I will now offer one last talk before we move on to the Q&A and case studies. So today I'm going to deliver our last talk about increasing the diversity and cultural competence of your team. I have no financial disclosures or relationships to discuss. In terms of the objectives of the talk today, I really want to define diversity, equity, inclusion and cultural competence. I want us to learn about the current state of diversity in gastroenterology, understand why it is important to have diversity and cultural competency, and then help us to understand that we need to commit to incorporating strategies to increase diversity and cultural competence. So diversity is a component with acceptance and respect at its core. It has many facets which include things like age, gender, race, ethnicity, religion, disability, sexual orientation. Essentially, it is recognizing the value of each person's inherent uniqueness. Equity does not necessarily mean equal. Diversity is eliminating the unbalanced conditions that create disparities in access, opportunity, and advancement. And finally, inclusion is the environment where the workforce feels respected, valued, and acknowledged. What is implicit bias? It really is the unconscious attitudes that lie below the surface but may influence our behaviors. There must be training so that we can recognize our unconscious attitudes or perceptions because they influence our behaviors or decisions. And there have been studies that have shown, in terms of hiring, that men and women typically will show a stronger preference for male candidates even when all applicant materials are identical. So this stresses the need to really understand and recognize unconscious bias and attitudes to affect change. What is cultural competency? Cultural competency is an institutional framework that can help expand an organization's internal and external capacity to support and implement protocols that improve worker attitudes, cross-cultural communication, diversity of staff, and ongoing relationships with multicultural communities and stakeholders. The next slide really just shows some data, and it looks at the active gastroenterology physicians by race and ethnicity. This was data collected back in 2018. And what I hope you see here that this demonstrates is that the U.S. healthcare workforce is really not reflective of the diversity that we have in our population or the people that we serve to offer healthcare. And it's unfortunate because this diversity in medicine is linked to improved access to care for underserved communities, and it positively influences patient outcomes. Now when we look at GI faculty and racial representation at medical schools throughout the U.S., what we see here is the same. The proportion of the underrepresented minority faculty has increased over time when we look from 1980s to the current state, with the largest increase seen in Hispanic and Latino faculty. However, there really has not been a change with respect to the proportion of African Americans or Blacks within the academic faculty within the past 20 years. And when you look at American Indian, Alaskan Natives, or Native Hawaiians, those physicians really represent about less than 0.2% of all academic faculty positions. So I hope this highlights that we are not there yet, and that diversity really needs to be championed. We talked a little bit about kind of faculty members, but what happens to kind of students or medical students? There's been a strong correlation between the proportion of matriculating URMs, medical students, to the proportion of URM faculty, and what we see is there really has not been an increase in the proportion of URM medical school graduates. So there's been really minimal change in these numbers as well. They've also noted in terms of the data that there's been a steady decline in the proportion of URM GI fellowship applicants, so people applying to become gastroenterologists. What are the challenges that are unique to underrepresented minorities and physician scientists? Really, it's an experience. Oftentimes they will report experiencing interpersonal biases or microaggressions and discrimination. They have reduced availability of effective mentorship and sponsorship. So when you're looking for a mentor, oftentimes you look for a mentor that looks like you, that has gone through experiences similar to you, and that's why diversity is important for our URM physician scientists. And the reality is there's a concern that they may confirm stereotypes. There's a reluctance to kind of increase that communication across all the various cultures within a medical school because there are concerns that they may be perceived wrong or be captured under certain stereotypes. Here, this figure shows the relation of race or ethnicity group of physicians in California to the race and ethnic groups of the patients in their practice. And what I hope this highlights is that Black physicians care for significantly more Black patients, and typically patients with Medicaid compared to other ethnic group physicians, and that Hispanic physicians care for more Hispanic patients and uninsured patients than do other physicians. So in general, minority patients prefer a doctor with a similar background. So it's important that if we are really going to address health disparities, that we include diversity in the population of health care providers that are out there to serve patients. So looking at the importance of racial and cultural factors in patient-physician relationships, I'm going to kind of reiterate what I've talked about before. Really when there is race and ethnicity concordance, physicians are rated as providing better interpersonal care than other race physicians. So when we think about increasing diversity, I really want to bring home the idea that if you increase diversity, you increase the quality of care. URM physicians increase care in underrepresented communities, and they promote research, often in health care disparities, and look into inequities. And this can help to cultivate mentors for future health care providers. So a diverse health care workforce improves familiarity with cultural customs, values, behaviors in our patients, which enables us to address disparities in health care outcomes for our unrepresented groups or underrepresented groups. I share this slide to transition to discuss gender issues in gastroenterology. Here we're looking at active physicians by sex in gastroenterology. This is data from 2018, and really what the pie chart is illustrating is that there is a significantly less proportion of female gastroenterologists when you're comparing them to males. A small number of women holding positions of significant leadership in academics is also a problem. So there are real gender issues in GI medicine. Not only are there a disproportionately larger amount of males, but a 2015 study found that among the top 50 NIH-funded medical schools, only 13% of the department leaders were women. So this culture of predominantly male leadership in medicine and GI is discouraging for women, and we often talk about this glass ceiling effect. Studies also suggest that there are gender discrimination that contributes to the lack of advancement for women in academic medicine and contributes to actual job satisfaction. So when you look here at this figure, you can see that there are significantly more men than women that obtain the rank of full professor. You may ask the question, why do we need more female representation? Again, sex coordinates between patients and physician is linked to medical decision-making and better treatment for chronic diseases like diabetes, hypertension, and obesity. Specifically for GI, there have been published and anecdotal data that suggest that female patients prefer to be seen by a female gastroenterologist. Also earlier, we talked in an earlier lecture about LGBTQ representation, and so I also want to again highlight that here, that sexual and gender minorities, other underrepresented groups in GI are not reflected when we look at the data. This includes lesbian, gay, bisexual, transgender, and queer individuals. So it's really important that we identify barriers to LGBTQ representation. We need to encourage that diversity within the healthcare system. We need to empower LGBT physicians. We want to remove stigma. We need their input to create opportunities for networking, professional development, and education. We need advocacy for research pertaining to LGBTQ issues, and we want to create an accepting and healthy environment for LGBTQ physicians. I'm going to come back to this idea about addressing implicit bias because it's so important, so I'm repeating it again. Implicit bias training is paramount for inclusion. We have to try to avoid microaggressions, and we have to really insist on greater equity and diversity in everything we do in healthcare. We should strive for that equity not only in clinical healthcare, but also in research and funding opportunities and grants. My next slide talks about cultural competency interventions. The majority of cultural competency training for the healthcare workforce remains focused on building awareness and associating changes in the attitudes of practitioners. We really need more assessments of practitioner behavior outcomes and evaluations of training impacts on patient health outcomes. We need to really prioritize the teaching of real practical skills and their applications in everyday practice. We want to include culturally appropriate curriculum. We want to set educational goals and competencies as they're related to issues of sex, sexuality, and gender-related clinical care, and we really want to provide diverse patient experience. There are studies that have shown that for med students in school where they have ethnically and racially diverse student bodies gain greater exposure to racial and ethnic differences and actually feel like they're more prepared to care for minority populations. So cultural competency interventions are extremely important. My last slide is just going to talk about practice pearls and kind of the takeaway points from this lecture. All URM groups need to see people who look like them in their professional positions. We want to create a safe environment where differences are valued and celebrated and that reducing healthcare disparities must be a priority and we should strive to practice with cultural humility and compassion for all patients. I'm going to stop there and just say thank you.

diversity

cultural competence

medical teams

healthcare disparities

implicit bias training