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Equity, Quality and Inclusion

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Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training
Hu YY, Ellis RJ, Hewitt DB, Yang AD, Cheung EO, JT Moskowitz, Potts JR, Buyske J, Hoyt DB, Nasca TJ, Bilimoria KY.
N Engl J Med. 2019 Oct 31;381(18):1741-1752.

Rationale for inclusion: This paper is the largest and most comprehensive survey study of resident experiences in training (99.3% response) with regard to discrimination harassment and abuse. It demonstrates widespread and persistent discrimination based on gender and race, similar to other surveys going back decades, links this to burnout and suicidal ideation, and critically, shows large heterogeneity between programs suggesting some departments have successfully addressed some forms of abuse while others have not.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Recognizing and Reacting to Microaggressions in Medicine and Surgery
Torres MB, Salles A, Cochran A.
JAMA Surg. 2019 Sep 1;154(9):868-872.

Rationale for inclusion: Description and recommendations for identifying and responding to discriminatory behaviors frequently encountered in medical and surgical practice

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Estimating Implicit and Explicit Gender Bias Among Health Care Professionals and Surgeons.
Salles A, Awad M, Goldin L, Krus K, Lee JV, Schwabe MT, Lai CK.
JAMA Netw Open. 2019 Jul 3;2(7):e196545.

Rationale for inclusion: Implicit bias testing of self-identified health care providers by Project Implicit IAT as well as Gender-Specialty IAT tested at a national surgical meeting in October 2017. Both implicit bias and *explicit* bias were higher in healthcare providers and surgeons associating men with surgery and career, and women with family and family medicine.  Authors recommend awareness to implicit bias to help negate effects.

CAVEAT: Data Review and cross-sectional study from self-identified health care professionals.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

#EAST4ALL: An introduction to the EAST equity, quality, and inclusion task force
Bonne S, Williams BH, Martin M, Kaafarani H, Weaver WL, Rattan R, Byers PM, Joseph DK, Ferrada P, Joseph B, Santos A, Winfield RD, DiBrito S, Bernard A, Zakrison TL.
J Trauma Acute Care Surg. 2019 Jul;87(1):225-233.

Rationale for inclusion: The introduction of the #EAST4ALL task force outlining the experiences of trauma surgeons, the affect of discrimination and abuse on our patients and workforce and mission statement of the task force.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Reducing Implicit Bias: Association of Women Surgeons #HeForShe Task Force Best Practice Recommendations.
DiBrito S, Lopez CM, Jones C, Mathur A.
J Am Coll Surg. 2019 Mar;228(3):303-309.

Rationale for inclusion: The best practice guidelines from the Association of Women Surgeons #HeForShe task force emphasize departmental strategies for decreasing bias in the work force including cultural shift, bias literacy, counter-stereotypic exposures, deliberate hiring and promotion strategies, mentoring and empowerment.

CAVEAT: Not a study 

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Association of Racial and Socioeconomic Diversity With Implicit Bias in Acute Care Surgery.
Zebib L, Strong B, Moore G, Ruiz G, Rattan R, Zakrison TL.
JAMA Surg. 2019 Feb 20.

Rationale for inclusion: Implicit bias testing of trauma care providers was completed in a "majority minority" diverse city in the United States. Rates of racial bias in favor of whites were significantly lower compared to trauma surgeons from other cities, as was class bias. DIversity may be protective against implicit bias.

CAVEAT: Single center study of multidisciplinary trauma care professionals

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Gender Differences in Academic Medicine: Retention, Rank, and Leadership Comparisons From the National Faculty Survey.
Carr PL, Raj A, Kaplan SE, Terrin N, Breeze JL, Freund KM.
Acad Med. 2018 Nov;93(11):1694-1699.

Rationale for inclusion: A 17-year longitudinal follow-up of the National Faculty Survey that identifies predictors of advancement, retention, and leadership for women faculty.

CAVEAT: Longitudinal follow-up of a prior survey

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Ensuring Equity, Diversity, and Inclusion in Academic Surgery: An American Surgical Association White Paper.
West MA, Hwang S, Maier RV, Ahuja N, Angelos P, Bass BL, Brasel KJ, Chen H, Davis KA, Eberlein TJ, et al.
Ann Surg. 2018 Sep;268(3):403-407.

Rationale for inclusion: This white paper from the American Surgical Association (ASA) appointed a Task Force objectively addresses issues related to equity, diversity, and inclusion with the discipline of academic surgery. 

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine
National Academy of Sciences
National Academies of Sciences, E. and Medicine (2018). Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine. Washington, DC, The National Academies Press.

Rationale for inclusion: Most comprehensive report available on the pervasive nature of sexual harassment in the sciences including medicine, including recommendations for change.  

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Association for Academic Surgery presidential address: sticky floors and glass ceilings.
Greenberg CC.
J Surg Res. 2017 Nov;219:ix-xviii.

Rationale for inclusion: This articulate, data-driven and insightful presidential address for the Association for Academic Surgery addresses gender disparities in surgery.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Gender Parity in Critical Care Medicine.
Mehta S, Burns KEA Machado FR, Fox-Robichaud AE, Cook DJ, Calfee CS, Ware LB, Burnham EL, Kissoon N, Marshall JC, Mancebo J, Finfer S, Hartog C, Reinhart K, Maitland K, Stapleton RD, Kwizera A, Amin P, Abroug F, Smith O, Laake JH, Shrestha GS, Herridge MS.
Am J Respir Crit Care Med. 2017 Aug 15;196(4):425-429.

Rationale for inclusion: This paper discusses the importance of diversity on guideline panels, the disproportionately low representation of women on critical care guideline panels, and existing initiatives to increase the representation of women in corporations, universities, and government.

CAVEAT: Practice guidelines, not a study

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Strategies for Identifying and Closing the Gender Salary Gap in Surgery.
Sanfey H, Crandall M, Shaughnessy E, Stein SL, Cochran A, Parangi S, Laronga C.
J Am Coll Surg. 2017 Aug;225(2):333-338.

Rationale for inclusion: Thorough summary of the gender pay gap in surgery and strategies to remedy the disparity.

CAVEAT: Review

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

National Survey of Burnout among US General Surgery Residents
Elmore LC, Jeffe DB, Jin L, Awad MM, Turnbull IR.
J Am Coll Surg. 2016 Sep;223(3):440-51.

Rationale for inclusion: A national survey of surgical residents showing an astonishing 69% of surgical residents demonstrating symptoms of burnout on at least one scale with women reporting higher rates. 

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

The effect of an intervention to break the gender bias habit for faculty at one institution: a cluster randomized, controlled trial.
Carnes M, Devine PG, Baier ML, Byars-Winston A, Fine E, Ford CE, Forscher P, Isaac C, Kaatz A, Magua W, Palta M, Sheridan J.
Acad Med. 2015 Feb;90(2):221-30.

Rationale for inclusion: This is one of the few single-blind, cluster randomized controlled studies of a gender-bias-habit changing interventions.  The intervention was in the form of a workshop that ultimately resulted in significant increases in self-reported action to promote gender equity and changed the department climate. 

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Unconscious race and class bias: its association with decision making by trauma and acute care surgeons.
Haider AH, Schneider EB, Sriram N, Dossick DS, Scott VK, Swoboda SM, et al.
J Trauma Acute Care Surg. 2014 Sep;77(3):409-16.

Rationale for inclusion: This was a web-based survey of EAST members that found that unconscious preferences for white and upper-class individuals is prevalent among acute care surgeons, although this did not appear to affect clinical decision making.

CAVEAT: Survey

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Reducing implicit racial preferences: I. A comparative investigation of 17 interventions
Lai C, Marini M, Lehr S, Cerruti C, Shin JE, Joy-Gaba J, Ho A, Teachman B, Wojcik SP, Koleva S, Frazier RS, Heiphetz L, Chen E, Turner R, Haidt J, Kesebir S, Hawkins CB, Schaefer H, Rubichi S, Sartori G, Dial CM, Sriram N, Banaji MR, Nosek BA.
J Exp Psychol Gen. 2014 Aug;143(4):1765-85.

Rationale for inclusion: From Brian Nosek of Project Implicit and the Center for Open Science Reproducibility Project, the project was a competetion to identify strategies most effective at reducing implicit bias. The data demonstrates most interventions were ineffective, however, experience with counterstereotypical exemplars, evaluative conditioning methods, and arming subjects with strategies to override biases resulted in measureble decreases in bias. 

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Disparities in trauma care and outcomes in the United States: a systematic review and meta-analysis.
Haider AH, Weygandt PL, Bentley JM, Monn MF, Rehman KA, Zarzaur BL, et al.
J Trauma Acute Care Surg. 2013 May;74(5):1195-205.

Rationale for inclusion: This meta analysis evaluating trauma outcome disparities by race, insurance, and socioeconomic status (SES) found that mortality among trauma patients in the United States is associated with differences in patients' race and SES.

CAVEAT: Observational nature of the included articles and the inherent risks of selection bias and confounding associated with such studies.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Gender differences in the salaries of physician researchers.
Reshma J, Griffith KA, Stewart A, Sambuco D, DeCastro R, Ubel PA.
JAMA. 2012 Jun 13;307(22):2410-7.

Rationale for inclusion: This survey-based study with a 71% response rate found significant gender differences in salary among mid-career academic physicians even after adjusting for differences in specialty, institution, academic productivity, rank and work hours.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Gender differences in the salaries of physician researchers
Reshma J, Griffith KA, Stewart A, Sambuco D, DeCastro R, Ubel PA.
JAMA. 2012 Jun 13;307(22):2410-7.

Rationale for inclusion: This survey-based study with a 71% response rate found significant gender differences in salary among mid-career academic physicians even after adjusting for differences in specialty, institution, academic productivity, rank and work hours.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

The role of unconscious bias in surgical safety and outcomes.
Santry HP, Wren SM.
Surg Clin North Am. 2012 Feb;92(1):137-51.

Rationale for inclusion: Comprehensive review of the evidence in support of unconscious bias and resultant disparate health outcomes. 

CAVEAT: Review article 

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Women in academic surgery: the pipeline is busted.
Sexton KW, Hocking KM, Wise E, Osgood MJ, Cheung-Flynn J, Komalavilas P, Campbell KE, Dattilo JB, Brophy CM.
J Surg Educ. 2012 Jan-Feb;69(1):84-90.

Rationale for inclusion: A trend analysis of AAMC data tracking trends in female medical school enrollment, surgical residency training, and achievement of full professorship at US Medical Schools for the 15 years from 1995 to 2009.

CAVEAT: Simple trend analysis, not controlled for confounding variables

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

Compensation and advancement of women in academic medicine: is there equity?
Ash AS, Carr PL, Goldstein R, Friedman RH.
Ann Intern Med. 2004 Aug 3;141(3):205-12.

Rationale for inclusion: This survey of full-time U.S. medical school faculty found that female medical school faculty neither advance as rapidly nor are compensated as well as professionally similar male colleagues.

CAVEAT: This is a cross-sectional study of a longitudinal phenomenon. No data are available for faculty who are no longer working full-time in academic medicine, and all data are self-reported. 

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

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