Joe and I felt very passionate about making sure this next topic was included because this is very intrinsic to quality in gastroenterology and hepatology, both from a perspective of the clinicians but also for patients and patients understanding how important this is. And so, you know, I'm really excited for Joe to be giving this talk to finish up our day before the Q&A. And he's very passionate about this topic and I think will do a great job moving us forward. Thanks, Joe. Thanks, Raj, very much. So thank you all in the audience for persevering until the very end of the day. Hopefully it'll be worthwhile. This is the last topic of the day, but I might argue, perhaps the most important and the topic of this presentation is diversity, equity and inclusion in GI. This is something, of course, that has always been important, but unfortunately and thankfully is something that has come to the forefront in recent years for a multitude of reasons, including its intrinsic value. But throughout the day, we've heard many examples, particularly by Nitika about the interplay between DEI within a unit and patient satisfaction. And certainly in the business world, there's tons of evidence of improved organizational performance associated with increased DEI. So the objectives of this session for me are to define diversity, equity and inclusion, to give you a snapshot of diversity in the field of GI as it compares to the population in general, to hopefully be able to impart on you the importance and the benefits of not only acknowledging the value of, but celebrating and leveraging DEI in our units and across the healthcare system, and to discuss some proven strategies for improving and sustaining DEI in GI and in our units in general. So diversity in healthcare encompasses acceptance and respect, and this is obvious. And it's an understanding that everybody is unique and recognizing, and I would argue above and beyond recognizing, sort of embracing, celebrating and leveraging our individual differences toward improved performance and toward the common good. And the goal is to create a culture where individual differences are respected and again leveraged for the greater good, and all employees are treated equally and receive the same opportunities for growth and advancement. And I think one key concept is that equity is not equality. And it took me a little bit of time to fully grasp this concept, but once I did it completely changed my worldview on this problem. And so this illustration sort of highlights the difference between equity and equality. In the left panel, equality is when people are given equal resources regardless of their specific needs. So there's a tall man, a short girl, and a handicapped would-be spectator. Each of them are given a box, so they've all had quote-unquote equal treatment. It's neutral for the tall man who can see the field anyway. It's sort of somewhat beneficial, but suboptimal for the short girl because she can't see great, but at least she can see something, and it's completely useless for the handicapped spectator because they can't see at all. So the resources were equally distributed, but the outcomes are obviously uneven with most people having suboptimal outcomes. Now in contrast, equity is unequal distribution of resources according to need to achieve even outcomes that are optimal for everybody. So in this case, the man gets no box at all because it makes no difference to him. The girl gets two boxes, so now she can see over the fence comfortably and watch the match. The handicapped spectator gets no box at all. Instead, they get a ramp because that's the only way to get that person to the point where they can see the game. And so unequal distribution of resources, but even outcomes and optimal outcomes for everybody, and that's sort of the essence of equity. And then once that happens, a rainbow emerges, and everybody's healthy and happy, and all is good with the world. And so this is a fundamental difference, but then the big question becomes as we try to achieve this, is everybody going to be willing to give up that box in order to achieve a greater good? And that's where the hard work is. So just like many things in medicine, or in life and medicine, diversity is not one thing. It's a spectrum, right? And so diversity in medicine encompasses racial and ethnic diversity, gender diversity, differing socioeconomic backgrounds, national origins, differing sexual orientations, gender identity, physical abilities and disabilities, and differing religions. And each one of these is important intrinsically in and of itself. But what in aggregate these amount to, particularly in an organization, is what's known as cognitive diversity. And it turns out that cognitive diversity is the most important form of diversity for organizational success. So different ways of looking at a problem, and thinking about a problem, and troubleshooting a solution, and innovating around particular key performance indicators and so forth, all those outcomes, all those processes and outcomes are improved by cognitive diversity. And so the distribution of U.S. population by race and ethnicity in 2010 showed that basically 65% of Americans were white, 16% Latino, 12% or so Black, and a little bit less than 5% Asian. And by 2050, this is going to shift fairly significantly. First of all, there's going to be a population growth, and then less than 50% Americans are going to be white for the first time. Above 30% are going to be Latino, and there'll be a slight growth amongst Asian populations. And the reason this is important is because our goal in the field of gastroenterology should be for multiple reasons, including many that Neetu did a great job expressing this morning, for multiple reasons, we need to do our best to mirror the U.S. population as gastroenterologists. And we don't do that now, and certainly we're not on the right track to do that for 2050. And that's why something fundamental needs to be changed, underscoring the importance of presentations like this and the hard work that comes as a result of that. And so part of the reason there's limited diversity in GI is because of what's known as a leaky pipeline. So as mentioned, about 46% of the population are UIM or underrepresented in medicine, right? But only 11% of medical school matriculants are underrepresented in medicine. And by the time you go through the pipeline with losses along the way, and you get to the point of the practicing gastroenterologist, only 9% are underrepresented in medicine, which is a huge disconnect with the U.S. population, and certainly with where the U.S. population is projected to be. And again, we can't take incredible, high quality, safe, compassionate, empathetic care of our patients if we are so dissimilar from them. This is another way of looking at the problem of the limited diversity in GI, as you can see. Of all gastroenterologists, 66% are Caucasian, 20% are Asian, and the predominant group within the Asian population are Indian men. And even though, you know, all forms of different ways of thinking are important, Asian populations are considered overrepresented in medicine. But to the true traditionally underrepresented populations, Latinos and Blacks are less than 10%. And same exists for gender disparity. So you know, 50% of the patients we take care of are women, but only 30% or so are women. And this is a problem. So what is the rationale for addressing this issue? For bringing it to the forefront? And so for being vocal in, particularly from my point of view, in my allyship to improve this, right? So first and foremost, it's just the right thing to do. And this is what's known as the justice argument. So most of us fundamentally understand the difference between right and wrong. And we know that every human has intrinsic value, and people should have the right to do what they're passionate about as a vocation. And sometimes that's gastroenterology, and everybody should have the right to do that at every level, at the nursing level, at the leadership level, at, you know, at the end hospice level, right? And so this is a justice argument, and in and of itself, it definitely, you know, has great weight and holds water. But beyond this, there are several additional arguments in favor, right? So the first, number one, is that this cognitive diversity, this diversity of experiences, and perspectives has been shown in many different contexts, especially in the business world, equates to more intelligent and thoughtful approach to project and program development, to problem solving, and to innovation. Number two is that diversity of humans in general, regardless of whether or not you're able to achieve true cognitive diversity, creates a greater sense of belonging and connectedness at the organizational level, right? And so this results in higher satisfaction amongst employees and staff, and greater resiliency in the face of problems, right? And this is, you know, obviously, at the forefront, you know, staffing issues are such a problem in our end hospice units, and units that have, are able to create a more sort of cohesive environment that really celebrates difference to create more connectedness, and belonging are the ones that tend to be more resilient in the face of attrition. And then importantly, if you combine number one and number two, you're better able to achieve the ultimate goal, which is the higher quality delivery of healthcare services to all patients. And along the way, a better patient experience, and as mentioned, I think Nitika did a great job explaining the sort of interrelatedness of DEI and patient satisfaction. And so in terms of more concrete arguments, so part of the importance of advocating for and promoting our colleagues who are underrepresented in medicine, is that there are plenty of studies across specialties that show that higher physician-patient concordance results in improved outcomes, because you're able to achieve better buy-in on the behalf of the patient, more adherence to the treatment plan and to medications and so on and so forth. And so concordance can be achieved at the gender level or at the sort of racial level and so forth, but also achieving a level of cultural competency. So when there is discordance, physicians and nursing staff who are more culturally sensitive are better able to connect with patients of different backgrounds. And part of the process of achieving cultural competency is having many people and diverse people within your organization who can teach you about that, more so than going through an educational module. Of course, as mentioned, underrepresented in medicine bring varying points of view, which is important for innovation and has been shown to augment organizational success. And then practically speaking, those who are underrepresented in medicine are more likely to practice in underserved areas, which is a huge unmet need in the United States, and are more likely to do research in health care disparities and mentor future generations of those who have been traditionally underrepresented. And these last two bullet points are critical to solving the problem at the, you know, addressing the root cause of the problem. And so, you know, all that sounds great. And some of you may still sort of say, well, that's all sort of sounds squishy. What about, you know, what about the data? Show me the data, right? And so these are data just in a diversity in health care workforce. But of course, this has been reproduced in many different contexts, and the data in the business world are even more impressive. And that's part of the rationale behind certain states now mandating diversity at the board level for large corporations and so forth. But at least in health care alone, organizations that are more diverse can have about a 20% higher innovation revenue. They have 35% higher, they have a 35% performance advantage over more homogeneous organizations, and they're 36% more profitable, you know, so there's a strong business case to be made beyond just the humanistic case and the argument in favor of sort of the intrinsic value and the justice argument. So you know, perhaps that's the easy part, perhaps, you know, it's easy to sell people on the value. But of course, the hard work is, you know, how do you change, right? And typically, like many things we've discussed today, this requires a cultural change model. And if you sort of go through the steps, it's very similar, at least in concept, to many of the models you want to use to change quality in your unit, right? The Six Sigma and the Lean model and so forth. But and, you know, in full disclosure, I'm certainly not an expert, having not, you know, personally overseen or been involved in sort of this at the structural level, and I'm sure there are many nurse managers in the audience who could certainly add, you know, some insights and educate all of us on this, but it turns out that in this context, it is critically important to establish buy-in, especially at the leadership level. This type of thing apparently needs to come from the top. And of course, that can be made on the basis of the justice argument. But, you know, as TR mentioned, in terms of changing behavior around endoscopy, really it's the business case that tends to move the needle. And so it's important to highlight the hardcore financial and clinical benefits of embracing and leveraging DEI within a unit, within a hospital and so forth. And then like everything else we've discussed all day, the importance of measurement. It's important to take stock, not only just sort of demographics within your organization, but also do things like cultural assessment to figure out, you know, where you stand. And this, you know, there are resources available and certainly Eden and I can help you get your hands on some of these, you know, publicly available resources for things like cultural assessment, but also know that there are companies and organizations that will do this, that will come in as external consultants and assess your culture and assess your diversity and provide a blueprint. And of course, this is not inexpensive, right? And so it takes buy in and it takes a willingness to make a capital investment, so to speak, in this, but very much worthwhile based on the return on investment. And then once you have a sense of where you stand and on that basis, you're able to put together goals for your organization, as well as, you know, we talk about quality indicators in health care, but in business we talk about key performance indicators. And once you do that, then you need to start the conversation and you raise awareness at the grassroots level, you make it clear how important this is organizationally or, you know, within your sort of sphere. And you hope that that inspires people to get involved and to sort of move the needle at the ground level. In the process, you build a clear plan and apparently the organizations that have been most successful doing this have done this at the employee level with strong support by leadership. And then just like everything else, you've got to implement and continually measure and evolve and pivot as things either are successful or are not. And so improving DEI is complicated. It's a journey. This is a sort of complex framework for how to do it at the organizational level. But admittedly, you know, unless people have a role at the organizational level, it's difficult to sort of move the needle on that scale. But there's certainly many things that we each can do, whether or not we're leaders, you know, one of the concepts that came up earlier is, you know, leading from the bench, right? Abby Wambach once personally said that, you know, if you can't lead from the bench, then you can't lead on the field, right? And so all of us can play a role. And this comes in many different ways. The strategies to improve DEI within an endoscopy unit involve education and training around the scope of the problem, around cultural competency and sensitivity, around unconscious bias and microaggressions. And these are things that hopefully can mirror and align with institutional priorities because most hospital systems now are sort of attuned to this and have curricula around this. And it's just a matter of sort of interpolating that at the unit level in a way that makes sense to people who work in that particular level as opposed to mandating that people watch a bunch of modules and accrue a certain number of hours. It has to be personalized, right? I think it's critically important to celebrate diversity, right? For a long time, diversity was sort of for many people an eye roll, something that, well, you got to do it because of the optics and so forth. I think once you buy in to the concept that there's real value for all of us in diversity. And so I'll use, you know, without throwing an entire subspecialty under the bus, but I will use the example of interventional endoscopy as a place traditionally in which there's been very little diversity. And so from my point of view, and I'm just speaking on behalf of myself, I think that has led to a culture that is characterized by sort of a toxic masculinity and machismo that I think has sort of permeated into the research we're putting out, permeated into how much people like working in our unit. And it's only been in the last few years, knock on wood, that there's been an influx of a bunch of really talented and enthusiastic women in interventional endoscopy that are, you know, literally changing sort of the landscape in which we work. So I think celebrating that is critically important. I think mentorship, of course, plays a major role, not only in terms of mentoring the future generation of underrepresented in medicine so they won't be underrepresented, but also in mentoring other people that sort of look like me and think like me to take a broader look and a deeper look at this problem. And, of course, from a practical point of view, eliminating bias in the hiring and promotion process is critically important at every level in a healthcare system. And so obviously this is a pervasive problem. Many of you are familiar with well-publicized experiments that have shown that people like Hunter and Caitlin are much more likely to get a job interview compared to Deshaun and Tanisha, even though they have the exact same resume. And thinking along those lines, which in most cases just, you know, innocent, so to speak, can result in very homogeneous organizations, which is sort of the opposite of what we're trying to achieve. And what that speaks to is what's known as unconscious bias, which are attitudes or stereotypes that are basically baked into us because of an entire lifetime of seeing this in action and sort of living in that ecosystem that affect our understanding, actions, and decisions in a way that's completely unconscious to us or sort of we can't sense. And one of the ways this manifests is in what's known as microaggressions. So microaggressions individually in and of themselves are little benign examples where people are put down, but in aggregate can result in a culture that leads to serious problems. And so a brief example that comes up all the time, but it actually literally happened to me last week, I was on a text chain with one of our GI fellows and an internal medicine hospitalist. Our GI fellow was an overrepresented in medicine man. Internal medicine hospitalist was a woman. And we were talking about the care of the patient. And in the same text message, the fellow refers to me as Dr. Almunzer and refers to the hospitalist by her first name. She didn't take offense. Not really a huge deal. He's a really nice, kind, thoughtful guy and wasn't malicious by any extent. It was an honest, simple mistake. He didn't think about it. But the problem is that these little things can amount to an environment and a culture that eventually leads somebody to overlook one of our female colleagues for a promotion or come to them about putting in their promotion packet two years after they really had met criteria according to the Promotion and Tenure Committee's guidelines. And so the microaggressions reflect a greater culture that needs to be dismantled at every level. And there's plenty of evidence both in healthcare and outside of healthcare that there's a strong association between unconscious bias and an organization's culture and success. Again, the more we can embrace and celebrate and diversify and include, the more likely we are to innovate, to problem solve, to be resilient in the face of adversity, et cetera. And so we all need to have concrete strategies to address unconscious bias in the workspace. And it all begins with looking in the mirror. It begins with awareness and understanding. You got to recognize it in yourself. You got to acknowledge your assumptions. And it's okay. Part of the problem as I've learned in my sort of relatively new journey in DEI is that there's a literacy and there is a fluency around this topic that's hard that we're all learning about. And so the default is just to keep your mouth shut because you don't want to offend anybody. But I think most people would acknowledge that most people who would likely be offended would acknowledge that the bigger offense is not saying anything, right? So I think we need to sort of get over that, do our best to become fluent, do our work, but at the same time stay vocal because allyship will be critically important in this journey. But we have to look at ourselves critically in the mirror and we have to look at our colleagues and look at everybody at the divisional level or at the organizational level, including the leadership. I think it's important to call out and to work on microaggressions. There's an emotionally intelligent way of doing that and there's a sort of wrong way of doing that. And that's sort of the art of leadership. But it needs to happen. And, of course, in a concrete sense, we really need to have equity. Not necessarily, well, for sure equality, but we need to evolve toward equity in hiring and advancement. And, again, there are tools for this. There are sort of somewhat evidence-based approaches to this and tools that can be implemented. And I encourage all of you to make this a priority just like the patient experience and just like moving forward sustainable endoscopy. And, you know, as mentioned, reframing company culture, not only around DEI but around safety and around quality, you know, is a challenge. But, like everything else, data sort of will rule the day. And so it's important to use objective data to drive cultural change. And, again, this can be done in several different ways. It can be done quantitatively because there are disparities and cultural competency assessments that are available and can be done. But it can also be done qualitatively. There's no reason why you can't survey your staff, get them together, figure out, you know, figure out where the problem is, where they feel they're not connected, where they feel they don't belong, how could that be approved. You know, you'll be surprised at the straightforward, practical, inexpensive ideas that might come of that. And most places, I think, are now moving toward having some sort of formal structure around equity and justice. And so, you know, many divisions have a or organizations have a chief equity or chief diversity officer. Some divisions have council, DEI councils, or at the very least an equity champion. And along these lines, you know, we got to keep our leadership accountable as well, right? I mean, you know, this can, you know, we can make a lot of headway at the ground level, but unless your leadership is accountable, that's a problem. And leaders need to take accountability and need to sort of help us move the needle in the right direction. And then, again, you know, microaggressions are seemingly innocent and benign, but, you know, reflect a broader culture that is seriously problematic if our goal is to leverage and celebrate and really improve DEI in the field. And so along these lines, I think, you know, again, diversity should not be a mandate for the optics. It should be done because it has real intrinsic value and organizational value. And part of doing it, part of creating connectedness and belonging is celebrating people's differences in a way that, you know, everybody can learn. And so things like developing a multicultural calendar, creating a culture-focused bulletin board, encouraging educational opportunities around cultural sensitivity, not only in how we treat our patients, but how we treat each other, investing in employee diversity training programs, and, of course, supporting advancement opportunities for our underrepresented medicine colleagues. And, again, you know, I try to be pragmatic in everything I sort of do and say, and, you know, it's very easy to, quote, unquote, invest in a program and end up having people do, you know, four more hours of mandatories. They're just flipping through the slides as quickly as possible, failing the test once to get the right answer so that they can complete the test and move on, right? That's, you know, it's an easy investment, but does it result in real change? And so that's where I think we need to be thoughtful and innovative around, you know, how do you get people truly engaged? How do you get them connected with one another to the point where they actually, you know, want to take the time to sort of reframe how they think about this? And what I will say, having just gone through our DEI module at MUSC, I will say that the portions of it that I felt were most educational and resonant were actually the TED Talks. So, you know, one idea that came of it for me is that, you know, I think encouraging your employees to watch a series of TED Talks on this topic, at least to me, was the most resonant. So, in summary, diversity is the range of human differences, and it's about empowering people by respecting and appreciating what makes them different. And, of course, our demographics in the U.S. are rapidly changing, but the GI workforce does not mirror this, and the problem's only getting worse, and it's up to all of us to start to try to move the needle in the other direction. I hope I've sort of demonstrated that there's a number of important benefits to patients, but every stakeholder in having a diverse workforce, and there's a strong business case to support this, which you should use. Improving diversity within an organization requires an entire team and is a continuous journey, just like changing a culture to that of quality or safety. You gotta assess, generate objective data. You need to implement change. You need to measure that change and pivot as appropriate, get your leadership to buy in. As mentioned, there's a variety of strategies and tools that, you know, we will help you get your hands on if interested, that it can improve DEI. Again, it's hard to affect change at the organizational level, but at the unit level, particularly in an ASC, which is sort of a closed model, it's very achievable. And then, again, organizations should not look at diversity just as a point in time, but rather an evolving process as the needs of our patient, as the composition and needs of our patient population evolve. Thank you very much.

diversity

equity

inclusion

gastroenterology

hepatology

patient outcomes