Department of Surgery, UC Davis Medical Center
It wasn’t long ago when diversity and inclusion were distantly affiliated with the field of medicine. These days, the concept is incorporated into the mission of residencies, departments, and universities across the nation that train medical professionals. Recent data supports such a move. In fact, diversity within groups has been shown to lead to higher quality of patient care as well as higher productivity, innovation, and risk assessment.1
A recent review of large-scale studies published from 1999 to 2019 found an improvement in patient outcomes and reduction in healthcare disparities with a racially diverse workforce.1 This is also reflective of trends in education, as students tend to fare better with racially representative management.2 On a larger scale, this is likely because diversity introduces vantage points that challenge the status quo, thereby bringing about changes in practice where they are most needed. Groups composed of diverse individuals have also demonstrated a reduction in risk taking. For example, in the financial world, diverse investing groups are found to undertake better assessments of risk.3 These significant outcomes put into perspective the social and economic importance of representation.
Why is this important in Surgery? The 2020 Census Bureau data show that the White alone adult populations decreased from 74.7% in 2010 to 64.1% in 2020. In contrast, about 40 percent of Americans now identify as racial or ethnic minorities and the multiracial adult population has increased from 2.1% in 2010 to 8.8% in 2020.4 Despite this ever-diversifying population in the United States, women and underrepresented minorities (URM) lack proportionate membership in the surgical workforce. Of tenured surgical professors, African-Americans and Hispanics make up only 1.8% and 2.7% respectively.5
It is well known that strong mentorship can increase academic productivity, improve career satisfaction, and help achieve career goals. Yet, lack of mentorship continues to be a barrier to UM students, trainees, and faculty throughout their medical career.6 However, the mechanisms by which diversity begets further diversity, and the “day-to-day” of how representation improves outcomes, is less known. We believe the cornerstone is culturally specific mentorship.
When minorities, particularly in medicine, interact with individuals who look more or less like them, know their culture, and understand their upbringing, they are more likely to be drawn to those fields. At UC Davis, we have seen this through personal experience, and we will highlight several instances where culturally specific mentorship has played an important role in education and patient care.
I, Atrin, am an Iranian immigrant, as was the attending I was working with in clinic one day. While I’m a surgery intern and she a world-renowned surgical oncologist, it took a singular interaction to connect us: a Farsi-speaking patient.
I remember it clearly – father (patient) and son (translator) sitting side by side, awaiting news of the father’s gastric cancer workup. It was quickly evident within the first few minutes of the appointment that the patient himself was growing frustrated and confused by the risks and benefits of a gastrectomy. In that moment, my attending easily switched into fluent Farsi to help guide him and his son to understand the morbidity of the operation. This, in the end, made the difference, as it helped the patient choose to defer the high risks of surgery.
Standing behind her, as I have done many times in these attending-to-patient translations, I remember distinctly not feeling out of place as I typically do when the language being spoken is not one I understand. Instead of waiting until after the patient encounter to ask what had transpired, I was able to work on plans and orders with her and the patient in real time. It was efficient. It was satisfying. It was the best care that the patient could have received.
And that was a very successful feeling. To have shared an experience with a world-renowned surgeon that I know very few others would have been able to, I suddenly felt as if “who she was” was attainable and accessible to me. As someone who grew up reinforced into thinking that she did not belong in the world of surgery — competitive fellowships, climbing the ladder of academics, teaching — that was a new and freeing feeling. And all because we shared a common language. That, I believe, is the first step in which minorities begin to climb the sociopolitical ladder of academics that then alters the course of patient and healthcare outcomes in the field of medicine.
As another Iranian-American surgery intern, I, Cyrus, feel lucky to have found a mentor who is of a similar background as me. Having recently moved to California from the East coast, the long hours of residency make it easy to feel isolated from my family. There are many things to love about California but there’s no place like home. Home is more than just a physical location. I’ve witnessed my mentor counsel a patient in Farsi, and it did feel satisfying, like the best care the patient could have received. I’ve heard my attending speaking Farsi in the operating room. These moments relieve the isolation of moving across the country alone and help make residency feel more like home.
I remember caring for my grandfather, who spoke minimal English, through his cancer diagnosis. Our family was able to translate for his doctors, but I remembered wishing he could ask questions to and get answers from them directly. There was always a feeling of disconnect between him and them. I may be transferring these feelings, but I can’t help but sense a similar feeling in Farsi speaking patients who are using a translator until I speak to them in Farsi.
All of the attending surgeons I have trained under so far in residency have had impressive bedside manner, regardless of the patient’s native language. But as Dr. Toussi wrote above, there is something to be said about connecting with a patient in their first language beyond the literal meaning of spoken words. Cultural sensitivity, particularly when it is our culture, feels particularly powerful in the field of surgical oncology.
My background as an Indian American in a program with culturally diverse mentors has afforded me (Sneha) similar feelings of belonging, as it has for Dr. Toussi and Dr. Sholevar. Cultures differ in significant ways, many of which have medical impact, especially in the post-operative period.
In taking care of an older post-operative patient of Indian origin, my team, noting her poor oral intake after abdominal surgery, recognized how her vegetarian restriction and decades of exclusive Indian diet could result in the patient’s aversion to the Western foods brought before her. In another instance, a multi-generational Indian family was preparing to take our patient, who required maximal care, home after his hospital stay. While my attending initially offered long term care facility options, she recognized the cultural importance the family placed on caring for their members and quickly shifted to setting up the family for success at home. Experiences like these have shown me the positive effects of cultural inclusivity on patient care and through this, have furthered my own surgical education.
Increasing representation of URMs is vital to improving surgical care for our patients and preparing the next generation of culturally competent surgeons. Mentorship has been shown to be an important asset toward increasing diversity, equity, and inclusion within surgery and should start as early as possible and continue throughout surgical practice.6
While culturally-specific mentorship can be very impactful, as noted above, it is important to state that a mentor does not have to look like their mentee. This is very important for URM trainees as there may be few people in positions of power that come from similar backgrounds as them. Some would even argue that finding mentors who are not like you can be just as impactful. Mackey importantly points out that seeking out mentorship across identity lines may not provide the same experience as having a mentor who looks like you, but it still provides amazing benefits. Mentees benefit from professional guidance, but also gain expertise dipped in the lived experience of their mentor. This, of course, is a two-way street and mentors can benefit from learning about the experiences of their mentee. Think of it as one way of enhancing your intercultural competencies, while building up your professional acumen.6
Thus, it is essential for academic surgeons to seek opportunities to not only act as mentors, but also as sponsors and allies. These qualities should also be included in the mentorship relationship to maximize the impact mentorship can make in improving surgical diversity and making meaningful impact on patient care.7
- LE G, P B. Diversity improves performance and outcomes. Journal of the National Medical Association. 2019 Aug 2019;111(4)doi:10.1016/j.jnma.2019.01.006
- Pitts DW, University GS. Diversity, Representation, and Performance: Evidence about Race and Ethnicity in Public Organizations. Journal of Public Administration Research and Theory. 2021;15(4):615-631. doi:10.1093/jopart/mui033
- Levine SS, Apfelbaum EP, Bernard M, Bartelt VL, Zajac EJ, Stark D. Ethnic diversity deflates price bubbles. 2014-12-30 2014;doi:10.1073/pnas.1407301111
- United States Census Bureau. 2020 Census Illuminates Racial and Ethnic Composition of the Country. https://www.census.gov/library/stories/2021/08/improved-race-ethnicity-measures-reveal-united-states-population-much-more-multiracial.html.(LastAccessed 01/15/2022)
- Slakey et al. JAMA Surg. 2013;148(6):511-515. doi:10.1001/jamasurg.2013.1230
- Mackey, J. All of Your Mentors Will Not Look Like You: Mentorship Across Identity Lines. Age of Awareness. https://medium.com/age-of-awareness/all-of-your-mentors-will-not-look-like-you-mentorship-across-identity-lines-dbeaff9f1e5. (Last Accessed 02/03/2022)
- Sola R, Roberts S, Thomas TJ, et al. Impact of Mentoring on Diversity and Inclusion in Surgery. The American Surgeon. 2021;87(11):1739-1745. doi:10.1177/00031348211047486