Diversity, Equity, and Inclusion: A strategic priority for the American Pediatric Surgical Association

Abstract

The American Pediatric Surgical Association (APSA) is a professional organization composed of over 1500 members dedicated to providing high-quality surgical care to infants and children. The organization was founded in 1969 with the mission to “ensure optimal pediatric surgical care of patients and their families, to promote excellence in the field, and to foster a vibrant and viable community of pediatric surgeons.” In collaboration with other national and international organizations, APSA creates educational guidelines and standard of care policies for the surgical care of pediatric patients that influence public policy and set best practices.[1]American Pediatric Surgery Association. https://eapsa.org/apsa-info/about-us/, Accessed 21 July 2019.Google Scholar APSA recognizes the broad diversity of the United States population and that the membership and leadership of our organization is not reflective of this diversity. The APSA Board of Governors (BOG) has recently committed to advance diversity, equity, and inclusion (DEI) in all aspects of pediatric surgery. APSA's strategic prioritization of DEI is presented in this paper. (Table 1)Table 1Position statements endorsed by the American Pediatric Surgical Association.Position statements on diversity, equity, and inclusion supported by APSAAPSA acknowledges the potential for enhanced productivity, creativity, and innovation within diverse organizations.APSA recognizes the positive impact a diverse cadre of pediatric surgeons may have on healthcare outcomes, patient satisfaction, and patient compliance.APSA adopts “Equity and social justice” as the fifth pillar of its organizational mission statement and “Inclusion, representation, and participation for all” as the foundation of its pillars.APSA endorses the activities of a member committee dedicated to the study and promotion of diversity, equity, and inclusion in pediatric surgery.APSA supports implicit bias assessment to enhance awareness and generate discussion and reflection regarding existing disparities in the care of pediatric surgery patients.APSA urges medical schools, general surgery residency programs, and pediatric surgery training programs to enact measures targeted at increasing the diversity of learners who will become pediatric surgeons.APSA encourages transparency and intentional hiring and promotion practices that are inclusive, fair, and open for women, underrepresented minority groups, surgeons with disabilities, and for all.APSA champions the establishment of mentorship and sponsorship programs specifically aimed at increasing the retention and recruitment of women and underrepresented pediatric surgeons.APSA uniformly condemns discrimination, racism, verbal and physical abuse, and sexual harassment.APSA promotes the importance of wellness, mental health, and work-life balance to the well-being of its membership and to the positive health outcomes of pediatric surgery patients.APSA advocates for efforts to create workplaces that are conducive to new parents at all levels of surgical training and practice.APSA pledges to engage in initiatives and strategies to address differential healthcare outcomes related to social determinants of health.APSA commits to achieving organizational benchmarks in the quest for increased diversity and inclusion among its membership and leadership. 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Sherbin L How diversity can drive innovation.Harvard Bus Rev. 2013; ([accessed 10 January 2020])https://static1.squarespace.com/static/5ae89190aa49a17d6e450047/t/5b0d92c4aa4a99c9a42ddd3c/1527616197302/How+Diversity+Can+Drive+Innovation+_HBR.pdfGoogle Scholar,[32]Florida R. The economic geography of talent.Ann Am Assoc Geographers. 2003; ([accessed 10 January 2020])https://onlinelibrary.wiley.com/doi/abs/10.1111/1467-8306.00314Google Scholar Diverse teams also have a higher tendency to focus on facts, a greater expectation and acceptance of differing opinions, and an increased awareness of individual biases.[33]Rock D. Why diverse teams are smarter.Psychology Today. 2017; (Mar 9 Aug) ([accessed 10 January 2020])https://www.psychologytoday.com/us/blog/your-brain-work/201703/why-diverse-teams-are-smarterGoogle Scholar In the healthcare field specifically, diversity bonuses have been found on a range of topics. Diverse medical school student bodies enrich the educational experience for all students.[34]Whitla D.K. Orfield G. Silen W. et al.Educational benefits of diversity in medical school: a survey of students.Acad Med. 2003; 78: 460-466https://doi.org/10.1097/00001888-200305000-00007Crossref PubMed Scopus (145) Google Scholar An additional example of the diversity bonus is the finding that higher NIH funding rankings is found in surgical departments with more women professors.[35]Valsangkar N. Fecher A. Rozycki G.S. et al.Understanding the barriers to hiring and promoting women in surgical subspecialties.J Am Coll Surg. 2016; 223: 387-398Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar APSA membership in 2019 was 72% male and 70% White surgeons.[36]Newman E.A. “Advancing organizational excellence: leveraging differences as our strengths.” APSA Annual Meeting. 21 May 2019. Boston, MA.Google Scholar From 1937–2019, 26 (11.5%) Pediatric surgery fellowship directors were women, and in APSA's first 50 years, six (12.8%) APSA BOG members and four APSA presidents (8.0%) were women.[37]Glick P.L., Chen M.K., Escobar M.A., et al. A Genealogy of North American Pediatric Surgery: from Ladd Until Now, Ed 2.0. APSA Annual Meeting. 19 May 2019. Boston, MA.Google Scholar The first Black President of APSA presided from 2017 to 2018.[38]APSA Past Presidents, APSA website. https://eapsa.org/apsa-info/about-us/our-heritage/apsa-past-presidents/ [accessed 31 December 2019].Google Scholar This problem of demographic underrepresentation is not exclusive to pediatric surgery and in fact remains prevalent throughout most medical specialties.39Aziz H.A. Ducoin C. 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In extending these ideas to the realm of pediatric surgery, we assert that the complex mission of APSA is best served by an active, engaged membership rich in identity diversity, cognitive repertoires, and socioeconomic and cultural backgrounds. APSA seeks to engage talents from a diverse group of learners and surgeons as the surest way to achieve the highest quality clinical care and create solutions to the next generation of challenges in pediatric surgery. This task requires a multi-faceted approach designed to improve our organization's performance, better support all our members, and position us strategically to accomplish the aspirational goal of a work force reflective of those we serve. To comprehensively build strategies that address these factors, the APSA BOG created a fifth organizational strategic pillar termed “Equity and Social Justice” and modified the foundation of APSA's strategic pillars to read “Inclusion, representation, and participation for all.” (Fig. 1) The Diversity, Equity, and Inclusion Committee (DEI Committee) was established in the summer of 2018 to guide the organization in this arena, and committee members were selected from APSA membership. Through a process of iterative group revision, the following mission statement was created:Diversity, equity, and inclusion are core values for APSA that drive excellence and innovation in clinical care, research, education, advocacy, and leadership. We will broaden organizational diversity across cultural, demographic, cognitive, and practice style domains. Our environment will advance pediatric surgeons to attain their greatest potential, work in partnership to eliminate health inequities, and provide the highest quality of pediatric surgical care for all. Operationalizing this mission statement and changing the culture of our organization will require: 1) increasing education and raising consciousness among current pediatric surgeons, APSA BOG members, and allied healthcare practitioners on the importance of representation and inclusion; 2) formalizing strategies that lower the impact of implicit bias and racism throughout the organization; 3) career development of underrepresented surgeons needed to support the next generation of children, 4) affirmatively supporting programs that address the needs of potential pediatric surgeons throughout medical school, residency, and fellowship;[46]Butler P.D. Britt L.D. 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To better understand the composition of APSA membership and the alignment with its patient population, the DEI Committee will distribute a membership survey to gather demographic information such as race / ethnicity, gender, sexual orientation, and religious preferences. The survey results will guide the agenda of the DEI Committee with strategies that increase DEI within APSA's membership and leverage identity and cognitive diversity bonuses. Implicit bias may negatively impact patient-provider interactions, treatment decisions, and patient outcomes. Implicit biases can lead to negative evaluation and treatment of a person based on identity characteristics such as gender, race, sexual orientation, weight status, or disability. Implicit biases have been shown to exist among healthcare providers at similar (typically low or moderate) levels as they exist in the general public.[48]Hall W.J. Chapman M.V. 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Gonzalez C.M The implicit association test in health professions education: a meta-narrative review.Perspect Med Educ. 2019; 8: 267-275Crossref PubMed Scopus (17) Google Scholar As an initial step towards lowering the influence of bias within our organization, the APSA BOG has committed for all current members to take IATs and require future members to do so when on boarding. We encourage committee chairs and members to take these as well to incorporate bias awareness and focus on lowering bias in all aspects of organizational work. The DEI Committee will provide targeted educational opportunities on bias and racism that aim to stimulate self-reflection and open discussion. We will do this by submitting topical articles to the APSA “Articles of Interest” email; writing themed articles for quarterly submission to the Journal of Pediatric Surgery; developing an online toolkit for APSA members and the public; contributing content to the Pediatric Surgery Library (http://www.pedsurglibrary.com); and sponsoring plenary and break-out sessions at the APSA Annual Meeting. We believe that initiatives that provide ongoing awareness and strategies to decrease the influences of bias, paired with broad-based changes that directly address structural and systemic forms of bias and discrimination will ultimately contribute to a more open and representative organization and improved health care for patients.[59]Kang S.K. Kaplan S. Working towards gender diversity and inclusion in medicine: myths and Solutions.Lancet. 2019; 393: 579-586Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar The disproportionate effect the Covid-19 pandemic has had on minority populations[60]Webb Hooper M. Nápoles A.M. Pérez-Stable E COVID-19 and racial / ethnic disparities.JAMA. 2020; https://www.doi.org/1001/jama.2020.8598Crossref PubMed Scopus (752) Google Scholar and the high-profile killings of several Black Americans by police in the spring of 2020 have given APSA cause to again consider the healthcare effects of racism in the United States. In light of these events, the APSA BOG issued a statement to its membership and the public on the organization's commitment to equity and social justice.[61]Waldhausen J. Newman E. Statement on equity and social justice.Am Pediatr Surg Assoc. 2020; ([accessed 26 June 2020])https://eapsa.org/apsa-info/about-us/news/statement-on-equity-and-social-justice/Google Scholar APSA acknowledges ongoing racial injustices that disproportionately affect people of color and those living below the poverty line. APSA members are called on to address and engage in these complex societal issues. The organization pledges to foster an open and inclusive culture, ensure programmatic development that directly addresses structural and systemic barriers to care for marginalized patients, and continuously raise consciousness around challenging issues like implicit bias, generational poverty, and racism. The path to becoming a pediatric surgeon is demanding in rigor and duration. The success rate of matching into a pediatric surgery fellowship position averages 50%, despite applicants pursuing 11–13 years of post-graduate training, having a median of 15 publications, completing additional pediatric subspecialty training, and spending an average of $8000 on fellowship interviews.[62]Savoie K.B. Kulaylat A.N. Huntington J.T. et al.The pediatric surgery match by the numbers: defining the successful application.J Pediatr Surg. 2020; 55: 1053-1057Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar,[63]Chandler N.M. Litz C.N. Chang H.L. Danielson P.D Efficacy of videoconference interviews in the pediatric surgery match.J Surg Educ. 2019; 76: 420-426Crossref PubMed Scopus (31) Google Scholar This effort is especially challenging for underrepresented minorities and students from disadvantaged backgrounds. Socioeconomic factors such as poverty or parental education attainment may limit access to high-quality schools, which may prevent a promising student from even beginning this journey.[64]Youmans Q.R. Essien U.R. Capers Q 4th. A test of diversity - what USMLE pass/fail scoring means for medicine.N Engl J Med. 2020; 382: 2393-2395Crossref PubMed Scopus (13) Google Scholar Lack of mentorship and access to courses and study materials for standardized exams further exacerbate leaks in the pipeline. As a result, exam scores are frequently lower among Black, His