Shoring up the pipeline: Increasing diversity in surgery by enhancing equity and inclusion in the surgical learning environment

HIGHLIGHTS

  • Describes the importance of increasing diversity in surgery at the key phases of surgical training: recruitment, retention, and promotion
  • Identifies how mentorship and sponsorship enhance equitable recruitment of surgeons
  • Explores how policies that address both traditional and nontraditional family structures increase surgeon diversity and retention
  • Summarizes how diverse role models help maintain an inclusive surgical culture beyond residency

Arguably delayed, the importance of diversity among health care professionals—that is, a broad representation of viewpoints, socioeconomic backgrounds, gender, sexual orientation, disability status, race, and ethnicity—and its impact on patient care and outcomes is increasingly recognized.1 How do we, as surgeons, create and sustain a more diverse, equitable, and inclusive profession? Attempts to improve diversity often focus on increasing the number of diverse individuals admitted into the medical education system; however, it is evident that this approach alone is incomplete.2-4 Many diverse individuals are being lost to attrition along the way through leaks in the pipeline.

Evaluation of and improvements to the surgical learning environment can help identify and plug the attrition leaks encountered along the continuum of surgical training. A medical student’s first impression of the surgical learning environment, often through student clerkships, influences whether they perceive themselves as “the kind of person who can be a surgeon.” Ongoing immersion in the environment further exposes the student to overt and covert messages that either confirm or refute the perception of fitting the surgical mold.

Equity and inclusion are critical adjuncts to diversity in the surgical learning environment.5 Equity means being fair and impartial through assurances of equal access to the same opportunities. Equity is distinct from equality, which means treating everyone the same and is based on the unrealistic assumption that each individual is starting from the same point. Consider this example: not all surgeons are the same height. Standing at the operating room table to watch or retract can become uncomfortable when the table is too high or too low. Equality would dictate providing everyone with the same height step to reach the operating table regardless of need or surgeon height—thus, the six-foot surgeon, the four-foot surgeon, and the surgeon in a wheelchair all get the same six-inch step. Equity would entail raising or lowering the table, providing steps of varying height, or providing assistive equipment depending on individual needs (see Figure 1).

Inclusion involves providing opportunities to those individuals who might otherwise be excluded or marginalized.5 In medicine and surgery, inclusion means ensuring that traditionally recognized groups such as women and racial and ethnic minorities are part of the picture; however, inclusion also necessitates reflecting on and expanding commonly held definitions of diversity. Other less recognized groups also benefit from intentional inclusion efforts, including individuals with different socioeconomic status, physical abilities, cultural practices, or gender and sexual identities.6 Inclusive environments integrate individuals with different needs without drawing attention to their differences.

If we want to repair the leaking pipeline and make a more equitable and inclusive surgical training environment, we need to examine the structural, environmental, and cultural aspects that may intentionally or unintentionally contribute to “othering” during surgical training.5 In this article, we explore ways to increase diversity in surgery through equity and inclusion at the key phases of surgical training: recruitment, retention, and promotion (see Figure 2).

Recruitment

Julie Freischlag, MD, FACS, FRCSEd(Hon), DFSVS, President-Elect of the American College of Surgeons (ACS), has noted that a turning point for women in academic surgery occurred when The Ohio State University, Columbus, appointed Olga Jonasson, MD, FACS, to serve as the first woman chair of surgery. As Dr. Freischlag has stated, “Dr. Jonasson becoming chair showed us all that it could be you being chair.” This quote from Dr. Freischlag, the first woman chair of surgery at Johns Hopkins School of Medicine, Baltimore, MD, demonstrates a key principle to increasing diversity, equity, and inclusion in the surgical workforce—role models in leadership positions encourage a diversified workforce.7 Relating to and seeing yourself in your leaders can motivate individuals to strive for those positions. If those same role models also become mentors and sponsors of rising scholars, their effect on diversity in the field of surgery is amplified.

Both mentorship and sponsorship are vital to the successful recruitment of diverse individuals into surgery. A mentor is an experienced person who can provide guidance to other, typically less experienced individuals, whereas a sponsor provides more active support by presenting juniors as candidates for promotion, awards, committee positions, and other career advancement opportunities.8

One survey of surgeons from underrepresented in medicine (URiM) backgrounds demonstrated three factors that contribute to the success of these individuals: seeing surgeons from similar backgrounds serve as role models; participating in URiM organizations, such as the Latino Medical Student Association or Society of Black Academic Surgeons to increase exposure to possible career trajectories; and engaging in formal mentorship relationships that ultimately led to increased opportunities via sponsorship.9 Indeed, medical student mentorship of high school students has demonstrated that early exposure to career-specific mentorship benefits individuals from URiM groups who otherwise may have considered a career outside of medicine or surgery.10

A growing body of organizational development literature demonstrates that mentorship is more effective than other initiatives aimed at increasing workforce diversity.11 One of the toughest challenges to developing a diverse workforce is addressing implicit biases. Interestingly, upon entering an assigned mentor-mentee relationship, mentors have been shown to undergo cognitive changes that allow them to see their mentees as protégés who are deserving of advancement, rather than viewing their mentees on the basis of race or gender.12

Sponsorship has gained new focus in medicine, though it has played a longstanding role in corporate culture.13 Often, sponsorship relationships develop organically between same-gender or same-race individuals; female residents, in particular, may seek female mentors and sponsors as examples of women who have succeeded in a traditionally male-dominated profession. However, it increasingly has been recognized that factors such as lack of opportunity or lack of power on the part of the sponsor may reduce the efficacy of same-sex or same-race sponsorship, highlighting the importance of cross-gender and cross-cultural mentorship and sponsorship.14

Critical to increasing diversity in surgery is a recruitment process that is standardized and free of explicit or implicit bias. Despite an abundance of research that indicates diversity can enhance problem solving and increase productivity and efficiency, general surgery residencies lag behind the general population of the U.S. with respect to sexual identity, racial, and ethnic diversity.15,16 That these gaps persist, despite being recognized for decades, is indicative of inherent problems with the resident selection process.

One critical issue in the selection process is the high cost of the residency interview process itself, both for applicants and for institutions. A 2018 study showed that the average cost of the interview process across 128 institutions was $100,438 for university-based programs.17 This expense is compounded by the potential costs of attrition and/or remediation incurred as the result of “poor selection,” which may exceed $3,000 per episode of intervention.18 Well-qualified candidates with financial hardship also may have limited ability to apply to multiple or faraway programs because of cost.

Adopting structured interviews for residency positions encourages a process that fairly and reliably assesses candidates and promotes diversity and decreases personal bias, allowing interviewers to concentrate on objective criteria and scoring systems. Providing training on how to ask questions, explaining the process of objective assessment, and including specific recommendations for interview day can significantly improve inter-rater agreement.19 Other methods to increase diversity during the selection process include minimizing the use of screening tools such as standardized tests, creating a diverse and inclusive interview team, and reexamining the institutional decision-making process.18

Virtual interviews may be used to open the door to more diverse candidates. The surgery community converted to virtual interviews for fellowship and residency programs to adapt to the coronavirus 2019 (COVID-19) pandemic. Those who may have been discouraged to interview for cost or time constraints now have the ability to participate. This decreases costs for programs while increasing the diversity of the applicant pool. Although the results of this process have yet to be evaluated, the successes or failures of this process will be illuminating. We encourage programs to examine their interview processes to ensure effective and fair strategies to select candidates.

Attrition

Once diverse candidates have matriculated into surgical residency, the focus must shift to retention. Surgical residents at highest risk for late attrition are Hispanics, women, and trainees in military programs.2 Factors associated with attrition in residency are manifold; residents may leave for lifestyle or family reasons, but more often attrition results from a lack of mentorship, marital issues, workload, and length of training.20

Although men and women have similar cumulative attrition during the first three years of residency, beyond that point, women have a significantly higher cumulative attrition.21 In a survey of interns, women reported that surgery was an unwelcoming career, a reason for leaving secondary to difficulty in maintaining work-life balance, limited flexibility in training, and lack of role models.3 More women consider leaving residency, and married women with children reported the highest levels of residency-induced strain on family life.22,23 Research also has shown that Hispanic residents are more likely to start training while starting a family and have more difficulty balancing family and work during their internship.2 These data underscore the importance of supporting all residents as they seek to achieve work-life balance.

Systemic support systems

Most residents find surgical training extends well into the typical time frame of starting a family and female residents’ peak reproductive years.24 As an increasing number of women enter surgery and the paradigm of household gender roles continues to shift, programs must work to support family planning during training.25 At present, there is a lack of uniformity in policies regarding parental leave, access to childcare, and availability of facilities to express and store breast milk.26 Each of these areas can be significantly improved to maintain a culture of diversity and inclusion during training.

To address some of the concerns related to work-life balance, the American Board of Surgery recently expanded its leave policy, as has the ACS. Effective the 2019–2020 academic year, residents may take documented leave to care for a new child, including birth, adoption, or placement of a child in foster care; to care for a seriously ill family member; or to recover from a personal serious illness. With these changes, residents qualify for up to six weeks of paid leave per academic year. We recommend that those authoring parental leave policies at the local level collaborate with national board leaders to develop consistent standards for traditional and nontraditional family structures.27

Recognizing the importance of helping trainees maintain well-being, including the support of their families, is integral to retaining a diverse workforce. Several studies have highlighted the provision of childcare as a way of supporting women trainees; women surgeons are more likely to have a spouse working outside the home and are more likely to feel that child-rearing duties slowed their professional advancement.28

As traditional gender roles and child-rearing practices continue to evolve, these considerations become important for male trainees as well. Subsidized, on-site childcare with extended hours is one approach to ease the strain on residents who have children.29 At the Mayo Clinic, Rochester, MN, a sick-child daycare program helps parents avoid missing work, and the medical center reports that the workdays saved offset the day care center’s operating costs.30 Surgical educators should recognize that family obligations and roles extend beyond the traditional nuclear family unit and, as a result, should develop robust support structures to support diverse life experiences during residency.

Optimal educational support

Retaining diversity within surgical residencies requires programs to foster the personal growth of each trainee. It long has been presumed that all trainees enter residency with the same basic skills and knowledge, including the ability to successfully self-regulate their own learning. The latter is an assumption that may be incorrect as the diversity of our trainees increases, and it is important that institutions and the learning environment support and actively help residents develop the self-directed learning skills they will require throughout their career. It therefore is necessary that training programs shift from a teacher-centered approach, where learners passively receive knowledge from educators, to a student-centered approach, where learners shape their own understanding.31

Moving toward a student-centered approach will involve variety, creativity, and flexibility in our educational strategies. At present, surgical education relies heavily on textbook readings and traditional didactic lectures combined with sufficient clinical exposure to ensure competence. This approach favors trainees who prefer to learn by reading or writing; however, surgical trainees often are kinesthetic or multimodal learners.32 By transitioning to a multimodal educational approach that includes visual presentations, audio recordings, written outlines, anatomical models, and simulation, surgical training programs will address multiple learning style preferences, as well as individual needs. For example, trainees with visual and auditory impairments as well as learning disabilities have been shown to benefit from a diversified educational approach.33 Knowledge retention, engagement, and motivation may be enhanced by using active learning techniques rather than lecture-based approaches.32 Debates, small-group discussions, role playing, and simulation allow learners to manipulate basic knowledge into more advanced levels of understanding and play a critical role in addressing the broad educational needs of a diverse learner population.

Attention also should be paid to the surgical learning environment itself, both physical and sociocultural. Educational spaces and activities should use a universal instructional approach that allows every learner to access all learning experiences.33 Training institutions should have universally accessible medical equipment, ensure availability of culturally appropriate sterile head coverings in the operating room (OR), and create flexibility in educational scheduling for needed health care appointments.33 Programs can foster a supportive and inclusive learning environment by emphasizing the importance of mentorship and guidance and normalizing help-seeking behavior.34 Programs should ensure that in addition to standardized examinations, they include formative assessments that evaluate learner performance, such as simulation care pathways that encompass many aspects of patient care.32,35 Educators also should consider how their individual actions may influence the learning environment. By reflecting on our own knowledge gaps and how to fill them, residents can model how to become self-directed learners.

Recognizing and addressing bias, especially unconscious bias, is paramount to creating more equitable and inclusive learning environments. In the setting of resident education, it is important to recognize that unconscious bias influences patient care and how we teach. Studies have shown that women have decreased operative autonomy secondary to the unconscious bias many surgical educators have toward these trainees.36 This variance in autonomy is likely unintentional, but educators should be aware that their biases may limit the success of their trainees.

Educators also must be cognizant of their approach to leadership. Surgical faculty often assume an authoritative approach in the OR; learners, however, often prefer an explanatory or consultative approach, as it facilitates better understanding of the decision-making process.37 A central part of being an educator is the desire to help trainees grow into self-directed, clinically excellent surgeons. Fostering diversity, by carefully seeking to increase equity and inclusion in the surgical learning environment, can do just that.

Maintaining diversity beyond residency

Another obstacle facing surgical trainees is the relative paucity of diverse role models in academic surgery.38 Previous work has demonstrated the importance of social interaction and fit to retention in a program.39 Increasing diversity among faculty and leadership in training programs will improve recruitment and retention of diverse surgical trainees.

Another obstacle facing surgical trainees is the relative paucity of diverse role models in academic surgery.

Unfortunately, the challenges of diversity, equity, and inclusion continue. A 12-year review of URiMs with academic appointments at U.S. medical schools found both women and racial minorities were represented at lower rates than their proportion in the general population.4 This disparity was most apparent at the highest levels of academic rank, including professor, chair, and dean positions.4 Similar results have been demonstrated in academic surgery, with women being less likely to achieve the rank of full professor in all surgical subspecialties and even lower odds in general surgery.40 These findings mirror historic trends in leadership of national surgical organizations.41,42 Increased recognition of these discrepancies and the trickle-down effect on recruitment and retention of diverse trainees have encouraged a national conversation calling for increased diversity in leadership as a priority for the future of academic medicine.43,44

Mentorship and sponsorship

One way to encourage diversity and inclusion in surgery after residency is through mentorship and sponsorship of URiM residents and young surgeons. Junior faculty URiMs and women comprise a significant portion of teaching positions.45 However, advancement beyond this level occurs at a rate lower than their male, non-URiM counterparts, and these individuals are at high risk for attrition and burnout.45 Exit interviews have consistently identified several key themes related to equity and inclusion: lack of mentorship or inconsistent mentorship, lack of recognition for teaching efforts, and difficulty with achieving work-life balance.46 These concerns must become priorities to recruit and retain a diverse surgical faculty cohort.

Mentorship and sponsorship carry significant weight among young faculty, the population most at risk for burnout secondary to lack of career fit and decreased amounts of time dedicated to meaningful work.47,48 Mentorship and sponsorship require a commitment from both the mentee and mentor. Institutions must support this commitment by providing the time and resources for career and academic advising, encouraging frequent feedback, and by providing trainees and junior faculty ready access to tools that allow them to turn their intellectual capital into academic career capital.47 Mentorship should ideally begin early, remain consistent throughout training, and continue after formal training ends in order to maintain diversity in surgery. It also is important for academic institutions to anticipate and prepare for the amount of time that mentorship requires.

Maintenance of a diverse, equitable, and inclusive community of surgeons relies on continuous improvement of the process of “mentoring mentors,” even at the level of senior leadership. Chairs and deans should have coaches or mentors, as these types of relationships have been shown to improve the mentoring abilities of even experienced leaders.49,50 Time spent as a mentor, extent of mentoring, mentor prestige, and collegiality of the relationship have been linked to increased career satisfaction.51 Recognition of the multiplicity of needs of mentees and the variety of roles mentors can play will help us broaden our ability to address the unique needs of an increasingly diverse population of surgeons.

Maintenance of a diverse, equitable, and inclusive community of surgeons relies on continuous improvement of the process of “mentoring mentors,” even at the level of senior leadership.

In addition to mentorship and sponsorship programs, structural factors such as institutional policies are important to creating equitable environments in which diversity can thrive. One important intervention that can enhance diversity in academic surgery is transparency in the promotion and tenure process. Public availability of hiring, promotion, and financial compensation policies creates a culture of accountability and may help decrease issues of unconscious bias, especially for URiM populations who frequently lack representation at the decision-making level.52

One approach is the use of a structured curriculum vitae scoring system to guide hiring practices.53 Structured evaluation and predefined criteria help decrease unconscious bias and promote equity within the hiring process and should be extrapolated to promotions consideration. The importance and value of transparency in hiring and promotions has been repeatedly endorsed in academic medicine, as has recognition of the need for open discussion in order to accurately measure disparities and the effects of potential interventions.41,54 Defined benchmarks and criteria for diversity also can help us to identify and understand areas where we are falling short of our goals for diversity in surgery.

The surgical culture

It also is necessary to create equitable and inclusive work climates that allow diverse individuals to succeed and advance their careers in academia. Consideration of external obligations that surgical faculty may encounter, such as domestic responsibilities, when implementing institutional programs and policies can improve productivity and retention. Availability of part-time or delayed tenure tracks, access to childcare and domestic assistance, and financial support for dedicated research can help ensure a diverse faculty cohort. Critical evaluation of academic culture with interventions targeted at bias awareness and reduction also foster productivity and promotion of diverse populations.55

Prioritization of mentorship and sponsorship, transparency in the hiring and promotion process, and creation of equitable and inclusive work environments can benefit all surgical faculty, but are critically important to fostering diversity in surgical leadership—which can, in turn, increase recruitment and retention of diverse surgical trainees.

Conclusion

To ensure diversity in the surgical workforce, we must ensure that people make it into the pipeline and make it out the other end by addressing our processes for recruitment, retention, and promotion. A summary of key recommendations for each stage of surgical training can be found in Table 1. As a starting point, we need to recruit diverse candidates through early mentorship and sponsorship opportunities in surgery, as well as by addressing deficiencies in the resident recruitment and selection process. Once diverse candidates make it into surgical training, they need support systems that allow them to succeed, including leave policies and support for family units with equitable and inclusive policies. We need to examine and modify our teaching practices to better account for individual learning needs and styles. Finally, we must ensure that trainees have an adequate number of diverse role models, which means addressing the faculty promotion process to ensure diverse candidates continue to advance to academic leadership positions. We also need to coach our leaders and actively address the unconscious biases that exist in our surgical culture.

As we look toward the future, we must continue to expand our definition of diversity beyond the male/female gender dichotomy and URiM label. Our definition of diversity must recognize additional factors, such as socioeconomic status, physical ability/disability status, and sexual identity, all of which have important ramifications for delivery of high-quality patient care.

An increasing body of literature describes how intersectionality, or presence of multiple diverse characteristics, can compound the struggles of diverse individuals.56 Surgery requires one of the broadest skill sets in medicine. The more we can do to ensure we are expanding the diversity of the surgical workforce, the more tools we will have to offer our patients and to continuously improve our own practices. A holistic approach to addressing the pipeline of surgical training and shoring up leaks along the way via explicit recognition of the importance of equity and inclusion increases our chances of creating a diverse surgical workforce in the future.

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