UVA diversity in surgery 2019 rev - University of Virginia School of … · 2019-12-16 ·...
Transcript of UVA diversity in surgery 2019 rev - University of Virginia School of … · 2019-12-16 ·...
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Edwin P. Lehman Lectureship
University of Virginia
Department of Surgery
September 18, 2019
“Diversity in Surgery”Presented by:
Sharon L. Stein, M.D.Director of Research, Surgical Outcomes & Effectiveness Center
President Elect, Association of Women SurgeonsUniversity Hospitals/Cleveland Medical Center
Disclosures
• Medtronics – Advisory Council
• Merck – Speaking
• (Smith Medical – Advisory Council, spouse)
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Edwin P Lehman Lectureship
• Qualities of the Surgeon
Honesty
Curiosity
Rational approach to suffering
Equanimity
Courage
Diversity in Surgery
Sharon L. Stein, MDMurdough Master Clinician in Colon and Rectal Surgery
President Elect of Association of Women Surgeons Cleveland OH
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Diversity in Surgery
• Why Diversity Matters
• We Are Not Diverse
• We Are Biased
• You Can Change
Why Diversity Matters
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Diversity
Why Diversity Matters• Broadening of perspectives• Improve learning outcomes for all students
– Active learning– Intellectual engagement– Motivation– Empathy – Cultural understanding
• Students trained at diverse medical school are more comfortable treatment patients from wider range of backgrounds
Whitla DK et al. Acad Med 2003; 78: 460Curin P et al. Harvard Education Review 2002; 72: 330
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Why Diversity Matters• Improves health care for underserved patients
– Practioners who are black, Hispanic, Native Americans
• More likely to work in underserved communities
• More likely to treat minority patients
– Providers who are black, Hispanic, Native Americans and women
• More likely to care for poor, Medicaid patients
Kingston et al. The Right Thing to Do, National Academy Press 2001Cantor et al. Inquiry. 1996:33; 167
Why Diversity Matters
• Leads to increased patient choice and satisfaction– Minority patients are more likely
• To seek care from professionals of their own racial and ethnic background
• To report higher quality care when receiving care by professionals of their own racial and ethnic background
– Visits last 2.2 minutes longer
Cooper‐Patrick et al. JAMA 1999; 282: 583Cooper et al. The Commonwealth Fund 2004
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Why Diversity Matters • Companies in the top quartile for racial and ethnic diversity
– 35 percent more likely to have financial returns abovemedians.
• Companies in the top quartile for gender diversity – 15 percent more likely to have financial returns abovemedians.
• There is a linear relationship between racial and ethnic diversity and better financial performance: – for every 10 percent increase diversity on the senior‐executive
team, earnings before interest and taxes (EBIT) rise 0.8 percent.
Hunt V, Mckensie.com 2015
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We Are Not Diverse
US Population by Race
Kaiser family foundation 2018 Chrisbourg.worldpress.com 2019
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US Population: Women Working
Racial Diversity in Medical School
• White 60%
• Asian 20%
• Hispanic/Latino 10%
• Black 7%
• Native American .2%
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Gender Diversity in Medical school
2Major Deficit in the Number of Underrepresented Minority Academic Surgeons Persists.Butler, Paris; Longaker, Michael; MD, MBA; Britt, L; MD, MPHAnnals of Surgery. 248(5):704‐709, November 2008.
Choice of Residency
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Yeo, A Novel Predictive Model for Identifying Surgical Residents at Risks for Attrition Annals Surg 2017
Why We Don’t Attract/Keep URM
• 27 qualitative interviews
– (70% black, 11% Hispanic, 4% Native American, 15% mixed ethnicity/race, 56% female)
• 3 major themes of training experiences– Daily barrage of microaggressions/biases
– Tasked as race/ethnicity ambassadors (minority tax)
– Challenges negotiating professional/personal identities
Asare et al Jama Netw Open 2018
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Obtaining Board Certification
• Study of graduates of ACGME certified programs (3373 graduates) with intention on graduate survey to become certified in surgery
– 60.4% became ABS‐BC
• Women, URM, >28 years at graduation
• More recent graduation, privately owned medical schools, failure of Step 2CK less likely to be BC
Andriole, JACS 2013
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Major Deficit in the Number of Underrepresented Minority Academic Surgeons Persists.Butler, Paris; Longaker, Michael; MD, MBA; Britt, L; MD, MPH
Annals of Surgery. 248(5):704‐709, November 2008.
URM in Academic Surgery
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Diversity in Academic Surgery
AAMC data 2014
0.1% 13% 2.6% 2.3% <0.1%
9% 2% 1.6% 78%
👩🏻 ⚕=9.4%
Recruitment, Retention and Promotion
• 47% of medical students
• 46% of residents (all)
• 38.3 % of surgery residents
• 19% of all surgeons
• 31% of instructors
• 24% assistant professors
• 16% associate professors
• 8% professors
AAMC data 2014, AAMC 2015 Andriole et al. J Am Coll Surg 2007; 204(3): 469
Women are:
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• Hispanics
• 4.5 % of medical students
• 8.5% of surgery residents
• 5.0% assistant prof
• 5.0% associate prof
• 4.0% professors
• Hispanic Surgeons
• 4.5 % of medical students
• 8.5% of surgery residents
• 5.0% assistant professors
• 5.0% associate professors
• 4.0% professors
• Black Surgeons
• 5.7 % of medical students
• 6.2% of surgery residents
• 3.8% assistant professors
• 2.5% associate professors
• 2.0% professors
Diversity in Surgical Chairs
AAMC data 2014
X23
X4
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• Lifestyle concerns
• Financial pressures
• Having to work in white environment
• Lack of mentorship
Diversity
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We Are Biased
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We Are ^ Biasedall
https://implicit.harvard.edu/implicit/
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Implicit Association Test
• We prefer white (70%W, 50%B)
• We prefer men
• Even members of minority groups prefer majority groups
– Gay people implicit bias for straight, but not as strong as straight people
Project Implicit, Accessed 2019
Examples of Bias• Identical application CV’s except names
– Preference for male applicants – Steinpreis et al, 1999
• Organizational leadership skills– Association with white over minorities
– Gundemir, Horman 2014
• Clinicians more likely to diagnose– Whites over ethnic minorities
– Green 2007
• Racial bias at police stops, prosecutions, bail and sentencing– Ghandnoosh 2014
• Academic journals– Anonymous authorship resulting in increase female representation by 30%
– Budden 2008
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Bias in Selection
Facial attractiveness and obesity AS important as academic metrics
Microaggressions/Implicit Bias
• Affinity bias
– Tendency to be more receptive to people who resemble our lives is some way.
– ’’I like Joe, he reminds me of my brother.”
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• Confirmation bias
– Tendency to supports our beliefs and ignoring details to the contrary
– ''He's from Appalachia so, of course, he isn't very well educated.''
Microaggressions/Implicit Bias
• Halo effect
– Tendency to assume that everything about someone is great, if we like something about them
– ”Mary is well‐behaved, so she must also be smart.''
Microaggressions/Implicit Bias
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• Perception bias– Tendency to stereotype people based on a group they belong to
– “Siva must be good at math because Asians are usually good at math."
Microaggressions/Implicit Bias
• Bandwagon bias
– Tendency to believe something because others believe it.
– “I’ve heard that Kazumi isn’t a great resident, so she probably won’t do a great job.”
Microaggressions/Implicit Bias
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You Can Change
American Board of Surgery
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American Board of Surgery
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How Do We Change?
• Decision Making
– System 1: Reaction
• Swerving to avoid a car
– System 2: Deliberate Reasoning
• Can focus on the wrong things, irrelevant information
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Mentors and Role Models
• Mentors are important in choosing specialty– 72% of mentors were in the same specialty
– Tend to practice in same specialty
– 62% of academic surgeons found their mentor in PGY2/3 year
McCord et al. J Surg Res 2009; 155: 136
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Writing Letters of Recommendation
• Remember letters about men – 4x more likely to mention publications – 16% longer – 2.5 x as likely to minimize assurance (she can do the job)
– Emphasize accomplishments not effort – Letters for women 7x more likely to mention personal life
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Interviewing Candidates
• Identify the skills for the job
– Create a matrix to evaluate
• Structured interviews• Same questions for every candidate
• Same matrix to evaluate
University Hospitals/Cleveland Medical Center Interviews
• Study of our residency
• Determination of key attributes
• Minimal requirements
• Structured interviews
• Less applicants
• Higher match
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Sponsorship
• Study of gender representation at national surgical meetings
– Overall 28% female
• Percentage of females on program committee positively correlated with female speakers (p<0.001)
• Panels with 50% or greater female moderators more likely to have female speakers (p<0.001)
Zaza and Stein, In publication 2019
TABLE 4
Formal vs informal speaker introductions by gender
Copyright© 2019 The American Society of Colon and Rectal Surgeons 62
Female Representation and Implicit Gender Bias at the 2017 American Society of Colon and Rectal Surgeons’ Annual Scientific and Tripartite Meeting
Davids, Jennifer S.; Lyu, Heather G.; Hoang, Chau M.; Daniel, Vijaya T.; Scully, Rebecca E.; Xu, Ting Y.; Phatak, Uma R.; Damle, Aneel; Melnitchouk, Nelya
Diseases of the Colon & Rectum62(3):357‐362, March 2019.
doi: 10.1097/DCR.0000000000001274
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Sponsorship
Francis Collins, NIH
Sponsorship
• Preventing Manels
– Agree not to be part of a manel
– If manel, sponsor a diverse candidate
• At National Conferences
– Code of conduct for introductions
– Behavior
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Defeating Microaggressions
Diversity in Surgery
• Why Diversity Matters
• We Are Not Diverse
• We Are Biased
• You Can Change
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You Can ^Change create
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• https://youtu.be/FyHWlubDvkw