The Impact of Discrimination and Ways to Address It as An Individual, Department and Society

Allison M. Janda, MD

Diverse teams and diversity are mandatory to fulfill the full potential for the field of anesthesiology and for the best care of our patients, Jeanine Wiener-Kronish, MD, emphasized. Introducing the panel, Leadership Advisory Board Panel I: Toward Diversity, Inclusivity and Excellence at the AUA, at the AUA 2021 Annual Meeting on May 13, she provided multiple examples of how diversity of teams leads to more influential scientific papers, increased quality of innovative solutions to problems, more productive collaborative science and how diverse teams positively impact patient care.

Moderated by Dr. Wiener-Kronish, who is from Massachusetts General Hospital, the panel focused on the importance of diversity, equity and inclusion (DEI) and how the Association of University Anesthesiologists can promote DEI throughout the field of anesthesiology. The presenters Maya Hastie, MD, Meghan Lane-Fall, MD, MSHP, FCCM and Valarie Armstead, MD provided their insight, experience and suggestions to emphasize, cultivate and expand DEI initiatives and goals in the field of medicine during this excellent and impactful panel.

Maya Hastie, MD, an Associate Professor of Anesthesiology, Program Director of the Adult Cardiothoracic Anesthesia Fellowship and the Co-Director for the Faculty Development and Career Advancement Program at Columbia University Medical Center, defined diversity based on intrinsic factors, or “things we’re born with,” and secondary characteristics, which are dynamic. Secondary characteristics can change throughout our lives such as education level, work experience or religion. Stereotypes, prejudice and bias constructed around diversity has led to discrimination. The policies that uphold prejudice or bias result in systems of oppression.

She emphasized that for decades, there have been many examples of systemic discrimination within the medical field including the perpetuation of systemic discrimination by major medical societies and their policies. This systemic discrimination has been extremely detrimental to individuals, communities and society as a whole, Dr. Hastie explained. Diverse teams are smarter. The exclusion of team members leads to negative outcomes and unfulfilled potential.

Black and Hispanic populations are drastically underrepresented in medicine, Dr. Hastie noted. Patient outcomes suffer when diverse teams are not involved in patient care. How we manage pain, labor, antiemetic prophylaxis and treatment of heart disease all have been shown to vary based on race and ethnicity. One study showed that when Black physicians cared for Black infants, the mortality rate of these infants was lower, emphasizing the message that a diverse team benefits patients. The road to making progress is long. Addressing the systemic discrimination entrenched in the medical field, and in society as a whole, requires prioritizing and focusing on addressing these issues to make progress, according to Dr. Hastie.

Meghan Lane-Fall, MD, MSHP, FCCM, an Associate Professor of Anesthesiology and Critical Care at University of Pennsylvania, shifted the conversation to focus on behavior change. Dr. Lane-Fall’s research agenda focuses on implementation science on behavioral change to find ways to effectively and fundamentally change behavior to make progress in DEI. She explained that diversity, equity and inclusion efforts are fundamentally about behavior change. Behavior change models outlined included social ecological and transtheoretical.

The social ecological model, developed by a psychologist, describes nested spheres of influence starting with the individual, then microsystem, mesosystem, exosystem and macrosystem. When applied to the medical field, the levels and applications in DEI start with the individual. Dr. Lane-Fall provided the example of how unconscious bias training can assist in individuals acknowledging and understanding our own biases. At the departmental level, groups such as the Inclusion, Diversity, Equity and Anti-Racism Committee at University of Pennsylvania and the intentional study of departmental equity metrics are crucial to make progress on promoting DEI within a department. Importantly, curriculum review addressing whether we teach our residents about discrimination issues and how to work on them is key to ensure that making DEI a priority is conveyed to trainees. At the level of the school of medicine, it is important to examine faculty training and retention, continue curriculum review and ensure bias reporting. At the level of the hospital system, staff hiring and development, bias training and reporting and financial support are needed to promote and fund DEI at a high-level. At the university level, faculty recruitment and retention should also be examined as well as how the university can promote community engagement.

The transtheoretical model, also known as the stages of behavior change, where an organization can be precontemplative (do not acknowledge issues), contemplative (acknowledge an issue but do not have a plan), preparative (getting ready to make some change), action (undertaking actions you’ve identified), and maintenance (continual effort to maintain these priorities). The transtheoretical stage-matched interventions are more effective and combining these two models can help apply stepwise change at the organizational levels noted in the social ecological model. To conclude her presentation, Dr. Lane-Fall highlighted a quote by Renee Navarro, MD, PharmD, Vice Chancellor of Diversity and Outreach and Professor of Anesthesiology at UCSF, “Diversity efforts should be about more than providing a ’pop of color.’” Dr. Lane-Fall emphasized that in order for meaningful and impactful DEI work to occur, supported and intentional continuous effort must be applied and is not meant to be performative.

Valerie Armstead, MD, FAAP, DABA, a Professor of Anesthesiology, Temple University Lewis Katz School of Medicine, spoke about how the AUA can leverage its influence to improve diversity in academic anesthesiology and the medical field. Dr. Armstead explained how it is crucial to have mentors from diverse backgrounds to give early-career faculty and trainees examples of success and to show representation in leadership. This top-down cultural shift is what can improve the field in a meaningful and lasting way. We all must recognize, understand, and be willing to study unconscious bias to accept that the problem is happening in real time and that this is not a historical issue, but a current one in need of attention and focus, Dr. Armstead explained. She emphasized the importance of creating a diversity, equity, and inclusion committee within a department led by a director of that group with “teeth,” as they need to have the ability to identify and actively address these major issues to make the substantial and needed changes with the support of the department or leaders in societies, such as the AUA. At an individual level, it is incredibly important to encourage representation and focus on member referrals to help spread the word and expand the focus of the group. It is incredibly important to be earnest and strive for transparency in recruiting initiatives, elections and assignments to add legitimacy to the vetting process and power allocation. To achieve these aims of encouraging representation, transparency and prioritization of DEI initiatives, it may be necessary to consult a DEI recruiting expert to help enact change and implement diversity-driven recruiting technology.

An engaging question and answer session followed with a wide variety of topics including ideas on what the aim should be for matching representation in the medical field with the community that field serves, and how to address the pipeline problems for underrepresented minorities in medicine generally, but also within anesthesiology. More specifically, the takeaway was that AUA should play a key role in addressing systemic discrimination, helping to break down barriers for underrepresented minorities in academic anesthesia and promoting engagement in DEI initiatives and programs.

View a list of additional resources and recommended reading provided during the session here.