Cultural complications: Why, how, and lessons learned. Harris CA, Dimick JB, Dossett LA. Am J Surg. 2020 Sep 8; S0002-9610(20)30567-5.
Problems in ‘diversity, equity and inclusion’ in academic surgery often seem so formidable and deep-rooted that even the most dedicated advocates do not know where to start in addressing them. The authors of this timely article have taken steps to move beyond a perfunctory ‘diversity check box’ to meaningful change. They have developed a first step toward lasting cultural change: a curriculum that frames medical instantiations of structural disadvantage as “Cultural Complications”. The curriculum teaches prevention, recognition and management of cultural complications via a Morbidity and Mortality format. The curriculum was designed for implementation at other institutions, and it can be requested at no charge from culturalcomplications.com
In their paper, the authors describe the basis for the curriculum and provide advice to others hoping to undertake a similar project. They discuss strategies for stage-setting, content delivery, and sustainability. For example, they advise that, in preparation, a prominent institutional leader outside the ‘expected diversity, equity and inclusion space’ should be enlisted. They point out advantages of leveraging the M&M context. They also provide guidance about what kind of resistance to anticipate and how to respond, as well as multiple strategies to improve content delivery.
The last section discusses means of ensuring the sustainability of the educational project. The authors emphasize adaptation to local context, allowance of imperfection, and acceptance that the project will be difficult. For example, they made an explicit decision to avoid ‘moralistic or social justice’ language, due to a judgment that staff who are possible to convince may be driven away by a such rhetoric. This is obviously a difficult judgment to make, and must be based on an assessment of what is possible at the given institution.
This study is limited in that it does not measure outcomes or rigorously evaluate the impact of the curriculum. Ideally, work like this will be used to create testable hypotheses, which are absent at the current stage. Nonetheless, we chose to recommend this publication for three reasons. First, we found the curriculum itself to be extremely enlightening. Second, we find the advice in the perspective to be useful and reflect many pitfalls we have encountered ourselves. Third and above all, as these and other authors (1) seem to understand, it is time for our profession to move beyond passive descriptions of problems with diversity and inclusion to concrete interventions. The cultural complications curriculum is ready to be adapted to your institution, provided you are willing to do the requisite work.
1. Effects of Gender Bias and Stereotypes in Surgical Training: A Randomized Clinical Trial. Myers SP, Dasari M, Brown JB, Lumpkin ST, Neal MD, Abebe KZ, Chaumont N, Downs-Canner SM, Flanagan MR, Lee KK, Rosengart MR. JAMA Surg. 2020 Jul 1;155(7):552-560. doi: 10.1001/jamasurg.2020. 1127. PMID: 32432669; PMCID: PMC7240638.
The Role of Race and Gender in the Career Experiences of Black/African-American Academic Surgeons: A Survey of the Society of Black Academic Surgeons and a Call to Action. Crown A, Berry C, Khabele D, Fayanju O, et al. Ann Surg. 2020 Sep 15.
Discrimination in the workplace is an ongoing problem in our field. The recent ABSITE-based survey of surgery residents (2) and this past year’s #EAST4ALL survey present useful data characterizing surgeon and trainee opinions about the prevalence of discrimination and harassment. However, upon noting that 16.6% of residents perceive discrimination on the basis of race, readers may wonder about the responses of certain racial/ethnic subgroups. According to this survey of the Society of Black Academic Surgeons (SBAS), the actual prevalence of racial bias in the workplace is much higher. This article has many strengths. The review of the literature in the introduction and discussion would be helpful to most readers seeking a greater understanding of failures in diversity within academic surgery, and there is a focus on the unfair disadvantages faced by Black/African American women surgeons.
The survey itself was developed by and administered to members SBAS. They received 53 responses from the 181 members anonymously surveyed, including 31 women. Significant differences in work/life issues are noted between men and women. For example, all 22 men were married, compared to 61% of women surgeons. Men were more likely to have attained a full professorship (41% vs 7%), although, in aggregate, they were older than women. Survey respondents were also asked to provide free text explanations of barriers to gender equity in the workplace. These responses are directly published in a supplemental document. Responses reflecting discrimination are striking: 97% of women experienced gender bias in the workplace, compared to 27% of men. 84% of women and 86% of men experienced racial bias. Only 1 of 31 women felt that salaries amongst academic surgeons were ‘equal’, compared with 7 of 22 men.
The study has a few limitations worth noting. The response rate was 29%, and it is possible that surgeons who had experienced discrimination would be more likely to participate. Also, 48% of men were over 50 years old compared to 31% of women, which could impact gender-based comparisons. Lastly, as has been true of multiple similar surveys, questions about discrimination did not appear to specify the victimized group (it may not have been clear to men whether they would be endorsing gender discrimination against themselves, or against women).
Despite these limitations, this study also helps to directly amplify the voices of black women surgeons. The dramatic findings above speak for themselves and highlight the importance of asking questions about discrimination directly to those who are most affected. These findings suggest that the prevalence of racial bias in academic surgery workplaces is much higher than one might think.
2. Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training. Hu YY, Ellis RJ, Hewitt DB, Yang AD, Cheung EO, Moskowitz JT, Potts JR 3rd, Buyske J, Hoyt DB, Nasca TJ, Bilimoria KY. N Engl J Med. 2019 Oct 31;381(18):1741-1752.
Perceptions of Equity and Inclusion in Acute Care Surgery: From the #EAST4ALL Survey. Tseng ES, et al. Ann Surg. 2020 Dec;272(6):906-910.
Only recently have trauma and acute care surgery (ACS) societies started to address deficiencies in equity and inclusion in the trauma surgery profession. The Eastern Association for the Surgery of Trauma was among the first to establish an Equity, Quality and Inclusion in Trauma Surgery Practice Task Force to increase awareness and provide education regarding the extent of inequity and exclusion in the field of ACS. The Task Force was charged with designing and executing a survey to examine the demographics, as well as exclusionary and biased behaviors witnesses or experienced by EAST members.
This validated, online, cross-sectional mixed methods survey evaluated disparities in acute care surgery associated with gender, race, ethnicity, sexual orientation, sexual identity and other potential sources of bias. There were 306 respondents, most of whom identified as white, non-Hispanic and male. Overall, 41.4% of respondents reported witnessing or experiencing unwanted sexual advances, or obscene or sexist remarks, and 40% reporting observing or experiencing prejudice, discrimination or antagonism directed against someone of a different race or ethnicity over the past year. Over half of the female respondents had witnessed or experienced sexual harassment, whereas 48.6% of surgeons of color witnessed or experienced racial/ethnic discrimination. Unequal or exclusionary behavior was more often observed in the workplace as opposed to academic conferences. Women were more likely than men to report unfair treatment due to age, appearance or sex.
This important survey is a necessary step towards raising awareness about the current state of diversity, equity, and inclusion within the trauma surgery profession. Despite a 13% response rate, which may limit the generalizability of some of the findings, these striking results suggest that mechanisms to address discrimination and harassment are lacking at the institutional level. Societies and organizational leaders must prioritize issues of equity and inclusion in the surgery community, and develop focused initiatives to correct them.
Disparities in Timing of Trauma Consultation: A Trauma Registry Analysis of Patient and Injury Factors. de Angelis P, Kaufman EJ, Barie PS, Narayan M, Smith K, Winchell RJ. J Surg Res. 2019 Oct;242:357-362.
Equity, diversity and inclusiveness have been a major focus in the profession of surgery. Discrimination in medicine at the physician or patient level plays an essential role in patient outcome. This has never been more apparent than in the COVID pandemic, where persons of color have had disproportionate rates of death compared to their white counterparts. The authors investigate the existence of bias at a single level I institution to determine the morbidity and mortality of the population.
In trauma, undertriage can be detrimental to patients and should be no more than 5% by ACS-COT standards. Black and Latino, female and older patients are more likely to experience morbidity and mortality after trauma. This may be secondary to bias that begins on presentation. The authors investigate the impact of race and gender at triage at a single Level I trauma center. Using their registry, the authors reviewed the time to consult for trauma patients as well as the appropriateness of triage. They identified 588 adult patients in their 18-month study who did not undergo activation and had consults to the trauma service. Based on their activation criteria, 14.1% of patients should have triggered activation. Importantly, black patients had an increased time to consult compared to white, while Asian/Pacific Islanders had lower time to consult. Overall, men had a shorter time to consult than women. There was no association between time to consult and ED crowding. Most of the patients were admitted, 476 patients (77.6%), with a median length of stay (LOS) of 3 days. Thirty-three patients (5.6%) went directly to the operating room, and 182 (31.0%) were admitted to the intensive care unit (ICU). Twelve patients died (2.0%). While time to consult was not significantly associated with mortality, one can only infer that this may be secondary to the sample size. The associations with longer time to consult for black and female patients were maintained after controlling for injury-related variables.
The study is limited by the sample size and it is from a single center. Further analysis over longer periods, and to include other centers would add insight into this phenomenon. The authors however, demonstrate that diversity, equity and inclusion extends to our patient population and should remain at the forefront in decreasing bias.
Effects of Gender Bias and Stereotypes in Surgical Training: A Randomized Clinical Trial. Myers SP, Dasari M, Brown JB, et al. JAMA Surg. 2020;155(7):552-560.
Diversity and inclusion in medicine is fundamental to continued growth and progress. Justice Powell defined this clearly in 1978, in the Supreme Court decision of Regents of University of California v. Bakke. He stated, “Holistic evaluation of applicants including the consideration of demographic characteristics, in addition to academic metrics” of medical students, “may bring to a professional school of medicine experiences, outlooks, and ideas that enrich the training of its student body and better equip its graduates to render with understanding their vital service to humanity” (3). In 2021, how to realize this and improve the representation of women and minorities in surgery is unresolved.
Understanding the different factors that contribute to underrepresentation remains key and Myers et al. investigate the underrepresentation of women in surgery and the impact of stereotypes. By performing a novel study survey and intervention, the authors demonstrate how a pro-male gender bias may influence the performance of surgical trainees. They perform a double blind randomized clinical trial of three academic general surgery programs utilizing surveys and brief interventions, and the impact on residents’ performance in the Fundamentals of Laparoscopic Surgery assessment.
In the first phase, the authors investigate the association between gender bias and research-related career engagement among trainees, and then in phase 2 they sought to understand the interaction between gender and stereotype threat on laparoscopic skill performance. Stereotype threat is the risk of confirming a negative stereotype, and contributes “to measurable differences in technical skill performance by depleting executive function and siphoning attention away from the task at hand”. Research subjects were required to have completed undergraduate medical education in the US and be interested in pursuing teaching or research as a principal component of their career to be included. Using validated scales to assess equity and fairness, susceptibility to stereotype threat, sense of belonging, resilience, career engagement, and identification with the domain of surgery, surgical residents answered a 55-question survey in phase 1. In phase 2, residents were randomized to receive a threat or protection. This occurred by way of the trainee reading either abstracts of two articles that reported women performed worse with regards to laparoscopic skills than men, or two abstracts that reported no gender-based differences in laparoscopic skills performance. Residents were surveyed after the FLS exam with the inclusion of additional questions on their self-assessment of their performance.
Of the 131 residents who met criteria for inclusion, 77 residents (91%) completed the study. Male residents who had a higher perception of pro-male bias had higher career engagement scores. However, no significant association was noted between perception of pro-male bias and career engagement scores among women. Men had significantly higher susceptibility to stereotype threat scores than women did on both surveys, while women had higher resilience scores than men. For women with a higher susceptibility to stereotype threat, a trigger of stereotype threat was associated with lower FLS scores, while protection against stereotype threat was associated with higher FLS scores. The authors conclude that negative stereotypes can be detrimental to operative performance for women and contributes to the underrepresentation of women in medicine. The sample size is small and the authors make no mention of racial differences. Race plays is a major role in both training and patient outcomes, and it would have been helpful to identify how this could influence the responses of participants. Nevertheless, although limited by the sample size and the impact of race/ethnicity, the study makes an important contribution to the literature and indicates the significance of removing gender biases in training.
3. Holistic review in medical school admissions and selection: a strategic mission–driven response to shifting societal needs. Conrad S, Addams A, Young G. Acad Med. 2016; 91:1472–1474.