Bridging the Racial, Ethnic, and Gender Gap in Gastroenterology

Abstract

Improving diversity in the biomedical workforce in the United States has been a long-standing goal.1Nickens H.W. Ready T.P. Petersdorf R.G. Project 3000 by 2000. Racial and ethnic diversity in U.S. medical schools.N Engl J Med. 1994; 331: 472-476Crossref PubMed Scopus (125) Google Scholar, 2Steinbrook R. Diversity in medicine.N Engl J Med. 1996; 334: 1327-1328Crossref PubMed Scopus (25) Google Scholar, 3Komaromy M. Grumbach K. Drake M. et al.The role of black and Hispanic physicians in providing health care for underserved populations.N Engl J Med. 1996; 334: 1305-1310Crossref PubMed Scopus (653) Google Scholar While efforts have been made, the needle has not moved toward this goal regardless whether this pertains to trainees, practicing physicians in gastroenterology (GI), or across all medical specialties.4Merchant J.L. Omary M.B. Underrepresentation of underrepresented minorities in academic medicine: the need to enhance the pipeline and the pipe.Gastroenterology. 2010; 138: 19-26Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 5Diversity in Medicine: Facts and Figures 2019. Association of American Medical Colleges.https://www.aamc.org/data-reports/workforce/report/diversity-medicine-facts-and-figures-2019Google Scholar, 6Carr R.M. Quezada S. Gangarosa L.M. et al.From intention to action: Operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology.Gastroenterology. 2020; 159: 1637-1647Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Benefits of growing and maintaining a culture that embraces, promotes, and actively pursues diversity, equity, and inclusion (DEI) have many positives for academic health centers, community practices, population and individual health, research, and innovation advancement to grow and sustain our biomedical research and healthcare workforce. Within academic medicine, diversity is recognized as key to excellence. As articulated by Dr David Acosta, “practicing conscious inclusion and equity-mindedness to achieve inclusion excellence — an environment where diversity is a strategic imperative, inclusivity is intentional, and exclusionary practices have been identified, critically deconstructed, and eliminated — will enable the bonuses of diversity to be revealed, actualized, and leveraged.”7Acosta D. Achieving excellence through equity, diversity, and inclusion.Association of American Medical Colleges. January 14, 2020; https://www.aamc.org/news-insights/achieving-excellence-through-equity-diversity-and-inclusionGoogle Scholar Among the many benefits are enhanced engagement and morale, increased productivity and job satisfaction, and increased trustworthiness and community responsiveness.7Acosta D. Achieving excellence through equity, diversity, and inclusion.Association of American Medical Colleges. January 14, 2020; https://www.aamc.org/news-insights/achieving-excellence-through-equity-diversity-and-inclusionGoogle Scholar A diverse faculty has a tremendous multiplier effect, including the ability to recruit diverse learners who view those faculty as mentors and role models. Underrepresented minority (URM) individuals, as defined by the National Institutes of Health and the National Science Foundation, are those whose racial or ethnic makeup is from 1 of the following groups: African American/Black, Hispanic/Latinx, Native American/Alaskan Native, or Native Hawaiian/Other Pacific Islander. Diversity provides tremendous benefit to patient care, particularly in underserved communities, when those who provide care are themselves diverse.8Saha S. Komaromy M. Koepsell T.D. et al.Patient-physician racial concordance and the perceived quality and use of health care.Arch Intern Med. 1999; 159: 997-1004Crossref PubMed Scopus (688) Google Scholar,9Takeshita J. Wang S. Loren A.W. et al.Association of racial/ethnic and gender concordance between patients and physicians with patient experience ratings.JAMA Netw Open. 2020; 3e2024583Crossref PubMed Scopus (148) Google Scholar A tangible aspect is better patient care, in part, because of improved compliance and trust by patients. There is also the impact of cultural competence10Blewett L.A. Hardeman R.R. Hest R. et al.Patient perspectives on the cultural competence of US health care professionals.JAMA Netw Open. 2019; 2e1916105Crossref PubMed Scopus (9) Google Scholar that contributes toward better patient-provider communication and trust. Importantly, the number of URM physicians who elect to practice in underserved communities is proportionately higher than other physicians.3Komaromy M. Grumbach K. Drake M. et al.The role of black and Hispanic physicians in providing health care for underserved populations.N Engl J Med. 1996; 334: 1305-1310Crossref PubMed Scopus (653) Google Scholar GI has had challenges in recruiting women and URMs. As of 2010, only 3.2% of GI fellows were African American, and 8.5% were Hispanic (Figure 1). For women, only 16% of GI fellows are women, despite 47% of U.S. medical students being women. By comparison, in the general U.S. population the racial, ethnic, and general comparisons are African-American (13%), Hispanic (11%), and women (51%).11U.S. Census BureauQuick Facts.July 1, 2021https://www.census.gov/quickfacts/fact/table/US/RHI725220#RHI725220Google Scholar Presently, there are 202 accredited GI fellowship programs with approximately 1735 GI fellows.12Brotherton S.E. Etzel S.I. Graduate medical education, 2019-2020.JAMA. 2020; 324: 1230-1250Crossref PubMed Scopus (41) Google Scholar Several interventions have been implemented to increase diversity within GI.13Carethers J.M. Quezada S. Carr R.M. et al.Diversity within US gastroenterology physician practices: the pipeline, cultural competencies, and gastroenterology societies approaches.Gastroenterology. 2019; 156: 829-833Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar,14Day L. Gonzalez S. Ladd A.M. et al.ASGE Membership and Diversity CommitteeDiversity in gastroenterology in the United States: where are we now? Where should we go?.Gastrointest Endosc. 2016; 83: 679-683Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar However, over the last decade we have not had much success is increasing the number of URM and female applicants to GI training programs (Figure 2).15American Association of Medical CollegesERAS statistics.https://www.aamc.org/data-reports/interactive-data/eras-statistics-dataGoogle Scholar The percentage of URM internal medicine (IM) residents applying to GI has been around 12.0% for the last 8 years, with a decline noted from 2015 to 2018 that has since improved (Figure 2).16Brotherton S.E. Etzel S.I. Graduate medical education, 2016-2017.JAMA. 2017; 318: 2368-2387Crossref PubMed Scopus (43) Google Scholar Alarmingly, profound declines have occurred among American Indian/Alaska Native and Native Hawaiian/Pacific Islander residents applying to GI fellowships (–37.5% and –25.0% annual change in applications, respectively) with only modest increases noted for African American/Black and Latinx applicants. With women, minimal changes noted in this number over the last decade (Figure 2).16Brotherton S.E. Etzel S.I. Graduate medical education, 2016-2017.JAMA. 2017; 318: 2368-2387Crossref PubMed Scopus (43) Google Scholar How do U.S. GI fellowship programs compare with other IM subspecialties and medical residencies as it relates to diversity? GI, in addition to pulmonary and critical care and hematology and oncology, are the only IM fellowships with a proportion of URMs under 10% (Figure 3A), and only 6 medical residencies (among 16) had a similar or lower proportion of URM residents when compared with GI (Figure 3B).17Santhosh L. Babik J.M. Trends in racial and ethnic diversity in internal medicine subspecialty fellowships from 2006 to 2018.JAMA Netw Open. 2020; 3e192048Crossref PubMed Scopus (39) Google Scholar Clearly, U.S. GI fellowship programs do not reflect either the U.S. racial-ethnic or gender diversity. Low numbers of URMs and women apply to and matriculate into GI fellowship programs, with little changes to these trends over the last decade.6Carr R.M. Quezada S. Gangarosa L.M. et al.From intention to action: Operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology.Gastroenterology. 2020; 159: 1637-1647Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Over the past decade, the American Gastroenterological Association (AGA) has begun to tackle lack of diversity in GI through prior programs that have reached a total of 2609 URM individuals at the medical student, GI fellow, and early career faculty levels. These programs established our ability to recruit individuals from URM backgrounds. In November 2017, the AGA both conducted online surveys and held interactive discussion focus groups of 20 early career URM gastroenterologists, hepatologists, pediatric gastroenterologists, and GI fellows. Surveys were designed to identify obstacles that dissuade or impede development of early career URM gastroenterologists and hepatologists. While many of the answers would be common to any physician interested in pursuing research (time, mentoring, departmental support), we also identified 7 areas in which URM GI fellows and early career gastroenterologists particularly struggle (Table 1).Table 1Academic Development Areas in Which URMs Struggle1. Lack of knowledge about how to become an investigator2. Lack of exposure to role models (ie, inspiration)3. Lack of mentorship4. Lack of sponsorship from mentors5. Lack of visibility within both the AGA and their institution for general leadership opportunities, not just leadership opportunities in the URM space6. Lack of programs within their home institution for leadership training7. Lack of support for pursuit of a career and personal identity as a physician-scientistData are derived from the AGA survey of URM GI fellows and early career gastroenterologists (5 years for fewer since completion of gastroenterology training).AGA, American Gastroenterological Association; URM, underrepresented minority. Open table in a new tab Data are derived from the AGA survey of URM GI fellows and early career gastroenterologists (5 years for fewer since completion of gastroenterology training). AGA, American Gastroenterological Association; URM, underrepresented minority. Three main themes emerged from these factors and were a lack of (1) research fundamentals, (2) leadership training, and (3) mentoring. Based on these lessons learned, AGA proposed a professional development program, through a competitive R-25 grant received from National Institute of Diabetes and Digestive and Kidney Diseases for early career gastroenterologists and GI trainees called the AGA FORWARD (Fostering Opportunities Resulting in Workforce and Research Diversity) Program that incorporates specific strategies to lower barriers and improve likelihood that URM physicians will pursue careers in biomedical investigation.18Anyane-Yeboa A. Balzora S. Gray 2nd, D.M. Improving diversity and inclusion in GI.Am J Gastroenterol. 2020; 115: 1147-1149Crossref PubMed Scopus (15) Google Scholar The AGA FORWARD program, through hands-on work with mentors and external coaches, trains URM physician-scientists with new skills and connections to successfully pursue research careers in GI. AGA FORWARD scholars develop skills in research and proposal development, planning for personnel, publications, and the timing of grant submissions. The AGA believes that this approach to integrating skills will provide a solid foundation for success. Other GI societies have also implemented programs to increase diversity in GI, including the American College of Gastroenterology’s “Prescription for Success” and #DiversityinGI social media campaign, the American Society for Gastrointestinal Endoscopy’s 5-year DEI Action Plan and the American Association for the Study of Liver Diseases’ global speaker database to guide nominations for committee assignments, speakers, and moderators for their programs. At the trainee level, the vast majority of programs recruit fellows through a national fellowship match progress. This time-tested process lends itself to the natural selection of candidates across a wide spectrum of backgrounds, experiences, and sexes. However, URMs represent only 9% of GI fellows in the United States.19Jackson C.L. Food for thought: opportunities to improve diversity, inclusion, representation, and participation in epidemiology.Am J Epidemiol. 2020; 189: 1016-1022Crossref PubMed Scopus (6) Google Scholar A structured trainee selection process would benefit from a keen eye toward attempting to balance race and sex when contemplating merit and other considerations. GI fellowship programs should consider URMs for leadership positions and members selection committees. Implicit bias training may help identify and address biases and lead to a more open-minded evaluation. A diverse fellowship program will ultimately improve faculty diversity through retention. In order for academic GI to be successful at creating a diverse environment, divisional leaders must make DEI initiatives a priority. Alignment with institutional goals is critical. A dedicated leadership position to focus on these initiatives, regular cultural humility and implicit bias training, collaboration with local agencies, and an infrastructure built to support and encourage research and mentorship of URMs is imperative for moving the needle in this realm (Figure 4). Conscious bias is relatively easy to identify and confront. However, unconscious bias is more insidious and probably more harmful, as the individuals delivering bias are often unaware.20Lewis D. Paulsen E. Proceedings of the Diversity and Inclusion Innovation Forum: Unconscious Bias in Academic Medicine. How the Prejudices We Don’t Know We Have Affect Medical Education, Medical Careers, and Patient Health. Association of American Medical Colleges, Washington, DC2017Google Scholar For example, women and African Americans may be labeled aggressive for the same behaviors that are called assertive in a White man. Therefore, before embarking on changing the recruitment process, some program evaluation is in order. Fellow selection is a process of balancing a candidate’s cognitive and noncognitive skills. Cognitive skills that are easily measured by grades, board scores, and papers written, tend to dominate. Noncognitive skills like interpersonal communication, maturity, commitment, dependability, and honesty are often assessed during the interview and may be biased by cognitive achievements, the so-called halo effect. Exam scores and research productivity are frequently used to determine whom to interview.21Hartman N.D. Lefebvre C.W. Manthey D.E. A narrative review of the evidence supporting factors used by residency program directors to select applicants for interviews.J Grad Med Educ. 2019; 11: 268-273Crossref PubMed Scopus (32) Google Scholar, 22Crowley A.L. Damp J. Sulistio M.S. et al.Perceptions on diversity in cardiology: a survey of cardiology fellowship training program directors.J Am Heart Assoc. 2020; 9e017196Crossref PubMed Scopus (14) Google Scholar, 23Lam C.C. Zimmern A. Colon and rectal surgery residency selection criteria: a National Program Director Survey.J Surg Educ. 2021; 78: 519-524Crossref PubMed Scopus (5) Google Scholar, 24Bonifacino E. Ufomata E.O. Farkas A.H. et al.Mentorship of underrepresented physicians and trainees in academic medicine: a systematic review.J Gen Intern Med. 2021; 36: 1023-1034Crossref PubMed Scopus (33) Google Scholar Yet, there is no firm evidence regarding what predicts success in advanced trainees. Speaking to the candidates’ referees to confirm areas of uncertainty is a good strategy. Interview bias may be decreased by blinding interviewers to a candidate's scores and letters; structuring the interview by asking everyone the same questions and scoring answers consistently; using questions that have no right or wrong answer but include a hypothetical that tests judgment, ethics, or team play21Hartman N.D. Lefebvre C.W. Manthey D.E. A narrative review of the evidence supporting factors used by residency program directors to select applicants for interviews.J Grad Med Educ. 2019; 11: 268-273Crossref PubMed Scopus (32) Google Scholar; having multiple interviewers, and requiring all interviewers to have implicit bias training. Reach out to colleagues at other institutions who are women or URMs and who may know of promising candidates. Develop relationships with programs that traditionally train more URM and female residents. Affiliate with Historically Black Colleges and Universities medical schools. For example, Veterans Affairs and Municipal hospital systems like Cook County, Chicago; Health + Hospitals system, New York; and Miami-Dade County also train larger numbers of URMs. Residents from these programs are often hardworking multitaskers who have mastered systems creativity in resource poor settings. The absence of faculty members who are women or persons of color can make your program seem uninviting. Talented candidates will not want to be pioneers navigating that system alone. They will need and want a cultural mentor whom they can trust. Well-organized and institutionally supported mentorship programs increase candidate satisfaction and aid in retention and recruitment.25Farkas A.H. Bonifacino E. Turner R. et al.Mentorship of women in academic medicine: a systematic review.J Gen Intern Med. 2019; 34: 1322-1329Crossref PubMed Scopus (92) Google Scholar While you may not be a cultural mentor, you can be an effective skills mentor. Grant writing, manuscript preparation, CV formatting, interview skills, and contract negotiation to name a few areas in which formal mentorship relationships can be made and built upon. In the private sector, a good recommendation is to take an actual picture of your organization to see who is literally seated at the table and to decide who you would like to be there (https://biasinterrupters.org). Invest in formal anti-bias training resources26D’Angelo R. White Fragility: Why It’s So Hard for White People to Talk About Racism. Penguin Random House, New York2018Google Scholar and embark on individual study to understand the history of bias in America and in medicine.27Washington H.A. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. Doubleday, New York, NY2006Google Scholar,28Stephenson-Famy A. Houmard B.S. Oberoi S. et al.Use of the interview in resident candidate selection: a review of the literature.J Grad Med Educ. 2015; 7: 539-548Crossref PubMed Scopus (94) Google Scholar We recommend a multipronged approach to diversification of the recruitment pool at multiple levels: in premedical education, medical school, residency, GI fellowships, and early GI careers: •Career development opportunities such as the AGA FORWARD Program. •Take a balanced unbiased approach to assessing cognitive and noncognitive candidate skills.•Implicit bias training for program directors, search committees, and selection committee members.•GI fellowship training program self-assessment on communities served; fellows’ opportunities for engaging community; curricular elements designed to enhance cultural humility and linguistic competence and amplify understanding of racism as a public health crisis, and social determinants of health. •Mitigate bias in job announcements by removing gendered language in job postings.•Competitive recruitment packages—assess for implicit bias in how these are offered.•Insertion of explicit statements that raise awareness of how the institution values DEI beyond an Equal Opportunity Employer statement.•Diverse search committee structure.•Well-organized mentorship program.•National Institutes of Health funding opportunities (eg, diversity supplements to existing supplements, Office of Minority Health).•Diversification of faculty and leadership positions.•Engage clinical faculty with faculty in research and academic endeavors. •Actively look for qualified candidates in programs who have historically trained women and URMs in large numbers.•Diversification of content in our journals in social media (journals, conferences, social media, listservs).•Post career opportunities in nontraditional sources (eg, social media and listservs). By employing these recommendations to improve diversity in digestive diseases, we will ultimately improve care for our patients. Espousing diversity in healthcare can lead to cultural humility and agility as well as the ability of providers to offer services that meet their patients’ unique social, cultural, and linguistic needs. The better our patients are represented and understood, the better they can be treated. Health equity is achievable through these proactive, short-term and long-term measures. As Owen Seymour Arthur (former prime minister of Barbados) is quoted, “For he who has health, has hope; and he who has hope, has everything” (https://www.quotetab.com/quotes/by-owen-arthur).