We're going to be talking about DEI, but covering particularly in the workplace, which some of these topics we've talked about today, and we're not going to talk about healthcare disparities, which in and of itself can be a topic itself. Those are my disclosures, which are not relevant to today's talk. So today's objectives, we're going to define what is diversity, equity, and inclusion. We're going to talk about diversity, particularly in the field of GI and the importance and benefits of it in healthcare, and also speak about the proven strategies for improving and sustaining DEI in GI and in the workplace. So what is diversity in healthcare? Our first question. Understanding that everyone is unique and recognizing our individual differences encompasses acceptance and respect, a culture where all employees are treated equally and receive the same opportunities for growth and advancement, or D, all of the above. Okay. Perfect. Everyone knows DEI. I'm going to go make this brief as well. So let's start with the definition of what is equity. So imbalances within our social system result in the need to provide equitable processes. Equity in the box on the right refers to providing resources appropriate to the environment to obtain equal outcomes. So you can see here that the imbalance is the wall, and equal outcomes is so that everyone has an opportunity to watch the game. And so in terms of health, the World Health Organization describes equity as the absence of avoidable or remediable differences among people, whether those are groups defined by social, due to caste or tribe, economic, based on wealth, demographic, due to age, gender or race, or geographic, countries, regions, urban, or even rural areas. So to understand equity, it's important to distinguish it from equality. So equality, which is the picture on the left, implies that each individual or unit should receive the same thing. So in that picture, it's the same level of height. In health, this would translate to all individuals paying the same amount for the same health service or receiving the same amount of information about their health service. However, some groups within a society may have greater need than others, and we know that. So equity focuses on eliminating those differences between the groups when those differences can be addressed. So in health care, that would translate to a sliding payment scale for those same health services or differing amounts of information based on prior knowledge and access to information. Spectrum of diversity in medicine comes with a whole host of characteristics that all contribute to our cognitive diversity and all contribute to the advancement of our profession and patient care. So race, we all know, is an inherited quality, and it refers to the person's physical characteristics, such as skin color, facial features, hair color. Ethnicity, on the other hand, is identified as a social group you belong to. It refers to the shared cultural characteristics, such as language, ancestry, practices, and beliefs, as opposed to nationality, which is the relationship between a person and the political state to which they belong to or are affiliated with, and that equals citizenship. Then we cover gender, socioeconomic status, sexual orientation, geographic location, physical ability or inabilities, religion, and career stage. So if we look at the U.S. population, underrepresented minorities account for 35% of our U.S. population, and it estimated over time in the future 2050 that underrepresented minorities will represent 50% of our U.S. population, and so we've sort of touched upon this census data showing that we are living in a more diverse America. So if we look at this in terms of medicine, and particularly in GI, we're all familiar with this leaky diversity pipeline, and what the AAMC defines as underrepresented in medicine as racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population. So the prior slide we talked about was census data that looked at underrepresented minorities representing 35% of the population, but increasing about 50% in the future 2050. So when we look at medical school, underrepresented minorities represent only 11% of graduating students, and then if we go down the pipeline to internal medicine residency, same thing, only 9% are underrepresented minorities, GI fellowship no different at 10%, and overall practicing gastroenterologists are 10%, 9%. So if you look at this leaky pipeline, there's a few things that we can take from it. One, there is a significant bottleneck between the population and entrance into medical school with regards to the representation of underrepresented minorities. Two, by having a small number entering medical school, that has downstream effects for the specialties thereafter, including medicine and GI. So this sort of highlights that we need to do more work to recruit a diverse trainee field, and we must repair this leaky pipeline. So if we look at GI, it's not a surprise that we lack diversity in our field. In practicing gastroenterologists, if you look at the breakdown of race and ethnicity, two thirds are Caucasian. And if you look at breakdown by gender, more than 80% are men. So more and more it's changing where there are actually more Asians, Hispanics represented, but still African Americans are well below 5%. So this is also, if you look at it, med school composition faculty, it's the same thing where two thirds are white, two thirds are men, and it's even more skewed at the senior level of professorship and associate professorship. So what about DEI and gastroenterology? What do we need to do? Where are we now and where do we need to go? So this is a slide that I took from DDW, which every year has wonderful DEI talks and also a reception that I encourage people to go to and attend if you haven't already. But the good news is that all of our societies, GI and hepatology, have committed to the initiatives of DEI. All advocate for the diversity in staff and governance, research grants for underrepresented investigators, including women, support research and health disparities, ensure quality for all, and work to reduce inequalities in healthcare delivery and access. So in 2017, it was a wonderful year. It was amazing. We had four societies' leadership. The presidents were all women. That was Anna Locke, Carol Burke, Sheila Crow, and Karen Woods. And we hope to see that again in our lifetime and that it won't be sort of like a full moon, blue moon kind of year, but it's something that we can see on a regular basis. I also wanted to highlight some of these important GI groups that, again, I encourage people to become familiar with. Some of them that I've included here include Rainbows in Gastro, which are champions of the LBTQ plus community, overcoming disparities of sexual and gender minority patients and providers, Women in Endoscopy, who champion the advancement of women through education, professional growth, and leadership development, and also the ABGH, which is the Association of Black Gastroenterologists and Hepatologists, addressing healthcare disparities in gastrointestinal liver disease and liver diseases disproportionately affecting Black communities, to name a few. I also wanted to take some time to highlight what the ASGE is doing in terms of their DEI initiative, and I wanted to refer you to this paper, The Diversity in Gastroenterology in the U.S. Where are we now and where should we be going? And that was done, that was spearheaded by the ASGE Membership and Diversity Committee, which is led by our current ASGE president, Dr. Jennifer Christie. And some of the other ASGE DEI initiatives, which are important, include Women in Endoscopy Special Interest Group, and that's a forum for women gastroenterologists to achieve individual excellence at every stage of their career. The LEAD program, which I was fortunate to be a part of, which is Leadership, Education, and Development program for women in their early career stages. And also what's new to ASGE and is exciting is the ELEVATE program, which is a retreat that specifically focuses on early-stage, underrepresented and minority gastroenterologists to provide foundations for a successful career, and to work and to look at the initiative On a medical student level, ASGE also has started a DDW Experience Travel Award. So it's trying to spark the interest of our field and sharing that passion to young trainees. What's the rationale for diversity? Well, it's just the right thing to do. Justice is what is called for, changing dysfunctional structures and providing everyone access to opportunities and resources needed for success. It's shown to be proven benefit of better productivity, delivery of healthcare from workers in a diverse environment. Diversity leads to more intelligent and thoughtful approach to problem-solving, and most importantly, innovation. And what we were talking about before, which are sort of the softer features of a greater sense of belonging, connectiveness and satisfaction among employees, and that translates to patient care as we talked about today. So we come to our second question. How much improved profitability is associated with a diverse workforce? 5%, 10%, 35%, 50%. You guys are so good. So that it's correct. Benefits of profitability have been shown to be about 35%. So looking at companies, business companies, they noted that diversity is a key to a thriving flourishing and successful organization. And that 35% performance is explained by two things. Diversity really being driven with profit margins through innovation. And that innovation is through the sharing of diverse ideas from people from all kinds of backgrounds to expand your thinking pool. So six benefits of a diverse workforce we've talked about a little bit, but they're more likely to serve an underserved community. They help exchange cultural customs, values, and behaviors. They bring different points of views. That is going to translate to more enhanced employee engagement and retention, which is important. More likely to perform research in underrepresented minorities. So another important study that came out of Harvard Business Review showed that diversity unlocks innovation and drives market growth. And they looked at companies that had both inherent diversity, which is a trait that you were born with, such as gender, ethnicity, sexual orientation, as we talked about, or acquired diversity, which involves traits that you gain from experience. So if you're talking about a person who's worked in another country and can help appreciate cultural differences, for example, while selling to female consumers can increase your gender intelligence. So that's all examples of an acquired diversity. And what these companies, what the study showed that these two types of diversities, the inherent and acquired, are needed to drive innovation by creating environments where you're able to think outside the box and ideas can be heard. And this translated to higher market share growth and capturing new markets. So they highlight six behaviors to unlock this type of innovation, and that then those six include ensuring that everyone is heard, making it safe to propose novel ideas, giving team members decision-making authority, and that's really key, sharing credit for success, giving actionable feedback, and implementing feedback from the team. So we touched upon importance of underrepresented minorities in medicine. So how can we translate that diversity? We talk about it in a profitability innovation way, but what about in medicine? So what we know is that it's important because there are a number of reasons. Underrepresented minorities can help exchange cultural customs, values, and behaviors which help in patient compliance and adherence. As we know, patients prefer doctors who share the same race and ethnicity. They also have varying viewpoints for innovation and organizational success, which can be translated in medicine. They are more likely to serve underserved communities, are more likely to conduct research in healthcare disparities, and also are important in playing a role in mentorship for others who are in the similar track of their career. So next slide, where do we begin this cultural change model? Well, we know that it's a process, and where it starts is from leadership. Leadership, as we talked about today, sets the tone for all that we do in our organization, and it's no different in medicine. They look for guidance and direction on what is acceptable, appropriate, or won't be tolerated in the work environment. So if a leader does not value or respect inclusion, that sentiment, whether it's spoken or unspoken will inevitably corrupt the workforce. So there's a trickle down effect where there is no buy-in from the top and it shows up in the way that people collaborate with one another or advocate or not advocate for each other. So we need to get key leadership buy-in. Then you have to take stock and do cultural assessments, goals and KPIs, which are key performance indicators. And that can come in many forms. Sometimes it's from employee satisfaction surveys. It can be employee engagement levels, meaning you can send out a net promoter score which says on a scale of zero to 10, how likely are you to recommend your organization for a place of work? Then the next is to start a conversation, raise awareness, inspire and involve, build a plan for the future, employee led, which is key and executive sponsored. Embed, meaning constructive reassurance, inclusively communicate and evolve so that you're continuously monitoring, reviewing and adapting. So again, the most important thing is that leadership is the start of it where it's changes need to come from the top. What you can see here is that hospital, we know about U.S. physicians as you talked about at medical school and rolees and how skewed it is, but it's even more skewed when you look at the leadership at hospitals and at medical schools where majority, 88%, 74% are white and majority are men. So what does inclusive leadership look like? Leadership style that values team members, invites diverse perspectives, creates an atmosphere where people feel their opinions and contributions improve the company's wellness. That's really the key. So improving organizational DEI as we talked about is a process, it's a journey. Overall goal is to create an inclusive environment where everyone feels like their voice is welcome, heard and respected. How do we do that? We start by building and recruiting a diverse organization. And that starts with identifying current status, identifying what some barriers may be and setting goals for what your initiative will look like. And this may include partnering with diversity talent recruiting companies. It may also partner with community representatives in healthcare organization building and planning so that you have multiple voices at the table and also multiple opinions to help you create that initiative and make sure that you can enforce and employ it. Then you continue on level three, which is acceleration by supporting and promoting to continue to drive that diversity. Strategies to improve DEI in the workplace sort of touched upon this today in multitude of ways, but really it comes from celebrating our differences, eliminating biases in the hiring and promotion process, mentorship is key, education and training and that all changes institutional culture. Comes to our next question, what strategies can we employ to improve DEI in the workplace? Create a blind system of reviewing resumes so people do not see demographic characteristics, create dashboards to monitor diversity and only leadership positions, become an ally or be comfortable with being a bystander or E, A and C. Perfect. So as we know, hiring and advancement really has to take a look at what we can do to recognize bias and remove these barriers. Data shows that hiring process is unfair and can be full of biases. Candidates names alone has shown to immediately cause unconscious bias. So organizations must strive to eliminate this in the hiring and promotion process as best as they can. So striving to uncover unconscious bias. So bias in the community is replicated in any work environment without intervention. And there are many types of unconscious biases, we all have it. So what is unconscious bias? It is the attitudes or stereotypes that affect our understanding actions and decisions in an unconscious manner. Unconscious bias is a human condition and it takes intention to redirect it. Decision-making capacity can be riddled with unconscious bias and direct casual link between unconscious bias and organization culture and success. So through learning and practicing inclusion in action while becoming an upstander and an ally, biases can be uprooted. So it's possible. So strategies to address this. First, it starts with awareness and understanding, recognizing it, paying attention to it and acknowledging what your assumptions are. Workplace applications, addressing microaggressions and discussed about equitable hiring and advancement so that there are equal opportunities for promotion and advancement for all. And skills and strategies to leverage tools for counter balance, counteracting these biases. So microaggressions are subtle but they're not absolved of their effect. Research shows that cumulative effect of microaggressions can contribute to a whole host of things including hostile and invalidating work climate, devalued social group identities, lower work performance, physical problems, including depression, anxiety, insomnia and mental health issues due to the stress, low self-esteem and emotional turmoil. So this is an important topic that was discussed at this year's DDW, discrimination and microaggressions in medicine, understanding being an upstander versus a bystander. So again, talking about the damage caused by being a bystander, being silent and how that negatively impacts us in the healthcare work environment. So bystander by definition means not doing anything to disrupt the bias and upstander on the other hand, steps into effectively address an issue and also support the person or group who's being targeted. And so in this picture, we can see that we're all guilty of developing affirmations and defense mechanisms to protect our status of being in a group and trying not to be out of the group. And the bystander effect also contributes to a group thinking mentality, meaning, well, I'm not gonna say anything at this point because I'm sure someone else is going to bring it up so I don't have to have that responsibility because I feel awkward doing it. So that's a group thinking mentality. So this is something that we really need to be aware of and notice that we can take action against trying to change these kinds of things. That leads us into allyship. Allyship is a lifelong process of building relationships based on trust, consistency and accountability with marginalized individuals and it's not self-defined. It takes work and effort and must be recognized by those you are seeking to ally with. So it's a personal relationship and the victim should be the focus. It's not a performance, but again, a building relationship that's lifelong. And I wanted to highlight this book by Dr. Lutherow who is a leader in DEI in the workplace. And she talks about allyship and how it starts by creating a listening culture and sort of the emphasis of what we've been talking about that people want to be heard. People want to feel respected and have their ideas feel like they're just as important as the next person who may or may not look like them. So seven behaviors to promote allyship that she describes include being curious, being introspective, learning your biases, acknowledge what you don't know or what you don't see, engage in empathy, promote authentic conversations, be vulnerable and make courageous decisions. Don't be that bystander where you think, okay, someone else is going to bring it up so I don't have to. So creating and celebrating diversity, these can be small steps, it can be big steps. And I can say that I really liked Jenny's talk this morning about how she really personalizes her leadership and her community with her endoscopy unit. And that starts with little things that celebrate all of our differences and community as a workforce. I love the idea about sharing socks and somehow to change that into a multicultural event, maybe not just for Halloween, but for others celebrating individual cultural holidays is a great idea. But small things, big things that you can do that will make a difference in the long run because again, this is a journey. I would say that the most important thing though is a debrief to strengthen allyship. The debrief is everyone's chance to reflect on the moment and support one another, let everyone know how you feel and ask how others are feeling. So it's a two-way communication. And it's also a great time to display a growth mindset and get feedback how you can be a better upstander the next time. So reframing company culture, that is all about data data. And sort of talked about that in all aspects of quality, whether you wanna change behavior of your employees, of your physicians, of your organization, you need data to do that. And so you have to conduct disparity assessments, have staff focus groups and equity champions and counsel them. You have to also evaluate your leadership and make sure your leadership takes accountability because that's where you have a closure of your loop that everyone has accountability and everyone has buy-in. And another important point is to create a safe space where microaggressions can be addressed. This is kind of a busy slide, but I just want to highlight the important parts, which is that the University of Michigan Surgery Department had developed this process innovative program called the Michigan Action Progress System. And it's basically a process where people can raise concerns about feeling invalidated without fears of retribution. And it was really more for the trainee level to feel that they will not have any repercussions or retributions to bring up microaggressions in a safe environment, but it can easily be applied to the workplace. And the goal is to focus on the needs of the person who is marginalized or feeling the microaggression, consolidating the handling from the concerns by one person, which is in here in this model, a MAPS representative, transparency and documentation, and emphasizing in the end support, education and improvement and closing the loop so that everything is documented and you can see if there's any trends. And if there are trends that you can go back to it and that's the data that you need so that you can implement change and educate. So what can we do on the trainee staff level and administrative leadership level? We sort of talked about this, but it's basically unconscious bias training, cultural competency training curriculums and standardizing evaluation processes so that there is no bias and it's fair for performance reviews. And again, talking about leadership, really it's about intentionality, commitment and accountability. So where do we want to be? We want to be all the way on the right, which is justice. Becoming an anti-racist, anti-sexist, anti whatever institution requires removing the systemic causes of inequity. So the reality is that there are disparities. Some get more than is needed while others get less. Equality we talked about is that everyone benefits from the same support. Equity is better because people who need more support get the support that they need and so that everyone has the same outcomes. And justice is a systemic cause of inequity that's being removed. So that's the fence so that identities are maintained and everyone can be accountable. And another pictorial diversity is all the ways in which people differ and we celebrate that. Equity is a fair treatment, access, opportunity and advancement for all people. One's identity cannot predict the outcome. And inclusion, a variety of people have power, a voice and importantly decision-making authority. So in summary, diversity is a range of human differences and it's about empowering people by respecting and appreciating what makes them different. Demographics in the US are rapidly changing but the healthcare workforce and GI particularly do not mirror this change and so we need to work harder to change that leaky pipeline. Number of important benefits to patients, providers, medical teams and healthcare systems and future providers for having a diverse healthcare workforce. And lastly, improving diversity within an organization and workforce requires the entire team and it's a continuous journey. We talked about assessment, data, leadership, institutional culture, mentorship. And a variety of strategies are outlined today to improve DEI within GI and in your organization. Essentially, the principles of being an upstander and applying it in allyship. And finally, organizations should not look at diversity as just a point in time but rather an evolving process of learning, adjusting, reflecting and leading. This is a call to action, not just in principle but what these ideas are is how can we do better? How can we be better? And that's sharing our successes and also our failures as we grow together in this journey so that there is diversity, equity and inclusion in your organization. The journey is challenging yet we all can position ourselves as agents of change and transformative leaders. Thank you.

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