THE SURGICAL WORKFORCE – PROMOTING DIVERSITY, EQUITY AND INCLUSION
TAKING STEPS TO PROMOTE DIVERSITY, EQUITY, AND INCLUSION IN THE SURGICAL WORKFORCE
REJECTING CREDIT SORES FOR EVALUATION OF RESIDENCY AND FELLOWSHIP APPLICANTS
Published Online: July 6, 2022. doi:10.1001/jamasurg.2022.1065
Corresponding Author: Steven W. Thornton, BS, Duke University School of Medicine, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710 (steven.thornton@duke.edu).
.Additional Contributions: We acknowledge the valuable contributions made to the content and conceptualization of this Viewpoint from Justin Rucker, MD, MPH, Duke University Medical Center, Durham, NC. No compensation was provided.
There is growing emphasis on the importance of recruiting and training surgeons who reflect the patient population, including underrepresented racial minority groups, women, those from rural communities, immigrants, people with disabilities, those within the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community, and individuals from low-income backgrounds. This is demonstrated by the American College of Surgeons (ACS) statement on diversity, which says “The ACS upholds…its strong commitment to multiculturalism and equal opportunity, respecting and nurturing the diversity of its membership. It recognizes that specific recruitment and development of [individuals] from diverse and underrepresented groups is essential to enhancing the strength of the ACS.”1 We wholeheartedly endorse such a focus within surgery.
The publication and ultimate correction of “Predictive Value of Credit Score on Surgery Resident and Fellow Academic and Professional Performance” by Berry et al2 highlights the danger of not having racial, ethnic, socioeconomic, and other forms of diversity in all of our endeavors as surgeons. The need for such representation clearly extends to research and recruitment. The fundamental problem with their article, as acknowledged in the subsequent correction,3 is that the authors “interpreted data in isolation of social realities” and failed to recognize the “extensive socioeconomic variables and historical context” impacting credit scores. We appreciate their receptiveness to the scholarly criticism they received and their willingness to reexamine conclusions. Ultimately, we laud the decision to “use [feedback] to better assess [their] own biases and those within the world around us.” Still, we wonder whether such a correction would have been necessary if more diverse perspectives were present during research design, manuscript writing, and the peer review process. In light of the robust conversation generated by their original publication and its subsequent correction, it is important to explore the value of diversity, equity, and inclusion in surgical training along with strategies that can be used to cultivate it.
Evidence shows that promoting diversity, equity, and inclusion within surgery leads to higher patient satisfaction, better health outcomes, more efficient teams, and increased resident wellness.4 Diversity allows for differing perspectives, varied experiences, and improved problem solving. As others have commented, it also fosters innovation and inspires trust from the patients that we are charged with caring for. In an academic setting, it allows us to ask more inclusive research questions and to improve access to care. Progressive colleagues have demonstrated that beyond seeking such attributes from applicants, a culture of allyship can be purposefully cultivated within the existing trainee community.5 The key question, then, is how to recruit and develop a diverse workforce that allows us to achieve these outcomes. The ACS has laid out an inspiring vision for our future, and it is imperative that we think critically about our role in achieving it.
Historically, surgical residencies and fellowships have emphasized quantitative metrics such as United States Medical Licensing Examination board scores, number of peer-reviewed publications, conference presentations, and course grades when evaluating applicants. As a discipline, surgery has lagged behind the wider culture in terms of achieving diverse representation within the workforce.6 Recently, many programs have transitioned to a more holistic review process that values applicants’ identities and life experiences in addition to their quantitative metrics.7 The rationale for deemphasizing traditional quantitative measures is that they favor applicants who have privilege by virtue of their race, such as access to tutoring, mentoring, or support networks, that underrepresented applicants often lack.8 But this transition is not a trivial challenge.
The change comes at a time when there are increasing numbers of highly competitive applicants to residency and fellowship programs. Training programs have appropriately begun increasing their focus on distance traveled and maximization of available opportunities as measures of what applicants have achieved with the resources that have been available to them. But diverse talent cannot simply be recruited at the residency or fellowship application stage. It must first be cultivated in the years leading up to this important professional milestone, as progression to that stage requires enormous effort from anyone, but especially those from disenfranchised populations. To this end, attention must be given to institutional diversity, equity, and inclusion and the support of individuals underrepresented in medicine at every level in the surgeon pipeline.
Students who are underrepresented in medicine should be supported on their path to the residency and fellowship application process, and the diversity pipeline must be a point of emphasis.9 Underserved kindergarten through 12th grade and college students in low-income or rural communities, along with those from first-generation families, should be exposed to career opportunities in medicine and surgery through partnerships with local schools and colleges. Preclinical medical students who are underrepresented in medicine should be connected with near-peer mentors in surgery who can help them build their curriculum vitae, network with faculty, grow as researchers, and achieve success in the clinical environment. Programs that do this have demonstrated that early mentorship during medical school increases preparedness for and interest in surgical careers. Senior medical students from backgrounds that are underrepresented in medicine should be supported financially to complete visiting clerkships with national leaders, to attend research meetings, and to defray the growing financial burden of applying to surgical residencies. Such scholarship programs have become increasingly popular at leading academic centers across the country and are an excellent example of the support we should be providing to exceptional students from all backgrounds underrepresent in surgery.
Surgery, as with medicine and our culture at large, stands to benefit from systems and policies that promote diversity and inclusion. While it is tempting to focus on evaluating large applicant pools with convenient quantitative metrics such as credit scores, United States Medical Licensing Examination performance, publication cutoffs, or course grades, doing so dramatically impedes our ability to recruit talent from diverse and underrepresented communities. Instead, we must holistically consider factors predictive of caring, compassionate surgeons who will encourage our discipline to fulfill its potential. The data support that this promotes the vitality of our profession. We must redouble our efforts to equitably empower and evaluate those who wish to join our ranks so that we may achieve our shared vision of a strong, diverse surgical community that represents the patients that we care for.
