The AGA Equity Project: Where We Are, and Where We Go from Here

Background

The American Gastroenterological Association (AGA) maintains a strong history of creating and sustaining impactful programming to support diversity and inclusion for physicians and scientists in gastroenterology and hepatology. After the inception of its Diversity Committee in 1993 (formerly the Underrepresented Minority Committee), AGA expanded its commitment to diversity, equity, inclusion and justice in 2020 with the Equity Project. This three-year equity strategic plan more concretely and systematically operationalizes the organization’s Diversity Policy throughout the organization, identifying opportunities for greater impact by leveraging all levels and stakeholders in the society to be invested in the success of the project, extending beyond the scope of the Diversity Committee alone [1].

The AGA Equity Project vision to achieve equity and eradicate health disparities in digestive diseases outlines an implementation plan across six domain areas with desired future states (Figure 1): 1) Justice, Equity, and Education, with a just world free of health disparities in digestive diseases and free of inequities in access and effective health care delivery; 2) Research and Funding, with state-of-the-art and well-funded research that aligns with the realities of the current multicultural patient population and disease states; 3) Workforce and Leadership, with a world where it is expected and normal that both members and society leadership structures are diverse, and people of color and women are included in organizational decision making; 4) Recognition, with increased visibility and awareness of accomplishments of diverse leaders; 5) Bias, with an engaged AGA membership and staff educated about unconscious bias and committed to the eradication of racism and prejudice towards patients, colleagues, and communities; and 6) Engaged Next Generation, with a diverse, culturally and socially aware, large and vocal early career membership that leads the field towards achieving this vision.

Figure 1.

AGA Equity Project Vision. The illustration each Domain that was addressed by the Equity Project; the Current state of the domain withing the AGA; and the Desired future state. This figure was reproduced from Carr, Quezada, et al [1] with permission.

This vision and plan were developed collaboratively, with important input from AGA staff, by a diverse group of members who now serve as the Equity Project Advisory Board, with representation from clinical and basic sciences, private and academic practice, physician and advanced practice providers, all with expertise in various digestive disease processes. Approved by the AGA Governing Board in summer 2020, the Equity Project was effectively backed with tangible resources that catalyzed mobilization of its collective vision and plan. Now in its third and final implementation year, the Equity Project has yielded meaningful results while continuing to drive the organization forward toward achieving its goal of achieving equity and eradicating GI health disparities. This commentary provides a status update on AGA’s Equity Project objectives and identifies future directions for the organization to sustain momentum beyond the three-year plan as a national leader in equity, diversity and inclusion in gastroenterology and medicine at large.

Equity Project accomplishments and ongoing work by domain

Domain 1: Justice, Equity and Education

Reinvigorated national discourse on social determinants of health and their driving impact on disparate healthcare outcomes, in conjunction with broader recognition of systemic social barriers perpetuated by policy, have inspired even more robust participation in advocacy efforts among AGA members. In September 2022, an all-time high of 91 AGA members participated in Advocacy Day, with a specific increase in representation of women and people of color, advocating for policies that impact GI health and increase access to gastrointestinal care for our nation’s diverse patient populations. Overall, there has been four specific congressional briefings on DEI topics since summer 2020. This increase in congressional briefings produced a major policy victory in 2022 eliminating financial barriers to colorectal cancer (CRC) screening by requiring private insurers and Medicare to cover the full screening continuum which is critical to achieving health equity in colorectal cancer [2]. Preventive care is being challenged again, and AGA signed a joint statement led by the American Medical Association alongside 61 medical associations and societies to continue to advocate for preventive care access for all [3].

In concert with its growing advocacy work, AGA amplified its efforts to enhance provider awareness of health inequities and tools to address these challenges through educational platforms such as existing career development workshops and Digestive Disease Week (DDW) sessions, as well as via new platforms such as the Small Talk, Big Topics podcast that targets the GI trainee and early career community [4]. In its first season, Small Talk, Big Topics broadcasted 16 episodes focusing on topics most relevant to early career and future gastroenterologists including building resilience, women in GI innovation, and GI health disparities. While amplifying provider education, AGA also invested additional resources to update and enhance patient education material incorporating language diversity and a lens of cultural humility in its content [5].

Domain 2: Research and Funding

A deeper understanding of the underlying causes and overall impact of GI health disparities will prompt strategic investment of resources and efforts that generate positive change. To accelerate the pace of knowledge growth in this area, AGA established a Healthcare Disparities Research award for meritorious work in racial and ethnic healthcare disparities and created a fundraising event known as AGA Giving Day which raised over $300,000 earmarked specifically to support health disparities research with 9 pilot research awards, and 38 abstract awards, and diverse investigators through an AGA Research Scholar Award supported by the AGA Research Foundation [6]..

AGA leadership’s genuine commitment also inspired and secured a generous private donation to create the Aman Armaan Ahmed Family Summer Undergraduate Research Fellowship (SURF) Program, launched in 2021 to support undergraduate students from traditionally underrepresented backgrounds in biomedical research. In this program, awardees perform 10 weeks of mentored summer research in digestive diseases with prominent investigators in gastroenterology and hepatology. These students are also provided opportunities to interact with diverse leaders in gastroenterology and hepatology through panel discussions that focus on the GI career path, mentorship, and navigating the profession as a minority in the field. In addition, and as a complement to the SURF program, Dr. Harvey Young established the AGA Dr. Harvey Young Education and Development Foundation’s Young Guts Scholar Program, which further extends AGA’s reach in increasing early career opportunities and strengthening the pipeline of diverse future leaders in gastroenterology. Through the Equity Project, AGA also recognized the need to create platforms that raise visibility of health disparities research. As a result, special sections with associated section editors were created in both its flagship journal Gastroenterology in 2021 and in Clinical Gastroenterology and Hepatology in 2022. These sections are dedicated to publishing commentaries and original research focused on GI health disparities and promoting equity in the profession [7].

Another important platform to amplify the reach of research in equity and disparities is through programming at Digestive Diseases Week (DDW). Recognizing this valuable opportunity, the AGA Institute Council solidified its commitment to include diverse speakers, moderators, and programming at this national meeting by establishing a DEI subcommittee charged with reviewing and reporting on the council’s DEI initiatives in this space annually [8]. With representation from each of the council’s 13 special interest sections, the DEI committee helped clarify strategies the AGA Institute Council can utilize to enhance diversity, equity and inclusion at DDW [8] (Figure 2). In addition, the 2022 AGA DDW president plenary session (overseen by the 2021–2022 president, John Inadomi) central theme was DEI-related efforts and their impact, as related for example to research findings pertaining to GI health equity [8].

Figure 2.

AGA Council strategies to enhance conference diversity, equity and inclusion. The illustration summarizes the approaches used by the Council and its review committees.

Domain 3: Workforce and Leadership

Through earlier programming, AGA’s efforts to tackle the lack of diversity in gastroenterology have reached a total of 2,609 underrepresented individuals at the medical student, fellowship, and early career levels. These earlier programs established the organization’s ability to recruit individuals from diverse backgrounds.

In 2017, AGA conducted online surveys and held interactive discussion focus groups with diverse gastroenterologists, hepatologists, pediatric gastroenterologists and fellows. Surveys designed to detect obstacles for the development of early career minority gastroenterologists and hepatologists identified seven areas of challenge, and three main themes emerged: a lack of knowledge about research fundamentals, need for leadership training, and need for more mentorship and sponsorship. In addition, an assessment and strategies for recruitment in GI training programs to expand pathways for career development were recently reviewed by AGA [10].

Based on lessons learned, AGA proposed a professional development program through a competitive NIH R25 grant received from NIDDK for early career gastroenterologists and GI trainees called the AGA FORWARD Program that incorporates specific strategies to reduce barriers and increase the likelihood of underrepresented gastroenterologists successfully pursuing careers in biomedical investigation [7]. The FORWARD program, through hands-on work with mentors and external coaches, participants develop new skills and connections to successfully pursue research careers. AGA FORWARD scholars build their skillsets in research and proposal development, planning for personnel, publications, and the timing of grant submissions, among other areas critical to research success. Among the inaugural FORWARD cohort of graduates, nearly 70 percent of graduates are serving in AGA leadership roles and have received R level federally funded grants and national recognition in the field. In addition, two NIH supplement awards were secured that built on the parent R25 were secured during 2021–2022 and 2022–2023. GA believes in this approach to provide a solid foundation for success and has submitted during summer 2022 a proposal to renew FORWARD NIH R25 funding and further expand on this highly successful program.

Finally, with oversight from the Diversity Committee, and support by AGA staff, AGA has continuously monitored membership demographics, with a specific focus on diversity of committee membership and leadership. Most notably, as of 2022 AGA has achieved gender parity in leadership, with 50 percent of committee chairs positions now held by women.

Domain 4: Recognition

The Equity Project Advisory Board members appreciated the need to amplify recognition of diverse members and leaders in the field. In this vein, AGA established the Distinguished Recognition Award for Diversity, Equity and Inclusion as part of its collection of Distinguished Awards presented at DDW. In addition, AGA has reorganized in 2022 its awards selection panel mechanism to maximize nominations of diverse groups and to prevent awardee selection bias. Furthermore, ongoing recognition of underrepresented members led by AGA Communications staff and Diversity Committee members manifests through communication campaigns tied to various heritage awareness months and the quarterly Equity Project Newsletter.

In conjunction with AGA staff, Diversity Committee members are working to develop a database of notable diverse GI physicians and scientists to serve as a central resource that will facilitate identifying individuals for awards, professorships, and conference presentations.

Domain 5: Bias

In this area, the Equity Project Advisory Board recognized the need to address bias and promote equity for AGA staff as well as its membership. Previously in 2017, AGA’s staff leadership embarked on a journey to create organizational health which included identifying four core behavioral values for staff which at the time were defined as staff who were Innovative, Collaborative, Engaged and Open. In 2020, AGA enlisted consultation of an expert in driving organizational change that supports equity, diversity and inclusion. In addition to providing specific training to AGA staff on structural racism, implicit bias and microaggressions, this expert also provided guidance in the development of an internal TIDE (Taskforce for Inclusion, Diversity and Equity), charged with undertaking a deep assessment of AGA policies, staff education and values with an equity lens. The TIDE recommended adding Inclusive as a fifth core value to “cultivate a welcoming and empowering environment for colleagues”.

To mitigate bias in the gastroenterology fellowship recruitment and selection process, in the second implementation year of the Equity Project, AGA created a guide for Program Directors to inform the 2022–2023 application cycle with recommendations on incorporating equity and inclusive practices that can be incorporated before, during, after fellowship interviews. This inaugural document was shared through AGA University and will be further enhanced with data-driven practices as program directors learn from initial recruitment strategy implementation.

Domain 6: Engaged Next Generation

One of the critical Equity Project goals is to increase AGA’s engagement with the next generation of gastroenterologists, as well as with current and new diverse members. Of course, these are the individuals who will sustain and further develop the intended vision and goals of the AGA Equity Project. Embedded in the Equity Project plan is the goal of leveraging collaborative partnerships with other GI societies to achieve this goal. AGA has cultivated a longstanding partnership with the Digestive Health Physician Association (DHPA) which encompasses 105 practices in 39 states and employs 2400 physicians, with many young members participating in AGA committees and its Governing Board. As highlighted at the 2021 AGA Presidential Town Hall by then president Bishr Omary [11] and Presidential Plenary at DDW 2022 by past president John Inadomi [9], the recently formed Association of Black Gastroenterologists and Hepatologists (ABGH) promotes health equity and aids career development for Black gastroenterologists, hepatologists and scientists, with execution of its mission performed in concert with shared goals of the Equity Project [12]. Partnership with the Latino Medical Student Association (LMSA) affords exposure of the practice of gastroenterology and hepatology to a younger generation of diverse students who will be able to shape its future.

AGA also reinstated a renewed version of the previously successful Investing in the Future Program. The 2022 program differs from previous iterations in several ways. This GI pathway program now targets residents in addition to fellows and doubled its previous participation numbers with 60 GI interested trainees, compared to 22–30 participants in previous years. The revamped program now includes designated educational tracks in IBD and IBS focusing on impact in minority populations in these disease areas and included a special panel discussion segment on ‘Meet the AGA Leadership’ held at DDW 2022 that included then AGA President-elect John Carethers, Equity Project co-Chair Sandra Quezada, Diversity Committee Chair Ronke Idirobu, and Women’s Committee Chair-elect Aimee Lucas. Many participants mentioned this as a program highlight, valuing the ability to meet and greet diverse AGA leaders and engage them with questions. Also, the SURF and Young Guts programs engage students earlier in the pipeline to gastroenterology and have already provided research opportunities and mentorship support to 18 underrepresented undergraduates since the programs’ inceptions in 2021 with the expectation that planting the seed early will influence the course of each of these scholar’s career trajectory toward gastroenterology.

Future directions for the AGA Equity Project and its goals

Since commencement and support of the Equity Project under AGA past president Bishr Omary, each successive and future president (including John Inadomi, John Carethers, Barbara Jung and Maria Abreu) as well as AGA CEO Tom Serena and all AGA staff have not only pledged to see completion of the 3-year initial goals of the Equity Project [13], but continue its long term intent as it becomes imbued into the fabric of AGA culture, and will have ongoing oversight by the AGA Diversity Committee. In parallel, an Intersociety Group on Diversity (IGD) was formed in 2021 as a coalition that includes diversity committee leaders from AGA, ASGE, ACG, AASLD and NASPGHAN to work together on impactful goals to increase diversity among our societies’ members, our trainee pipelines, leadership in the field, and address health disparities. The IGD collaboratively surveyed members across GI societies to identify salient challenges and priorities for diversity in gastroenterology. Notably, a forthcoming article in the December 2022 issue of Gastroenterology outlines initial survey results.

The AGA will synthesize feedback from this survey to develop data-driven priorities for future work to further drive the society’s dedication to equity. AGA will continue to invest in the future pipeline of diverse students, residents, and fellows in the field, advance the field through scientific discoveries, and tackle gastrointestinal disease, recognizing the disproportionate burden impacting marginalized communities.

The inception [1] and journey of the AGA Equity Project to date have been incredibly exciting and gratifying for all those involved. The work to achieve equity is ongoing and requires continual self-assessment and repeated commitment renewal. As an organization we must recognize that our collective actions are tremendously powerful, with the potential to benefit our patients, organization, and profession for generations to come. AGA is committed to further building on the foundation laid by the Equity Project, and to sustaining its transformational impact in our field.