Keywords
Key points
- •Diversity and inclusion in Hand Surgery is necessary to overcome health disparities and inequities. All surgical fields that lead to a career in Hand Surgery have a stark lack of diversity of sex/gender and race, at every level of the workforce, from trainees to practicing physicians.
- •Success in the development and retention of a diverse workforce requires sustained commitment from leadership.
- •It is essential that leadership weaves the work of diversity, equity, and inclusion throughout all aspects of the work of the department or practice at the local level.
- •Efforts to intentionally increase representation of women and racial minorities should be continued and encouraged locally, regionally, and nationally.
Introduction
“A truly inclusive corporate culture is one that accommodates all of the ways in which we are different from one another – and does so intentionally.”Ruchika Tulsyan1
The “business case” for the need for diversity, equity, and inclusion in companies has been established by multiple studies and researchers around the world.
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The practice of medicine can be viewed as such; however, to view it solely as such diminishes the work that physicians do. Diversity and inclusion in medicine, and in particular, our field of Hand Surgery should strive to overcome health disparities and inequities. Without it, we will not reach equity in our provision of care.All surgical fields that lead to a career in Hand Surgery have a stark lack of diversity of sex/gender and race, at every level of the workforce, from trainees to practicing physicians.
3
, 4
, 5
, - Taylor E.
- Dacus A.R.
- Oni J.
- et al.
An Introduction to the Orthopaedic Diversity Leadership Consortium: Advancement of Our Orthopaedic Leaders of Diversity, Equity, and Inclusion Through Networking, Strategy, and Innovation.
J Bone Joint Surg Am. 2022; https://doi.org/10.2106/JBJS.21.01350
6
This continues to limit the pipeline of diverse Hand surgeons, due to the lack of role models and mentors for students and trainees considering their chosen career, specialty, and/or subspecialty. Additionally, it limits the education and professional growth of the current faculty in an inclusive environment that will benefit patient care.1
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, 8
, 9
Although Hand Surgery has recently increased diversity compared with other musculoskeletal subspecialties, it still does not reflect that of our patient populations and studies on health disparities in Hand Surgery remains limited.
10
, 11
, 12
, - Brisbin A.K.
- Chen W.
- Goldschmidt E.
- et al.
Gender Diversity in Hand Surgery Leadership.
Hand (N Y). 2022; https://doi.org/10.1177/15589447211038679
13
By improving the diversity of colleagues in our field, as well as all musculoskeletal care, we can improve doctor–patient communication and understanding of cultural views of health care, patient satisfaction, decrease health disparities, and potentially contribute to more physicians working in underserved areas.6
Although statistics on the low diversity in surgical fields are often published, a guide to effective recruitment and retention is lacking, and it is recognized that a single strategy cannot be applied to all.
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The formula for change within one environment will be different than another based on the culture of each organization and the obstacles that are preventing the recruitment of diverse teams. The following information assumes supportive leadership and is meant to provide actionable items to consider based on publications and lived experiences, rather than serve as a prescriptive defined path to success.- Taylor E.
- Dacus A.R.
- Oni J.
- et al.
An Introduction to the Orthopaedic Diversity Leadership Consortium: Advancement of Our Orthopaedic Leaders of Diversity, Equity, and Inclusion Through Networking, Strategy, and Innovation.
J Bone Joint Surg Am. 2022; https://doi.org/10.2106/JBJS.21.01350
Authors’ Note: To narrow the scope of this article, we have chosen the audience of an academic leader. These recommendations can be formatted to fit any practice. Additionally, consistent with our culture to date, very few studies have been done to study the inequity of race. It is noted that the number of racial minorities within Hand Surgery, including Plastic and Orthopedic surgery, does not reach statistical significance in studies. This deficit is proof of the need for change.
Recruitment
Commitment to Diversity, Equity, and Inclusion
“If you are neutral in situations of injustice, you have chosen the side of the oppressor.”Archbishop Desmond Tutu
Success in the development and retention of a diverse workforce requires personal commitment from leadership. Both your own commitment as a leader, as well as hospital and/or organizational leadership. Although your commitment should be inclusive of a mission statement, financial and time investments, you must also commit to supporting a change in culture of your department. This requires continual recommitment and the need to hold oneself and one’s organization accountable. This is when the true change will begin and last.
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Until our health systems and department leaders commit to changing the environment, it may unfortunately continue to be stagnant.Create a Strategic Plan
“Diversity is being invited to the party; inclusion is being asked to dance.”Vernã Myers
“Equity is being part of the planning committee.”Ruchika Tulshyan
The commitment to recruiting, supporting, and retaining diversity in Hand Surgery requires a strategic plan, and along with this, cultural humility. To create the greatest impact, it is beneficial to elevate someone as a diversity leader to partner in developing the strategic plan and commit to seeing it through.
5
If your department or practice does not currently have diversity of physicians, consider contacting the Office of Equity and Diversity for your hospital, affiliated medical school, or hiring a diversity, equity, and inclusion (DEI) consultant. Do not assume that you are going to be able to solve this problem on your own. When creating a strategic plan, it is essential that leadership weaves the work of DEI throughout all aspects of the work of the department or practice.- Taylor E.
- Dacus A.R.
- Oni J.
- et al.
An Introduction to the Orthopaedic Diversity Leadership Consortium: Advancement of Our Orthopaedic Leaders of Diversity, Equity, and Inclusion Through Networking, Strategy, and Innovation.
J Bone Joint Surg Am. 2022; https://doi.org/10.2106/JBJS.21.01350
14
This will aid in transformation of the environment to one of inclusion. If the plan is only to enhance diversity through increasing the number of diverse trainees and faculty/surgeons, without a commitment to changing the environment, the diversity will not be maintained. At each institution, the surgeon diversity leader needs to assess the learning and care environments, strategize effective interventions, and accurately measure the impact of change initiatives.Institute of Women’s Policy Research (IWPR). Pay equity and discrimination.
https://iwpr.org/equal-pay-about/
Date: 2021
5
It is important to note that this change will take time and dedicated effort.- Taylor E.
- Dacus A.R.
- Oni J.
- et al.
An Introduction to the Orthopaedic Diversity Leadership Consortium: Advancement of Our Orthopaedic Leaders of Diversity, Equity, and Inclusion Through Networking, Strategy, and Innovation.
J Bone Joint Surg Am. 2022; https://doi.org/10.2106/JBJS.21.01350
Strengthening the Pipeline of Future Colleagues
Improve diversity at leadership levels
Recent studies addressing sex diversity and work-family integration in Orthopedic Surgery noted a greater percentage of female residents in programs that had a higher percentage of female faculty, women at higher academic rankings, more women in leadership roles, and a women’s sports medicine program.
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Okike and colleagues reported that racial minority medical students who attended medical school at institutions with high racial minority representation among Orthopedic faculty and residents (>8% and >10.5%) were more likely to apply into Orthopedics than those with low racial minority representation among Orthopedic faculty and residents (<4% and <6.1%).17
Multiple studies have confirmed the lack of gender and racial diversity in the leadership of both American Society for Surgery of the Hand and American Association for Hand Surgery as well as Orthopedic, Plastic and General Surgery departmental leadership.14
,Institute of Women’s Policy Research (IWPR). Pay equity and discrimination.
https://iwpr.org/equal-pay-about/
Date: 2021
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This data provides an opportunity to understand our potential for change within leadership that can lead toward increasing the diversity of applicants, trainees, and colleagues.- Schiller N.C.
- Spielman A.F.
- Sama A.J.
- et al.
Leadership Trends at Hand Surgery Fellowships.
Hand (N Y). 2022; https://doi.org/10.1177/15589447211073977
Participation in programming is successful
“You can’t be what you can’t see.”Marian Wright Edelman
Successful recruitment of a diverse pool of candidates requires commitment to increasing the diversity of our trainees. Earlier exposure in medical school, mentorship programs, and trainee and faculty diversity can increase diverse applicants.
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Transformation of Promotional Practices
At the trainee level, one of the most important aspects of surgical training is the acquisition of skill through mentorship. The more we push aside those who need it the most, the more detrimental it can be to their skills. To combat this phenomenon, a surgeon must have awareness of one’s own biases and create clear expectations and communicate these expectations to their trainees about participation in clinical care both in and outside of the operating room. Additional opportunities for skill acquisition, such as hosting industry laboratories or working with trainees in a surgical skills laboratory, can improve surgical confidence and enrich our participation as educators.
In addition to skill acquisition, research is another opportunity for mentorship. In creation of your DEI strategic plan, consider tying a commitment to education and mentorship of diverse trainees into the structure. An awareness that mentorship and education are a time commitment, thus with a limited number of women and underrepresented in medicine (UIM) surgeon mentors, there is a need for greater participation of all faculty in this work.
Once a department has hired a surgeon from a racial minority group or woman, the commitment to unbiased support, mentorship, sponsorship, and promotion must be a priority. This should include cultural humility, which will be discussed later in this article.
Ensure Equitable and Fair Salaries
Salary equity is a key component of an overall approach to equity and should be considered one element in a comprehensive diversity, equity, and inclusion strategy. Salary assessments are essential to implementing process changes that support equity, and should be evaluated at minimum at initial hiring, promotion, undertaking leadership roles and when creating an incentive structure beyond collections or the relative value unit.
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It must also be noted that when considering salary audits, the data must be disaggregated.24
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The research of the Institute for Women’s Policy Research has elucidated that “It will take 40 years -- or until 2059 -- for women to finally reach pay parity. For women of color, the rate of change is even slower: Hispanic women will have to wait until 2224 and Black women until 2130 for equal pay.”24
Of the women Orthopedic surgeons surveyed, 78% reported being the breadwinner in their home.15
The cost of maternity leave is significant, thus there must be support given to change this. It devalues the participation of women and when they are already underpaid, which further contributes to salary discrepancy.26
Finally, in addition to base salary, equitable compensation must also consider resources that are allotted to each surgeon, including clinical support staff, OR and clinic time, administrative assistants, and research coordinators.Broaden Your Applicant Pool
To truly change the culture of Orthopedics, make efforts to mitigate bias in your hiring practices. Request referrals from a diverse group of colleagues and ensure that job openings are advertised publicly and broadly, including on websites of specialty group organizations that support racial minorities and women. Ensure that the duration of the job posting promotes a diverse pool of applicants. Plan ahead for anticipated retirements and growth to allow for a diverse group of applicants to interview. Although hiring practices commonly include personal referrals, consider that racial minorities and women often have less sponsorship, which translates to less potential options for employment. With regard to residency interviews, ensure that at least 50% of applicants are from non-White, nonmale backgrounds.
Holistic Application Review—It is Not Just for Residency Applications
“Endorse and employ a frame shift that challenges century-old ideologies that force minority populations to ‘fit in’ rather than belong.”Bradford, DeGeorge, Williams, Butler7
The holistic review process was shown to include a significantly higher than expected percent of female, traditionally UIM, first generation, and self-identified disadvantaged applicants in the interview pool than selected using academic metrics alone.
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Create a consistent system in a holistic application review to combat bias.30
If the process is not systematic, the inconsistency of your application review process can serve as a potential blind spot for bias.17
,26
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,- Poon S.C.
- Nellans K.
- Gorroochurn P.
- et al.
Race, But Not Gender, Is Associated with Admissions into Orthopaedic Residency Programs.
Clin Orthop Relat Res. 2020; https://doi.org/10.1097/CORR.0000000000001553
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Consider redefining what educational background you are seeking from your candidate. Recognize that different training programs provide variable opportunities for mentorship and scholarly activities. Ensure that you have a method of examining skills and intellect. Avoid interviewing only “those who you know are well trained.” When checking their references, be aware of biased statements from your peers or colleagues.Standardize the Interview Process
“Instead of wondering why they aren’t thriving on the level playing field, imagine how the field can be changed to allow everyone to thrive.”Emily Nagoski, PhD and Amelia Nagowski, DMA
Through standardization of the interview process, it provides each candidate to have the opportunity to present themselves in a positive frame of reference. Seek to understand “How will this candidate enhance our culture?” rather than answering, “How will you fit in to our culture?” Create a corresponding interview scorecard with a rating scale and score immediately following the interview to avoid memory bias, where one is more likely to remember feelings and affinity rather than specific answers. If you cannot describe or are not consistent with the reason why a candidate is not a cultural fit, likely your consideration is biased.
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Available at: https://biasinterrupters.org/
In preparation for the process, provide bias/allyship training for the selection committee. The traditional unstructured interview format used by many residency programs consists of open-ended inquiries reflecting the preferences and biases of individual faculty interviewers.
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Unstructured interviews are heavily relied on in making ranking decisions, yet they demonstrate poor interrater reliability, low predictive validity, and unfavorable applicant reactions.34
Through training for interviewers, mitigation of bias can be successful.Support and Retention
“Increasing diversity does not, by itself, increase effectiveness; what matters is how an organization harnesses diversity, and whether it’s willing to reshape its power structure.”Robin J. Ely and David A. Thomas2
Proactive Actions
The following actions provide a checklist of considerations to improve the DEI culture and initiative in your leadership practices. Unconscious bias is a key driver of leadership-linked disparities. Minority faculty have noted that they have experienced an inadequate recognition of work, exclusion from faculty activities, and alienation from fellow faculty.
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Disadvantaged groups across the medical spectrum have called for improved transparency in leadership decision-making and the establishment of clearer faculty expectations for advancement.- 1.Appoint and support a diversity leader in your practice.5
- Taylor E.
- Dacus A.R.
- Oni J.
- et al.
An Introduction to the Orthopaedic Diversity Leadership Consortium: Advancement of Our Orthopaedic Leaders of Diversity, Equity, and Inclusion Through Networking, Strategy, and Innovation.J Bone Joint Surg Am. 2022; https://doi.org/10.2106/JBJS.21.01350
A committed faculty member to DEI work is of paramount importance. Include your diversity leader in the development of the strategic plan for the department. They must have decision-making authority, protected time for the work and a budget to support their initiatives and salary. Ensure that as the leader, you align with and support your diversity leader. This includes requiring engagement and accountability of your organization in addition to the physicians in your department.
Genuine and lasting change of an environment will require open minds and discussion about the team’s personal growth in cultural humility. This ability for communication does not come easily, particularly when we have not been trained to communicate with our team in such a way. To facilitate this development, dedicated and protected time for education as well as facilitated content will best support lasting change. Expect that this is an iterative process and will take commitment and support over time to change the environment.
- 3.Be proactive and equitable in supporting and developing your faculty members.
Hold regular meetings with new surgeons—consider monthly and when comfortable transition to quarterly. Include a discussion of goals within the first few meetings and continue to revisit these goals at each meeting. Use faculty promotion or practice structure as a guide for goal setting to aid faculty in understanding opportunities for and deciding on their areas of career interest. This will aid in their identification of strengths and your ability to align opportunities with their strength and interest.
Ensure both mentorship and sponsorship of all faculty. Encourage mentorship participation equally throughout faculty. If it is incentivized, consider increased merit for successful mentoring of racial minorities and women, particularly at the trainee level. Evaluate everyone’s ability to be a mentor. Simply calling oneself a mentor and being successful in this role are not the same. Recognize that mentors are not uniformly effective. As an example, when evaluating certain leaders for their mentorship, you may note that trainees experience great success working with them, leading to publications and successful match rates. At the same time, they may not be successful at retaining young surgeons, particularly women and racial minorities, in their division. Although a person may be an excellent teacher, he/she is not serving as a faculty mentor well. Expecting this will not necessarily lead to successful retention within the division. To retain faculty that work under such leaders, mentorship will be required through other avenues, such as other divisions within the department or departments in the hospital.
- 4.Perform annual reviews.
“Companies need performance management systems that tie feedback and evaluation criteria to bona fide task requirements rather than group stereotypes.”Robin J. Ely and David A. Thomas2
Provide consistent structure for annual review that is self-reported and allows the faculty to include accomplishments and future goals. Through these annual reviews, you will understand the work of your faculty and how you can support and sponsor their success toward promotion. If possible, meetings should take place in a neutral conference room rather than your office. Include intentional discussion about DEI work. To support accountability to your strategic plan and commitment to DEI work annually, at the conclusion of the annual reviews, collate the DEI work being done by everyone in the department and review it with the diversity officer. Consider it in the context of your strategic plan. Highlight publicly the successful work of others to encourage and promote further DEI work. Identify gaps and who may help to fulfill the work in those areas.
- 5.Be aware of the potential for bias within feedback systems.
If patient reported feedback is a part of the incentive structure, be aware of the potential for harmful bias. When providing patient reported feedback, it has been shown to be most successfully to share in 1-on-1 meetings rather than publicly posted and without comparison to named peers.
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Understand the questions being asked of your patients, considering the patient’s potential for unconscious bias to be involved in the score.Include system level improvement work to support the feedback from patient satisfaction. Many of the considerations in the patient reported feedback are not under the control of the physician being rated. Attempt to equalize and elevate the ratings as a practice or department, rather than use the ratings to compare physicians to one another. If one surgeon shines, seek to understand how you can incorporate their success into the work of the department/practice. Through this, we elevate the care of our patients.
- 6.Be aware of the potential for bias in productivity models.
Concerning referrals, awareness needs to be paid as to how these are distributed. Depending on the payor model, evaluate the patient distribution to new partners. Often, they are assigned the Medicaid or self-pay patients. If your system includes collections-based incentive at any level, surgeons are disincentivized to treat these patients. An unfavorable payor mix can lead to lower collections, thus lower income for the young surgeon. Lower collections may lead to a false belief that they are not “doing the work” and therefore do not deserve a comparable salary. This may lead to earlier burnout of the young surgeons, which can lead to their leaving the practice or worse.
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More importantly, this is also a discriminatory system that discourages care for the patients who are less fortunate and often need it the most. Be aware of gender bias against women surgeons. It has been shown that when the patients of women surgeons experience a complication, this can be detrimental to their referral stream. When it happens for men, it has much less impact.42
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- 7.Support and celebrate all faculty successes publicly through use of internal websites and marketing.7
Create a relationship with the marketing department or director and educate them around your strategic plan. Ensure diversity in marketing, balancing the visibility throughout all physicians in the department, highlighting the work that they are proud of that is leading them toward promotion. If you are only celebrating that of the leaders who are established, this does not give the younger surgeons the opportunity to shine. Publicizing volunteer activities such as faculty involvement in activities aimed at developing a diverse pipeline for Orthopedic Surgery, such as the Perry Initiative, can both highlight the work of the department and educate the hospital system and community about the underrepresentation of women within Orthopedic Surgery.
- 8.Require leadership education for all surgeons.
Leadership is critical to our role as surgeons to ensure excellence in patient outcomes, clinical performance, and professional development. For success in the clinical realm, we must lead a multidisciplinary group of experts in complementary fields, including hand therapists, nurses, technicians, and administrators. Leadership skills are rarely intentionally taught within the medical, residency, or fellowship curriculum. The skills often overlap with those used for patient care, such as empathy, listening, and communication skills; however, they also include the ability for critical conversations, humble inquiry as well as strategic planning and alignment of departmental and hospital level goals.
- 9.Provide all faculty opportunities for leadership roles that lead to their advancement and promotion.
Ensure that you are supporting your faculty toward career advancement at the same rate, specifically by providing the same opportunities to women and racial minorities for leadership roles in your department, hospital, national organizations. Although achievements may vary, consider the mentorship that supports each surgeon to be successful at achieving their goals. If there is inequity of success, seek to understand what has led to this.
James White in Anti-Racist Leadership makes the point that men are often promoted on potential, and women and racial minorities are promoted only after they have proven many times over that they are deserving of the promotion. This he calls prove it again bias.
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This statement emphasizes that the decision to apply, or recommendation to promote, often comes from a relationship with a mentor or sponsor. Consideration for promotion should be given to accomplishments and achievements when making recommendations. Moreover, if potential is used, this should be applied in the same way for all candidates, ensuring that the need to be unbiased has been considered.- 10.Support each faculty through sponsoring their leadership in your medical school, hospital, and/or national organizations.
Ensure that you distribute the work among your group equitably. Having identified career goals through regular meetings, as well as knowing the strengths of your faculty, either self-identified or observed, will allow you to match each surgeon with work that will engage them and lead to success. If these roles are offered, ensure that you are clear about how much their time will be supported and they are not penalized for the time spent in their commitment to the success of the department.
- 11.Require Community engagement, both local, regional, and international for faculty on an annual basis.
This can include community “clean up” events, providing volunteer patient care at your free clinic, covering high school sports teams, supporting athletic events such as runs or walks, serving meals on holidays, participation in volunteer surgery with local or international surgical teams, being on the board of important local organizations. Include trainees in this work when possible. Consider engaging with the DEI office at your institution to understand opportunities for local impactful work that can be provided by the department.
- 12.Include articles at journal clubs that include health equity at each session. Host one educational session dedicated to addressing DEI topics annually.
With the awareness that care has been inequitable for non-White and nonmale patients, it is important to illustrate how this health inequity applies to the care we provide. This encourages our colleagues and trainees to consider bias in their own care and provide consideration as to how their own research initiatives and care processes may change to be more equitable. By organizing an annual journal club or retreat focused specifically on DEI, this can provide an opportunity to work together with skilled facilitators to aid in continued education and growth in understanding the inequity of our culture because it relates to patient care and collegiality. This inclusion of health equity research regularly will highlight the void of current antiracist research with the goal of inspiring curiosity and further research.
- 13.When developing a team dynamic—use validated and positive coaching and organizational tools.
There are several options available for workplace personality assessments, some more validated than others. Consider using the Clifton Strengths assessment test, developed by Don Clifton after asking the question, “What would happen if we studied what was right with people versus what’s wrong with people?” In medicine, this is antithetical to our mindset. We are constantly working to “fix what is broken” or how to solve the problem that our patient has brought to us. By taking an approach to building a team based on highlighting people’s positive traits, it has been shown to lead to success. It is recommended that trained facilitator participate in the work for maximal improvement.
- 14.Have a family leave policy and clinical scheduling that is inclusive and fair for both women and men.
Flexibility and control over how teams accomplish their work must promote individuality, with the understanding that best practices must be followed, adequate access to care provided, equity ensured, and collegiality valued.
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This is absolutely necessary when supporting work-family integration in surgical fields for this to improve gender diversity.15
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Regarding family leave for women, asking them to take extra call to “make up for their absence” while pregnant, needs to be reconsidered and because it may be a contributor to the higher risk of complications during pregnancy for women Orthopedic surgeons.45
Similarly, we must also advocate for our male colleagues also to take advantage of family leave. In addressing these times of absence, if you or others experience bias around it, consider asking yourself or others what they would do if that surgeon had a medical emergency.- 15.Ask that each faculty give a Grand Rounds lecture in an evenly distributed timeline to highlight their work. Consider inviting a diverse panel of visiting Grand Rounds or specialty series lecturers.
As Grand Rounds lectures are an opportunity to highlight the work of academic faculty, this is a good opportunity to promote the work of all faculty. In doing so, trainees can identify potential mentors within their intended or chosen field. This requires intention that there be a balance of speakers from the department, rather than simply the “senior speakers” from a group known to be majority White and male.
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- 16.Encourage research on health equity in patient care and require the consideration of health equity in every project.
It is essential that all patient populations be included in the research and quality improvement work done to support our patient care decision-making. Although this is often evaluated at the Institutional Review Board (IRB) level, understand that there is bias built into all systems. Seek to understand the diversity within the population that you care for and the resources of the hospital to support the participation of all patients in research. As with all fields of medicine, there is a great need and opportunity for health equity and health disparities research within Hand Surgery.
As health equity is understudied, consider encouraging younger surgeons or those surgeons with the most diverse patient population in the department to study their outcomes. Invite these surgeons to be the Grand Rounds speaker or on a panel at a national meeting. Ensure that they are participating in national registries. If this surgeon does not feel they have the time to participate, find ways to support them such as assigning a research coordinator or administrative assistant to their patient population to input the data into a registry or support a study. Allow them the time off to participate in a meeting, without penalizing them for this absence. When attending meetings with younger colleagues, introduce them to your peers to expand their network.
- 17.Incentivize accountability for DEI behaviors.
Require evaluation of diversity and inclusion efforts in performance evaluations. Link diversity and inclusion efforts to promotion of faculty to next levels of professorship. Use evaluation of diversity and inclusion efforts to help determine salary increases. Publicly acknowledge program residents, staff, and faculty who show inclusive values.
- 18.Commit to diversity of staff—in addition to faculty.
As a diverse group of leaders is important, so is a diverse team. By encouraging inclusive hiring practices in your clinics and operating rooms and with the appropriate leadership of these staff, will aid in changing the environment and culture. Middle management, such as clinic or operating room management, is of key importance to this cultural change.
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Because they are the leaders of your staff, it will be important to partner with them, and the hospital system, on this initiative.Reactive Actions
- 1.Resist personal bias and use a process of due diligence when reacting to concerns or complaints about all faculty, especially racial minorities, and women.
Having a preestablished relationship with each faculty member, which includes regular meetings, annual reviews, routine feedback from residents, and staff who work directly with that faculty member, leads to improvement for each person. When necessary, it will aid in avoiding a negative bias toward the faculty when negative reports are made. Remember that all leaders make mistakes. Consider each situation with a root cause analysis, using due diligence to understand the occurrence. Most often, these arise due to miscommunication and with bias involved. Several studies have noted that racial minority and female trainees contending with discrimination and less respect than their peers often feel that they are less valued or underappreciated. This has been shown to lead to attrition and burnout in the trainee population.
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If due diligence is truly used to understand the reported concern, and the consideration given to the potential for multiple biases in the interaction, this may lead to culture change that retains diverse faculty members.- 2.Pulse check human resources (HR) by evaluating the complaints and interactions that have occurred around racial minorities and women.
Multiple important studies have evaluated discrimination of surgeons in the workplace.
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Sudol and colleagues confirmed the association among racial/ethnic–minority surgeons and anesthesiologists with a high risk of discrimination and mistreatment.47
Women surgeons in all specialties were found to experience a gender-based double standard in their conflicts, due to an expectation that they conform to gender over professional norms. The authors recognized the need for equitable adjudication of conflicts to lead to a change in their work environment.48
By discussing these concerns with HR, it may allow for identification of systemic gaps in bias that can be addressed. This may be a role for an ombudsperson within the institution.- 3.Create a supportive structure for faculty when they have surgical complications.
Surgical complications and litigation can be some of the most stressful times in our career. For women and racial minorities, this may compound to an already stressful environment and can lead to feelings of isolation. Many departments have a process for reviewing these cases internally. Yet, a well-established system for the faculty member to process their own stress from the event and subsequent management of it does not exist to our knowledge, other than individuals who independently seek counseling. Consider meeting with these surgeons and supporting them through the process when appropriate. If you see a change in their productivity, consider the potential for a change in referral patterns as a result and provide an avenue for support.
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- 4.Recognize signs of physician burnout and support faculty to avoid this or recover if they are experiencing it.
It is important to recognize that burnout can lead to increased complications and perceived disruptive physician behavior.
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Orthopedics overall have recently been found to have a higher prevalence of suicide.40
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Prior literature has also shown that female surgeons experience dissatisfaction with the ability to maintain relationships with family and the ability to parent, and this is associated with higher levels of burnout, depression, and low career satisfaction.15
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Thus given the high potential for burnout and isolation in women and racial minority faculty, leaders must recognize, understand, and address the unique challenges of their underrepresented employees that can lead to a downward spiral and subsequent attrition.22
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Summary
“…I believe deeply that we cannot solve the challenges of our time unless we solve them together, … by understanding that we may have different stories, but we hold common hopes; that we may not look the same and we may not have come from the same place, but we all want to move in the same direction – toward a better future for our children and our grandchildren.”Barack Obama
This work is collection of considerations for the work that we all must do, rather than a defined recipe to success. There is no “one size fits all” solution. Our expectation is that as our culture begins to change, so will the process. We look forward to hearing your experiences and all that is learned in the process.
Conflicts of interest
No conflicts of interest or funding sources.
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