Essentially, Klaus Mergner asked if I would give this presentation, which he entitled Diversity Issues in GI, A Potpourri of Challenges and Opportunities. So I have to admit, this is something I had not really researched before. So I had to do a little bit of digging and diving to try and see what were the current thoughts, where did we stand and what could we do better? So again, a lot comes down to definitions. So with regards to diversity, equity and inclusion, or if you're a Twitter aficionado, you will know that this is hashtag DEI. I've actually taken this analogy from the DEI group in Ann Arbor. So basically what they say is that diversity is where everyone is invited to the party. Equity means that everyone gets to contribute to the playlist. And inclusion means that everyone has the opportunity to dance. Another really important buzzword that if you're not familiar with at the moment is probably useful to implant into your brain. And it's this concept of social determinants of health, or SDOH. And this is sort of a rather large phrase, cumbersome phrase, created by the U.S. Department of Health and Human Services. And I'm just going to read it out to you just to try and imprint it in your brain, because it's actually really an important one. And it's conditions in the environments where people are born, live, learn, work, play, worship and age that affects a wide range of health, functioning and quality of life outcomes and risks. So as you can anticipate, if we have defects in financial status, food insecurity, health inequity, a lot of that then is going to have this downstream effect of impacting health outcomes. And I attribute this particular slide to Dr. Fola May, who you're probably familiar with as a strong advocate for colon cancer screening. She works in UCLA. She's a social media guru. And she has highlighted that the downstream health outcomes can negatively impact heart disease, cancer, obesity. And obviously, with the most recent pandemic with COVID-19, we're all very much aware of who are the subsections of society who are at increased risk and really have poor outcomes when it comes to hospitalization and ICU stays. So this is our big challenge. It's health inequity. And I think that this really stems from this other concept or buzzword that if you're not yet familiar with, you should. And it's that of implicit bias. So this is the attitudes, the beliefs or thoughts beyond the realm of our conscious awareness. And it affects how we view and interact with our environment. And it's very well researched that implicit bias, as it goes up, the quality of care that we deliver to our patients goes down. So as you can see with my little cartoon here, the giraffes are just going to win hands down at this game of volleyball. The little rhinoceroses haven't got a chance. So that's inequity. And a lot of this stems from distrust over the years. And when I went in to have a little look at this in greater detail, some of this was actually new to me and a little bit on the shocking side. And it made me really understand more why people come to health care situations with distrust. And a couple of examples are in the 1840s, minorities underwent painful procedures without anesthesia. There were minority men with syphilis who at the time did not receive effective treatment and that was intentionally withheld from them. And as recently as the 1970s, men and women underwent sterilization procedures without informed consent. So this really is now an opportunity for us to work with medical education, enhance our practice settings, have a team-based approach to try and change this, to promote a culture of safety. And that also extends into our professional organizations and our partnerships with industry. So essentially we can do more. And just to give you a few more examples of what happens in society and why people are distrustful of us and therefore may not come to us at the appropriate time. So it's been identified that black patients, when they come for clinical visits, that it's less patient-centered. That individuals with acute pain, if a black patient, they are prescribed opioids of a lesser dose. And it has also been revealed that black patients who went ahead and had replacement surgery were less likely to receive regional anesthesia for joint replacements. So that's something we have to do better at that. The other area of note is the last month of life. There's been studies done on this with regards to the care and the differences between both black and white populations. And it's significantly notable that in the last month of life, a black person is more likely to be hospitalized and more likely to be admitted to the ED compared to a white person. So I like to have a look and see what other people are doing outside the world of gastroenterology and what could we learn from them. And within the pain medicine group, they've decided to have what they call the inside out approach. So basically that they would look upon themselves, their training programs, their organizations, try and enhance that first of all, then reach out to the community, and then subsequently like a domino effect, reach out to society. So where do we have our challenges in GI? And I think one of the main ones really is in the relationship with colorectal cancer screening and the inadequacies or the fact that we're not able to reach out to everyone at an appropriate time or with appropriate education or with explanations. And a lot of that is deemed to stem from health disparity, that we don't recognize barriers. So when we give colonoscopy information to patients, it's in English. It's not necessarily in another language. Again coming back to implicit bias. And then cultural incompetency, that we have these inherent thoughts that even if we make an effort to describe a procedure or a technique to somebody, no matter what we say to them, they're not going to either appreciate it. That's an interpretation and a false interpretation that we make. It's considered to be cultural incompetency to do that. So in order to dig a little bit more into this, I had a little look at the colon cancer screening knowledge amongst a wide variety of ethnic subgroups. So to start, within the Arab-American community, a study was performed in Dearborn in Michigan and it was of patients who were already involved in cancer screening programs. And we sort of thought, looking into this, well, look, if they are already involved in this, surely they would have a heightened awareness. But when the researchers dug into it, they found that that was not the case. That in fact, 70% of participants didn't know what a colon polyp was. The vast majority of them were not aware of their individual risk. Almost half of them had never even had a screening test. And the barriers primarily were due to expense, lack of insurance, and very sadly, lack of advice by physicians. If we look at the Hispanic community, there are differences there also. And I'll just draw your attention to the changes here that were actually state-based for screening colonoscopy. So it was interesting. In Ohio and in Guam, Hispanics have a higher screening rate than non-Hispanic whites. If you happen to live in New York, Indiana, or Delaware, the disparities are the smallest. And then there are other states where the disparity is more evident. So it was in North Carolina, Texas, California, and Nebraska. In Puerto Rico, you've probably come across this concept of the inflatable colon. So they were trying to do an education program to encourage people to get colonoscopy. And they noted that it wasn't age or gender or even perhaps education. The greatest barrier for that particular cohort at that time it was studied was the fact that the people in Puerto Rico that they discussed this with had a great fear of colorectal cancer screening. They really didn't know what it was about. And that again is something that is incumbent upon us to change. It's a communication fault on our part. When we look at the Korean-American group, the barriers to screening there came from cultural opinions such that perhaps older Korean-Americans thought that cancer is just a part of life. It's just going to happen. There's no need to screen. Another misinterpretation is that colonoscopy is to make a diagnosis of cancer. They didn't actually see or appreciate that this is a means of actually cancer prevention. So what physicians within the Korean-American community wanted to do was to try and improve clinical communication and to really work on a concept of trying to minimize the anxiety that patients would have regarding these procedures and the embarrassment that they experience. So moving away from ethnic subgroups, I'm actually just going to bring you on a little tour about gender differences. So this was an interesting paper just out and what I thought was different, and I had never really thought about it myself before, was I think we're all familiar that perhaps a female patient undergoing colonoscopy may have a subtle preference that the endoscopist is female over male. But certainly it's not going to be a major demand. But what this particular study noted was that if the endoscopy team was all female, that this was something that they really would embrace. It wasn't necessarily the endoscopist himself or herself. On the flip side, it was men primarily between 50 and 70 who had their gender preferences and that if possible, they would like to be looked after by a male endoscopist. And to such an extent that sometimes people are willing to wait a little bit longer or pay a little bit more for the endoscopist of a specific gender that they're looking for. This is a different style of colon cancer screening issue, and it's a paper that comes from Pakistan, and it was a survey of more than 1,000 people, again, looking at this concept of male and female endoscopist preference. And you'll see that really from a female perspective, as you would sort of acknowledge or have the insight that the vast majority of women would look for a female endoscopist if they had the opportunity. And a lot of that, as you can anticipate, was related to religious values and family pressures. So colonoscopy isn't the only entity that we work in that has disparities. I'm sure when you've been on the liver floor, working people up for transplants, there is actually a lot of inequity within liver transplantation. And those who are involved in liver transplant programs are now really trying to make a conscious effort to try and introduce implicit bias training into their programs. And that's because so much of the liver transplantation workup is actually quite subjective. So they really want to sort of promote this implicit bias at the level of the organization and to outreach and community practices. I move a little bit now because we said that this was a potpourri-style conversation and talk, and it's really to highlight the lack of diversity in clinical trials. It's been 30 years since the FDA and the Revitalization Act took place. And the goal of that particular idea was that minorities, which would include women, would actually have a greater role within clinical trials. And despite efforts, it was re-reviewed in 2011, and it was really noted that, in particular, the Hispanic community and the African-American community was really under-representative within clinical trials. So to such an extent, last year, the FDA tried to offer guidance to groups as to how to enhance and promote diversity within clinical trials. And as you can imagine, if this was a pharmaceutical trial, we're not really seeing the ideal end product if it's just been evaluated in healthy 40-year-olds. We need to have people of all ages, genders, genetics, BMIs, much more inclusive to ensure that particular medication, is it effective or not? So again, the challenge with the diversity in clinical trials, particularly within the pharmaceutical industry, is they're really, really anxious to get the drug out as soon as possible. And also, when it comes to inclusion and exclusion criteria, you'll find for a lot of drugs that are being created, exclusion criteria would be hypertension, diabetes, obesity. And as you can imagine, the downstream effect there is there are certain sections of society that cannot be included within that if they adhere to such strict inclusion and exclusion criteria. So that's all been a little bit heavy. Just going to give you a little bit of a break here. These are my friendly bears. They've all got different colors of fur, and everybody has a nice treat to have a good scratch. So what I'm going to move into next is more the diversity, equity, inclusion aspect within ourselves and within gastroenterology. Where are the challenges and the opportunities? So I think it's important that we look at where we've come from at the level of medical schools. And last year, a collection of medical schools in New York released the breakdown of ethnicity within their schools. And as you can see, I'm not sure if you can pick this out, but the blue circle represents the population within the New York area, and then medical students with the mulberry sort of color. And you'll see that probably the greatest change is within the American Indian and Alaska Native group, very much underrepresented. If you look completely over onto the right, which is looking at the white population, you'll see that the white population within that New York area is about the 76%, and in medical school, it's about 49%. And then if you move just a little bit to the left, having a look at the Asian population, that's really quite flipped over. So the Asian population, it's 22% in their medical schools, whereas it's 6% within the population. So there are all sorts of different mixtures and concoctions within that. But how can we either begin to overcome that or illustrate this as a challenge? Rome wasn't built in a day. It's not going to change overnight. But I'll just give you an example of what some medical students do. And this is actually the Mayo Medical School, where I am in Rochester. And they have a council for diversity, equity, and inclusion. They have an e-newsletter. They highlight a student of the month, faculty of the month, interest group, things like that. So they're beginning to introduce this concept at a much earlier stage than perhaps you were exposed to all of this in a more formal way. When we look at this within GI, it's important to know the breakdown and the percentages. So according to the American Association of Medical Colleges, underrepresented populations within medicine include Hispanic population, black Native American population, and Alaska Natives. And they are of the opinion that 33% of the US population are composed of those groups, however, only 9% of GI fellows and 10% of GI faculty. I show you this slide not so much to highlight advanced endoscopy training, but it's just to highlight the green boxes. So this was a study looking at trainee experiences. But I just wanted to highlight that in 2020, only 19% of matched applicants for advanced endoscopy were women. And the other interesting one was that 55% of successful applicants were originally foreign medical graduates. So that brings in another eclectic mix into the people that you're working with, you're at fellowship with, your early career with. And we just have to be more, I think, cognizant and sensitive to who we are and the people we work with and what's around us. So one opportunity that has taken place, and again, I refer to where I work with Mayo Clinic, that they have created a 10-part inventory. And this isn't exclusively for GI. This is just right across the board. And this is something that might be important to you when you're looking for your job moving forward. But it's really super important that health equity training is incorporated into your fellowship, that your program director does it, that your colleagues do it, and that the faculty that you work with also really embrace this. It has to be an all-in system. But it's important when you're reaching out. You've heard earlier today about the academic side of things, the private practice side of things, a lot on economics that I think is just profoundly important. But in addition to that, you need to make questions or try to ascertain where you're going to work. Does it include diversity, equity, inclusion? Is this an important part of their research studies? Is it part perhaps of their mission statement? Where do they stand at the moment with various underrepresented minorities within their staff levels? Are they making active statements to incorporate people and be more diverse? So whether you work in a large academic institution or whether you're in a private practice, whether you're by yourself, it's very important, as other people have alluded to, that there's an inclusive work environment. So opportunities ahead for GI. I think one of the really important things that will help us to improve in the DEI arena is the mentor-mentee partnership. And this is something that you may have it formally set up for you at where you work. It may be something that you need to make a deliberate effort to reach out and to try and assist yourself in that way. But in some way, shape or form, that should be there. It's going to be super important that there's implicit bias training for yourself and for all of your colleagues. And that it's important that the concept of diversity in leadership and teams is recognised. I will say for ASGE, some of you may actually already be involved in this, a new programme started in July. It was a mentor-mentee programme for senior fellows. And I'm actually delighted to say there's probably about 50 pairs of mentor-mentee partnerships. It's a two-year programme. So if you didn't apply this year and it's something that you're interested in, always consider that in the next 12 months. I think probably around April time will be the application time. And I really think that that will help to have successful relationships as you move forward. And rather than just exclusively focusing on the next generation and what could be done better, it's important that we actually have a look at the leaders that we aspire to be or who are in the positions currently. What do they do? What training do they get? That is actually a really important question for you to ask when it comes to your interviews as well. How up to speed are they? Things are changing. I'll give you an example of changing within journals and the editorial boards. So JAMA have highlighted that they think that publications such as the H-Index are being increasingly used for hiring, salaries, grants, retention, promotion and tenure decisions. This was something that was completely new to me. If we look at Neurology, which is sort of the premier neurology journal, they now have a monthly update within the journal. And a couple of subsections include, what's the new research in DEI, a did you know section, a call for submission so that people would actually submit their personal experiences and then also for some blogs. Last year was considered to be a very important year for women, according to The Lancet. They had two major projects and the goal was to promote women and advance women in science. So again, this was quite a change. More recently in science, I don't know if you look at that as a journal, there was an article entitled Mothers of Invention. And this particular article you'll see just in the top right there, was an ophthalmologist who has had a profoundly interesting career, has generated many patents, has intellectual property. But at the same time, what came through as sort of the bottom line of the article was, yes, women are more likely than men to invent specifically for women, but that there are many obstacles that will limit their participation in the innovation system. Our own journal within GIE has in more recent times, modified the author statements. So when you are submitting your manuscript now, say for example, to GIE, you'll be going through a lot of questions pertaining to the diversity of your authorship, the diversity of your study subjects. Was it an inclusive approach? And really, again, just trying to be more balanced and thoughtful in what we do. So the future. It's always interesting to go back and see what happened in the past. So what used to exist in ASGE was a committee that pertained to membership and diversity. It was pooled together at that time. So about five years ago, they had a diversity initiative and what they wanted to do, and this would have been five years ago. So think about that time frame. They wanted to invest in the future. They wanted to invest in women. They wanted to promote leadership for women. They wanted to create a mentorship programme, promote diversity through the means of awards and grants, and then also to address health care issues within the LGBTQ community. So you'll see from that over the five years, in fact, they did instigate and operationalise an awful lot of that. There's a similar scenario within the AGA. Again, they're very much trying to promote diversity, but rather than talking about it, they say that they want to create, you want to go from intention to action. You want to operationalise this. Stop talking about it, do something about it. And one of their sort of areas that they're very keen to try and pursue is this area of cultural competency, that we become, you know, more sensitive about ourselves, our immediate surroundings, that therefore will have a knock on effect with the patients that we interact with, the research environments that we work with, etc. So I leave you with a phrase from Maya Angelou, and she said, it's time for parents to teach young people early on that in diversity, there is beauty and there is strength. And I think if you take a step back and say, where do you see in your own experience the most productive teams? And you will see that the most productive teams are the diverse ones, the ones that come with multiple backgrounds, multiple cultures, ethnicities. And in fact, even if you were looking at this from a business perspective, it has been scientifically proven that the most diverse teams are, in fact, actually the ones that have the best revenue as well, if you wanted to think about it that way. I also want to highlight that in 2017, for the first time in history, the three GI societies and the liver society, that the presidents of all of those organizations were, in fact, women. And I just want to highlight she's here in the room. Dr. Colleen Schmidt was a prior president of ASGE and one of a series of women as well involved in that role. So this is my last slide, and I realize that you may have a lot of perhaps education questions that you'd like to ask. So Ed Dellert asked me to highlight this to you. He's the chief publications and learning officer. And that happens to be his email. If you've got education questions pertaining to ASGE. So with that, I think I have about two minutes to go. I don't know if anyone has any particular question or even if it's not a question to me, but perhaps if it's a business question, an academia question, I see, you know, Dr. Dominance is still here. Dr. Nunn is still here. Oh, yep. Sorry, Dr. Vakari, terribly sorry you're here. Oh, you were just announcing you were here. OK. Any particular question or anyone from the virtual audience? I mean, there was a question about deciding between private versus academic jobs, and if there are suitable hybrid models, how do you navigate learning more about that? Gosh, can I pitch that question, perhaps? Does anybody offer some insights into the concept of a hybrid model? Dr. Dominance. Yeah, I think my microphone is live. I mean, there are all sorts of different academic settings, you know, like Virginia Mason in Seattle is a place. I don't know if you're still here. He used to work at Virginia Mason, which is many people would view it as a private setting, as I mean, the hospital employee model. But they have residents there and they have, you know, they do a lot of publication, a lot of research. So they're being paid more like a private practice type of model. But they don't have, you know, lesser ranks there. They have a joint appointment with the university affiliates. So I think that's kind of a hybrid model. I'm sure there are many other models. Like I said earlier, there's no like one model of academics. There's there's thousands. Thank you.

diversity

implicit bias

healthcare disparities

clinical trials

mentorship programs

practice settings