groups are not considered underrepresented minorities in medicine? Choose the best answer. All right, so wonderful. The majority answered correctly, 43% for Asian. That is correct. And as we go through this presentation, we'll talk more about these underrepresented groups. So women physicians comprise what percentage of practicing gastroenterologists? OK, good. So that's correct. 65% picked approximately 20%. I think it's great that everyone is so aware of this. So female medical students are more likely to experience sexual harassment from faculty and staff than students from non-science, technology, engineering, and mathematics. Is this true or false? And the audience is on point today. So sadly, this is true. And finally, our last question. So intersectionality adds to the impact of disadvantage. True or false? All right, great. That's true. So intersectionality adds to the impact of disadvantage. And we'll get to that further in our talk today. All right. So I'm going to be talking about increasing the diversity and cultural competency of your team. I have no financial relationships with commercial support to disclose. So today, we're going to learn what diversity, equity, and inclusion mean, as well as understand what cultural competency is. I'm going to paint a picture of the current state of diversity in GI and convey the benefits of a diverse and culturally competent health care workforce. And by the end of this talk, I hope everyone will commit to these ideals and be a force for change and improvement. So diversity is a concept with acceptance and respect at its core. It has many facets, which can include age, gender, race, ethnicity, culture, religion, geography, disability, sexual orientation, socioeconomic status, area of expertise or experience level, and so on. Essentially, it's recognizing the value of each person's inherent uniqueness. Equity is about eliminating the unbalanced conditions that create disparities in access, opportunity, and advancement. Therefore, equity does not mean equal. Finally, inclusion is an environment where the workforce feels respected, valued, and acknowledged. Implicit bias or unconscious bias is the automatic impact of our attitudes or stereotypes on our actions, view of the world, and the decisions we make without our awareness. We need to learn from them and recognize them in our daily decision making. There's a popular study that's often discussed. It was a nationwide study on implicit bias where they used a sample of biology, chemistry, and physics professors. And they were asked to evaluate the application materials of an undergraduate science student, female or male, for a lab manager position. What was interesting was that both the male and female faculty participants rated the identically qualified female student as less competent and less hireable. Both the male and female faculty participants also offered the female student a lower salary and less mentoring. So this goes to show that it isn't enough to simply put women on committees or selection committees. There must be training to recognize the unconscious attitudes or perceptions that can influence behavior or decisions. Health care professionals are key in determining the nature of interactions and experiences a patient will have with the health care system. When there are cultural and linguistic differences, the stage is set for potential miscommunications, distrust, disempowerment, and decreased satisfaction for the patient. Cultural competence is one strategy that we have to address these disparities. It's an institutional framework to support and implement protocols that improve attitudes, cross-cultural communication, staff diversity, and ongoing relationships with multicultural communities and stakeholders. Practitioners with increased cultural competence have been linked to increases in patient satisfaction and even adherence to treatment recommendations. The American Association of Medical Colleges, or the AAMC moving forward, traditionally reports groups underrepresented in medicine as Hispanic, Black, Native Americans, and Alaskan Natives. However, the AAMC allows for this definition to include underrepresented groups relative to unique communities. So the definition of underrepresented can change depending on where you are or where you live. The traditional underrepresented groups comprise about 33% of the US population, but only 9% of GI fellows and 10% of GI faculty between 2018 and 2019. So to give some perspective, in 1980, approximately 4% of GI physicians were from underrepresented groups. So basically in the span of 40 years, we've only had a 6% increase in representation from underrepresented minorities in GI. Or this is the little pipe that shows that on this chart. So, you know, if the US population continues to grow at a similar pace, by the 2050 census, nearly 50% of our population will be non-white or a person of color. This is unfortunate because diversity in medicine is linked to improved access to care for underserved communities, and it positively influences patient outcomes. In general, diversity greatly improves our capacity to innovate, and evidence shows that when teams include different kinds of thinkers, they outperform homogenous groups on complex tasks. So they have better problem solving, they innovate better, and more acute predictions, which all lead to better performance and results. As mentioned in the last slide, the proportion of underrepresented minority, or URM, faculty increased from 4% in 1980 to about 10% in 2017, with the largest increase occurring in the Hispanic or Latino faculty. However, there was no real change with respect to the proportion of African American or Black academic faculty within the last 20 years. And American Indian, Alaska Native, and Native Hawaiian physicians represent less than 0.2% of all faculty positions. It's important to point out that the proportion of URM academic faculty has never exceeded more than 10% at any academic rank. And what's more concerning is that now there's a decline in the proportion of URMs at the junior academic faculty level too. So to drive these points home, there's a strong correlation between the proportion of matriculating URM medical students and the proportion of URM faculty. Sadly, there has hardly been any change in the proportion of URM medical school matriculants between 1980 and 2016. And this is despite the fact that the positions have increased by a quarter in the same time period. And of course, with a weak pipeline, then it's not surprising that there's a steady decline in URMGI fellowship applications as well. So there are many challenges to underrepresented minorities. Intersectionality poses an increased risk for attrition. So different social categorizations can add to the impact of disadvantage. That goes back to our polling question. Underrepresented minorities are less likely to come from money, and they more often anticipate a need to support extended family. An example is that black medical students consistently graduate with more debt than their peers. URMs are more likely to experience bias, microaggressions, or discrimination. There's also less availability for effective mentorship and sponsorship. Finding sponsors is challenging for two reasons. The first is, is there are so few underrepresented minorities in positions of leadership, and then sponsorship is overwhelmingly provided by non-minorities. The other issue is, is that unlike mentorship, sponsorship does not necessarily require an established relationship. This makes sponsorship more vulnerable to both explicit and implicit bias. So seeking and accepting sponsorship may be uncomfortable for an underrepresented minority. Imposter syndrome may also ingrain an aversion to seeking and accepting opportunities that are perceived as partly non-merit based. Then we get to the minority tax. So diversity initiatives depend on dedicated URM and non-URM faculty. These efforts are usually insufficiently weighted in career advancement decisions. We need to rethink how we value the time and resources of those who lead these important initiatives. Initiatives like credit towards promotion or even financial incentives need to be standard. There is also concern that their actions may confirm negative stereotypes. For example, an underrepresented minority may be ambivalent to seek opportunities that are specific to individuals from underrepresented backgrounds. So they may not wanna apply for a minority supplement grant because they think it may drive a stereotype. This bar graph is showing that Black and Hispanic physicians care for significantly more patients of their own race. This is a reflection of these patients seeking physicians of their own race due to a personal preference or because of shared language. Furthermore, it's important to know that this preference exists even when proximity to the physician is not a factor. So in general, minority patients prefer a doctor from a similar background. With race and ethnicity concordance, physicians are rated as providing better interpersonal care than other race physicians. For Black patients, the strongest association between racial concordance and patient satisfaction was the respondents rating of their physicians treating them with respect. Patient satisfaction is an important aspect of healthcare quality. Patients were also more likely to receive preventative care and other necessary healthcare, which correlates with access to healthcare. The same is true on the flip side. Black physicians rated White physicians more often than non-White physicians as excellent in listening to concerns. Interestingly though, it didn't change the overall provision of healthcare. Increasing diversity will increase the quality of care. For example, Black physicians are five times more likely to practice in predominantly Black areas. A diverse healthcare workforce will help improve familiarity with the cultural customs, values, and behaviors of our patients, which enables us to address disparities in healthcare outcomes for underrepresented groups. Finally, diversity will help us better address disparities in health outcomes that are observed in certain racial and ethnic patient groups because those from underrepresented backgrounds are going to be interested in the adverse social determinants of health. Studies show that diverse teams produce more high-quality studies that help a greater number of patients. Articles including an international author are cited more than studies with authors all from the same country. Another great example of diversity in research is the Okinawa Institute of Science and Technology's rise in ranking after they implemented a policy which mandated that 50% of their researchers hail from outside of Japan. The pie chart is illustrating that less than 20% of practicing gastroenterologists are female. The picture to the right is a picture of faculty and fellows at the University of Mississippi in 2017. This picture is a great example of the male predominance in this field. I circled myself in yellow as the lone woman in the division at that time. So now, four years later, we have three women faculty members and a female fellow, so I feel we've come a long way. Gastroenterology remains a male-dominated field. Essentially, male faculty predominate, whereas women are more represented as early career faculty and trainees. A study in 2015 reported that among the top 50 NIH-funded medical schools, only 13% of the department leaders were women. The predominantly male leadership in GI and medicine in general creates a glass ceiling effect. I also want to quickly mention that due to these gender disparities, female GIs also experience disadvantages even in the endoscopy units. This extends from decision-making regarding new product purchasing, unit supplies, we have to use equipment designed for men, we have higher injury rates, and even how industry representatives interact with us. On this slide showing the percentage of women in academic ranks, you can see that significantly more men than women obtain the rank of full professor. Despite the fact that there is more gender parity for medical school applicants, matriculants, and residents across all specialties in recent years, the proportion of female academic faculty is about 40%. The higher the academic rank, the more this percentage decreases. And the only rank for which women outnumber men is at the clinical instructor level, which is the lowest rank. Studies suggest that gender discrimination is at least partially responsible for the lack of academic advancement for women, and it also contributes to job dissatisfaction. Also, productivity differences do not fully account for the advancement deficit. A 2004 study showed that at all levels of productivity, women were still less likely to be full professors than their male peers. And even when adjusting for hours worked or the number of patients seen, women physicians still earn less than their male peers. For GI specifically, this difference has been shown to be over 20% between male and female gastroenterologists. Interestingly, the difference was only seen in academics. Make note that this salary discrepancy exists in medicine in general, but it's not as exaggerated as is seen in the GI practice. Another example of how intersectionality causes disadvantage is seen in pay. Women that have multiple intersectional identities suffer a greater magnitude of salary discrepancy because each identity adds on more disadvantage. So you're a woman, which is a disadvantage, and let's say you come from an underrepresented background, or you're an international medical school graduate, or you identify as an LGBTQ physician, all of these can add impact to the disadvantage you experience. Women are expected to be as productive as their male colleagues with less support. They receive less NIH funding, even when controlling for subject content and the potential of the researcher. To the right is a photo of our all-female GI lab at the University of Mississippi. This was highlighted in a campus communication because it's not often that you see a female-run scientific lab. So proud of us for that. The Med2 and Time's Up movements have also brought attention to the issue of sexual harassment in medicine. This study from 2020 applied the Sexual Experiences Questionnaire, which is a standard measurement for sexual harassment, to academic medicine. It was the first time the survey had been used in an academic medicine setting. Women were significantly more likely to have experienced gender harassment and unwanted sexual attention than men, from both institutional insiders and from their patients' and patients' families. It's interesting and notable that over 50% of men also reported gender harassment from insiders. So increased experiences of harassment were also independently associated with lower mental health, lower job satisfaction, and lower sense of safety at work. There is limited evidence that exists regarding the rates or impact of sexual harassment within academic medicine. The National Academies of Sciences, Engineering, and Medicine define sexual harassment as gender harassment, unwanted sexual attention, or sexual coercion. They found that female medical students were 220% more likely than other STEM students to experience sexual harassment. That number is just astounding to me. Another study showed that 39% of female GI fellows experienced sex discrimination during their training, and 19% were subject to sexual harassment. The reason for all of this likely lies in the historical male dominance of medicine, strong hierarchies, and an ingrained culture of tolerating mistreatment. I just want to point out some benefits of more female representation in medicine, which includes better decision-making and treatment of certain chronic diseases. And for GI specifically, data suggests that female patients prefer female endoscopists to care for them. Lesbian, gay, bisexual, transgender, and queer individuals are also underrepresented in medicine. They are considered sexual and gender minorities. Unfortunately, many barriers to identity disclosure still exist. There are anti-gay and anti-transgender attitudes, as well as potentially severe personal and professional consequences. Identity concealment has been shown to have significant negative effects on physical and mental wellbeing. In 2015, Manchin colleagues published In the Closet in Medical School in Missouri Medicine. They found that approximately 16% of students identified as a sexual and gender minority. Nearly one third of them concealed their sexual identity in medical school. The most commonly cited reasons were that it's nobody's business and fear of discrimination. In 2013, the AAMC survey revealed 6% of the over 3,000 respondents reported LGB identity. These students reported increased levels of stress, social isolation, lack of social support, and financial concerns compared with their heterosexual colleagues. There is a knowledge void when it comes to the LGBTQ community in medicine as patients and also as providers. The lack of information causes suboptimal delivery of care to these patients. For example, I think we have a long way to go in properly addressing our transgender patients, which sounds like it should be simple enough, but it is a significant problem. Remember for patients, every interaction contributes to the overall care experience. It's important for all members of the healthcare team to communicate in a respectful and sensitive manner with our patients. Like other underrepresented minorities, the LGBTQ community suffers from poor access to care and increased incidences in diseases like certain cancers, HIV, and mental health disorders. Living in a high prejudice area has even been linked to a shorter life expectancy. A survey on LGBTQ patient experiences found, one, that most believe providers were not prepared to care for them. Two, more than half reported confronting discrimination. Others reported outright denial of standard medical and surgical treatment due to the provider's religious or personal objections. They were denied admission to long-term care facilities, and many reported unnecessary physical examinations. Exclusion from clinical trials and epidemiological analyses further hinders the study of these disparities. Since at least 4.5% of Americans self-identify as LGBTQ, we need to see this reflected in our healthcare workforce. There is evidence that positive role modeling by an increased interaction with the LGBTQ physicians decreased both explicit and implicit bias among medical students towards their LGBTQ patients. More physicians disclosing their sexual identities will help address disparities and increase research in LGBTQ healthcare. Finally, how can we make an overall impact? The educational pipeline poses a challenge to underrepresented students who may not have had sufficient educational exposure or support. We need to prioritize programs that enhance mentorship and diversity. They have been extremely successful in advancing the career of these individuals, and we must implement them at the earliest stages of education. Other areas to address the pipeline include programs for mentorship, summer research, publication opportunities, and shadowing experiences. We should strive for everyone to have implicit bias training. Unconscious or implicit bias affects judgment and can pose a critical barrier to the recruitment and retention of a diverse biomedical workforce. Certainly, there should be mandatory training for anyone sitting on admissions or promotion committees. Also, the admissions criteria can disproportionately disadvantage some URMs, and we should strive to expand the definition of excellence and adopt a more holistic view of applicants. Traditional medical schools have often failed to adequately address topics like cross-cultural patient-physician interactions, health disparities, and actionable strategies to improve health outcomes for underserved communities. Promoting and implementing a more culturally appropriate curriculum is important to correct this. Lastly, the magnitude of the salary discrepancy between men and women is greater for women with multiple intersectional identities. Given the overlapping and interdependent systems of discrimination are disadvantaged that each identity brings. Also, non-U.S.-trained physicians earn less than U.S.-trained physicians. This has been shown in the infectious diseases specialty. We must commit to correcting these disparities, to being transparent, and to not continue to perpetuate these pay gaps. Addressing implicit bias is so important that I'm going to repeat it again. Ideally, everyone should have this training, but especially anyone in a position of power. This training will allow those individuals to confront prejudices that may impede their ability to select diverse candidates. Also, allyship is very important. Dr. Francis Collins, head of the NIH, said he would not speak unless there was female representation. That is a strong stance in support of his female colleagues. The majority of cultural competency training for the health workforce remains focused on building awareness and associated changes in attitudes of the practitioners. We need more assessments of practitioner behavioral outcomes and evaluation of training impacts on patient health outcomes. We need to prioritize the teaching of practical skills and their applications in practice. As far as a culturally appropriate curriculum, we should set educational goals and competencies as related to issues of sex, sexuality, and gender-related clinical care. We can continue to learn and grow by providing CME with the goal of encouraging comprehensive, compassionate, and culturally competent patient-centered care. The type of patient experiences we provide The type of patient experiences we provide in training are so impactful. Studies have shown that med students in allopathic schools with ethnically and racially diverse student bodies gain greater exposures to racial and ethnic differences. And thus, these students feel more prepared to care for minority populations. At the organizational level, the leadership needs to embody diversity and minority recruitment should be a priority. Institutions can also develop programs and services for their underrepresented patients through interpreter services and by using language-appropriate health education materials. We can also address some of the unique challenges faced by underrepresented physician-scientists by incorporating financial benefits, which include signing bonuses, low-interest rate loans, tuition remission, and child and elder care support. The minority tax can be eliminated by compensating for the service required to advance these initiatives. The isolation surrounding disadvantage and intersectionality can also be alleviated through professional organizations and social networks. Instead of pointing out differences, emphasize strengths and resiliency. Address implicit bias with meaningful training. There are several things we can do to address the lack of mentorship training. First, we need to enhance our pool of mentors. Addressing intersectionality and connecting underrepresented minorities with local professional networks, as well as strengthening connections to national leadership programs would go a long way to improving inclusivity. Not only do we need mentorship, but sponsorship is just as important. It's essential for academic success and it should be equitable. Those in leadership should have this on their radar and work to correct disparities in sponsored activities across divisions. Finally, we need institution-wide policies and strategies to support equity and inclusivity. It's critical to have consistent and transparent policies and metrics as related to promotion. Institutions should also focus on recruitment and retention packages for underrepresented minorities. Allyship refers to members of an advantaged group supporting and including underrepresented groups or the marginalized. For example, Dr. Collins refusing to be part of a MANL or panel of only male speakers. We can all advocate for transparency and pay, supportive maternity leave policies, and support breastfeeding. There is a strong role for female allies and she for she. There is a strong role for female allies and she for she. I'm actually here today because Dr. Jennifer Christie nominated me for this talk. And last but not least, let's empower LGBTQ physicians. We must remove stigma and encourage their input and involvement. As with other underrepresented groups, opportunities for networking and professional development should be developed and we should implement programs that promote awareness of LGBTQ related issues in GI. These physicians can help advocate for and direct research pertaining to LGBTQ issues. All of this is possible if the environment is healthy and accepting of everyone. All underrepresented groups need to see people who look like them in these professional positions. We need to have personal and institutional accountability for inclusion. I hope that after this talk and with more awareness and acceptance, there will be a renewed commitment to evolving institutional culture. Institutions should realize that the degree of diversity in their leadership will ultimately affect their ability to attract and retain a diverse workforce. And finally, the heart of this is about reducing healthcare disparities. This should be a priority for all of us as we strive to practice with compassion and cultural humility. There's no room for intolerance of our natural human differences and especially not in the sacred relationships between physicians and their patients. Thank you all for your attention.

underrepresentation

diversity

cultural competency

women in gastroenterology

sexual harassment

intersectionality

LGBTQ individuals