNMA) https://snma.org/ Committed to supporting current and future underrepresented minority medical students, addressing the needs of underserved communities, and increasing the number of clinically excellent, culturally competent and socially conscious physicians.

Building the Next Generation of Academic Physicians (BNGAP) www.bgnap.org Vision: to help develop a diverse academic medicine workforce that will train medical students and residents to effectively address evolving health care needs and work towards health equity in the U.S.

Medical Student Pride Alliance (MPSA) https://www.medpride.org/ Activist and social organization committed to empowering sexual and gender minority medical students and allies, increasing the number of physicians trained in LGBTQ+-inclusive healthcare, and addressing the unique needs of queer communities through research, advocacy, education, and service.

Association of Women Surgeons (AWS) https://www.womensurgeons.org/ (blog.womensurgeons.org) Educational and professional organization whose mission is to inspire, encourage, and enable women surgeons to realize their professional and personal goals.

National Hispanic Medical Association (NHMA) https://www.nhmamd.org/ Represents the interests of 50,000 licensed Hispanic physicians in the US. Dedicated to empowering Hispanic physicians to be leaders who will help eliminate health disparities and improve the health of Hispanics.

Society of Black Academic Surgeons (SBAS) https://www.sbas.net/ Motivates, mentors, and inspires surgeons and medical students to pursue academic careers and make significant contributions to the advancement of the field of surgery.

Society of Asian Academic Surgeons (SAAS) https://www.asiansurgeon.org/ Founded to focus on the personal and professional development of Asian academic surgeons with the belief that the best way to increase Asian representation in the leadership of academic surgery is to prepare future generations to succeed

Association of American Indian Physicians (AAIP) https://www.aaip.org Strives to motivate American Indian and Alaskan Native students to remain in the academic pipeline and to pursue a career in the health professions and/or biomedical research, thereby increasing the number of American Indian and Alaskan Native medical professionals in the workforce. AAIP strives to improve the overall health of American Indian and Alaskan Native Communities through a variety of programs. AAIP has fostered several programs that directly address widely acknowledged disparities in American Indian and Alaskan Native health.

Latino Surgical Society (LSS) https://latinosurgicalsociety.org/ @LatinoSurgery Established in 2018 to cultivate, nurture, and support the advancement of Latino surgeons.

Excelsior Surgical Society https://www.facs.org/member-services/mhsspacs/ess, As part of the Military Health System Strategic Partnership, this society is administered through the American College of Surgeons. The society offers a “home” for the military surgeon within the ACS, and serves as both an on-ramp to membership in the College as well as an “off ramp” for surgeons as they separate from the military and transition to civilian practice.

2. Investigate opportunities at your local institutions to participate in summer programs for undergraduate and medical students URiM. Encourage URiM undergraduate and medical students to participate in summer programs locally or regionally. Many summer programs are research focused but may include clinically relevant activities, speakers, and opportunities for mentorship.

AAMC has a list of summer undergraduate research programs

https://www.aamc.org/professional-development/affinity-groups/great/summer-undergrad-research-programs

Brown University has a list of URiM-focused summer research opportunities available in the East and Midwest regions

https://www.brown.edu/academics/college/advising/health-careers/resources/activities-related-health-care/opportunities-students-backgrounds-under-represented-health

3. Write supportive, unbiased evaluations and letters of recommendation

• Data

• Grading disparities with URMs in clerkships: Studies analyzing MPSE and clerkship evaluations found that URMs encountered grading disparities compared to their white colleagues and were less likely than other students to receive honors clerkship grades or be selected for honor society memberships. Low, Pollack ² Teherani, Hauer ³
• Narrative evaluations tend to reflect students’ personal traits rather than competency-related behaviors: Observational study of nearly 90,000 clerkship evaluations from core clinical rotations at 2 medical schools in different geographic areas – Many words and phrases reflected students’ personal attributes rather than competency-related behaviors. There was a significant difference observed in narrative evaluations associated with gender and underrepresented minority (URM) status, even among students receiving the same grade. Rojek, Khanna ⁴

• The Gender Bias Calculator: https://www.tomforth.co.uk/genderbias/ Plug in your letter of recommendation for a candidate and receive an assessment of “female-associated” and “male-associated” words used. (Interactive assessment)

• Tip Sheet: Avoiding Gender Bias in Reference Writing (University of Arizona .Commission on the Status of Women) (Reference Sheet) https://csw.arizona.edu/sites/default/files/avoiding_gender_bias_in_letter_of_reference_writing.pdf

4. Prepare students for residency interviews

“Prepare Students for their Surgical Residency Interviews with a Residency Workshop” (epublication) Describes Massachusetts General Hospital’s residency interview workshop with review of ERAS application, mock interviews with surgeons, and applicant reflection (June 2019) https://www.facs.org/education/division-of-education/publications/rise/articles/interview

5. Offer a mentored student clerkship for URiM students

Funded Away Rotations for Minority Medical Students (FARMS) Database: Directory of funded away electives for medical students from backgrounds underrepresented in medicine. www.farms.mydocspace.com

Residency recruitment

Many programs struggle with matching a diverse resident group despite perceived efforts at recruitment of a diverse group. The ability to recruit, retain, support, and promote URiM surgeons is multifaceted. This section provides tools and examples of “best practices” from residency programs nationwide to spotlight your program’s diversity efforts and recruit, match, and retain a diverse applicant pool.

BEST PRACTICE: University of Pennsylvania developed a 3-faceted approach for surgical residency recruitment: UIM-focused 4 week paid (1500 reimbursement for lodging and travel) visiting clerkship program; holistic review of residency applications (attenuate the focus on traditional metrics of board scores, grades, and number of authored publications) and heighten the emphasis on candidates’ experiences and attributes; and targeted outreach to candidates from the University of Pennsylvania’s Alliance of Minority Physicians (UIM-focused housestaff, junior faculty, and medical student support and mentorship network).⁵

1. 1.  Create a web site that reflects your program’s diversity and inclusion efforts

• Resident “bios” with photo, hometown, college, medical school, hobbies, why you came to this program https://atriumhealth.org/education/graduate-medical-education/physician-residencies/surgery/residents
• Consider including ⁶:

1. • Detailed biographies of residents and faculty including their goals, hobbies, interests, backgrounds (not just regurgitation of CV)
   • Educational support systems available from your department or sponsoring institution
   • Links to community groups or activities
   • Photos of residents and faculty
   • Diversity statement (see above for examples for writing diversity statement)

2. 2. Implement a holistic approach to interviews.

Residency programs interested in increasing recruitment of URiM residents should consider how USMLE Step 1 cutoffs may exclude many of these candidates. Training programs that use discreet USMLE cut-offs are likely excluding URiM applicants at a higher rate than their non-URiM applicants. Recruitment efforts directed toward racially and ethnically diverse trainees should include a focused strategy to interview applicants who might be overlooked during conventional applicant screening.

Residency programs may have perceptions different than reality for their diversity efforts related to interview invitations: From a recent study of 10 general surgery (5 university-based, 5 independent) residency programs with a stated interest in diversity (2018 review of ERAS applications): Women and URM applicants had lower USMLE Step 1 scores than male and White applicants, respectively. There was a lower proportion of URM applicants with a USMLE Step 1 score >240 (62% of Asian applicants, 59% of White applicants, 50% of Hispanic/Latino applicants, 36% of Other race/ethnicity applicants, 29% of African American applicants, and 25% of Native American applicants [p < 0.001]).

General surgery residency programs are intentionally interviewing women but not URiM. Women were more likely to be selected to interview than men in a multivariate model adjusting for other factors. Women constituted 41% of the total applicant pool but 48% of the selected to interview pool whereas men made up 59% of the applicant pool but 52% of those selected for interviews (p < 0.001).

Identification as a non-White race/ethnicity was a significant independent predictor for decreased likelihood of interview selection (odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.59 + 0.89; p = 0.003). Hispanic/Latino origin applicants constituted 12% of the applicant pool but only 6% of those selected to interview. 50% of applicants were White, but interviewees were 64% White. ⁷

BEST PRACTICES:

• “How Can Best Practices in Recruitment and Selection Improve Diversity in Surgery?” (Review) Outlines strategies for general surgery recruitment:

Recommendations for Modifying Current Selection Processes to Increase Diversity Gardner 8
Incorporate screening tools that level the playing field for all groups	Situational judgment tests – confront applicants with descriptions of standardized realistic situations and ask them to select the most appropriate response.
Reconsider the role of personal statements and letters of reference	Non-standardized and highly subjective. Low reliability and validity, may go against efforts to widen access to certain populations as they may reflect applicant’s unequal access to coaching, resources, and individuals of elite status within the profession.
Become familiar with how your program is making initial screening decisions	Programs must ensure that use of USMLE cut scores, international medical graduate requirements, and other inclusion/exclusion criteria are fair, evidence-based, and appropriately used.
Select an inclusive interviewing team	Programs should consider strategically choosing individuals who will bring diverse outlooks and who are respectful of different cultures and characteristics to interview candidates. Have a clear and open conversation with team members before beginning the interview process to ensure that all faculty interviewers are on the same page with the goals and strategies of the interview process. Prepare interviewers with answers for questions diverse candidates may ask (protocols for m (aternity leave, etc).
Incorporate structured interviews	Faculty should be trained on the basics of conducting structured interviews, ensuring all questions are related to the position, asked similarly of all applicants, and that they are using rating tools in the same manner. Programs should also teach interviewers about common biases and interviewer mistakes, and equip them with skills to identify and overcome such biases.

BEST PRACTICES for holistic application selection:

• Holistic application selection: Internal medicine residency program at UT Health Science Center in Houston evaluated residents in a holistic manner evaluating life experiences and personal attributes – including demonstrated commitment to the underserved, substantive leadership roles, fluency in Spanish, and being representative of Houston’s diverse population based on self-identification by race/ethnicity in the Electronic Residency Application Service (ERAS). Using a USMLE cutoff 10 points lower than the preestablished USMLE score minimum, the 2 faculty application reviewers assigned a score of 2 for each applicable experience/attribute and invited any applicant with a minimum experience/attribute score of 4 to interview. This score was not considered in generating the rank list. ⁹

• In an effort to increase the number of URMs invited to interview, the neurology residency program at Duke University School of Medicine eliminated its step 1 cutoff score as an applicant “screen.” They educated application reviewers in implicit bias and instead reviewed all applications using a point system that included medical school grades (0-6 points), extracurricular activities and leadership (0-2 points), research experience (0-2 points), letters of recommendation (0-2 points), USMLE Steps 1 and 2 (or Comprehensive Osteopathic Medical Licensing Exam, COMLEX, scores for osteopathic applicants) (-2-6 points combined), and life experiences (0-5 points). Assigned at the discretion of the reviewer, life experience points could be awarded for military service or for being the first person in one’s family to attend college. This strategy increased the number of URMs invited to interview. The only statistically significant difference in this scoring system between URM and non-URM was Step 1 score. ¹⁰

3. 3. Consider your interview strategy

• Develop a diverse interview team – who is present during interview days and who is interviewing candidates is important in resident selection

Stanford University SOM: Women and URMs applying in surgery were more likely than male and White applicants, respectively, to find gender and racial diversity of faculty and residents a positive influence on program ranking.¹¹ The percentage of female faculty members in surgical specialty residency programs may predict the number of female trainees. One study found that for each 1% increase in female faculty in surgical specialties, the percentage of female trainees increased by 1.45% (p<0.001).¹²

NRMP applicant surveys cited factors that were important to them when ranking residency programs (2008-2017): cultural, racial, and ethnic diversity of the geographic location (geographic diversity), and cultural, racial, ethnic, and gender diversity of staff at the target institution (institutional diversity). For all specialties, residents citing diversity as a factor in program selection increased from 27 to 36% for geographic diversity and from 18 to 31% for institutional diversity. At surgery programs, the percentage of residents selecting diversity as a factor in selecting a program increased from 24 to 28% for geographic diversity and 19 to 22% for institutional diversity. Applicants’ 5-point ratings of the importance of diversity during ranking (1= not important and 5 = extremely important) rose during this period: geographic diversity from a mean of 2.7 to 4.2 and institutional diversity from a mean of 2.4 to 4.2 for all applicants. ¹³

• Educate faculty and residents on acknowledging and mitigating implicit bias

Reducing Implicit Bias in Admissions Interviews: 4 Strategies Ohio State University College of Medicine uses https://youtu.be/-053AUVYPw8 (3 minute video with Dr. Quinn Capers IV on these strategies)

1.  Common identity formation – don’t stop interview until you find some common identity (sports team in common, birth order, hobby)
2. Perspective taking – empathy actively reduces unconscious bias
3. Consider the opposite – when you have information that leads you to one conclusion, force yourself to go back and consider the opposite prior to making a decision
4. Counter-stereotypical exemplars – focusing on persons from a group against which you have a bias that have characteristics which you admire

Unconscious Bias Educational Resources

• “Avoiding Unconscious Bias: A Guide for Surgeons.” 2016 Royal College of Surgeons

https://www.rcseng.ac.uk/library-and-publications/rcs-publications/docs/avoiding-unconscious-bias/

• “Overview: Proceedings of the Diversity and Inclusion Innovation Forum: Unconscious Bias in Academic Medicine” (eBook)– Explores the role of unconscious bias in seven key areas of academic medicine; outlines benefits of diversity and inclusion and summarizes potential interventions to remediate the biases in modern academic medicine. Developed by the AAMC and The Kirwan Institute for the Study of Race and Ethnicity at Ohio State University, with input from national experts.

https://store.aamc.org/proceedings-of-the-diversity-and-inclusion-innovation-forum-unconscious-bias-in-academic-medicine.html

• Harvard Implicit Association Test (Interactive assessment) Measures attitudes and beliefs that people may be unable or unwilling to report. https://implicit.harvard.edu (Tests include Native American; Disability; Race; Gender-Science; Arab-Muslim; Asian American; Weapons; Gender-Career; Sexuality; Age; Religion; Presidents; Weight; Skin-tone

• Standardize interviews

BEST PRACTICES for standardizing interviews were compiled by the AAMC¹⁴: https://www.aamc.org/system/files/c/2/469536-best_practices_residency_program_interviews_09132016.pdf

BEST PRACTICE: Internal Medicine Residency Program of the John P. and Katherine G. McGovern Medical School at the University of Texas: Standardize the interview day process and reduce the influence of subjective interviewer bias during interviews with potential residents. Introduce questions designed to assess specific competencies such as applicants’ ability to work in teams, approaches to problem solving, and capacity to adapt to changes. They developed a standardized list of questions, and faculty interviewers were asked to pose two of these questions (randomly assigned) to each applicant and then to consider the quality of the responses in their overall assessment of the interview. ⁹

• Determine benchmarks interviewing and ranking underrepresented applicants (Black or African American, Hispanic, Latino or of Spanish origin, American Indian or Alaskan Native, or Native Hawaiian or Pacific Islander) and identify other aspects of diversity in your applicants including socioeconomic (including first in family to attend college or medical school); experiences with the medical community; interactions with a diverse or disadvantaged community; rural versus urban childhood; members of the armed forces; multiple language fluency; immigrant status; gender; and sexual orientation and sexual diversity

Data on URiM is limited based on self-reporting. However, self-reported data available through ERAS that may be helpful in benchmarking applications received, interviews conducted, and matched applicants may include: race/ethnicity, languages spoken (“fluent” or “near-fluent”), gender, place of birth, and hometown. Review your data for the last several years to understand recruitment opportunities.

Consider your geographic area in determining benchmarks. If you are in a geographic area with a high population of Hispanic/Latino patients, consider factors such as Hispanic/Latino self-reported race and Spanish fluency or near-fluency as benchmarks for recruitment. See other suggestions for recruiting residents who may be

Please see below for instructions for benchmarking internally with data from ERAS.

4. 4. Host specific recruitment events for potential residents with interest in diversity and inclusion. The University of Virginia GME hosted a “Diversity Day” and a “Second Look Weekend” for potential residents. The GME office sponsored funding for applicant travel and accommodations to attend this weekend through GME and medical alumni funding.

How are you supporting diverse residents?

Support representation in national societies – Apply for institutional membership, encourage residents and faculty to participate as an excellent source of national support and sponsorship

Association of Women Surgeons https://www.womensurgeons.org/ (blog.womensurgeons.org) Educational and professional organization whose mission is to inspire, encourage, and enable women surgeons to realize their professional and personal goals.

National Hispanic Medical Association https://www.nhmamd.org/ Represents the interests of 50,000 licensed Hispanic physicians in the US. Dedicated to empowering Hispanic physicians to be leaders who will help eliminate health disparities and improve the health of Hispanics.

Building the Next Generation of Academic Physicians (BNGAP) www.bgnap.org Vision: to help develop a diverse academic medicine workforce that will train medical students and residents to effectively address evolving health care needs and work towards health equity in the U.S.

National Hispanic Medical Association (NHMA) https://www.nhmamd.org/ Represents the interests of 50,000 licensed Hispanic physicians in the US. Dedicated to empowering Hispanic physicians to be leaders who will help eliminate health disparities and improve the health of Hispanics.

Society of Black Academic Surgeons (SBAS) https://www.sbas.net/ Motivates, mentors, and inspires surgeons and medical students to pursue academic careers and make significant contributions to the advancement of the field of surgery.

Society of Asian Academic Surgeons (SAAS) https://www.asiansurgeon.org/ Founded to focus on the personal and professional development of Asian academic surgeons with the belief that the best way to increase Asian representation in the leadership of academic surgery is to prepare future generations to succeed

Association of American Indian Physicians (AAIP) https://www.aaip.org Strives to motivate American Indian and Alaskan Native students to remain in the academic pipeline and to pursue a career in the health professions and/or biomedical research, thereby increasing the number of American Indian and Alaskan Native medical professionals in the workforce. AAIP strives to improve the overall health of American Indian and Alaskan Native Communities through a variety of programs. AAIP has fostered several programs that directly address widely acknowledged disparities in American Indian and Alaskan Native health.

Latino Surgical Society (LSS) https://latinosurgicalsociety.org/ @LatinoSurgery Established in 2018 to cultivate, nurture, and support the advancement of Latino surgeons.

Excelsior Surgical Society https://www.facs.org/member-services/mhsspacs/ess, As part of the Military Health System Strategic Partnership, this society is administered through the American College of Surgeons. The society offers a “home” for the military surgeon within the ACS, and serves as both an on-ramp to membership in the College as well as an “off ramp” for surgeons as they separate from the military and transition to civilian practice.

Association of Out Surgeons and Allies (AOSA) @OutSurgeons is a new organization for surgeons, resident surgeons and allies interested in promoting acceptance and equity within surgical subspecialties meant to promote the visibility of LGBTQ+ surgeons and develop mentorship opportunities.

Accommodating religious dress

In order for hospitals, medical schools, and medical centers to incorporate and accommodate for Hijab in the Operating Room, oftentimes, policy needs to be written or edited. For example: Disposable hoods are available for those requiring coverage of the head and neck for modesty and/or religious purposes.

Hijab in the OR (see infographic) https://hijabintheor.com/

Video: A Guide to Hijab in the OR (3:30 min) https://youtu.be/6o8Yowqueeg

Education and training on diversity and inclusion

BEST PRACTICE: The University of Virginia College of Medicine sought to recognize how their institution’s history impacted its relationship with the community and with diverse populations. They developed a multi-faceted diversity and inclusion initiative related to graduate medical education programs, including:

• Development of a Housestaff Council on Diversity and Inclusion – the founding secretary and president were surgery residents. This council developed and organizes an annual weekend conference on diversity and inclusion. https://med.virginia.edu/gme/diversityandinclusion/tdiconference/ “The GME department works closely with UVA faculty and the Housestaff Council for Diversity and Inclusion to stimulate meaningful conversations about race, privilege and representation in our community. Our goal is to ensure that all residents, no matter their race, sexuality, country of origin, gender, religion or able-bodiedness, feel included at UVA.”

• Creation of a Task Force on Diversity and Inclusion for the Department of Surgery, led by the Vice Chair, which is open to any resident or faculty who wishes to participate.
• Promotion of Grand Rounds exploring history of UVA Medical Center with respect to issues of race

Responding to bias incidents

Have a policy for responding to bias incidents (Example: Mayo’s 5-part response to inappropriate patient or visitor behavior) (journal article describing policy) Warsame and Hayes ¹⁵

https://journalofethics.ama-assn.org/article/mayo-clinics-5-step-policy-responding-bias-incidents/2019-06

Supporting and mentoring/sponsoring URiM residents

BEST PRACTICE: Alliance of Minority Physicians at the University of Pennsylvania Health System: Mission is to develop leaders in clinical, academic, and community medicine, through active recruitment, career development, mentorship, social engagement and community outreach geared towards underrepresented faculty, housestaff, and medical students. http://www.allianceofminorityphysicians.org/

Breaking down barriers for women physicians of color

https://greenlining.org/wp-content/uploads/2017/10/Breaking-Down-Barriers-for-Women-Physicians-of-Color-1.pdf

The Greenlining Institute and the Artemis Medical Society interviewed 20 women physicians of color to understand their experiences and barriers they face. Interviewees described lack of support during high school and college, lack of seeing a physician of their race, and barriers to entry into medicine including expense of the medical school application process, repeated tokenization, and lack of diversity among medical school faculty. Recommendations discussed include supporting health career pipelines, increasing diversity in medical student admissions and faculty, developing robust mentorship and support networks, adopting specific training in cultural competence and racism in medical schools and residency, and addressing financial and structural barriers including gender pay inequity and unfair maternity leave policies.

Supporting female surgery residents

AWS Pocket Mentor for Surgeons in Training and Medical Students, Fifth Edition 2013

https://cdn.ymaws.com/womensurgeons.site-ym.com/resource/resmgr/images/Website_Transition/2013PocketMentor1.pdf

Provides helpful advice for all medical students and residents on clinical expectations, clinical and operative experiences, championing your education, problems and pitfalls (including substance abuse, relationships, discrimination, harassment, and poor patient outcome), self-care, and planning for the future.

AAMC Gender and Sexual Harassment Resources (repository of resources)

https://www.aamc.org/what-we-do/mission-areas/diversity-inclusion/harassment

Based on the findings and recommendations in Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine (2018). Includes presentations on sexual harassment and its impact on professional outcomes, pervasiveness of sexual harassment in academic medicine, infographics and handouts on the problem and how to overcome it.

https://www.nap.edu/visualizations/sexual-harassment-of-women/

AAMC Sexual Harassment Foundation Presentation and Discussion Questions June 2019 (Presentation slides)

https://www.aamc.org/system/files/2019-08/presentation-diversityandinclusion-sghfoundationpresentation-080819.pdf

Presentation that can serve as a foundational primer to help institutions and leaders initiate conversations on their campuses regarding sexual harassment. Defines how to create a safe environment, types of sexual harassment, definitions of key terms, institutional barriers, and keys to prevention through allyship and bystander intervention.

Values affirmation exercise for female surgery residents. (manuscript describing exercise) For women, a values affirmation exercise may improve clinical performance. Values affirmation exercise: Ask participants to select the 2 or 3 values most important to them and then, on a separate page, to discuss the rationale for their choices. Salles, Mueller ¹⁶

Promoting and supporting community organizations:

https://diversity.uahs.arizona.edu/diversity-connections/lgbtq-interest-group/resources — University of Arizona lists community resources for LGBTQ+ issues

Training residents, faculty, and staff as Ally

“To be an ally is to take on the struggle as your own; stand up, even when you feel scared; transfer the benefits of your privilege to those who lack it; acknowledge that while you, too, feel pain, the conversation is not about you.” From Guide to Allyship: An open source guide meant to provide resources for becoming a more effective ally. http://www.guidetoallyship.com/

Ally Training (Sunny Nakae, MSW, PhD; ACGME 2020)

Concern	Typical Response	Ally Response
The security guards racially profile me.	What? They are so nice to me!	I’m sorry to hear that. Tell me more.
I’m having a hard time with my attending.	Don’t worry about it. She’s like that to everyone.	That sounds really difficult. How can I help?
I feel so disrespected when he talks to me like that.	Don’t take it personally. Just move on.	That’s upsetting. How can I be supportive when that happens?
I can’t believe he said….!	He’s old school. He doesn’t mean any harm.	That’s unacceptable. I will do my best to personally address this.

Ally Phrases

Suggestions for ways to respond to concerning statements or microaggressions – stating what you mean and not letting inappropriate statements pass, but not leaving room to engage in a lot of discussion.

• “What did you mean by that?”
• “Here’s how I am hearing you, is that what you intended?”
• “I’m surprised to hear that from you.”
• “I disagree.”
• Respond by stating what is important to you (“I don’t believe in gay marriage.” “I believe that all families deserve equality under the law.”).
• Respond with an empathetic comment (“I hate having to walk by those bums.” “It must be awful sleeping on the street.”).
• “I’m uncomfortable right now.” Or “I’m uncomfortable with that.”
• “You/we are better than that/this.”
• “Can we step back for a minute?”

Additional Resources for Education, Training, and Support

Training for Recognizing and Responding to Microaggressions

MTV’s 2015 “Look Different” Campaign features videos demonstrating common microaggressions: “I can’t tell Asians apart;” “You’re different for a black guy;” “How’d you get into that school?;” “You’re pretty for a dark girl;” “What up, Bin Laden?;” “You don’t look Jewish;” “Your English is so good.” (videos, 20-40 seconds)

https://www.youtube.com/playlist?list=PLhDDMRkwHvr2yj_0lBMyfhMpLe523u5EQ

https://www.higheredtoday.org/2016/07/27/understanding-and-combatting-microaggressions-in-postsecondary-education/

Framework for responding to Microaggressions: (Power Point presentation) Open the Front Door, Action, XYZ

University of Arizona College of Medicine – Tucson, Office of Diversity and Inclusion (2020). Microaggressions [PowerPoint slides]. Tucson, AZ (include slides).

Recognizing Microaggressions and the Messages They Send – University of California Microaggression List (image and link below)

https://sites.google.com/site/cacmnow/university-of-california-microaggression-lisy

Sexual and gender diversity (LGBTQ+)

A recent The New York Times article shed some light on the “awkwardness” some LGBTQ+ patients face during doctor visits. “When being heterosexual is presumed even in doctors’ offices, those who identify otherwise can feel marginalized and less likely to seek medical care”. To combat this trend, medical schools are increasingly requiring LGBTQ+ health issues be taught within their curriculula. For example, Harvard Medical School is actively recruiting LGBTQ+ students given research showing that patients receive better care when cared for by doctors who identify like them. Not coincidentally, Harvard’s recent entering medical school class was 15% LGBTQ+. https://www.nytimes.com/aponline/2020/02/19/health/ap-us-med-lgbtq-medicine.html

• LGBTQIA+ Glossary of Terms for Health Care Teams from the National LGBT Health Education Center(https://www.lgbthealtheducation.org) has a comprehensive glossary of terms including a chart listing “Outdated and Insensitive Terms to Replace” and alternative, appropriate modern terminology. https://www.lgbthealtheducation.org/wp-content/uploads/2020/02/Glossary-2020update-final.pdf

• Webinar from AAMC Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development (video)

https://www.aamc.org/what-we-do/mission-areas/diversity-inclusion/lgbt-health-resources/videos/creating-welcoming-environment (1:30:00)

Medical schools face a variety of challenges in creating safe, welcoming and nurturing environments for sexual and gender minority students, including those who identify as lesbian, gay, bisexual, transgender, or gender nonconforming. Realizing that each institution’s context is unique, this webinar will provide an overview of methods and resources institutional leaders can use to improve the climate at their institution for students of diverse sexual orientations, gender identities, and forms of gender expression.

Data – Experiences of Surgery Residents who Identify as LGBTQ+

• ¹⁷2014 survey of 388 general surgery residents – 11% (43) identified as LGBT. Of these LGBT residents:

• >30% did not reveal their sexual orientation when applying owing to fear of not being accepted. Over 50% actively concealed their sexual orientation from fellow residents and attendings.
• 54% witnessed homophobic remarks by nurses and residents and 30% by surgical attending physicians.
• Experienced targeted homophobic remarks by fellow residents (21%) and attendings (12%) – none reported these events.

• {Heiderscheit, 2020}: 2020 survey of 314 national LGBTQ+ general surgery residents:

• LGBTQ+ residents were more likely to experience sexual harassment (46.8%), discrimination (58.9%) and bullying (75.2%); attendings were the most common source of the mistreatment across the board.
• LGBTQ+ residents are equally as likely to be satisfied with the decision to become a surgeon but are significantly more likely to consider leaving their programs (21.1%) or even consider suicide (8.3%) compared to heterosexual.

These data have called on various organizations to take action. The medical student pride alliance (MSPA), twitter handle: @MSPA_National is quickly recruiting followers and has called for a petition to add a section within the Electronic Residency Application Service (ERAS) to list sexual orientation, gender identity or pronouns; a step towards a more inclusive community and diverse physician workforce. You can add your name by following the link: https://www.medpride.org/eras-petition to sign the petition.

• “Safe zone” training – free online resource for powerful, effective LGBTQ+ awareness and ally training workshops (Educational presentation) https://thesafezoneproject.com/

• Learning Modules for providing culturally competent care for LGBTQ+ patients

https://www.lgbthealtheducation.org/resources/type/learning-module/

• The Equal Curriculum – The Student and Educator Guide to LGBTQ+ Health

Newly published book by Dr. Lehman and his team. The book is aimed at educating doctors and medical students to effectively work with and treat members of the LGBTQ+ community. His goal is to help close the healthcare gaps for sexual and gender minorities. The book offers an explanation of terms related to sexual and gender identity and history of the LGBTQ+ community as it relates to medicine. Chapters include: LGBTQ+ Health Disparities, LGBTQ+ Friendly Clinic Encounter, Child and Adolescent Medicine, Adult Primary Care, Sexual Health, Transgender Health, Emergency Medicine, HIV/AIDS, Psychiatry and Neurology, amongst others. https://www.springer.com/gp/book/9783030240240

• UCSF LGBTQ+ Trainees Speak Out (video) – medical students and a resident speak out about their experiences https://youtu.be/ldBgORJhILU (58:30)

• 10 Ways to Be an LGBTQ+ Ally & a Friend (educational list) (from https://www.glaad.org/resources/ally/2 GLAAD, formerly the Gay & Lesbian Alliance Against Defamation)

• Be a listener.
• Be open-minded.
• Be willing to talk.
• Be inclusive and invite LGBT friends to hang out with your friends and family.
• Don’t assume that all your friends and co-workers are straight. Someone close to you could be looking for support in their coming-out process. Not making assumptions will give them the space they need.
• Anti-LGBT comments and jokes are harmful. Let your friends, family and co-workers know that you find them offensive.
• Confront your own prejudices and bias, even if it is uncomfortable to do so.
• Defend your LGBT friends against discrimination.
• Believe that all people, regardless of gender identity and sexual orientation, should be treated with dignity and respect.
• If you see LGBT people being misrepresented in the media, contact us at glaad.org.

Six Pronoun Practices to Build Trans-Affirming Workplaces & Why They Matter By Eli Green December 16, 2019 https://www.diversitybestpractices.com/six-pronoun-practices-to-build-trans-affirming-workplaces-why-they-matter

https://www.transgendertraininginstitute.com/

• Gender neutral pronoun practice (educational, interactive worksheet) – A guide for how to practice using gender neutral pronouns and how to adapt to a person’s preferred pronouns

http://showyourlovetoday.com/wp-content/uploads/2018/09/Pronoun-Practice.pdf

General Diversity Resources

“Succeeding in Academic Medicine: A Roadmap for Diverse Medical Students and Residents” – January 14, 2020, by John P. Sánchez (Editor) (Book)

This first-of-its-kind book for underrepresented racial and ethnic minorities (URM), women, and sexual and gender minorities in medicine offers the core knowledge and skills needed to achieve a well-planned, fulfilling career in academic medicine. In 12 chapters and with a unique focus on a practical approach to increasing diversity and inclusion in academic medicine, this book demystifies the often-insular world of academic medicine. It comprehensively outlines career opportunities and associated responsibilities, how to transform academic-related work to scholarship, and offers a clear and transparent look into the academic appointment and promotion process. By focusing on the practical steps described in this book, students and residents can develop a strong foundation for an academic medicine career and succeed in becoming the next generation of diverse faculty and administrators.

• “The Common Thread” – the 4 Essential Modules of Cultural Inclusion (UAB School of Medicine) Building Belonging, Understanding Bias, Cultural Competency, and Conflict Resolution https://youtu.be/qeBCqlxaxyY https://youtu.be/sooBTyYzVoY (Videos)

• AAMC Roadmap to Diversity: Integrating Holistic Review Practices into Medical School Admission Processes(PDF) (epublication)

https://store.aamc.org/roadmap-to-diversity-integrating-holistic-review-practices-into-medical-school-admission-processes-pdf.html#additional

This publication offers schools the tools and knowledge to help align admission policies to ensure proper diversity. This publication provides schools with the tools to align admission policies, processes, and criteria with institution-specific missions and goals. It also helps establish ground rules for sustaining the benefits of medical student diversity to support its overall mission and goals.

• Building High-Performing Teams in Academic Surgery: The Opportunities and Challenges of Inclusive Recruitment Strategies. Michigan Promise Working Group for Faculty Life Research. Dossett LA, Mulholland MW, Newman EA, Acad Med. 2019 Aug;94(8):1142-1145. Strategies from University of Michigan https://journals.lww.com/academicmedicine/FullText/…

• Perspectives: The Role That Graduate Medical Education Must Play in Ensuring Health Equity and Eliminating Health Care Disparities (2014) (Review) ¹⁸

Health care disparities still exist. The ACGME places strong emphasis on graduate medical education’s role in eliminating health care disparities by asking medical educators to objectively evaluate and report on their trainees’ ability to practice patient-centered, culturally competent care including collecting data on outcomes by patient race, cultural identification, and language. Moreover, training programs and institutional leadership need to collaborate on ensuring data collection on patient satisfaction, outcomes, and quality measures that are broken down by patient race, cultural identification, and language. A diverse physician workforce is another strategy for mitigating health care disparities and using strategies to enhance faculty diversity should also be a priority of graduate medical education.

https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.201402-068PS

• Robin DiAngelo, “White Fragility: Why it’s so hard for white people to talk about racism,” June 2018. This book challenges racism by working against and understanding what the author terms “white fragility”, a reaction in which white people feel attacked or offended when the topic of racism arises. DiAngelo stresses that all white people play a role in perpetuating white supremacy—and that it is possible for them to change this if they are willing to examine how underlying assumptions influence their behavior. White fragility is the result of socialized beliefs about race, racism, and white supremacy. When white people’s racial comfort is challenged, they feel a range of defensive emotions, which they externalize through negative actions and behaviors. To combat white fragility, white people must first become more aware of their internalized convictions, and then actively teach themselves to respond differently in the moment.

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