Abstract
Background:
Strategies to address inequities, bias, and discrimination that disadvantage Canadian physicians from marginalized groups are urgently needed. We describe a multilevel needs assessment of equity, diversity, and inclusion (EDI) in 2 departments of surgery that focused on identifying evidence-based interventions.
Methods:
We invited members of the departments of surgery at the University of Calgary and the University of Saskatchewan to complete the Diversity Engagement Survey (DES), a 22-item instrument designed to understand workplace engagement and inclusion among physicians, with higher scores indicating greater engagement and inclusion. Leaders completed a Leadership EDI Readiness Assessment to understand their own barriers to EDI work and an Organizational EDI Readiness Assessment to understand structures for EDI in their division. Leaders were provided resources and interventions to address the identified gaps in these assessments.
Results:
The most common organizational gaps in structures for EDI work in surgical divisions and training programs (n = 34, 37.4%) were in community outreach and measurement and reporting. Surgeons who identified as cisgender men (n = 101) felt more engaged and included than those who identified as cisgender women (n = 43; 3.81 [standard deviation (SD) 0.73] v. 3.51 [SD 0.78]; p = 0.04). White cisgender men (n = 66) had the highest feelings of engagement and inclusion (mean 3.95 [SD 0.62]). Participating surgical sections and training programs were directed to evidence-informed initiatives to improve community outreach and measurement and reporting to address EDI in their settings.
Conclusion:
Our findings support that gender and racial or ethnic identities influence the workplace experiences of surgeons in Canada. A multilevel approach to EDI work in surgical departments can direct leaders to areas for intervention.
Abstract
Contexte:
Il est urgent de se doter de stratégies de lutte contre les inégalités, les biais et la discrimination que subissent les médecins canadiens appartenant à des groupes marginalisés. Nous décrivons ici une évaluation multiniveau des besoins en matière d’équité, de diversité et d’inclusion (EDI) dans 2 départements de chirurgie afin d’identifier des correctifs reposant sur des données probantes.
Méthodes:
Nous avons invité les membres des départements de chirurgie de la University of Calgary et de la University of Saskatchewan à répondre à un sondage en 22 points sur la diversité conçu pour mesurer et comprendre les sentiments d’engagement et d’inclusion chez les médecins dans leurs milieux de travail, les scores obtenus étant directement proportionnels au degré d’engagement et d’inclusion. Les chefs de département ont répondu à un questionnaire portant sur leur état de préparation en matière d’EDI afin de mettre au jour leurs propres réticences à l’endroit des correctifs proposés, et sur l’état de préparation des organisations afin de cerner les structures d’EDI en place dans leurs divisions. On a proposé aux chefs de département des ressources et des exemples de correctifs visant à combler les lacunes révélées par les évaluations.
Résultats:
Les lacunes organisationnelles les plus communes au plan des structures d’EDI dans les divisions et les programmes de formation en chirurgie (n = 34 [37,4 %]) étaient les mécanismes de sensibilisation, d’évaluation et de reddition de comptes. En chirurgie, les personnes s’identifiant comme hommes cisgenres (n = 101) ont dit se sentir plus engagées et incluses que celles qui s’identifiaient comme femmes cisgenres (n = 43; 3,81 [écart type (ET) 0,73] c. 3,51 [ET 0,78]; p = 0,04). Ce sont les hommes cisgenres de race blanche (n = 66) qui ont exprimé le plus grand sentiment d’engagement et d’inclusion (score moyen 3,95 [ET 0,62]). Les divisions et les programmes de formation en chirurgie participants ont été orientés vers des stratégies fondées sur des données probantes pour améliorer leurs mécanismes de sensibilisation, d’évaluation et de reddition de comptes pour mieux intégrer les principes d’EDI dans leurs milieux.
Conclusion:
Nos observations confirment que les identités de genre et de race ou d’ethnie influent sur les expériences en milieu de travail dans les départements de chirurgie au Canada. Une approche multiniveau aux stratégies d’EDI peut orienter les chefs de département vers les secteurs d’intervention.
Ample evidence has documented disparities in the medical workplace that disadvantage physicians who identify as women and gender minorities, racial or ethnic minorities, or additional marginalized identities.1–3 These disparities, which include lower compensation, 4 greater harassment and discrimination,5,6 and slower academic trajectories,7–9 have been demonstrated in surgical specialties and in Canada. Although the measurement of these disparities has become increasingly common and rigorous,10 progress in reducing disparities has been slow. At present, there are few interventions demonstrated to improve inclusion and equity, and many interventions address interpersonal bias rather than taking a systems-level approach to dismantling discrimination.11,12
Despite this lack of evidence, a multilevel, targeted approach to equity, diversity, and inclusion (EDI) work in medical organizations is desperately needed.13 The objective of this study was to document engagement with equity and inclusion work among surgical leaders, subspecialty divisions, and surgeons, and to describe how this measurement was explicitly linked to targeted interventions to improve these disparities.
Methods
In this cross-sectional study, we sought to comprehensively describe the baseline state of diversity and inclusion work at 2 academic surgical departments in different Canadian provinces. We used validated instruments to understand diversity and inclusion work from the perspective of the department membership, the leaders in the department, and the current organizational structures.
Setting
A description of the governance, subspecialty sections, and postgraduate training programs in each university’s Department of Surgery, is provided in Appendix 1, Section 1, available at www.canjsurg.ca/lookup/doi/10.1503/cjs.015923/tab-related-content. In brief, the University of Calgary Department of Surgery (Calgary, Alberta) has about 350 members across 13 specialty sections, of which 65 hold leadership positions, and the University of Saskatchewan Department of Surgery (Saskatoon, Saskatchewan) has about 250 members and 26 leaders across 10 specialty sections and residency training programs.
Survey administration
We adapted and combined existing readiness and diversity engagement assessment tools for EDI and antiracism work to be applicable to physicians and medical leaders. All instruments underwent pilot testing and cognitive interviewing for refinement before use. Participants were invited to complete each voluntary, anonymous self-administered survey (Qualtrics) through email from the EDI leads in their departments, with 2 reminder emails. Participants were offered to submit their contact information to enter to win a $500 gift card as incentive to participate. All participants provided informed consent.
Leadership EDI readiness
We invited all leaders in the departments of surgery to complete the Leadership EDI Readiness Assessment, a tool adapted from Race Forward.14 The Leadership EDI Readiness Assessment is a 25-item survey that uses frequency and agreement Likert scales to assess individual attitudes, knowledge, skills, and behaviours for EDI and antiracism work (Appendix 1, Section 2). This assessment allows participants to reflect on their internal barriers to EDI and antiracism work. Participants were sent resources to improve their readiness for EDI and antiracism work based on the domain that they scored the lowest (Table 1).15–35 Resources were selected and matched to domains based on study team expertise. Only response rates for the Leadership EDI Readiness Assessment are reported, because this assessment contains sensitive data and individual leader scores were accessible only to the participant in hopes of reducing social desirability bias and allowing genuine reflection.
Table 1.
Domains and example items from the Leadership and Organizational Equity, Diversity, and Inclusion (EDI) Readiness Assessments, paired with the suggested approach and resources for pursuing EDI work based on the results
| Domain | Example item | Suggested approach to low scores | Resource or strategy |
|---|---|---|---|
| Leadership EDI Readiness Assessment | |||
| Attitudes | I feel uncomfortable with people whose background is different than my own. | Leaders who have low attitude scores may not be ready to implement EDI initiatives. These leaders may be skeptical about the importance of EDI work and may have high resistance to change. | Encourage insight, reflection, and empathy through self-administered bias tests: |
| Differences in achievement in medicine are due to differences in work ethic and/or talent. | Focus on institutional requirements such as providing lactation spaces for people returning from parental leave or stipends for OCAP training for research teams.19 | ||
| Knowledge | How confident are you that you can define/explain race, racism, sex, gender, sexism, and misogyny? | Leaders who have low knowledge scores may be interested in EDI work but do not have foundational literacy to be effective or safe. | Emphasize existing learning opportunities: |
| Build EDI into existing learning opportunities: | |||
| Skills | How confident are you that you can receive feedback on your own bias and behaviours without becoming defensive? | Leaders who have low skill scores need training in how to safely and effectively leverage their position in leadership to mitigate harassment, discrimination, and bias. | Develop and practice skills: |
| How confident are you that you know what to do or where to refer a colleague who has experienced harassment, discrimination, and bias. | |||
| Behaviours | I read journal articles, books, or other educational material on EDI and/or antiracism. | Leaders who have low behaviour scores have not started acting in keeping with their stated values. | Incorporate EDI considerations into processes to make it easier to use skills:
|
| I publicly acknowledge the systems that tools.29 oppress people from marginalized groups. | |||
| Organizational EDI Readiness Assessment | |||
| Measurement and reporting | Does your division have written procedures to increase the recruitment, retention, and promotion of people from marginalized background (e.g., Indigenous people, women, gender-diverse people, people of colour)? | Consider strategies such as direct admission policies,30 candidate selection quotas,31 alternate application streams,32 or cluster hiring33 to diversify the applicant and selection pool. Develop a safe exit interview strategy that incorporates EDI principals and aggregates data to protect anonymity. |
|
| Does your division track the demographics of faculty who move on to other opportunities for disparities? | |||
| Inclusion | Our division collects information about staff satisfaction, desegregated by race, on a regular basis. | Use a standard instrument to regularly and safely collect data on the climate of the organization and transparently report data, disaggregated by identities when safe and appropriate.34 Adopt a decision-support tool for organization decision making.29 |
|
| Our division uses an equity toolkit or analysis to review our policies, practices, and procedures. | |||
| Medical education | Teaching responsibilities are evenly distributed among faculty. | Monitor and transparently report faculty contributions, disaggregated by identities when safe and appropriate. Create and adopt inclusive language and images toolkits.35 |
|
| There is a policy, mechanism, or procedure to ensure that teaching materials are culturally relevant, appropriate, and safe. | |||
| Community collaboration | Our division captures data on who we contract with. | Monitor and transparently report the demographics of vendors. Create and adopt an inclusive vendors guidance. |
|
| Our division prioritizes vendors owned by and partners led by people from marginalized groups. | |||
OCAP = Ownership, control, access, and possession.
Organizational EDI readiness
We also invited leaders in the departments of surgery to complete the Organizational EDI Readiness Assessment (Appendix 1, Section 3). This assessment was created using instruments from Race Forward,14 the Coalition for Communities of Color,36 the Puget Sound Cohort,37 and the Alliance for Resource Equity38 antiracism toolkits. The Organizational EDI Readiness Assessment is a 23-item survey that is rated on a 3-point scale from 1 (“we do not do this or I am not sure if we do this”) to 3 (“this is a consistent practice”), with higher scores suggesting greater organization engagement in equity work. The survey assesses current organization equity practices in the domains of measurement and reporting, inclusion, medical education, and community collaboration (Table 1). Similar to the Leadership EDI Readiness Assessment, the results of the organizational assessment were matched to suggested interventions to improve EDI and antiracism work within their organizations based on study team expertise.
Diversity engagement survey
We invited all members of both departments to complete the Diversity Engagement Survey (DES) (Appendix 1, Section 4).39 The DES is a 22-item survey to rate EDI in medical institutions using 5-point Likert agreement scales. The DES has 8 domains: common purpose, trust, appreciation of individual attributes, sense of belonging, access to opportunity, equitable reward and recognition, cultural competence, and respect.
Terminology
To protect the anonymity of participants, we combined Black, Indigenous, and people of colour (BIPOC) into a single group of participants who may experience racism to compare the experiences of these participants to White participants.40 We also combined nonbinary gender participants — which included those who identified as transgender, nonbinary, two-spirited, or other gender-diverse identities — with cisgender women, as these groups can experience sexism and misogyny. However, we acknowledge that these are heterogeneous groups of people with a range of experiences.
Intersectionality is a frame for understanding experiences of discrimination that was originally developed by Dr. Kimberlé Crenshaw to describe how marginalized identities may overlap to create unique experiences of discrimination.41 For example, a Black cisgender woman may experience sexism, racism, and misogynoir,42 a specific type of discrimination against Black women that can include discrimination against natural hair, policing of aggression, or adultification of Black girls. In this study, we focused on the intersection of specific gender and racial identities: white cisgender men, white cisgender women, BIPOC cisgender men, and BIPOC cisgender women.
We use the term “EDI work” to refer to antioppressive practices — “the act of challenging inequalities”43 — which includes antiracism and decolonization work, given the more common use of EDI in health care settings.
Statistical analysis
We performed statistical analyses in Stata (StataCorp, version 18). We excluded participants who did not answer any questions. We included participants who did not complete the entire survey instrument in the demographic results only. We expected missingness to be nonrandom, given the sensitive nature of the study questions. For the Organizational EDI Readiness Assessment, we calculated the total, mean, and mean per domain score for each participant, and the total, per item, and per domain median (interquartile range [IQR]) score for the whole sample. For the DES, we calculated means and standard deviations (SDs), total scores, and domain scores (as described by Pearson and colleagues),39 with higher scores suggesting greater engagement with diversity. We also stratified DES scores by gender identity, racial or ethnic identity, and the intersection of these identities. We used unpaired t tests and analysis of variance to compare mean DES scores between groups, where appropriate.
Ethics approval
The project was approved by the University of Calgary’s Research Ethics Board (REB22–1204) and was internally funded through the Department of Surgery.
Results
Leadership EDI readiness assessment
Forty-nine participants completed the Leadership EDI Readiness Assessment, including 35 from the University of Calgary and 14 from the University of Saskatchewan (both 54.0% response rate).
Organizational EDI readiness assessment
There were 34 leaders who completed the Organizational EDI Readiness Assessment, for a response rate of 37.4% (Table 2). The median total score was 36.00 (IQR 29.00–44.75), with a maximum possible score of 69 and higher scores indicating greater organization equity (Figure 1). There was no difference in total scores between the 2 universities. The overall median per-item score was 1.57 (IQR 1.26–1.99, range 1–3), with higher scores suggesting greater structural equity. At both sites, community outreach was the lowest scored domain, with a median of 1.00 (IQR 1.00–1.67) followed by measurement and reporting with a median of 1.43 (IQR 1.14–1.96).
Table 2.
Organizational Equity, Diversity, and Inclusion (EDI) Readiness Assessment scores
| Scores | Median (IQR) | ||
|---|---|---|---|
| All participants n = 34 |
University of Calgary n = 24 |
University of Saskatchewan n = 10 |
|
| Total score* | 36 (29.00–44.75) | 36 (29.75–44.25) | 35 (27.50–44.75) |
| Item score† | |||
| Overall | 1.57 (1.26–1.99) | 1.56 (1.29–1.92) | 1.52 (1.20–1.95) |
| Measurement and reporting domain | 1.43 (1.14–1.96) | 1.43 (1.25–2.00) | 1.36 (1.00–1.82) |
| Inclusion domain | 1.64 (1.43–2.00) | 1.79 (1.39–2.00) | 1.43 (1.43–2.07) |
| Medical education domain | 1.67 (1.38–2.00) | 1.67 (1.46–2.04) | 1.75 (1.13–1.96) |
| Community outreach domain | 1.00 (1.00–1.67) | 1.00 (1.00–1.67) | 1.00 (1.00–1.25) |
IQR = interquartile range.
The maximum score is 69 and the minimum score is 23; higher scores suggest more structural equity.
Each item is scored from 1 to 3, with higher scores suggesting more structural equity.
Fig. 1.
Organizational Equity, Diversity, and Inclusion (EDI) Readiness score at the University of Calgary (blue) and University of Saskatchewan (yellow). Supporting data are presented in Table 2.
Diversity engagement survey
There were 151 respondents to the DES, for a response rate of 25.2% (Table 3). Most participants identified as cisgender men (n = 101, 69.2%), White (n = 102, 69.9%), and White cisgender men (n = 66, 45.8%). The mean overall DES score was 3.72 (SD 0.76), with a range from 1 to 5 where higher scores suggest greater feelings of engagement and inclusion (Table 4). Scores were not significantly different between institutions. The mean score for the domain of equitable reward and recognition was lowest, suggesting less perceived equity in this area.
Table 3.
Demographics of survey respondents
| Characteristic | No. (%) of participants | ||
|---|---|---|---|
| All participants n = 151 |
University of Calgary n = 83 |
University of Saskatchewan n = 68 |
|
| Gender identity | 146 (96.7) | 81 (97.6) | 65 (95.6) |
| Cisgender man | 101 (69.2) | 56 (69.1) | 45 (69.2) |
| Cisgender woman | 43 (29.5) | 25 (30.9) | 18 (27.7) |
| Gender-diverse* | 3 (2.1) | 0 | 3 (4.6) |
| Racial or ethnic identity† | 146 (96.7) | 82 (98.8) | 64 (94.1) |
| Asian | 31 (21.2) | 21 (25.6) | 10 (15.6) |
| Black | 4 (2.7) | 1 (1.2) | 3 (4.7) |
| Hispanic or Latinx | 0 | 0 | 0 |
| Indigenous | 3 (2.1) | 1 (1.2) | 2 (3.1) |
| Middle Eastern | 9 (6.2) | 4 (4.9) | 5 (7.8) |
| White | 102 (69.9) | 58 (70.7) | 44 (68.8) |
| Not listed | 4 (2.7) | 1 (1.2) | 3 (4.7) |
| Intersectional gender and racial or ethnic identities | 144 (95.4) | 81 (97.6) | 63 (92.6) |
| White cisgender men | 66 (45.8) | 40 (49.4) | 26 (41.3) |
| BIPOC cisgender men | 34 (23.6) | 16 (19.8) | 18 (28.6) |
| White cisgender women and gender-diverse participants* | 32 (22.2) | 15 (18.5) | 17 (27.0) |
| BIPOC cisgender women and gender-diverse participants* | 12 (8.3) | 10 (12.3) | 2 (3.2) |
BIPOC = Black, Indigenous, and people of colour.
Includes people who identified as transgender, nonbinary, gender-fluid, gender-queer, two-spirited, and additional nonbinary gender identities. These were combined because of small numbers.
Participants were able to select more than 1 race or ethnicity.
Table 4.
Diversity Engagement Survey (DES) scores
| Group | No. of participants | Overall DES score, mean ± SD | p value |
|---|---|---|---|
| All participants | 136 | 3.72 ± 0.76 | 0.45 |
| University of Calgary | 73 | 3.78 ± 0.73 | |
| University of Saskatchewan | 63 | 3.68 ± 0.81 | |
| Gender identity | 0.04 | ||
| Cisgender men | 95 | 3.81 ± 0.73 | |
| Cisgender women and gender-diverse participants* | 37 | 3.51 ± 0.78 | |
| Racial or ethnic Identity | 0.05 | ||
| White | 91 | 3.81 ± 0.72 | |
| BIPOC | 39 | 3.53 ± 0.82 | |
| Intersecting gender and racial or ethnic identities | 0.01 | ||
| White cisgender men | 63 | 3.95 ± 0.62 | |
| BIPOC cisgender men | 32 | 3.53 ± 0.86 | |
| White cisgender women and gender-diverse participants* | 28 | 3.48 ± 0.81 | |
| BIPOC cisgender women and gender-diverse participants* | 9 | 3.59 ± 0.72 |
BIPOC = Black, Indigenous, and people of colour; SD = standard deviation.
Includes people who identified as transgender, nonbinary, gender-fluid, gender-queer, two-spirited, and additional nonbinary gender identities. These were combined because of small numbers.
Cisgender men felt more engaged and included than cisgender women (mean 3.81 [SD 0.73] v. mean 3.51 [SD 0.78], p = 0.04; Figure 2), and White participants had higher scores than BIPOC participants (mean 3.81 [SD 0.72] v. mean 3.53 [SD 0.82], p = 0.05). Of all intersecting gender and racial or ethnic identities, White cisgender men had the highest feelings of engagement and inclusion (mean 3.95 [SD 0.62]).
Fig. 2.
Mean per-item diversity engagement score, stratified by participant gender, racial or ethnic, and intersecting gender and racial or ethnic identities. Standard deviation (SD) represented by vertical bars. BIPOC = Black, Indigenous, and people of colour; SD = standard deviation. Supporting data are presented in Table 4. *p < 0.05. **p < 0.01.
Discussion
This cross-sectional survey study adopted a multilevel approach to understanding equity and diversity in 2 Canadian academic departments of surgery, including assessment of leadership, organizations (specialty sections and training programs), and individuals. About half of the leaders in both institutions engaged with EDI readiness self-assessment, although the reasons for nonresponse among leaders was not known. Organizational assessment suggested that most surgery sections or training programs did not have structures in place to support EDI work, particularly structures to support community engagement and to measure and report on EDI. In addition, we found a low perception of equity and inclusion observed among surgeons who identified as cisgender women and BIPOC compared with those who identified as cisgender men and White.
Although the Organizational EDI Readiness Assessment used in this study has construct validity and is based on best practices from national and international antiracism organizations, there is no known minimum acceptable score and the association between implementing these recommended practices with outcomes for individuals is not known. Future studies could assess the effectiveness of the recommended interventions in improving DES scores within the organization. At this time, we suggest using such organization assessments to support institutional reflection, goal-setting, and transparent monitoring of EDI work. Other standardized organizational EDI assessments have been developed for medicine and are similarly intended to provide direction to institutional EDI committees and suggest a rationale for how to prioritize and monitor improvements.44 For example, the American Association for Community Psychiatry’s Self-Assessment for Modification of Anti-Racism Tool (SMART) focuses on reflection and planning for improvement rather than documenting a score.44
In our analysis, many surgical sections or residency training programs did not have structures in place to support EDI work. There was also notable variation, with Organizational EDI Readiness scores ranging from near minimum to 4 outlier sections with scores greater than 50. These results suggest that both departments of surgery should focus on initiatives that strengthen community outreach to support EDI, given the low scores in this domain, while some individual surgery sections may need to also make focused improvements on EDI in medical education or in measurement and reporting. A formal evaluation of this type of targeted approach to organization EDI work can help medical organizations select priorities for intervention.
The DES was developed and tested in American academic medical institutions,39 and has since been used in additional clinical settings. The mean overall score in our context is lower than that reported in most American universities, although similar patterns, with lower scores for female and Black participants compared with male and White participants, have been observed in both settings.39 That White and cisgender men tend to perceive greater EDI at work than other groups, regardless of what instrument is used,39 has been a consistent finding in multiple settings, including at the University of Calgary45 and in Alberta.46 Although other studies that used the DES did not stratify their respondents by intersecting gender and racial or ethnic identities, they did have adequate sample size to stratify results by more granular categories of race or ethnicity. In these studies, Asian participants perceived greater equity and inclusion than White participants, reinforcing the heterogeneity of experiences of equity and diversity across racial and ethnic identities. This may partially explain why we did not detect a clear difference in perceptions between BIPOC and White participants, as reported in other studies39 and why BIPOC cisgender women in our sample had higher perceived equity and inclusion than White cisgender females and BIPOC cisgender males. Validation of the DES in the Canadian context is needed.
Further, our sample included nonphysician members of each department of surgery, including podiatrists, dental and oral health specialists, and oral and maxillofacial specialists, for whom the landscape of EDI is less known than for Canadian surgeons, although early data suggest similar patterns of disparities in these disciplines.47–49 Given our small sample, we were unable to compare the experiences of physician and nonphysician members.
Limitations
The results in this study may be limited by response bias. Surgeons with more interest in EDI topics (either engagement or skepticism) may have been more likely to respond to the survey invitation. However, our sample demographics are very similar to what is known about practising physicians and surgeons in Alberta and Saskatchewan50 (about 29% women) and so, unlike other EDI surveys, women do not seem to be overrepresented in our sample. Because EDI topics are sensitive, participant responses may be influenced by social desirability bias. The perceptions of leaders toward this measurement approach and the barriers to implementing the recommended initiatives are not known and are the topic of ongoing qualitative study. Lastly, we are unsure of the generalizability of our results to other contexts, especially those with different histories of racism, colonization, and sexism.
Conclusion
Despite these limitations, these results demonstrate a method for multilevel, comprehensive assessment of EDI in academic medical organizations and provide a strategy to use these results in a targeted way. Further, the findings support that gender and racial or ethnic identities influence the workplace experiences of surgeons in Canada, adding to a body of literature describing discrimination and exclusion in the medical workplace. Academic medical organizations must adopt evidence-informed approaches to these issues, which may include using a targeted measurement and intervention approach, as outlined here. This approach should be evaluated for usability by medical divisions and departments, acceptability to medical leaders, and effectiveness in addressing EDI gaps for membership.
Supplementary Information
Acknowledgements
The authors acknowledge Dr. Amanda Hall for her assistance in administering the survey in the University of Saskatchewan Department of Surgery and for her suggested revisions to the first draft of the manuscript.
Footnotes
Contributors: Shannon Ruzycki, Kenna Kelly-Turner, and Natalie Yanchar conceived and designed the study. Kevin Hildebrand contributed to data analysis and interpretation. Shannon Ruzycki drafted the manuscript. All of the authors revised it critically for important intellectual content, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.
Competing interests: Shannon Ruzycki reports funding from the Canadian Institutes of Health Research, Alberta Innovates, and the University of Calgary, as well as honoraria from the University of Saskatchewan and the University of Ottawa. Kevin Hildebrand reports participation with the Canadian Orthopaedic Foundation. No other competing interests were declared.
Funding: This work was supported by the Department of Surgery, Cumming School of Medicine, University of Calgary.
References
- 1.Hobgood C, Fassiotto M. Using the Rank Equity Index to measure emergency medicine faculty rank progression. Acad Emerg Med 2021;28:966–73. [DOI] [PubMed] [Google Scholar]
- 2.Sorgini A, Istl AC, Downie ML, et al. Pride & prejudice: a scoping review of LGBTQ+ medical trainee experiences. Med Teach 2024;46:73–81. [DOI] [PubMed] [Google Scholar]
- 3.Cohen M, Kiran T. Closing the gender pay gap in Canadian medicine. CMAJ 2020;192:E1011–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Dossa F, Simpson AN, Sutradhar R, et al. Sex-based disparities in the hourly earnings of surgeons in the fee-for-service system in Ontario, Canada. JAMA Surg 2019;154:1134–42. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Hu YY, Ellis RJ, Hewitt DB, et al. Discrimination, abuse, harassment, and burnout in surgical residency training. N Engl J Med 2019;381:1741–52. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ruzycki SM, McFadden C, Jenkins J, et al. Experiences and impacts of harassment and discrimination among women in cardiac medicine and surgery: a single-centre qualitative study. CJC Open 2022;4:676–84. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Bernardi K, Shah P, Lyons NB, et al. Perceptions on gender disparity in surgery and surgical leadership: a multicenter mixed methods study. Surgery 2020;167:743–50. [DOI] [PubMed] [Google Scholar]
- 8.Gawad N, Tran A, Martel AB, et al. Gender and academic promotion of Canadian general surgeons: a cross-sectional study. CMAJ Open 2020;8:E34–40. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Hunter J, Crofts H, Keehn A, et al. Gender imbalance amongst promotion and leadership in academic surgical programs in Canada: a cross-sectional Investigation. PLoS One 2021;16:e0256742. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Moody J, Aldercotte A. Equality, diversity, and inclusion in research and innovation: international review. Swindon (UK): UK Research and Innovation; 2019. [Google Scholar]
- 11.Hassen N, Lofters A, Michael S, et al. Implementing anti-racism interventions in healthcare settings: a scoping review. Int J Environ Res Public Health 2021;18:2993. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Mabeza RM, Christophers B, Ederaine SA, et al. Interventions associated with racial and ethnic diversity in US graduate medical education: a scoping review. JAMA Netw Open 2023;6:e2249335. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Canada’s health workforce: pathways forward. Ottawa: Canadian Academy of Health Sciences; 2023. [Google Scholar]
- 14.About Race Forward. Washington (D.C.): Race Forward; 2022. Available: https://www.raceforward.org/about (accessed 2021 Dec. 15). [Google Scholar]
- 15.Moon TR. Project Implicit. Cambridge (MA): Harvard University; 2011. Available: https://implicit.harvard.edu/implicit/takeatest.html (accessed 2023 Mar. 15). [Google Scholar]
- 16.The Ambivalent Sexism Inventory. Middletown (CT): Social Psychology Network; 2023. Available: https://secure.understandingprejudice.org/asi/ (accessed 2023 Mar. 15). [Google Scholar]
- 17.Neo-Sexism Test. IDRlabs; 2023. Available: https://www.idrlabs.com/neo-sexism/test.php (accessed 2023 Mar. 15). [Google Scholar]
- 18.McIntosh P. White privilege: unpacking the invisible knapsack Peace and Freedom Magazine 1989;10–12. [Google Scholar]
- 19.Schnarch B. Ownership, control, access, and possession (OCAP) or self-determination applied to research: a critical analysis of contemporary first nations research and some options for First Nations communities. J Aborig Health 2004;2004:80–95. [Google Scholar]
- 20.University of Alberta. Indigenous Canada. Coursera; 2023. Available: https://www.coursera.org/learn/indigenous-canada (accessed 2023 Mar. 15). [Google Scholar]
- 21.Affirming spaces for healthcare providers. Community-Based Research Center; 2023. Available: https://cbrc.learn.trakstar.com/PublicCoursePage?c=5115757698854&ca=5119846062721 (accessed 2025 Mar. 4). [Google Scholar]
- 22.Join the fight for racial equity. Anti-Racism Daily; 2023. Available: https://the-ard.com (accessed 2023 Mar. 15).
- 23.Saad L. Become a good ancestor [podcast]; 2023. Available: https://www.becomeagoodancestor.com/podcast (accessed 2023 Mar. 16).
- 24.Capers QT, Bond DA, Nori US. Bias and racism teaching rounds at an academic medical center. Chest 2020;158:2688–94. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Ruzycki SM, Holroyd-Leduc J, Brown A. Equity, Diversity, and Inclusion Moments to raise equity, diversity, and inclusion literacy among physician leaders. Can Med Educ J 2023;14:116–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Bystander Intervention Strategies (5D). Ottawa: Canada Go: Government of Canada; 2022. Available: https://www.canada.ca/en/department-national-defence/services/benefits-military/conflict-misconduct/sexual-misconduct/training-educational-materials/bystander-intervention-strategies.html (accessed 2023 Mar. 15). [Google Scholar]
- 27.Watch our bystander intervention training with Julie Lalonde. Ottawa: The Professional Institute of Public Service of Canada; 2022. Available: https://pipsc.ca/news-issues/human-rights-and-diversity/watch-our-bystander-intervention-training-julie-lalonde (accessed 2023 Mar. 16). [Google Scholar]
- 28.First responder to sexual assault and abuse training. Calgary: Association of Alberta Sexual Assault Services; 2023. Available: https://aasas.ca/training/first-responder-to-sexual-assault-and-abuse-training/ (accessed 2023 Mar. 16). [Google Scholar]
- 29.Racial Equity Impact Assessment. Washington (D.C.): Race Forward; 2009. Available: https://www.raceforward.org/sites/default/files/RacialJusticeImpactAssessment_v5.pdf (accessed 2021 Dec. 18). [Google Scholar]
- 30.Pathways to medicine: scholarship application manual. Calgary: Cumming School of Medicine; 2023. Available: https://cumming.ucalgary.ca/sites/default/files/teams/16/P2M%20Application%20ManualMarch-2023.pdf (accessed 2023 Mar. 15). [Google Scholar]
- 31.Ruzycki SM, Franceschet S, Brown A. Making medical leadership more diverse. BMJ 2021;373:n945. [DOI] [PubMed] [Google Scholar]
- 32.Panaccione R. Introduction of the Black applicant admissions process. University of Calgary MD Program Admissions; 2020. Available: https://wpsites.ucalgary.ca/mdadmissions/2020/07/07/introduction-of-the-black-applicant-admissions-process-baap/ (accessed 2023 Mar. 16). [Google Scholar]
- 33.Stewart M. Cluster hiring grows in popularity as institutions act to increase faculty diversity. St. Louis (MO): Insight into Diversity and Potomac Publishing; 2021. Available: https://www.insightintodiversity.com/cluster-hiring-grows-in-popularity-as-institutions-act-to-increase-faculty-diversity-and-advance-social-justice/ (accessed 2023 Mar. 16). [Google Scholar]
- 34.Ruzycki SM, Roach P, Ahmed SB. Unintended consequences of measuring equity, diversity, and inclusion in medicine. BMJ 2023;381:e073445. [DOI] [PubMed] [Google Scholar]
- 35.Ruzycki SM, Holroyd-Leduc J, Chu P. The importance of developing and implementing an inclusive language and image policy in medical schools. Acad Med 2022;97:9. [DOI] [PubMed] [Google Scholar]
- 36.Coalition of Communities of Color; 2022. Available: https://www.coalitioncommunitiescolor.org (accessed 2021 Dec. 15).
- 37.Puget Sound Cohort, Race Forward. Accountability principles. New York: Race Forward; 2019. Available: https://facingrace.raceforward.org/sites/default/files/RaceForward_PugetSoundCohort_FINAL.pdf (accessed 2021 Dec. 16). [Google Scholar]
- 38.Ten dimensions of resource equity diagnostic tool for districts. Watertown (MA): Alliance for Resource Equity; 2020. Available: https://educationresourceequity.org/dimensions-of-equity/ (accessed 2023 Mar. 15). [Google Scholar]
- 39.Person SD, Jordan CG, Allison JJ, et al. Measuring diversity and inclusion in academic medicine: the Diversity Engagement Survey. Acad Med 2015;90:1675–83. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.The myth of reverse racism. Calgary: Alberta Civil Liberties Research Centre; 2021. Available: https://www.aclrc.com/myth-of-reverse-racism (accessed 2022 Apr. 14). [Google Scholar]
- 41.Crenshaw K. Mapping the margins: intersectionality, identity politics, and violence against women of color. Stanford Law Rev 1991; 43:1241–300. [Google Scholar]
- 42.Bailey M. Misogynoir in medical media: on Caster Semenya and R Kelly. Catalyst (San Diego) 2016;2:1–31. [Google Scholar]
- 43.Burke B, Harrison P, editors. The Routledge handbook of social work theory. 1st ed. New York: Routledge; 2019. [Google Scholar]
- 44.Talley RM, Shoyinka S, Minkoff K. The Self-Assessment for Modification of Anti-Racism Tool (SMART): addressing structural racism in community behavioral health. Community Ment Health J 2021; 57:1208–13. [DOI] [PubMed] [Google Scholar]
- 45.Ruzycki SM, Freeman G, Bharwani A, et al. Association of physician characteristics with perceptions and experiences of gender equity in an academic internal medicine department. JAMA Netw Open 2019;2:e1915165. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Ruzycki SM, Roach P, Holroyd-Leduc J, et al. Experiences and perceptions of racism and sexism among Alberta physicians: quantitative results and framework analysis of a cross-sectional survey. J Gen Intern Med 2023;38:165–75. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47.Demopoulos CA, Kohli R, Dhar S, et al. Racial and oral health equity in dental school curricula. J Public Health Dent 2022;82 Suppl 1:114–22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Brower BA, Butterworth ML, Crawford ME, et al. The podiatric medical profession: a gender comparison. J Foot Ankle Surg 2020; 59:997–1007. [DOI] [PubMed] [Google Scholar]
- 49.Ferguson BL, Morgan M, Wilson SB. Trends in diversity related to gender and race in the surgical specialties and subspecialties inclusive of oral and maxillofacial surgery. Oral Maxillofac Surg Clin North Am 2021;33:491–503. [DOI] [PubMed] [Google Scholar]
- 50.Scott’s Medical Database. Ottawa: Canadian Institute for Health Information. 2020. [Google Scholar]
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