Diversity, equity, and inclusion within the Society for Pediatric Anesthesia: A mixed methods assessment

Myron Yaster MD and Lynne G. Maxwell MD

In today’s PAAD, Lynne and I will review a paper by Reece-Nguyen TL et al.(1) which is based on a survey of members of the Society for Pediatric Anesthesia.  There’s a lot to unpack in the survey results but before reviewing it, I feel compelled to make some very personal comments which reflect my personal views and do not reflect the views of SPA’s Board of Directors or the executive council of Ron Litman’s Pediatric Anesthesia Article of the Day. 

When I founded SPA in 1985/6, I had 3 goals which were incorporated into SPA’s mission statement: “The Society for Pediatric Anesthesia advances the safety and quality of anesthesia care, perioperative care, and pain management in children by educating clinicians, supporting research, and fostering collaboration among clinicians, patient families, and professional organizations worldwide”.  In the beginning, the “supporting research” goal was a dream rather than a reality.  No longer.  Today’s paper is yet another testimony to the efforts of the Society and its members to constantly improve our profession.  Just think of the Pediatric Difficult Intubation Registry (PeDIR) as an example.  Today’s topic, diversity, equity, and inclusion is another. This research and its aims are very personal and are essential to our survival. 

At Hopkins, in the 1980s, the obvious and overt issue was not racism and/or anti-semitism (it had been in the past, think Vivien Thomas and the Blalock Taussig shunt).  It was the failure of women to get promoted to the ranks of Associate Professor or Professor and really to any position of leadership in the institution. This changed in the 1990s when the Dean and CEO of the Hospital and Medical School, Dr. Ed Miller and the Chair of Medicine, Dr. John Stobo, said this was no longer tolerable or acceptable.  They made it their business to demand change and that Department Chairs, Division chiefs would be held responsible and either had to fix this or they would be removed from their positions regardless of grants, publications, and national reputation of their Departments and Divisions.  I saw this firsthand.  At a meeting of the adult pulmonary division which I attended (I was there to talk about pain in Sickle Cell Anemia and Acute Chest Syndrome), the following occurred.  This division of internal medicine was one of the best and largest in the country and the University.  It had a Nobel prize and Lasker award winners on its faculty.  Dean Miller opened the meeting and was there to give a “state of the union” address.  While pulling his index cards out to give his lecture, he looked around the room, put his index cards away, and asked the division chief, “do you see anything wrong here?”  Obviously not, this was after all the best of the best.  They had more grants and publications than most departments of medicine at Hopkins or anywhere else.  The Dean then said, looking at the Division chief in the eye and everyone else present, “there are no women in this group above the rank of assistant professor….you have 12 months to fix this or you and your leadership team are gone!” Drop the mic, shocked silence.  Within the year, women were not only promoted but actively recruited to positions of leadership.

This is what effective leadership can do.  Instead of ranking Departments and Divisions by their NIH grants and numbers of publications, isn’t it time to also rank them by the diversity of their faculty?  I think doing this would result in dramatic change.  Myron Yaster MD

Original article

Reece-Nguyen TL, Lee HH, Garcia-Marcinkiewicz AG, Szolnoki J, Fernandez AM, Mukkamala S, Lalwani K, Deutsch N, Jimenez N. Diversity, equity, and inclusion within the Society for Pediatric Anesthesia: A mixed methods assessment.  Paediatr Anaesth. 2023 Jun;33(6):435-445. doi: 10.1111/pan.14642. Epub 2023 Feb 7. PMID: 36715575

In 2018, the Society for Pediatric Anesthesia created the Diversity, Equity, and Inclusion committee in 2018 to prioritize diversity work.  In 2020, the Committee implemented a baseline survey of the Society’s members to assess demographics, equity in leadership, inclusivity, and attitudes toward diversity work.  Out of 3 242 SPA members, 1 232 completed the survey (38%).  What did they find?

“Respondents were 52.7% female, 55.7% non-Hispanic White, 88.6% heterosexual, 95.7% non-military, 59.2% religious, and 2.1% have an Americans with Disabilities Act recognized disability. All major United States geographical areas were represented equally with 71% practicing in urban areas and 67% in academic settings. Compared to men, women are less likely to be in leadership roles (p < .003), but the authors found no difference in participation and leadership when stratified by race/ethnicity, geography, international medical graduate status, or sexuality. Racial/ethnic minorities (p < .028), women (p < .001), and lesbian, gay, bisexual, transgender, and queer members (p < .044) more frequently hold lower academic rank positions when compared to white, heterosexual, and male members. Half of respondents were unsure whether diversity, equity, and inclusion challenges existed within the Society for Pediatric Anesthesia while the other half demonstrated opposing views. Among those who reported diversity, equity, and inclusion challenges, the themes centered around persistent marginalization, the need for more inclusive policies and increased psychological safety, and lack of leadership diversity”. The selection of comments presented in the article’s Table 4 reflects the diversity of opinions submitted by the respondents.

There is much to unpack in their results. First, women are doing a lot better in academic promotion and attaining leadership positions.  This is in no small part due to the efforts of SPA Women's Empowerment and Leadership Initiative (WELI).(2,3)  Second, a significant racial and ethnic representation gap exists since only 13.6% of survey respondents identify as Black or Hispanic themselves (6.3% and 7.3%, respectively).  This is essentially unchanged and is significantly lower than the number of Black and Hispanic medical students who enter anesthesia residencies.  This represents “a failure to recruit Black and Hispanic applicants at the residency and fellowship level”.(1)  In our view this is also an opportunity to improve with new programs modeled on the successful WELI program and Mission-Driven Mentoring Programs (MDMP).(4)  Third, this study broadened the definition of what constitutes racial and ethnic minorities to include other minoritized groups such as the LGBTQ+ community and people with disabilities.  Fourth, the response rate was only 38%.  This is a problem with all surveys and may seriously have biased the results.  Indeed, there was no consensus amongst respondents on whether DEI was a problem within our specialty.  It is possible that members chose to participate in our survey due to their own minority demographic characteristics or experiences, resulting in a possible overestimation of diversity within SPA due to self-selection bias. Finally, a design flaw in the survey did not disaggregate data from Asian respondents from other ethnic minorities and was a missed opportunity to understand the views of this important subgroup.

Please send your thoughts and comments and Myron will post in the Friday Reader response.

References

1.           Reece-Nguyen TL, Lee HH, Garcia-Marcinkiewicz AG, Szolnoki J, Fernandez AM, Mukkamala S, Lalwani K, Deutsch N, Jimenez N. Diversity, equity, and inclusion within the Society for Pediatric Anesthesia: A mixed methods assessment. Paediatr Anaesth 2023;33:435-45.

2.           Schwartz JM, Markowitz SD, Yanofsky SD, Tackett S, Berenstain LK, Schwartz LI, Flick R, Heitmiller E, Fiadjoe J, Lee HH, Honkanen A, Malviya S, Cladis FP, Lee JK, Deutsch N. Empowering Women as Leaders in Pediatric Anesthesiology: Methodology, Lessons, and Early Outcomes of a National Initiative. Anesth Analg 2021;133:1497-509.

3.           Schwartz JM, Wittkugel E, Markowitz SD, Lee JK, Deutsch N. Coaching for the pediatric anesthesiologist: Becoming our best selves. Paediatr Anaesth 2021;31:85-91.

4.           Nafiu OO, Haydar B. Mentoring Programs in Academic Anesthesiology: A Case for PROFOUND Mentoring for Underrepresented Minority Faculty. Anesth Analg 2019;129:316-20.