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Surgeon leaders need to educate, elevate, and energize to create a culture of diversity: An interview with Dr. Julie Freischlag

Julie Freischlag, MD, FACS, FRCSEd(Hon), is the first subject of the “Profiles of Diversity” series developed by the ACS Committee on Diversity Issues.

Shubhada Dhage, MD, FACS, SreyRam Kuy, MD, MHS, FACS, Amelia Grover, MD, FACS

April 1, 2019

Editor’s note: This article is the first in a series of “Profiles in Diversity” developed by the American College of Surgeons (ACS) Committee on Diversity Issues. These interviews are published periodically and spotlight prominent surgeon leaders who promote the value of diversity and inclusion both in the ACS and among its members. The full audio of this profile is available on the Committee on Diversity Issues page.

Julie Freischlag, MD, FACS

Julie Freischlag, MD, FACS, FRCSEd(Hon), is chief executive officer (CEO), Wake Forest Baptist Medical Center, and dean, Wake Forest School of Medicine, Winston-Salem, NC. In addition to her significant achievements in the field of vascular surgery, she has been a trailblazer as a surgeon leader and a strong advocate for diversity.

Shubha Dhage, MD, and SreyRam Kuy, MD, MHS, both members of the ACS Committee on Diversity Issues, conducted this interview December 11, 2018.

Tell us about your journey as a surgeon leader.

I am a vascular surgeon. I went to Rush Medical School, Chicago, IL, and then trained at the University of California-Los Angeles (UCLA). I became chief of the vascular division at UCLA and then became the first woman chair of surgery at Johns Hopkins University, Baltimore, MD. At that time, I was only the fourth woman chair in the country of a department of surgery. I was the only division chief of vascular surgery in the country that was a woman. Now as CEO and dean at Wake Forest Baptist Health, I’m the only CEO physician who is a woman in the southeastern U.S. and am one of about 28 deans in the country who are women.

As a chair, I started really noticing the need to promote inclusion and diversity. Mainly because when you look at leaders in surgery, deans, and CEOs, the lack of diversity is pretty poignant—not only in terms of gender, but also race and background.

In our institution, we are looking for leadership that’s diverse. For me, diversity and inclusion mean raising a great pipeline of people who come through at all levels and then rise to lead. As a result of developing the pipeline, our leadership will become more diverse.

What does diversity mean to you and to your institution?

Diversity to me means excellence. When you look at businesses and corporations, diversity has been paramount to achieving excellence. It’s through diversity, through differences of opinion coming together to ultimately make the best decision. Personally, as a chairwoman, I came to appreciate that when I wanted to make a decision or come up with a new way to accomplish a task, getting a diverse group together was invaluable in getting to the right answer. I did have a few examples where I thought I had pretty good ideas and planned to make a decision by myself. But, if I stopped and incorporated a diverse team, we made a better decision with more depth and flavor than mine alone. This diversity can be created by including people of different specialties in surgery, age, gender, and whether they are residents or students or of a different ethnic background.

As CEO, every year I choose a theme that serves as a focus for the institution. Wake Forest encompasses 20,000 staff people, five hospitals, 500 primary care practitioners, a medical school, a physician assistant school, and a nurse anesthetist school. This year at Wake Forest, we have chosen diversity and inclusion as our theme because it’s so important. It’s important when you start making corporate and business decisions at an academic health center that you remember the diversity in your organization and the diverse community you serve. We make all of our decisions based on how we will best care for the people who live in western North Carolina together.

It is a natural tendency to veer away from confrontation or diversity of ideas because sometimes people believe that makes decision making more complex and difficult. How do you overcome this challenge and encourage diverse discussions?

Most people think it’s difficult to be inclusive and diverse, and that challenge arises when people who have different beliefs enter into a conflict. Some people aren’t as fair as you would like them to be. I am somebody who loves everything to be fair. I think once you realize that your decision will be better if you take time to listen and bring in diverse views, you will find that you can’t even imagine making a decision without that diversity of opinion.

I will give you one example. I have been practicing for 30 years as a vascular surgeon. Just in the last five years, I have taken the opportunity to listen to a better way to take care of patients, which is by giving the patient a voice, too. I used to say, “You need to have a femoral popliteal bypass,” or “Your aneurysm just hit six centimeters, and I need to fix it.” In the past, I would just say, “We’re going to go do this procedure, and what date would you like the surgery?” I’ve grown as a surgeon, and now I have learned instead to ask the patient, “Do you want your aneurysm fixed?” or “Do you want a bypass?” You listen to what they have to say. This approach is patient-centered, and it’s actually better for the patient. You can adapt to it. It does take a new mindset that you’re going to focus on the patient—his or her desires and wants. Then you alter your behavior and availability appropriately.

If you take clinical inclusion of the patient’s voice, and you can then take it to your office and other places to be more inclusive, I think that can help people decide that listening and inclusivity aren’t that hard. Actually, it takes a bit more time, but you make better decisions.

What are specific steps you can take as a leader to foster and implement a diversity initiative so that it doesn’t feel like a directive?

An example is when I started as chair of surgery at Hopkins. Initially, we interviewed resident candidates from five to eight schools, and we received a few hundred applications, mainly because people thought we only looked at a few schools to fuel our residency. The residency program director and I expanded the pool and interviewed students from different schools. As we did that, the diversity of the pool increased because people started to apply to our program from multiple states. We then set two more goals: to increase the number of women and international graduates. We added looking at gender because only 10 percent of our applicants were women. International graduates, who were amazing candidates, allowed us to appreciate how difficult it is to be born and raised in a foreign country and want to train in the U.S. The diversity of our residency expanded.

When I was at the University of California (UC) Davis as dean and vice-chancellor, we really were trying to increase our faculty diversity. We found that it was very hard. We decided we needed to tell our residents that we wanted them to stay. Only about 17 percent of all our residents stayed at UC Davis. We worked hard to let them know that they could fit in and that they could stay. This extended our diversity initiative to our medical students. For our student applicants, we implemented a second-look opportunity and looked to our more diverse faculty who could talk to them, interview them, and represent where they came from. It takes a long time to change the culture, especially if you’re lagging behind. Those initiatives are still a work in progress. Trying to get more diverse students, and then more diverse students to stay on as residents and faculty, builds the pipeline through a domino effect.

Culture change requires patience. You allow things to happen over time and it can take many years to see changes in diversity and inclusion take shape.

What would you recommend to those junior surgeons (students, trainees, faculty) who are looking to champion diversity at their institutions?

Understand that no matter where you are, wherever you sit, wherever you were born, whatever your experiences, we all need to pay attention to inclusion and diversity. As you sit at a table or you sit with your team, you want to see a mosaic—you want to see different people with whom you interact each day.

At Johns Hopkins, we did an exercise during our diversity training. There was a box of beads of different colors: white, brown, black, and yellow. The instructors said, “Take the beads out according to the color of the people you spend time with during the day.” We realized very quickly that probably 80 to 90 percent of those with whom we interact look like us. As you look at your immediate team, if a mosaic is what you want to look like, then you need to really stretch to make that happen.

Part of it is just being aware that people who look like you may think differently than you, too. There are generational differences. When you look at women surgeons, you see women in their 30s, 40s, and 50s practicing. In a practice, there may be surgeons who are of different generations.

How have you been affected by bias, and do you have any tips on how to manage it?

I was interviewing for surgery residency in 1979 in Los Angeles. The chairman welcomed all young men and said, “Oh, and one woman.” I was only the sixth woman to finish at UCLA. I was only the sixth woman to get her vascular certification. At my first two jobs, I was the only woman on the surgical faculty at the University of California-San Diego and UCLA. When I went to Milwaukee, WI, I was one of two women faculty members.

I think for me the part that was so hard was being the only woman. People really were watching you closely. I really felt that you had to perform in a very good way, not only to survive and make it, but also to allow someone else to come behind you. If you did not do a good job, they might not allow other women into the program. I was really worried about that. I don’t remember feeling that I experienced unconscious bias or issues. I did know when I interviewed at UCLA for residency they were graduating a woman chief resident that year. I realized that she survived, so I probably could survive.

I think there were issues when I was looking for chair of surgery jobs. I had a dean at a very prominent medical school tell me over the phone that I was terribly qualified, but he didn’t think that he could hire his first woman chair ever in the department of surgery. He didn’t think culturally that his team was ready for it. In 2002, I was offered a job as chair at another institution, and then the offer was rescinded two weeks later because they didn’t think that they could support a woman. They really felt it was gender-oriented and not based on qualifications. I ended up getting the job at Hopkins, where I did have a supportive dean. But I was the only woman clinical chair. It was very groundbreaking. Now, there are 22 women surgery chairs across the country.

I think we have to challenge leaders to have the backs of the diverse people they hire. If they can’t do it, then it would not be worth it. They have to have your back to make you successful.

In the Journal of the American College of Surgeons, I wrote about how I wanted to go to the University of California San Francisco. Twenty years later, a Fellow of the American College of Surgeons told me that there were three women resident applicants the year I applied. The chair decided not to rank any women that year. Sometimes people will do things, and they don’t even realize it. That’s why implicit bias training is important. It’s probably not overt bias but unconscious bias. We have implicit bias training for all our search committees and all our medical students.

What would you tell your 20-year-old self about the trajectory and your experiences with bias and diversity?

Well, I used to think that, when you were younger, if someone wasn’t treating you well, or  if they weren’t listening to you, you really needed to fight for that position and you really needed to be very proactive; and I still think that’s somewhat true. So the way I used to describe it to 20-year-olds was that when a door was shut, you were supposed to beat down the door rather than go through a window, because you could hurt yourself. Now I feel what you need to do is to go through another door, and it actually does lead you to a better place.

That said, there still are things done to which you need to call attention. Now I think leaders really want to hear about it. Speak up, make sure people understand what you can do and what you want to do, then learn how to let people know that if they say or do something that’s offensive, even if there’s a hierarchy, you have an ability to say, “You offended me and I’m not feeling comfortable.” And I also tell people, “If you’re a bystander, you need to speak up and make sure people realize that what they’re saying or doing perhaps isn’t the best.”

I believe wherever you’re planted, even if things didn’t work out, you can end up blooming somewhere else.

What successful efforts have you seen, and what recommendations do you give an organization to continue to grow diversity?

The American College of Surgeons (ACS) has given me an incredible opportunity. I went to my first meeting in 1983, presenting at the Surgical Forum at Clinical Congress. I was fortunate enough to become a Governor through the Association of Veterans Affairs Surgeons. Then I was Secretary of the Board of Governors and then I became a Regent, which was amazing. I was the first woman Chair of the Board of Regents. It was all an incredible opportunity, and through that experience, I’ve watched the College grow in many ways. They started a Women in Surgery Committee, the Young Fellows Association, the Resident and Associate Society, and the Committee on Diversity Issues. I’ve seen so much inclusion, whether by gender or race or by specialty. I’ve been a member of many of the chapters because I’ve moved around the country, and they have been so great about including residents in their programs, as well as young surgeons, and really promoting diversity in that area.

It’s a very inclusive organization. I’ve seen such improvement just with having people find it easy to be part of the society and then also being able to participate on a local level or even on a national level.

It’s really wonderful as we’ve watched it grow. I can’t even tell you how important it has been to me to learn leadership skills, meet people, and be able to talk about all the things that go on in your life through the ACS.

Going back to the effective tools for managing bias and how we can think about instituting directives to fight implicit biases: although a lot of institutions are implementing programs, is there a false sense that they are actively working toward reducing bias and that there may be more effective ways to create cultural change?

When you talk about bias—implicit or not implicit— people get anxious. They worry that they’re doing the wrong things. We do worry that some people may back away from interacting with those individuals unlike themselves out of fear, especially with the #MeToo movement. Will women surgeons not have access to training programs, the ability to go to meetings, or have social interaction with other surgeons who are men? Are we going to be able to negotiate appropriate interactions and behaviors between each other? We have a new diversity and inclusion vice-president at Wake Forest who is working with us and really looking at how we go forward. I think the training is very helpful, but I also think that you need to really make sure people know that every day their job is to work on inclusiveness, too.

We just created a new vision statement about who we are, and it was pretty inclusive. It says, “We are a preeminent learning health system.” That means we’re constantly learning—whether it’s our students, our staff, or faculty—we are always learning, and that promotes better health for all. Also, health is mental and physical. It’s our patients. It’s all of this through collaboration, excellence, and innovation. I think that’s the piece—to be collaborative, not judgmental, to go toward excellence, which is diversity, and to be innovative about how we do things.

I do a monthly video here where we tell stories and talk about things that are going on in the institution. It’s been really wonderful to have people get to know me and to understand what we are doing. We also feature stories about things that people have done that show great inclusion. I think that it’s day-to-day, person-to-person work, and learning to reach out your hand to that other person makes a difference every day.

What are the three key takeaways from our discussion that our readers can address to have a lasting impact on increasing diversity in their communities, institutions, and practices?

There are three things, which are as follows:

  • Educate: You need to really create, enhance, and promote professional development and education. It means listening. Know your community, cultivate better educational programs to be more inclusive, and let people know what it looks like. What are the critical conversations? What kind of things can you do as a bystander to help people be included?
  • Elevate: Develop pathways to make sure that all voices are heard. One thing we do here is have affinity groups for Native Americans, African Americans, veterans, and other underrepresented health care professionals. We have a staff counsel for all our staff, and they are really working to elevate each group so we hear from everyone. We survey our people quite frequently to know what’s going on, and in turn, they become more engaged and feel that they have a voice.
  • Energize: You really need to motivate, inspire, and empower action. I was just at a leadership group meeting where I commented that it can’t be accomplished with diffusion. We have to have active transport. We really need to cultivate champions. We need to show inclusion in action through stories, and then I, as a leader, have to be totally accountable for what’s going on in my institutions. See something that needs to change, and make it happen.

Educate, elevate, and energize—these are the three things to do, and actually, all three of them will make you feel good about what you’re doing because you’re being active.