In the wake of the hateful and tragic death of George Floyd, the Black Lives Matter movement has had a national resurgence. While this movement has continued to advocate for the equitable recognition and value of black, brown, and indigenous lives in various cities, including Charlottesville, VA, since its inception in 2013, it only recently regained the national and international spotlight. Massive protests erupted across the U.S. after Mr. Floyd was brutally slain by a Minneapolis, MN, police officer. His death rocked the nation.
It felt all too familiar for the Charlottesville community, which continues to remember and honor local Unite the Right counter-protester, Heather Heyer, who was killed August 12, 2017 (also known as A12). On that day, Charlottesville community members banded together to oppose the Unite the Right rally led by white supremacists, alt-right, and Ku Klux Klan (KKK) members. Violence ensued. Black surgical trainees, including the coauthors of this column, cared for the sick and injured alongside colleagues of all backgrounds that weekend, while simultaneously grappling with fear, sadness, and anger.
In the years and months since these events, diversity and inclusion efforts at hospitals and within departments of surgery across the U.S. have experienced a rapid uptick; however, these programs have not necessarily been associated with improved conditions for diverse trainees.1 Diversity and inclusion efforts have had considerable success, especially when a multipronged approach is used to attract diverse trainees, including targeted recruitment, holistic review of applications, and inclusive visiting clerkship programs.2 However, significant institutional attempts at building an inclusive, equitable, and supportive environment for trainees of color that focus on retention have lagged behind. Nonetheless, because residents were among the frontline workers during A12, the University of Virginia (UVA) department of surgery had both personal and professional interests in improving the surgical training experience for residents of color and sought a path forward that focused on retaining diverse trainees.
To address recommendations and proposed departmental changes outlined in a previous “Residency to retirement” article by Dr. Martin, coauthor of this column, we describe the associated institutional or departmental response to each proposal.3 Efforts over the last three years at the UVA to improve the climate supporting a diverse and equitable setting for surgical trainees are detailed below.
Recommendations and responses
Recommendation 1:
“Acknowledgement by majority faculty and residency leadership of how residents’ race may influence their experience as surgical trainees. This recognition may help combat the sense of vulnerability associated with being an underrepresented minority in surgical training.”3
Response to recommendation 1:
Departmental and residency program leadership have publicly acknowledged and recognized the well-documented and daily life experiences of black and brown trainees who encounter racial and ethnic discrimination in the workplace.4 The leaders of surgery departments and training programs have condemned systemic racism, committed to anti-racism initiatives, and pledged to support the needs of black and brown trainees and their academic careers.
More specifically, the department of surgery formed a diversity and inclusion (D&I) council to facilitate a strategic approach to addressing challenges facing trainees from diverse backgrounds. The D&I council comprises faculty and resident members from diverse backgrounds who are at various stages of their careers. A faculty member and a chief resident co-chair the quarterly meetings for the entire year.
So far, the council has been successful in increasing transparency of the faculty workforce composition and drawing attention to pay parity. It recently charged designated subcommittees to conduct an anti-racist review of trainee education, departmental policies, career development, and research efforts. The subcommittees will then provide evidence-based recommendations for change in subsequent meetings. Most importantly, the D&I council has committed to continued reviews and recommendations on a rolling basis.
Recommendation 2:
“Formal and structured programs for mentoring and career development for all residents, which may ensure that opportunities that encourage pursuit of research, resident leadership activities, and academic development are offered in a more equitable fashion to all trainees. Mentorship and research during training have been shown to influence the pursuit of an academic career, an important finding given the continued underrepresentation of physicians of color in academic medicine.”3
Response to recommendation 2:
Trainees at our program who have projects accepted at academic meetings receive funding to present their work whenever it occurs; however, the opportunity to network with minority faculty surgeons at those meetings is limited by their underrepresentation in academic surgery.5,6
To provide equitable opportunities for networking and research partnerships with black and brown faculty, underrepresented trainees have been guaranteed funding to academic surgical meetings geared toward minorities in surgery, such as the Society for Black Academic Surgeons and the Latino Surgical Society, regardless of project acceptance, although abstract submission is highly encouraged.
A visiting medical student surgical clerkship scholarship also was established to fund travel and accommodations for minority students who would otherwise be unable to participate in an away rotation because of financial constraints. Furthermore, the departmental surgical society founded a Young Alumni Mentorship Program to broaden trainees’ access to recent program graduates as personal and professional mentors with plans for future networking at local and national meetings.
Recommendation 3:
“Actively shaping a programmatic and institutional environment that encourages discussion and recognition of racial fatigue, which may include creating opportunities for trainees of color to have planned social support in both formal and informal settings. Specific institutional mechanisms to respond to instances of racism and bigotry experienced by trainees should be well-defined and a faculty champion designated.”3
Response to recommendation 3:
To immediately address the trauma experienced on A12, faculty and trainees were given the time and space to safely debrief with behavioral medicine experts through a series of meetings. Members of the department also were made aware of the mandatory reporting and response system in place to address workplace discrimination. The role of a “wellness chief” was established to monitor and respond to diminishing trainee morale as well as to create and implement well-being initiatives.
In addition, training program members and leadership participated in a newly established Trainee Diversity and Inclusion Conference founded and led by the authors in conjunction with the graduate medical education (GME) office and Housestaff Council for Diversity and Inclusion (HCDI). The anti-bias and anti-racist concepts presented at this conference were further reinforced by department-wide participation in a bias training program—”Stepping in”—created and led by leaders of the institution’s department of medicine and the school of medicine’s diversity consortium. It is worth noting that the authors and other surgical trainees were instrumental in founding the HCDI—an organization established in response to the A12 events and led by trainees from multiple departments. The GME-sponsored HCDI is dedicated to recruiting a diverse trainee population via “diversity days” and “second look weekends,” providing support and a safe space for all trainees with social events and building community trust through engagement and advocacy.
Recommendation 4:
“Coordination of an institutional action plan to advocate for faculty, staff, and trainees facing discriminatory behavior from patients. This protocol should include both a pathway for reporting this inappropriate conduct and the designation of a core group of individuals who are available to respond to these issues on behalf of the institution.”3
Response to recommendation 4:
As part of an institution-wide policy, medical center leadership empowered attending physicians and health care supervisors to safely transfer patients who perpetrate racism and other discriminatory behavior or threats of violence toward health system employees, including trainees and staff. Scenarios and suggested scripts on how to navigate these situations were provided, and the department of surgery was encouraged to read and incorporate the suggested actions, if needed.
An office charged with addressing these issues was established under the leadership of a vice-president for diversity, equity, and inclusion who immediately established an “inclusive excellence framework” for the university. Program leadership and GME also refined their orientation presentation to incoming trainees to clearly highlight the mechanisms in place to encourage and support reporting of discriminatory acts.
Cultivating an anti-racist culture
Efforts focused on retention and support for trainees of color should supersede recruitment efforts. These efforts often extend far beyond the purview of any single department. These changes often require institution- or university-wide leadership and support. Leaders interested in building diverse and inclusive requirements must be committed to using their power and agenda to support these changes. Solely focusing on diversifying the trainee population without examining policies and ensuring that mechanisms are in place to support diverse trainees could be detrimental.7 Departments of surgery across the U.S. should use intentional, strategic, and evidence-based approaches to support their trainees while continuing to improve diversity via recruitment. In so doing, more trainees will be able to flourish both personally and academically in an inclusive environment that cultivates a greater sense of belonging.
References
- Acosta DA. Achieving excellence through equity, diversity, and inclusion. Association of American Medical Colleges. January 14, 2020. Available at: www.aamc.org/ news-insights/achieving-excellence-through-equity-diversity-and-inclusion. Accessed November 24, 2020.
- Butler PD, Aarons CM, Ahn J, et al. Leading from the front: An approach to increasing racial and ethnic diversity in surgical training programs. Ann Surg. 2019;269(6):1012- 1015.
- Martin A. Race and residency training in the post-Charlottesville era. Bull Am Coll Surg. 2018;103(2):55-58. Available at: https://bulletin.facs.org/2018/02/ race-and-residency-training-in-the-post-charlottesville-era/. Accessed November 24, 2020.
- Filut A, Alvarez M, Carnes M. Discrimination toward physicians of color: A systematic review. J Natl Med Assoc. 2020;112(2):117-140.
- Julien JS, Lang R, Brown TN, et al. Minority underrepresentation in academia: Factors impacting careers of surgery residents. J Racial Ethn Health Disparities. 2014;1(4):238-246.
- Ulloa JG, Viramontes O, Ryan G, Wells K, Maggard-Gibbons M, Moreno G. Perceptual and structural facilitators and barriers to becoming a surgeon: A qualitative study of African American and Latino surgeons. Acad Med. 2018;93(9):1326- 1334.
- Abelson JS, Wong NZ, Symer M, Eckenrode G, Watkins A, Leo HL. Racial and ethnic disparities in promotion and retention of academic surgeons. Am J Surg. 2018;216(4):678- 682.
