Applying the concepts of diversity, equity, and inclusion (DEI) to surgery is a significant undertaking when considering the scope of practice. By studying some of the constituent elements of surgery and medicine, surgeons can gain a better understanding of how DEI relates to the broader field. In the October 26 Panel Session Diversity and Inclusion in Surgery: Practicing What We Preach, panelists looked at diversity and inclusion in the context of clinical trials, cancer screening, and surgical education.
Racial and ethnic minorities in the U.S., specifically Black and Latinx individuals, are overrepresented in Phase 1 clinical trials—the trials with the least guarantees of safety and as-of-yet unproven clinical beneficence—and underrepresented in Phase 3 trials—the trials with proven safety and some amount of effectiveness, according to Oluwadamilola Fayanju, MD, MA, MPHS, FACS, the Helen O. Dickens Presidential Associate Professor and chief of breast surgery, University of Pennsylvania, Philadelphia. Dr. Fayanju discussed a study she led on disparities in breast cancer clinical trial participation, which found that Black and Latinx individuals are less likely to participate in clinical trials than their white counterparts. The reasons for this are complex, she noted, often intersecting with socioeconomic status and other variables.
These confounding variables are a useful proxy to show how difficult it is to address health disparities in research. “We have to do better for a number of reasons,” Dr. Fayanju said. If clinical trials fail to address diversity and inclusion, they will suffer from “conceptual blind spots, where we aren’t going to learn the pathophysiology of disease that occurs more commonly in certain groups because we don’t have the diversity of people in our trials,” she said, adding that lack of DEI will reduce generalizability of studied treatment, leading to disparate treatment and outcomes, as well as higher costs. She also discussed the importance of changing recruitment strategies, engaging the community, and more.
Disparities in medicine can be seen in the very act of screening for a disease, particularly cancer, suggested Cherie P. Erkmen, MD, FACS, professor, thoracic surgery, Temple University Hospital, Philadelphia. From screening ratios in minority populations that do not match their representation in the U.S. population to disparities in screening implementation that are apparent in race, ethnicity, and income, the U.S. populations undergoing cancer screening are not diverse and inclusive. But “when we look at screening, and really diversity and inclusion, let’s look at it from the other side—not at the disparities but at the opportunities to make screening accessible to everyone,” Dr. Erkmen said, suggesting that there are four key areas of opportunity.
With respect to education, a credible messenger must be employed to interact with diverse populations to help them understand the need for screening and engagement in shared decision-making. In terms of follow-up and navigation, screening teams must recognize that marginalized communities have much lower rates of follow-up screening after cancer detection and work to educate these populations on the need to return to screening and to help them continue to navigate the screening process. It also must be clear that diverse populations have access to equitable treatment if a screening exam reveals a cancer diagnosis in order to reduce screening disparities. Finally, in terms of outcomes and population-specific data, Dr. Erkmen suggested, “We have to exercise great judgment in developing screening criteria based on diverse population experience” to gain appropriate data and outcomes among groups.
“We have to have the ability to interact with and sometimes cohabitate with your medical colleagues, not only within your own specialty but those outside,” said Stephen C. Yang, MD, FACS, the Arthur B. and Patricia B. Modell Endowed Chair of Thoracic Surgery, and professor of surgery and oncology, Johns Hopkins Medicine, Baltimore, MD, speaking on the importance of incorporating DEI principles into surgical training. “And you have to be able to care for patients from different backgrounds and who hold different beliefs,” Dr. Yang said.
He summarized the DEI activities of both the Accreditation Council for Graduate Medical Education (ACGME) and the Association of American Medical Colleges (AAMC). The ACGME initiatives were broken down into the organization’s four pillars: an accreditation process built on an environment free from discrimination, harassment, or abuse; education, including an Equity Matters curriculum that drills down on DEI; outreach that includes increased communication from DEI leadership; and research based on survey-obtained, diversity-specific data that will inform future actions.
The AAMC has released a web-based DEI toolkit to aid medical schools that includes initiatives to address sexual and gender harassment, population health education, and more; a series of data and reports on diversity facts and figures and the state of women in medicine; and resources, such as a medical minority applicant registry and tools for addressing cultural competency training, among other issues. Dr. Yang suggests that surgical educators can “practice what they preach” through community outreach; updating admissions and interview formats; providing strong, diverse mentors; bringing trainees to practice in the clinic setting, which often hosts a diverse patient population; providing international rotation opportunities, when possible; and encouraging specialties to provide diversity research awards to encourage interest in this area.
This and other Clinical Congress 2021 sessions are available to registered attendees for on-demand viewing for a full year following Congress on the virtual meeting platform.