Keywords
Key points
Definition of allyship
Merriam Webster defines allyship as the state or condition of being an ally. Leaving the definition at this may imply that it is only a label. Delving deeper, “ally” is a noun and verb. In its most simplistic terms, allyship is a helper supporting another entity. In the context of diversity initiatives, allyship has been more clearly defined as “an active, consistent, and arduous practice of unlearning and re-evaluating, in which a person in a position of privilege and power seeks to operate in solidarity with a marginalized group.”
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This definition requires that allies must recognize that they are in a majority status and that affords them the power to support, promote, and help those in the nonmajority; this entails an educated assessment of the environment in which one interacts with others and knowledge about the challenges that marginalized groups can encounter. Perhaps more importantly, beyond identification as an ally, the ally must intentionally act in support of the nonmajority, and this demands open dialogue between the marginalized and nonmarginalized in what to do and how to do it.History of allyship
The first published use of the word allyship dates to 1849; however, it was not used in the modern sense of the word. In 1943 Albert Hamilton wrote about how allies may help with the fight for racial equality. Since the 1970s, supporters of the LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, Intersex, Asexual, and More) community have been identified as allies. As discussed earlier, allyship is not just labeling oneself as an ally. The more modern definition of identification, solidarity, action, promotion, and adjustment is more a recent construct. In fact, allyship was added to dictionary.com in 2021. That same year, it was also given the recognition of Word of the Year.
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In business, many companies have a dedicated division that focuses on initiatives of diversity, equity, and inclusion. All the top 5 Fortune 500 companies: Walmart, Amazon, Apple, CVS Health, and UnitedHealth Group have these divisions.
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It is less clear on how allyship is incorporated because this term is not on the front-facing resource pages for these divisions. This situation may change as the concept of allyship takes a more prominent role in social justice. For example, Google has an allyship program that aims to provide employees with knowledge, resources, and ways to enact allyship in their profession.5
Within health care, there is similar room for growth in discussing, learning about, and incorporating allyship. At the time of writing, there are no currently published articles discussing allyship in the Journal of Hand Surgery, the official journal of the American Society for Surgery of the Hand. In the Journal of the American Academy of Orthopedic Surgeons, there is 1 article on the topic. In the New England Journal of Medicine, there are 4 articles mentioning allyship.
Evidence for why allyship is helpful and needed
In business, putting the intangible benefits aside, diversity can increase financial productivity. The success rate of acquisitions and initial public offerings of partners with shared ethnicity was 26.4% compared with that of nonhomogeneous partnerships at 32.2%. Venture capital firms have notoriously low rates of diversity. When venture capital firms increased the percentage of female partners by 10%, fund returns grew by 1.5%.
In health care, it is important that physicians reflect the diverse population for whom they are caring for. In Orthopedic Surgery, there has been a consistent lack of diversity of gender, race, and sexual orientation. Nth Dimensions is a nonprofit organization that seeks to provide exposure, opportunity, and mentorship to underrepresented students in medicine. Part of their process to ensure diversity and equity includes training in allyship. The outcomes of participating in Nth Dimensions are impressive. Women and unrepresented minorities are, respectively, 45 and 15 times more likely to apply to Orthopedic Surgery residency.
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In addition, the match rate is 92% for those in the program compared with the national average of 77%.7
There are data to show that even modest programs can effect change. Workshops less than 2 hours on allyship for graduate medical trainees have been shown to significantly increase knowledge and comprehension of allyship.7
What Makes a Good Ally?
Warren and Warren
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surveyed 14 experts identified as established leaders in their respective fields. The experts were selected from diverse backgrounds to refine the definition of and criteria for an exemplary ally.8
Their definition and criteria for exemplary allies are those who:- 1.Tap into their values to support optimal functioning of marginalized group members
- 2.Listen to, give credence to, and amplify the voices of marginalized group members
- 3.Offer support in ways marginalized group members share is in their best interest
- 4.Are committed to staying informed about critical experiences of marginalized groups
- 5.Make space for marginalized groups in places they are not yet occupying
- 6.Go beyond sympathy and “get in the trenches” to work with marginalized groups
- 7.Have a disposition to act according to their ideals of allyship across life domains
- 8.Affirm their acts and express the principles and the moral rationale underlying the acts
- 9.Possess a willingness to risk their self-interest for the sake of their values of allyship
- 10.Leverage their privilege to inspire other privileged group members to allyship action
Similarly, Bourke and Espedido
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surveyed more than 4100 employees about inclusion. The 6 traits that distinguished inclusive leaders included the following:- 1.Visible commitment: Articulates authentic commitment to diversity, challenges status quo, and accepts accountability
- 2.Humility: Admits mistakes and creates space for others to contribute
- 3.Awareness of bias: Works to build awareness of personal blind spots and to ensure meritocracy
- 4.Curiosity about others: Demonstrates an open mindset with deep curiosity. Listens without judgment
- 5.Cultural intelligence: Attentive to others’ cultures and adapts as required
- 6.Effective collaboration: Empowers others and provides psychological safety
How do You Become a Good Ally?
There is no single, agreed-upon set of behaviors. Salter and Migliaccio
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proposed allyship behaviors and processes as 3 broad categories: knowledge and awareness, communication and confrontation, and action and advocacy.- Salter N.P.
- Migliaccio L.
Allyship as a Diversity and Inclusion Tool in the Workplace.
in: Divers within Divers Management (Advanced Ser Management, Vol. 22). 22. Emerald Publishing Limited,
2019: 131-152https://doi.org/10.1108/S1877-636120190000022008
Knowledge and awareness
Allies must be aware of and educate themselves about the experiences of marginalized group members. In the context of gender, male allies must learn to recognize sexism when it occurs. For the LGBTQIA+ community, it can entail learning to separate myth from fact. Understanding minority experiences needs to include the role the majority population plays in the minority experiences—intentional or unintentional. White people need to understand institutional racism, White privilege, and their own biases to truly be allies to people of different race.
Communication and confrontation
Although knowledge and awareness are important, an ally should communicate with others about these issues. The ally must actively participate and initiate in discussions about ways to promote minority rights. These communications should be public for others to witness. Confrontation is one means to challenge prejudice and discrimination in others; it can lead to positive change and breaks down the “bystander effect.”
Action and advocacy
Allies support and promote minority communities. Allies can provide tangible benefits to minority populations. Allies can help introduce minority-supportive ideas into their organizations, particularly within the leadership circle. Allies can educate people on minority issues and persuade others to change their minds. Allies can support minorities directly. Sometimes a simple act of kindness is invaluable.
Melaku and colleagues,
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described evidence-based best practices for becoming an ally in their recent Harvard Business Review article “Be a Better Ally.” Although their advice was addressed largely to White men, it applies to anyone in a privileged group who is striving for an inclusive organization. Their proposed steps are as follows:- 1.Educate yourself: It can be emotionally and cognitively exhausting for marginalized group members to bear the load of teaching you about their experiences with inequality and injustice. A good ally takes the initiative to read, listen, watch, and deepen their understanding. Request permission when asking others about their experiences. Recognize that the members of a marginalized group may not all have the same experiences; this is especially true if they are of different marginalized cohorts. A good example is that White women’s experiences are not necessarily similar to those of women of color. Generalization from 1 or 2 colleagues’ experience should be avoided. In addition, do not rely too heavily on your own experience. The perspective of a White male surgeon will not mirror that of a marginalized female surgeon. Finally, transform your perspective as a leader by staying alert to inequities and disparities. Pay attention to marginalized group members’ experience in meetings and gatherings—“Once you put on that lens, you can’t take it off. The world never looks the same.”18
- 2.Own your privilege: Being an ally requires recognizing the privileges that others have been overtly or subtly denied. Although it can be painful to admit that you have not entirely earned your success, it is necessary. A White male surgeon may have never thought about how his career decision affects his wife and kids, or why he is more focusing on his career instead of his family; however, it is a frequent question for women surgeons. White men are far less likely to need to adjust their style of speech, appearance, and behavior to succeed in their workplace. This “code-switching” is extra work that takes an emotional toll for marginalized group members.
- 3.Accept feedback: Intentionally seek feedback while recognizing the power dynamics at play. The request for feedback may add invisible labor and stress to the marginalized individual when they are not in secure positions. It is important to establish trusting relationships with members from marginalized groups who will give honest feedback about your workplace conduct. Value these comments.
- 4.Become a confidant: Marginalized group members who have succeeded typically had trusting relationships with White, male leadership who took a genuine interest in their careers. Make yourself available, listen generously, and empathize and validate their experiences.
- 5.Bring diversity to the table: Marginalized group members are often the “only” ones in the room who can experience outsider and impostor feelings. These feelings can be combated by inviting more from marginalized groups to gatherings. As an ally, ask specific questions of people whose contributions and expertise are often overlooked or devalued.
- 6.See something, say something: Rather than waiting for marginalized individuals to react and then get accused of “playing the race or gender card,” monitor your workplace and be decisive in shutting down racist or sexist comments and behaviors. Give your support in the moment, versus approaching the victim later to offer sympathy when you witness discrimination. Look out for gaslighting, which is a tactic used to invalidate someone’s experience. Physicians have a history of gaslighting both patients and colleagues. Consider a Nepalese woman who presents with complaints of chronic wrist pain. With a cursory examination, no radiographs, and no further workup she is dismissed as having “arthritis.” She is offered over-the-counter nonsteroidal anti-inflammatory medications and no follow-up. A White man with the identical condition is diagnosed after appropriate workup with early rheumatoid arthritis. In a different scenario, think about a young female attending who musters the courage to approach her Chairman about a recurrent pattern of inappropriate comments and behavior on the part of one of her male colleagues. Without exploring the circumstance, the young attending is dismissed with “Maybe you’re being oversensitive. Try being more of a team player.” If you are aware of these instances, intervene whether or not the members of the marginalized group are in the room—explain that you are offended and that such comments or behaviors are not acceptable or representative of your organization. These confrontations can be framed as a learning or growth opportunity for the offender and the team. Finally, avoid the common mistake of thinking that you are absolved of your own biases and prejudices, or be an ally to put yourself on a higher moral ground.
- 7.Sponsor marginalized coworkers: Seek out talented protégés from entirely different racial and cultural background. Nominate the protégés on the basis of their potentials rather than expecting them to prove that they can do a job in advance. Introduce protégés to key players in your professional networks to open up broader set of opportunities.
- 8.Insist on diverse candidates: Pay gaps, low retention, and stalled career progression for marginalized group members are due to bias and discrimination in hiring, professional development, and promotions. For hiring, insist on open job listings and targeted recruiting versus overreliance on referrals, which leads to perpetuation of workforce homogeneity. Make sure the candidate pool is diverse. Involve members of marginalized groups in the hiring process or assign another team member to serve as a “bias interrupter.”
- 9.Build a community of allies: Broaden your impact by joining or forming groups of colleagues interested in fighting racism and gender inequality.
In summary, to become a good ally, one needs to ask and listen. Listening to understand is different than listening to respond. One should join or partner with impactful groups, such as Ruth Jackson Orthopaedic Society (RJOS) and J. Robert Gladden Orthopaedic Society. One should act at home and nationally, which is particularly impactful coming from people already in leadership circle.
Contextualization: personal examples of benefitting from an ally
Real-world and personal examples of allyship often speak louder than theorizing about how allyship should work. The following anecdotes are written by individuals who have benefitted in various ways from allies in the fields of Orthopedics and Hand Surgery.
“As a female Orthopaedic trained hand surgeon, I have found myself in the non-majority throughout my medical training in the context of my co-residents, co-fellows, attendings, and now colleagues. In reflection upon different stages of my medical career, I believe that there have been many individuals who have helped further my career, both male and female. But, there are two male attendings who played pivotal roles as an ally. When I became interested in pursuing Orthopaedic Surgery as a medical student, I felt that I did not fit the mold. Where I went to medical school, the Orthopaedic residents were mostly male, wore cowboy boots, and chewed tobacco in the call room. Fortunately, I crossed paths with an attending who was an institutional and national leader in Sports Medicine. I expressed my concerns about not fitting in, and he dispelled that worry immediately. He told me that if I chose to pursue Orthopaedic Surgery, demonstrated disciplined work ethic, and had the appropriate credentials to match to Orthopaedics, that he would support me. While his words were powerful in changing my mindset, his actions were more powerful. He acknowledged my name in research presentations and publicly recommended me for Orthopaedic Surgery residency. Moreover, he connected me to the Chair of the Department where I ultimately ended up matching for residency and am now faculty. As a resident, I again fell into a distorted mindset that Orthopaedic Surgery requires a physical strength that I was lacking as a woman. This belief led to self-doubt with respect to capability in reductions, with surgical instruments and with procedures that required force. I expressed my concern for lack of strength one day to one of the trauma surgeons. Again, he was an institutional and national leader in his field. He stopped me immediately after I said that and told me that I had strength–my strength was going to be knowledge in using instruments to my power advantage. From that day forward, I felt safe in his cases. Importantly his support was not in a vacuum. I had heard him say to other attending surgeons on multiple occasions that I had good surgical skills. His allyship re-established my confidence in the operating room; a trait that I carry to this day.”
“Although I now realize how few women there are in Orthopaedics as compared to men, I have not always known those statistics. As I began choosing a career path in high school and college, I never considered myself to be someone who would benefit from allyship but have since realized that I’ve been the beneficiary of multiple acts of allyship (by both men and women) that have helped guide me on my path. Prior to my second round of medical school applications, the chief of vascular surgery at one of the local hospitals offered, unprompted, to help me with mock interviews. When I first started expressing interest in the field of Orthopaedics to male surgeons that I knew, it was always met with excitement and a willingness to help with shadowing experience and letters of recommendation. While in medical school, a female Orthopaedic Surgery resident sought me out in conversation at the gym; that conversation with a stranger turned into a roommate, friend, mentor, and now colleague. Finally, as a fourth-year resident attending the ASSH meeting, one of the male Hand surgeons from my institution asked me if I was going to attend the “Women in Hand Surgery” session. This surgeon attended the session with me and introduced me to the person who would become my Hand Surgery fellowship program director just a couple of years later. Each of these individuals acknowledged my goals, believed in my potential, and were willing to take the time to invest in me as a future Orthopaedic surgeon. They never emphasized the fact that I would be a minority in the field, and probably did not even think of themselves as allies in the moment. They simply saw me as someone who was committed to a goal and took action to leverage me in whatever way they knew how.”
“Even as a White, male medical student I did not fit the mold. The archetype resident in my program was a collegiate wrestler or football player, preferably from an Ivy league school. A young Asian attending became my mentor, ally and accomplice. When I was accepted to the program, I heard grumblings from senior residents “why did he get in”? The Ally was Dr. Freddie Fu. I got in because he advocated vociferously on my behalf. Dr. Fu went on to create one of the more diverse Orthopedic Surgery training programs in the country. I went on to develop a sensitivity for the power of the ally.”
Where Do We Go From Here?
There are numerous resources available for providers who want to take steps to exercise allyship via a formal mechanism, as well as organizations that provide opportunities for both allies and members of underrepresented groups. Although not an exhaustive list, these are well-established channels that serve as a starting point.
National level
At the national level, the American Academy of Orthopaedic Surgeons (AAOS) has included diversity as a strategic goal since 2018, with its Diversity Advisory Board in place to guide initiatives. To help track progress, the AAOS produces a Governance Diversity Report and a Diversity Dashboard Year End Review. The newly established IDEA Grant program (Inspiring Diversity, Equity, and Access) was created to provide resources for diversity, equity, and inclusion initiatives and can be applied for by any member of the Academy (www.aaos.org).
The RJOS, founded in 1983, provides a support and networking group for women orthopedic surgeons. Membership is available to women at all levels of training and practice. Men are also invited to join. RJOS hosts an annual meeting, offers a mentorship program, and has multiple committees that provide membership opportunities. Grants and scholarships for research and meeting attendance are made possible through the endowment with the Orthopaedic Research and Education Foundation (www.rjos.org).
The J. Robert Gladden Orthopaedic Society became formally incorporated as an affiliate specialty society of the AAOS in 1998 and aims to increase diversity within the orthopedic profession. Membership is open to all genders and ethnicities starting at the medical student level. Opportunities include their annual luncheon and biennial meeting, mentoring opportunities, research grants, traveling fellowships, and practice assistance (www.gladdensociety.org).
Nth Dimensions was founded in 2004 as a pipeline program to address the paucity of women and underrepresented minorities in Orthopedic Surgery. Programming includes surgeon-led lectures and workshops, medical student symposiums, and summer internships. Ninety-one percent of their scholars and affiliates have matched successfully into residency positions (www.nthdimensions.org).
Hand surgery subspecialty level
Within hand surgery, both the American Society for Surgery of the Hand (ASSH) and the American Association for Hand Surgery (AAHS) have various initiatives and programs that promote allyship. At the academic level, this includes publication of research in the Journal of Hand Surgery and HAND that touch on topics of allyship, diversity, equity, and inclusion as they relate to the field of hand surgery. At both organizations’ annual meetings, instructional courses, and panels that discuss these topics have become part of regular programming. To help with these initiatives, the AAHS has a committee dedicated to Diversity, Equity, and Inclusion, and the ASSH has a Diversity Committee/Task Force. In addition, the ASSH’s online platform Hand.e contains multiple lectures and seminars related to allyship, diversity, equity, and inclusion (www.assh.org, www.handsurgery.org).
Individual level
Although organizations and systems can be large contributors toward promoting allyship within Orthopedics and Hand Surgery, these larger movements are the result of individuals recognizing the importance of allyship and being committed to contributing to change. As such, the impetus to move toward allyship often comes after self-reflection, understanding biases, and being educated on topics related to allyship, DEI (Diversity, Equity, and Inclusion), and the underrepresented groups that are being advocated for. With that individual foundation in place, it then becomes easier to move toward advocating for systematic change.
At the ground level, some practical ways to pursue this individual growth are through becoming a student and testing your perceptions. What topics do you need to know more about or understand better? What are your implicit biases? How can you advocate for underrepresented groups in your daily practice? The online resource Hand.e has many lectures that can serve as launch points, including “Leadership Strategies: Women in Hand Surgery” by Dr Jennifer Wolf, “Diversity and Inclusion: How to be an Antiracist Hand Surgery Educator” with multiple authors facilitated by Dr Michael Galvez and Dr Megan Conti Mica, and “Having It All: Balancing Work and Home Demands of Being a Hand Surgeon” by Dr Julie Adams.
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, Wolf J., Leadership Strategies: Women in Hand Surgery [video]. Hand.e: American Society for Surgery of the Hand, 2019. Available at: https://www.assh.org/hande/s/watch?id=aBP0a000000LTYXGA4. Accessed September 17, 2022.
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, Galvez M., Dacus A., Bradford P., et al., Diversity and Inclusion: How to be an Antiracist Hand Surgery Educator [video]. Hand.e: American Society for Surgery of the Hand, 2021, Available at: https://www.assh.org/hande/s/watch?id=aBP5b0000008fr1GAA. Accessed September 17, 2022.
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The Harvard Implicit Association Test can be a helpful way of identifying areas of implicit bias (www.implicit.harvard.edu), and the LGBTQ Ally Identity Measure (AIM) is a validated 19-item tool that assesses the domains of knowledge and skills, openness and support, and awareness of oppression.Adams J. Having It All: Balancing Work and Home Demands of Being a Hand Surgeon [video]. Hand.e: American Society for Surgery of the Hand. November 18, 2019. Accessed September 17, 2022. https://www.assh.org/hande/s/watch?id=aBP0a000000LTYSGA4.
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Training that targets LGBTQ+ competency in the setting of health care has been shown to improve the AIM score among General Surgery residents and may have similar benefits when applied more broadly among other trainees and faculty.About Us. Project Implicit. 2011. Available at: https://implicit.harvard.edu/implicit/aboutus.html. Accessed September 17, 2022.
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Bigger questions
Despite the existence of these and other supportive programs on a larger scale, there are still challenges with regard to implementation of allyship and DEI initiatives at the health system and departmental levels. Below are some questions that may be helpful to consider and discuss among colleagues and leadership before engaging in these activities:
- •What do you see as the most important steps advocating for allyship, specifically in Orthopedics and Hand Surgery? At what time point are each of these steps or interventions most beneficial?
- •How do you want your institution to address diversity, equity, and inclusion? Who can you talk to in your organization to make these desires known?
- •The concept of a “minority tax” is well described in the literature and describes the tax of extra responsibilities placed on minority groups in the name of efforts to achieve diversity.16Are there undue burdens being placed on underrepresented individuals in your department/organization to carry the weight when it comes to work related to diversity?
- Rodríguez J.E.
- Campbell K.M.
- Pololi L.H.
Addressing disparities in academic medicine: what of the minority tax?.BMC Med Educ. 2015; 15https://doi.org/10.1186/S12909-015-0290-9 - •What is the return on this work for working toward allyship and DEI initiatives, and how can the adverse outcomes of the minority tax be reduced (i.e. removing minorities from diversity-related projects, providing protected time and/or compensation for these activities)? These are among suggested tactics proposed by Williamson and colleagues to reform the minority tax.17
- •What steps are being taken to battle diversity leadership burnout?
- •Are there adequate financial and personnel resources in place to successfully implement the desired programs and initiatives?
Closing thoughts
Being an ally begins with belief in and passion for gardening: the process of nurturing others in groups with less representation grow to their greatest potential. It is learned and begins with the humility of one who may sense inequity but has likely not felt it. It means maintaining an attitude of continuous sensitivity to others' experience: a willingness to see the terrain through their eyes. Being open to small changes and providing opportunities is the easy part. Addressing systemic and cultural issues is more challenging and sometimes requires confrontation. Most of us hate confrontation. Confrontation may risk alienating senior physicians who are part of your support system, but do not share your vision for our Hand Surgery specialty. The costs are real, but the benefits are greater. Diversity in a garden or a medical community is the only way to ensure sustainability.
Disclosure
The authors received no financial support in the creation of this article.
Acknowledgments
The authors thank Dominic Coutinho for helping them put together and edit this article.
References
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Wolf J., Leadership Strategies: Women in Hand Surgery [video]. Hand.e: American Society for Surgery of the Hand, 2019. Available at: https://www.assh.org/hande/s/watch?id=aBP0a000000LTYXGA4. Accessed September 17, 2022.
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Adams J. Having It All: Balancing Work and Home Demands of Being a Hand Surgeon [video]. Hand.e: American Society for Surgery of the Hand. November 18, 2019. Accessed September 17, 2022. https://www.assh.org/hande/s/watch?id=aBP0a000000LTYSGA4.
About Us. Project Implicit. 2011. Available at: https://implicit.harvard.edu/implicit/aboutus.html. Accessed September 17, 2022.
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- Addressing disparities in academic medicine: what of the minority tax?.BMC Med Educ. 2015; 15https://doi.org/10.1186/S12909-015-0290-9
- Minority Tax Reform — Avoiding Overtaxing Minorities When We Need Them Most.New England Journal of Medicine. 2021; 384: 1877-1879
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