Houston we have a problem: Diversity, Equity, and Inclusion in Anesthesiology: Part 1
Myron Yaster MD and Lynne G. Maxwell MD
The June issue of Anesthesia and Analgesia had 3 original articles and an editorial on the diversity, equity, and inclusion failures of our profession and of our training programs. They provide insights into opportunities for improvement, potential solutions, and evidence for why this matters. To do justice to these overlapping papers, we’ll review these papers in 2 parts, today and tomorrow. As always, your thoughts and opinions on this (and other PAADs) are important to us. So please send your thoughts to me (myasterster@gmail.com) or John Fiadjoe (john.fiadjoe@childrens.harvard.edu ) Myron Yaster MD
Editorial
Toledo P. Expanding Horizons: How Anesthesiologists Can Improve Health Equity. Anesth Analg. 2022 Jun 1;134(6):1164-1165. PMID: 35595690 1
Original article
Nwokolo OO, Coombs AAT, Eltzschig HK, Butterworth JF 4th. Diversity and Inclusion in Anesthesiology. Anesth Analg. 2022 Jun 1;134(6):1166-1174. PMID: 35130194 2
Original article
Diallo MS, Tan JM, Heitmiller ES, Vetter TR. Achieving Greater Health Equity: An Opportunity for Anesthesiology. Anesth Analg. 2022 Jun 1;134(6):1175-1184. PMID: 35110516 3
Original article
Wixson MC, Mitchell AD, Markowitz SD, Malicke KM, Avidan MS, Mashour GA. Raising Anesthesiology Diversity and Antiracism: Launching a National Initiative. Anesth Analg. 2022 Jun 1;134(6):1185-1188. PMID: 35595691
The consequences of slavery, the “original sin” of America, remain very much with us today. Racism, subtle, overt, long-standing, and structural, affects many aspects of our personal and professional lives. As pediatric anesthesiologists we think of ourselves as being above all of this, after all we are enlightened, caring professionals… yada yada…indeed, if anything we are “anti-racists”…but are we?
As a specialty, we’ve made tremendous strides in addressing gender diversity4 and increasing Asian Americans into our practices, but we have done a piss poor job of training and recruiting black, Hispanic, and Native American individuals. In my (MY) former practice (Colorado), there were virtually no black medical students, housestaff, fellows, or attendings…nada…zero! Hispanics? A bit better, but still ridiculously few in a State that is 20% Hispanic. Nationally the numbers reported in today’s reviewed papers are simply startling (< 5%) and have not really changed in decades. This is even worse in light of the fact that more than half of the children born in the US are now from racial/ethnic minority groups. Today and tomorrow’s PAAD reviews 3 papers and an editorial that address structural racism and lack of racial diversity in anesthesiology training programs and practices. To imply that the pipeline is broken or leaky presumes that it once was working. It never was. Fixing this workforce problem will be difficult or impossible unless and until we recognize the issues that have created it. As W. Edwards Deming, who was widely acknowledged as the leading management thinker in the field of quality said “every system is perfectly designed to get the results it gets”.
The editorial by Toledo presents an overview and illuminates all 3 of the original articles in this issue of the journal. It serves as a roadmap to read and offers suggestions for how we can improve health equity. She reinforces a basic idea: “we should apply the principles that have led to our past successes in patient safety to addressing equity”. We couldn’t say it any better ourselves.
Nwokolo et al. open their article with this: “Given that the clinical care in perioperative medicine includes patients of all ages, ethnicities, sexual orientation, and backgrounds, it is intuitive that anesthesiology departments and professional organizations need to be diverse if they will effectively represent these patient groups and fulfill the demands posed by this unique work environment. Nevertheless our reality is different”.2 “Many organizations, after self-examination, are currently prioritizing diversity and inclusion… After overtly racist or sexist barriers are removed, many assume that problems related to diversity have been solved, overlooking the implicit, structural, or institutional barriers that remain..2 This is what I (MY) experienced in Colorado. Much of these kumbaya, rosy-eyed statements are simply window dressing. Dr. Monica Cox in a tweet, put it best: “instead of showing me your diversity statement, show me your hiring data, your discrimination claim stats, your salary tables, your retention numbers, your diversity policies, and your leaders’ public action against racism (and anti-semitism)”. We would add, why in academic departments are the only important benchmarks used in hiring and rating leaders and departments their NIH funding and publication numbers? Why aren’t our leaders rated by their diversity numbers, recruitment and retention numbers? And if they fail, why aren’t they held accountable?
The numbers are simply terrible. The AAMC reports that minorities who are of Black, Hispanic, or Native American origin represent 6.2%, 5.3%, and 0.2%, respectively, of the graduating physicians in 2019.5 The numbers in anesthesiology are even worse.5 We want to underline that this is NOT about affirmative action or a political ideology. This is about benefit to the organization. “Business consultant companies have consistently shown the improved profitability and performance of corporations with greater gender and racial diversity”.6 “The business literature identifies validated organizational strategies and benchmarks for building and maintaining a diverse workforce that can be adapted for anesthesiology departments.”2 Some essential components identified by Nwokolo et al. include: leadership and departmental buy-in, recruitment and retention policies, a departmental culture of fairness, education, mentorship and sponsorship, term limits, and the development of outreach programs.
We’d like to focus on these.
Leadership and departmental buy-in: It all starts at the top but must also be bottom up. If leadership at the dean and departmental chair level haven’t bought in and endorsed placing diversity and inclusion as part of their core missions and if they do not have clear objectives and metrics to produce change, nothing will happen. “Dayenu” (from the Passover Haggadah/seder…roughly translated: “that would be enough for us”).
Recruitment and retention policies: “Women and minority recruits may face unique challenges in a nondiverse workforce; therefore, targeted recruitment and cluster hires may also be advantageous in diversity efforts. For instance, it might be advantageous to recruit 2 (or more) females at that time to create allyship in a predominantly male group.”2 “Dayenu”
Education: “…done correctly, there may be reduction in bias during candidate recruitment and selection process, and fewer challenging interactions across gender, racial, and ethnic lines between colleagues and patients”. “Departments should avoid using diversity and bias training as a “check box” aimed to provide leaders and institutions with “plausible deniability” (in the event of a lawsuit), rather the training should be focused on actually improving diversity.”2 “Dayenu”
Departmental fairness culture: “Departments that evaluate members of the faculty based on competency rather than arbitrary metrics, point systems, or a “good old boys club” are more likely to retain a diverse workforce. Strategies to foster this culture of fairness would likely include transparency in salary structure and promotion opportunities, and a commitment to adjustments when disparities are identified.”2 Departmental leadership opportunities for underrepresented minorities (URM) should not be limited to DEI positions. “Dayenu”
Mentorship and Sponsorship: “minority physicians are more likely to come from environments with few relatives or neighbors who are physicians who could provide mentorship. Mentors help navigate institutional norms, career progress, research aspirations, and provide risk assessments. Appropriate mentors for women and minorities increase the likelihood of retention and academic promotion, and increase publication success.”2 “Dayenu”
Term limits: “when leaders remain in their roles for indefinite periods of time, it reduces the opportunities for a more diverse group. Departmental leadership positions with term limits create “built-in” opportunities for new staff, generating new ideals and creating a sense of value.”2 “Dayenu”
Outreach programs: We will discuss this in great detail in tomorrow’s PAAD.
Summary: These papers are really calls for action. The pipeline from high school to college to medical school is simply broken. The Society for Pediatric Anesthesia has had spectacular success with its Women Empowerment and Leadership Initiative (WELI) (thank you Drs. Jenny Lee, Nina Deutsch, Jamie Schwartz, and others!), and has recently formed a Diversity and Inclusion committee under the chairmanship of Dr. Nathalia Jimenez, MD. Perhaps the WELI model should be expanded or reimagined for under represented minorities as an urgent step forward. Finally, we shouldn’t be waiting for another 10 or 20 years to address this urgent issue. Perhaps as stated above, our leaders and departments need to be judged on how well they recruit URM as well as by how many NIH grants and papers they publish in journals.
We’ve unpacked a lot of information in today’s PAAD. More to follow tomorrow. And again, don’t hesitate in sending us your thoughts. We’ll publish in a reader response.
References
1. Toledo P: Expanding Horizons: How Anesthesiologists Can Improve Health Equity. Anesth Analg 2022; 134: 1164-1165
2. Nwokolo OO, Coombs AAT, Eltzschig HK, Butterworth JFt: Diversity and Inclusion in Anesthesiology. Anesth Analg 2022; 134: 1166-1174
3. Diallo MS, Tan JM, Heitmiller ES, Vetter TR: Achieving Greater Health Equity: An Opportunity for Anesthesiology. Anesth Analg 2022; 134: 1175-1184
4. 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: 1497-1509
5. Association of American Medical Colleges: Diversity in Medicine: Facts and Figures 2019, 2020
6. McKinsey and Company: Diversity wins: How inclusion matters, 2020