Diversity is a term that has become common in our lexicon, usually accompanied by the words equity and inclusion. The focus on these issues has led to changes in our profession, some visible others not. But change is often slow and not without its problems. As I examine the changes the last three years have wrought, some stand out. These include the explosion of positions that promote diversity, equity, and inclusion (DEI) across departments of surgery, statements affirming a commitment to equity and inclusion, and the multitude of implicit bias or anti-racism training being offered. In surgery, we are very familiar with the quality and improvement process: identify a problem, implement a solution/change, and assess the change. We need to start doing this with our DEI efforts. What has been the impact of these changes? The answer is complex and beyond the scope of this blog, but I can share some observations.
Change Has Been Made
Some change is highly visible, and I see that in the diversity of the recent surgical residency classes. Three years ago, there was not a single Black female chair of surgery, now that drought has ended. Each applicant season I see more women and those underrepresented in medicine applying for surgery. I do wonder if this change is as visible to our patients and if it is, in what ways? Are there deep lasting institutional changes? It is unlikely because changes such as this take time. But this highly visible difference reminds us that change is a process, it is ongoing, and we all have the opportunity to make it a significant and lasting change.
Inclusion Has Been Difficult To Achieve
We have focused on diversity with some success but have not been as successful in implementing equity and inclusion. This is likely because both are harder to achieve, and inclusion is so elusive. It cannot be accomplished by hours of mandatory implicit bias or anti-racism training. It is less tangible than diversity but just as important. While diversity can be pursued at the organizational level and with policies, inclusion is less policy-driven and requires individual-level effort. The recent comments made at a major thoracic meeting exemplify how organizational policy vs. individual effort can make all the difference in inclusion. As the line from the original Avatar movie so poignantly shows, inclusion can be summed up in the phrase “I see you.” The entirety of you. Inclusion requires engagement one person at a time.
Advancing Health Equity Is Slow
Ensuring patients get the care they need is a core foundation of health equity. Ensuring diversity in medicine and surgery is one step on this path. However, diversity itself does not necessarily guarantee health equity if systems that sustain inequitable practices continue. So, what are we doing to ensure health equity? How do departments operationalize their mission statements supporting health equity into action? I think this is one of the most critical aspects of DEI work and where we fall short. Particularly since this is what is most visible to patients. To those who question the need for DEI or believe they already do this work and wonder about the need for reinforcement, this is how we answer them: how engaged are you with the community you serve? Is there bilateral communication?
This is a time of increased stress for all of us. Every meeting has an emphasis on burnout and or mental health. It is easy to become disillusioned with medicine as more and more administrative burdens are placed on our shoulders. Amidst this environment, I recently had an experience that reminded me of the why? Why do we care about diversity, equity, and inclusion? I was paired with an undergraduate freshman, who shadowed me for the week. I saw in her eyes the sparks that if nurtured can develop into a passion for medicine and hopefully, surgery. Her excitement at seeing a Black woman as a surgeon. Her disbelief as I cajoled a patient to surgery, his hesitancy due to missing work as the primary breadwinner for his family. There was also the uncertainty, the butterflies as you walk into a predominantly white space, a feeling I had forgotten after years of being in such spaces. But there were the team members that made her feel welcome. The intern with a welcome smile ready to assist and orient her to the OR. The message was clear – you are welcome here.
Wherever we are on the journey to create a diverse more inclusive health force and to create more equitable health systems, we must remind ourselves that it is a marathon, not a sprint. And while everyone’s pace may differ, what cannot waver is our commitment to finishing this journey.