Bridging that gap: a qualitative study of perceptions of equality, diversity and inclusivity in colorectal surgery in the UK and Ireland

Abstract

Background

There is a growing recognition on the importance of equality, diversity and inclusion (EDI) within surgery and the need to diversify the surgical community and its various organisations, in a bidto reflect the diverse populations they serve. To create, sustain and encourage a diverse surgical workforce requires an in-depth understanding of the current makeup of key surgical institutions, relevant issues pertaining to EDI and appropriate solutions and strategies to ensure tangible change.

Objectives

Following on from the recent Kennedy Review into Diversity and Inclusion commissioned by the Royal College of Surgeons of England, the aim of this qualitative study was to understand the EDI issues which affected the membership of the Association of Coloproctology of Great Britain and Ireland, while seeking appropriate solutions to address them.

Design

Dedicated, online and qualitative focus groups.

Participants

Colorectal surgeons, trainees and nurse specialists were recruited using a volunteer sampling strategy.

Methods

A series of online, dedicated, qualitative focus groups across the 20 chapter regions were held. Each focus group was run informed by a structured topic guide. All participants who were given the opportunity to remain anonymous were offered a debriefing at the end. This study has been reported in keeping with the Standards for Reporting Qualitative Research.

Results

Between April and May 2021, a total number of 20 focus groups were conducted, with a total of 260 participants across 19 chapter regions. Seven themes and one standalone code pertaining to EDI were identified: support, unconscious behaviours, psychological consequences, bystander behaviour, preconceptions, inclusivity and meritocracy and the one standalone code was institutional accountability. Five themes were identified pertaining to potential strategies and solutions: education, affirmative action, transparency, professional support and mentorship.

Conclusion

The evidence presented here is of a range of EDI issues which affect the working lives of those within colorectal surgery in the UK and Ireland, and of potential strategies and solutions which can help build a more inclusive, equitable and diverse colorectal community.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Large sample involving 260 participants across 20 focus groups.

• Anonymous nature of the focus group, with preservation and respect for individual identity is likely to have encouraged the disclosure of potentially sensitive equality, diversity and inclusion (EDI) issues.

• Limitations of volunteering sampling may have led to participants who were interested or affected by EDI issues to participate.

• Lack of participant demographic data may have led to bias in sample representativeness and may limit the wider generalisability of the results.

Background

The lack of inclusivity in the surgical workforce was highlighted in the Kennedy Review into Diversity and Inclusion commissioned by the Royal College of Surgeons of England and published in 2021.¹ In this overarching report, the individual surgical specialty associations and societies were encouraged to examine equality, diversity and inclusivity (EDI) internally within their organisations. The specialty society for colorectal surgery, the Association of Coloproctology of Great Britain and Ireland (ACPGBI) set up a task force to address key EDI issues affecting the organisation. The ACPGBI has had three female presidents out of 33 in its 32 year history (9.1%) and yet, as a recent paper demonstrates, the overall representation in the organisation at the executive level of women and of people from non-white backgrounds has been minimal to date.²

Attracting the best medical school graduates to surgery, retaining them, improving career satisfaction and encouraging innovation are all aims that surgical organisations rightly champion.^{3 4} These ambitions are supported by improving diversity and inclusion.⁵ Conversely, a lack of equity predisposes to burn-out and leads to attrition of workers.^{5 6} At present, there is evidence, that at least at a training level, there is a lack of equity in surgery in the UK and elsewhere.^{6 7} This is most commonly seen in academic surgery⁸ and those taking examinations.⁹ There is significant under-representation of women, minority ethnic groups and non-binary surgeons in leadership positions within surgery,¹⁰ which further contributes to the lack of diversity due to the lack of appropriate role models and mentorship.¹¹ The lack of diversity within the surgical workforce has implications for patient care, with patients from marginalised groups more likely to engage with healthcare services if they feel that they can identify with their clinician.¹²

The prospects for those working in surgery as a surgeon or surgical nurse from a minority background and their job satisfaction is affected by the ‘diversity climate’ of the workplace¹³ and the wider surgical culture in that country. Fostering an environment of inclusivity promotes workforce retention. This is of essential importance, given the significant attrition of women and under-represented groups in surgery.¹⁴ Understanding and responding to the needs of this population, which can be broad-ranging, from support for parents and families to accommodation of religious practices, is an essential aspect of improving inclusivity.¹⁵ Alongside this, we need to ensure the inclusion of groups that are under-represented such as those with disabilities and socioeconomic disadvantage. Surgical subspecialty associations such as the ACPGBI and the Royal College of Surgeons of England can influence the diversity climate in surgery by improving their own representation of under-represented groups.

The ACPGBI has not previously gathered data regarding diversity of its membership apart from gender. Before transformation of an organisation can take place, an in-depth understanding of the current situation and challenges needs to be made. The ACPGBI Equality Diversity and Inclusivity Task Force undertook to assess the current issues affecting equity in colorectal surgery and potential solutions to address these issues. An initial survey was followed up by a series of remote virtually based workshops. This work is presented both as a snapshot of the diversity challenges in a particular subspecialty of surgery in the UK and Ireland, and as a qualitative summary of the workshop feedback as to how surgical and other medical specialties facing similar challenges can begin to address them.

Aims

The aims of this study were to assess the perceptions of surgeons (consultants, trainees/residents SAS (Specialty and Specialist and locally employed doctors)) and nurse specialists regarding EDI in colorectal surgery, to identify relevant EDI issues and to seek potential solutions or strategies to promote and enhance EDI within the profession.

Methods

A series of dedicated, qualitative focus groups were held to which all members of the ACPGBI were invited. These were offered in all 20-chapter regions of the ACPGBI to guarantee access across the geographical spread of the organisation. All focus groups were held on Zoom by two dedicated facilitators from the EDI taskforce of the ACPGBI. The taskforce represented a diverse cohort of individuals including a patient representative. Each focus group was informed by a structured topic guide developed on the basis of a previous survey conducted to assess key quantitative indicators of diversity within the organisation (Appendix 1). The aims of the focus groups were reiterated at the start of each session and verbal consent from all participants was confirmed. All participants were given the opportunity to remain anonymous throughout the focus group to encourage open discussion and were offered a debriefing at the end. This study has been reported in keeping with the Standards for Reporting Qualitative Research.¹⁶

Patient and public involvement

The design, conduct and reporting of this study was performed in collaboration with the ACPGBI Patient Liaison Group. The ACPGBI EDI taskforce PPI member was RA, who provided an oversight of the study from a patient perspective.

Recruitment and eligibility

A volunteer sampling strategy was employed to recruit participants through regional chapter representatives of the ACPGBI, the ACPGBI website, social media platforms and regular newsletters.¹⁷ Participants were able to sign up to a regional focus group of their choice. All colorectal surgeons and nurses working within surgery, of all training grades, were eligible to participate in the focus groups, irrespective of their membership status with the ACPGBI. Participant demographic data were not collected to maintain individual confidentiality.

Researcher characteristics

An overview of researcher characteristics is provided for the ACPGBI EDI taskforce. These characteristics were provided voluntarily by individuals involved. DH and PS are British Asian, heterosexual, female colorectal surgeons. SS is a British Asian, heterosexual male colorectal surgeon. BG and MKL are Caucasian British, heterosexual, female foundation trainee doctors. CM-A is a male, Caucasian British, heterosexual colorectal surgeon. TC is a British Irish, white female heterosexual surgeon. AH is a consultant colorectal surgeon. CLB is a Caucasian, British, heterosexual, female surgeon. RA is a British Irish, white male, heterosexual, academic and patient representative.

Data analysis

All focus groups were recorded and transcribed verbatim and were appropriately anonymised prior to data analysis. Transcripts were imported into NVivo V.10 for data management and analysis. Transcripts were coded line by line using the principles of thematic content analysis.¹⁸ All data were coded by one researcher (DH), synthesising recurring ideas and concepts into codes. A detailed codebook was created during the transcription of the first five focus groups by two researchers. The codebook provided detailed definitions regarding codes to enable others to be able to easily interpret and apply them to the raw data if necessary. Codes which were sufficiently similar were synthesised into themes. All codes and themes were then discussed with a second researcher (TC) to ensure that they formed a coherent pattern and to check whether the identified themes reflect the meanings evident in the data set as a whole. We mapped the principles of trustworthiness; credibility, transferability, dependability and confirmability, to the principles of thematic analysis.¹⁹ During data familiarisation, we documented theoretical and reflexive thoughts and kept records of all data field notes, transcripts and reflexive journals. During initial data coding a coding frame, peer debriefing with the focus groups facilitators and diagramming to make sense of theme connections. When reviewing and defining themes, we used researcher triangulation using the raw data and the codebook. The defined themes were discussed with the wider ACPGBI EDI taskforce. Throughout the whole analysis process, we kept a meticulous audit trail.

Results

Between April and May 2021, a total number of 20 focus groups were conducted over a 1–1.5 hours’ time period over Zoom (Zoom.US, San Jose, California), with a total of 260 participants across 19 regional groupings of the society in Great Britain and Ireland hosted by the Chapter Representatives and two ACPGBI EDI Task Force members. Due to the anonymous nature of participation, demographic level data was not collected. Themes were extracted under two main domains: relevant EDI issues, and solutions and strategies to promote EDI within the ACPGBI. One region’s chapter meeting did not take place due to unavailability of the Chapter representative.

EDI issues

A total of 27 unique codes were categorised into seven themes and one standalone code. The seven themes are: support, unconscious behaviours, psychological consequences, bystander behaviour, preconceptions, inclusivity and meritocracy; the one standalone code was institutional accountability (figure 1).

Figure 1.

Identified EDI themes. EDI, equality, diversity and inclusion.

Support

The need for support to progress and develop through colorectal surgery training and beyond was a recurring concept across all focus groups. The complex relationship between support and the lack of appropriate role models and mentors to deliver this support was highlighted as a key factor limiting progression in colorectal surgery for members of the profession, particularly those who identify as already under-represented.

…there are no good role models who are already in those positions of power who've broken that glass ceiling effectively…

Other important aspects of this theme included a lack of understanding on how to provide support as allies and champions, difficulties in implementing guidance on tackling poor behaviours and potential personal and career repercussions in highlighting and reporting discrimination.

It puts people in a very uncomfortable position, just because they witness it, but they don’t know how to approach it or what to do.

Unconscious behaviours

Most of the discriminatory behaviour reported across all the focus groups was subtle in nature and consisted largely of undermining and microaggressions. Participants felt these behaviours were difficult to report, communicate and prove. Pre-existing unconscious bias was considered to be the root cause of many of the behaviours experienced.

…described in modern language as micro-aggressions. Small little steps to hold you back or if you want to put it, not push you forward…

…these are very subtle signs or feelers which are not really obvious to pick up on and on paper

Sometimes you experience subtle undertones, it’s the unconscious bias, the person saying it doesn’t actually realise. That’s what you experience.

Psychological consequences

The consequences of discriminatory behaviour on the victim are significant, with an impact on mental and physical well-being. Victims modify their behaviours, including displaying subservience to try and marginalise the impact of bad behaviour. Despite this however they continue to report significant emotional and psychological harm. The negative consequences of discrimination and prejudice are often not openly acknowledged, supported or reported.

I became subservient to authority, because that authority was always right, even when it wasn’t

…you have to police your behaviour and how you speak and who you can be open to…

…doubting your own self and thinking oh my god, I’m not really up to this level. Maybe I don’t belong in here. Maybe I’m out of this league completely.

Bystander behaviour

Participants who had experienced discrimination referred to the notion of ‘bystander behaviour’ whereby perpetrators of bad behaviour were well known by senior figures, however, there was little done to address or reprimand their behaviour or to support the victim of their behaviour, thus making the bystander complicit in the overall behaviour. Interestingly, bystanders recognised these behaviours within themselves and acknowledged the impact of their behaviours, while stating that these behaviours were due to a lack of understanding on how to approach and address these behaviours appropriately.

…I think, there will always be occasions where for an easy life, people don’t turn around and necessarily, stop the behaviour that they see. But that is not always, not showing your support, it actually completely undermines somebody’s confidence…

Even though you’re not being overtly, sexist, racist or whatever, you are acquiescing to it.

Preconceptions

Preconceptions concerning personal characteristics, race and gender were considered to be important factors affecting progression through colorectal surgery and within the ACPGBI. Personal characteristics that were considered to be ‘different’, including accents, affected participants’ ability to integrate seamlessly into surgical teams. People possessing these characteristics felt that they were assumed to have less surgical ability and were given fewer opportunities due to them. International medical graduates stated that they were more likely to be ‘encouraged’ into pursuing non-training surgical posts compared with UK graduates. Women described being ‘encouraged’ to consider pursuing alternative career options.

…sometimes people deal with you as if you don’t know what you’re doing. It’s the fact that you’re a foreigner, or you’re non-English speaker

I’m not getting the same opportunities as my colleagues and I think it’s just generally being pregnant, it’s just, there are just so many comments about it, comments about how you look…

It was difficult to, to integrate as well as I would have wanted to. And I think I suppose it’s different when you have a specific, ethnicity or race or religion….

Inclusivity

The need for inclusivity within colorectal surgery and the wider ACPGBI was echoed across all the focus groups. The need to ensure a level playing field for all in colorectal surgery to pursue equal opportunities was considered to be a key priority for the future direction of the ACPGBI. To achieve this requires an inclusive and representative ethos from within the executive membership of the ACPGBI. Representativeness within the ACPGBI needs to reflect the protected characteristics within the Equality Act 2010, geographical representation given the widespread location of the society’s membership within Great Britain and Ireland, and differing training routes and systems.

I think more needs to be done, in terms of bridge that gap, and trying to make people feel more included in terms of working together.

We need to strive for fairness and giving everyone the opportunity to reach their potential and the professional goals they would like to achieve.

ACPGBI council and committee reps are almost 100% consultant but very few who haven’t trained in the NTN (National Training Number) system. We all work with SAS doctors and there is no voice for them, and they are disproportionately women and from Black and Asian communities.

…everything is England centric; everything is in London.

Meritocracy

Creating a meritorious training system and colorectal society was seen as the only way the culture of perceived cronyism could be ended, thus enabling equal opportunity for all. Participants felt value for talent, competence, skill and ability should be the only things considered when reviewing progression within training or when considering appointments for posts within the ACPGBI. The current culture within colorectal surgery reflects an established network and familiarity between individuals, thus leading to the perception of ‘an old boy’s club’. This leads to opportunities being provided within the society and its annual meeting to a selected cohort of its overall membership. A lack of understanding of the ACPGBI structure and workings further contributes to its ‘closed network’ and prevents many who are unfamiliar with this from applying, thus amplifying, and perpetuating the lack of diversity within the organisation.

…how you get a seat at the table at the beginning is probably the real key because you know there doesn’t seem to be a reason why that wouldn’t be to a open much wider electorate, why the membership in general can’t decide…

…conferences and speakers, and ACPGBI like a lot of organizations, can appear to be like a closed shop at times, we do often see the same people, the same faces, see the same speakers on the circuit…

If they are effective and capable, then they should be, have an equal chance as the other person who hasn’t networked and is not well connected if it’s a fair playing field… The traditional way that people get these positions, may not be necessarily based on capability, but rather something else….

Institutional accountability

Institutions like the ACPGBI needs to take accountability for the wider EDI issues affecting their membership at a societal level and must provide appropriate strategies and solutions to address this. Senior leaders within institutions need to review key organisational processes to ensure that EDI is appropriately incorporated throughout the society and their surgical community. The approach to ensuring representativeness and diversity must be led from the top and filtered down to ‘grass-root’ levels through the organisation.

There needs to be discussion around these issues with, senior clinicians or leaders in our associations or training bodies leading the conversation

I think our society has as a duty, the ACP has a duty to say actually we need to put in much more solid things in place….

Potential strategies and solutions

A total of 15 unique codes were categorised into five themes: education, affirmative action, transparency, professional support, and mentorship (figure 2).

Figure 2.

Potential strategies and solutions. ACPGBI, Association of Coloproctology of Great Britain and Ireland; EDI, equality, diversity and inclusion.

Education

An educational programme is required to improve broader understanding of EDI issues affecting colorectal surgeons, while simultaneously addressing these issues. Educational initiatives promoting EDI will enable open and transparent ongoing discussion of key issues, will promote a supportive environment for further discussion and will promote inclusivity and diversity among the colorectal community. Ensuring inclusivity in the development and delivery of this educational programme, including the involvement of allies, will be central to the successful dissemination of a future programme.

The first thing to do, is to be up front with the situation and know that it happens and educate everyone about it.

We’ve got a wealth of experience in across the board in general surgery and it doesn’t have to be a club thing and we should put them out there and invite them all to join us in improving things for all.

Affirmative action

To increase diversity, equality and equity within the structure of the association, the notion of affirmative action or positive discrimination must be considered to ‘level up the playing field’ for a period of time until these principles are wholly integrated within the ethos of the society and the colorectal community. Positive discrimination must include all those who display protected characteristics within the Equality Act 2010, as well as differing training routes within surgery and the geographical locations represented by ACPGBI. This approach would enhance the value and contribution these members make to our community and society overall. This approach would require sufficient support from the wider membership of the society, appropriate support and integration of elected members and a defined time period. It was acknowledged by participants that this may be a controversial position.

We need good role models in positions of power to break that glass ceiling effectively and pave the way for others to apply and I wonder if we have a quota for a temporary period of time.

The sort of positive discrimination element is a difficult balance to strike because a quota serves the purpose of making sure you have representation which is diverse, but you run the risk of those who have got the positions having an element of imposter syndrome.

Transparency

A surgical society must ensure that all its processes are entirely transparent to the wider membership with regard to EDI. Three key strategies/solutions were highlighted through the focus groups centred on transparency, including transparent EDI quota reporting, selection processes and independent oversight. Transparent EDI quota reporting includes annual reporting of the composition of ACPGBI committees including the characteristics of committee applicants and elected members for each committee. Review of the current selection processes on to committees and elected roles is required with transparent, robust selection criteria and broader electoral processes. These processes require independent oversight to ensure that the proc ess is fair and adhered to, ideally with lay and diverse membership.

…baseline assessment of what the composition of the association is, how many members from each sector, how much representation is at the council level, and the exec level…

…regularly publish the sort of data they know people would be interested in. You know, particularly around the sort of charts that we’ve seen around its membership and wider colorectal surgery and then you get a better view as to how represented it is, you know, we could communicate a lot of those things better…

…improve transparency and trying to involve the membership in nominations and elections to committees.

The process really needs a massive amount of reform, and I think we need to have more lay people on the panel who represent more diversity who can go, ‘hang on a minute, why haven’t you picked that candidate over that one?’.

Professional support

The ACPGBI plays a significant role in providing professional support to its membership, and this should extend to providing support to tackle issues relevant to EDI within colorectal surgery. A dedicated portal should be set up to provide confidential help and support to members who may be experiencing issues relevant to EDI within their hospital setting. Peer-to-peer support should be encouraged with regard to shared experiences and solutions for EDI specific issues by the ACPGBI.

…someone feels that he is being treated unfairly or like there is discrimination against him or being victimised based on ethnicity, where he has graduated or family he belongs to, then I think the ACPGBI should help support them so that they feel protected…

EDI issues can affect members at different times of their careers and personal lives for example, pregnancy, parental leave, caring for ageing relatives and career breaks. Providing specific support to surgeons during these time periods is essential in ensuring that work–life balance is supported by all within the profession.

We should be acknowledging that family is important, raising your children is important, their health issues are important and facilitating that for our trainees and our colleagues you never know when you might need it.

Specific support should be provided to International Medical Graduates to enable smooth transition into working within the UK medical structure of the National Health Service (NHS) and to introduce them to the support offered by a surgical society such as the ACPGBI. Identifying the specific needs of this cohort of colorectal surgeons and creating a supportive programme to address this will increase the diversity of the wider ACPGBI membership and ensure appropriate integration within the colorectal community.

Those who are sort of refugee status, getting back in to training, especially surgical training. I think that’s a small group that gets overlooked quite a lot. I think we could develop a good programme to help these doctors. I’ve been involved in that, and it is just something simple where people who are highly qualified, very capable, very qualified but it is something simple like a language barrier.

Widening participation

The ACPGBI membership must be inclusive of all those working within colorectal surgery in Great Britain and Ireland. To widen participation and engagement with the society requires mentorship and role models. Mentorship provided by the ACPGBI must include an understanding of the workings and structure of the society while championing EDI. Role models and ‘success stories’ must be highlighted by the ACPGBI to promote current diverse members of the ACPGBI and to encourage others to apply for roles within the society.

We need success stories as well, to highlight diverse members leading an organisation for colorectal. The ACPGBI can provide a forum for these people to look up to…

You will have to have some champions for EDI who provide mentoring and coaching to members….

Discussion

Diversity has widened in the medical profession in the UK over the last 50 years,^{14 20 21} and yet surgical societies and Colleges appear to have lagged behind. International medical graduates make up the most rapidly growing part of the NHS workforce and are essential to its function, and women make up 57% of medical school graduates.^{20 21} However, the Presidents and members of the executive of this and many other surgical societies are disproportionately white and male and trained in the UK.

The evidence presented here is of a widespread culture of discrimination and microaggressions which affect working lives within colorectal surgery in the UK and Ireland. The themes of unconscious bias, psychological consequences and lack of meritocracy have previously been echoed within the surgical literature and are not unique to the colorectal community.^{22 23} Acknowledging their existence and impact is a first, key important step in addressing these issues, and in creating meaningful and sustainable change. Equity for surgeons, trainees, allied healthcare professionals and patients cannot be achieved without reducing bias and discrimination through intentional effort. We identified five key themes: education, affirmative action, transparency, professional support and mentorship, through which a more equitable and diverse colorectal community can be built. It will be through gradual and purposeful implementation of these themes, coupled with measurable goals that tangible institutional reform will be feasible. Effecting change within the colorectal community will require a multipronged approach, while driving a sense of accountability and personal investment. Central to this should be education and training that will be levelled at targeting implicit and explicit bias, with appropriate endorsement and support from within key organisations.

Work has already been done by the Royal College of Surgeons of Ireland on the lack of female representation²⁴ and this has laudably been followed up with a further report on progress.²⁵ This approach is to be recommended to the surgical societies such as the ACPGBI who seek to transform their representativeness and hence relevance to surgeons working within their specialty. However, women are only one under-represented group within surgery, with more work required to address the multiple facets of diversity, to create a truly inclusive surgical community. The reparations go beyond merely seeking a more representative leadership within surgical societies, although these will be easier to bring about with such representation. As evidenced by this paper, education of the majority of surgeons and involvement of them as allies is key to producing an improved diversity climate for all both within surgical societies and within surgical departments in the UK and elsewhere. This in turn will allow diverse patient groups to be more represented, with potential far reaching effects.²⁶ Educational avenues may involve unconscious bias training, training on how to spot and respond to microaggressions, and how to avoid bystander injury.²⁷ A structure of support and mentorship—beyond that which has evolved naturally, which seems at present to exclude the under-represented, needs to be set up and this will require funding. Constant self-reflection, with transparent internal publishing of the process of change is required to keep the membership’s trust. Many of those participating in the focus groups commented that this was the first time they had had a chance to express the discrimination and difficulties they had undergone, often for years. This needs to change.

The ACPGBI has moved to make this change permanent by replacing the task force with an elected and representative ‘EDI Steering Group’ with at least one member from every one of the 20 regional chapters. This group, from which there is an elected EDI Committee, reports directly to the ACPGBI Council and has active subsections to work on the outcomes of this paper and on the EDI transformation of the Surgical Society they represent.

The key strength of this work is the large sample size involved in the focus group with 260 participants across 20 focus groups. Furthermore, the anonymous nature of the focus groups, with no requirement to disclose participant identity, is likely to have facilitated and encouraged the disclosure of sensitive issues surrounding EDI. The focus groups may have been limited by the volunteering sample strategy which may have encouraged participation only of those interested in or affected by EDI issues. This coupled with the lack of baseline demographics may have potentially led to an unrepresentative sample, thus potentially limiting the wider generalisability of the results.

Conclusion

There is a need for progression on key failings of diversity and inclusion to be demonstrated by this and other surgical societies. With this work and that of the Diversity Report from the Royal College of Surgeons, there is enough evidence that issues of equity for under-represented groups need to be addressed urgently by those at the top of the surgical hierarchy in the UK and Ireland. In order not to lose a further generation of doctors from the surgical profession, this work needs to be widely understood and participated in by the plurality of surgeons, who can observe and help bring about the necessary transformation of this and other surgical societies to better reflect the breadth and diversity of surgeons and of the wider public they serve.

Data availability statement

No data are available.

Ethics statements

Patient consent for publication

Not required.

Ethics approval

This study involves human participants. Ethical approval for this study was granted by Newcastle University (Ref: 11968/2020).