Analysis of Diversity, Equity, and Inclusion Initiatives Presented Across US Academic Department of Surgery Websites in 2021

Abstract

Despite increased attention devoted to diversity, equity, and inclusion (DEI) within academic medicine, representation, lack of workforce and leadership diversity, and bias within medicine remain persistent problems. The purpose of the current study was to understand the current efforts and attention to DEI within academic departments of surgery in the United States. 251 department of surgery websites were reviewed, using a standardized data collection form and scoring procedure, accompanied by a 10 percent fidelity check by an independent reviewer. Only 16% of departments of surgery included DEI-specific information, such as a DEI mission statement or initiatives on their departmental sites, with less than seven percent of departments reporting a DEI committee. Such public information may have implications for recruitment and retention of diverse faculty and trainees, downstream effects for patient care, and could be critical to public accountability to improve diversity and create a culture of equity and inclusion.

Introduction

Within academic medical organizations, recent years have seen increased attention to efforts towards addressing underrepresentation in medicine, lack of diversity among healthcare leadership, and health disparities. One such approach has been the development of committees and task forces focused on diversity, equity, and inclusion (DEI). DEI efforts have occurred at all levels of academic medicine, from universities and medical schools, to individual departments and teams (Del Pino-Jones et al., 2021; Diaz et al., 2020). In light of the sociopolitical and cultural events of 2020, including the exacerbation of health disparities during the onset of the COVID-19 pandemic and the death of Black Americans such as George Floyd (Eichstaedt et al., 2021; Kim et al., 2020), more attention and urgency have been devoted to DEI efforts within academic medicine since 2020.

Despite the recognition of the critical nature of having a diverse workforce in medicine, and the far-reaching implications, recent data indicate the problem persists. Specifically, underrepresentation in surgery has been labeled a national crisis in medicine, while increasing diversity and inclusion in surgery, is an ethical and moral imperative (West et al., 2018). In 2004, the Institute of Medicine (IOM) put out a call to action to specifically and urgently address the lack of diversity within the medicine workforce (Bristow et al., 2004; West et al., 2018). The IOM outlined the importance of racially and ethnically diverse healthcare professionals for optimal care for diverse patient populations, improved physician–patient communication, and greater engagement of patients in medical decision-making (Bristow et al., 2004). Further research has indicated that a lack of diversity within the surgical workforce also has implications for the pathway of future surgeons, patient-centered care and outcomes, leadership within surgery and medicine at large, and the communities served by providers and health care institutions (Diaz et al., 2020; Dotson & Nuru-Jeter, 2012; Nehemiah et al., 2021; West et al., 2018).

Diverse leaders and team members who represent the communities they serve can be key in multi-level efforts to address gaps in health disparities (Crews et al., 2021; Diaz et al., 2020; Wingard et al., 2019) A recent 12-year retrospective study of academic surgeons in the United States (US) through 2018 found academic surgery faculty were almost 70 percent White and 75 percent male (Zhu et al., 2021). Further, only seven percent of academic surgical faculty in the US are of racial/ethnic backgrounds that are historically underrepresented in medicine, with little change in these rates even in recent years (Valenzuela & Arenas, 2020; Zhu et al., 2021). Black/African American female surgeons have been especially underrepresented among tenured faculty, NIH grant recipients, and departmental leadership (Berry et al., 2020). Similar disparities exist among surgical leadership. A 2021 study that assessed diversity among academic general surgery program leadership found academic surgery department chairs were almost 80 percent White, and over 85 percent male (Kassam et al., 2021). Additionally, approximately 75 percent of program directors, and 77 percent of vice-chairs of education, were also male (Kassam et al., 2021). Traditional gender roles, bias against women, lack of mentorship, and manifestations of sexism within medical culture all appear to contribute to gender inequities within surgical leadership (Zhuge et al., 2011). Research also indicates that the field of surgery is behind other specialty areas in efforts to reduce health disparities and improve health equity. A 2016 study of members of the American College of Surgeons found that only 37% of surgeons endorsed that health care disparities exist, while only 12% indicated a belief that disparities exist in their practice (Britton et al., 2016).

Despite the recent increase in prioritization of DEI efforts throughout academic medicine, we still know little about specific DEI initiatives among academic departments of surgery in the US. Given the collective imperative of addressing DEI within academic surgery to improve workplace diversity, diversity among leadership, and community-focused patient care through promotion of health equity, it is important to improve understanding of the national standard of current DEI efforts. The purpose of the current study was to add to this understanding through the study of publicly available DEI initiatives within academic surgery; in particular, this study reviewed the DEI-specific missions, visions, and goals of surgical departments, including committees and task forces responsible for organizing and implementing such efforts.

Methods

Design

A data collection form was developed to assess information and initiatives pertaining to diversity, equity, and inclusion within academic departments of surgery within the U.S. Departments of surgery were defined as departments that are part of an academic medical institution and focus on general surgery, as well as specialty surgery. Independent sub-specialty departments of surgery, such as a Department of Orthopedic Surgery, were not included in the current study. As no exhaustive list of US academic departments of surgery was publicly available, the roster of departments utilized in the current study was determined by assessing all Accreditation Council for Graduate Medical Education (ACGME) surgery training programs. These data were pulled from the ACGME-Public program website, under “list of programs by specialty” with the specialty selection “surgery” (Accreditation Council for Graduate Medical Education, 2021). Data were pulled for academic year 2021 to 2022 (N = 334). To focus on academic departments of surgery, rather than individual training programs, those programs that shared the same overarching institutional affiliation (N = 124, 37%) were grouped by institution (N = 41), making for a new subset of surgery departments (N = 251) that was then utilized for data analysis. (Fig. 1).

Fig. 1.

Academic Departments of Surgery with Diversity, Equity, and Inclusion Content. Note. Figure 1 outlines the process by which academic departments of surgery were determined using surgical training program listings, and how the data were broken down based on those departments with or without publicly available diversity, equity, and inclusion content

All data were collected from publicly available departmental websites. Website reviews included assessment of primary departmental websites and all tabs or subsections of a departmental site. Further, the search feature on each site was utilized to ensure all possible pages were identified for reviewed. For programs that had distinct surgical training program websites, separate from department websites, these were also reviewed to ensure all possible data were collected. In cases where only a surgical training program website was available and there was no department-level site or data, this was noted, and the program-specific data were excluded. The current study was determined to be exempt from human subject’s research requirements by the Northwestern University Institutional Review Board (IRB).

Data Collection& Analysis

Data collection occurred in Fall 2021 and focused on DEI initiatives and committees (or task forces). 20 variables, outlined in Table 1, were assessed related the presence and details of a DEI webpage, the structure of a DEI committee if listed, and the events, initiatives, and goal related to DEI. Both quantitative and qualitative variables were included to capture rates of DEI resources and programs, as well as some the specific and nuanced information available that could not be well captured by quantitative data alone. Departmental websites were reviewed by at least one member of the research team, with data entry into a shared and standardized form. Majority of the quantitative variables were coded using a numerical code system (0 = No, 1 = Yes, 2 = Not Applicable). Of the twenty total variables, six were reported qualitatively (indicated as “open-ended” on Table 1), including: website URL, resources, goals, events offered, social media channels, and any additional information.

Table 1.

20 Variables assessed across departmental website reviews

Variable of interest	Response code
DEI Webpage	Yes/No
Webpage URL	URL
DEI Mission/Vision Statement	Yes/No
Resources listed	Yes/No
List website resources	Open-ended
Goals	Yes/No
List goals	Open-ended
Events/initiatives	Yes/No
List events/initiatives	Open-ended
# of events/initiatives, 2021	0—X
Events offered	Open-ended
DEI-specific social media	Yes/No
List social media channels	Open-Ended
Committee	Yes/No
Committee leaders listed	Yes/No
Interdisciplinary	Yes/No
# of members	0—X
Chair or leadership involved	Yes/No
Trainees involved	Yes/No
Other relevant information	Open-Ended

Data fidelity checks were completed by an independent reviewer for 10 percent of the original data set (N = 33). Only one discrepancy was identified, for which a third reviewer analyzed the website to confirm the most accurate version of the data collected. Statistical analyses for quantitative data were conducted on the subset of departments that presented DEI-related content: analyses compared the trends and differences amongst this subset of departments and standard calculations including percentages and means were computed/performed using Excel. Qualitative data, summarized in Table 3, was coded thematically in Microsoft Excel by two independent members of the research team (AV and MC).

Table 3.

Diversity, equity, and inclusion goals & initiatives

Themes
Hiring/Recruitment	Retention	Accountability and Visibility	Education and Collaboration	Policy/Procedure Change through Research
• Improve diverse recruitment reflective of population •Form committees that enforce a transparent, holistic reviewing process	• Increase faculty and staff satisfaction • Develop strong support systems (mentorship committees) and collaborative environments	• Cultivate a culture that promotes collaboration • Encourage • Mindful conversation through bias testing, reporting systems, etc	• Incorporation of educational programs, resources, and communication • Target professional, personal growth and awareness	• Increase diversity in faculty, resident workforce and research through new programs and research opportunities
Examples
“Better mirror the population we serve through a systematic approach to recruitment and hiring” (Vanderbilt) - “ …every faculty recruitment benefits from a 3–5 member recruitment committee, comprised of members of the Division, Department, and multidisciplinary members external to the Department of Surgery. This helps ensure that diverse candidates of unique perspectives and experiences are identified, interviewed, and hired.” (Medical College of Wisconsin)	“Development of a Mentorship Committee for Assistant Professors to include fair and transparent processes for professional development, promotion, and tenure.” (Medical College of Wisconsin) – “Improved retention of members of the workforce from diverse backgrounds by providing active mentoring, support of their academic development and research, and building a supportive and inclusive community.” (Penn State)	“A reporting system that allows residents to raise concerns around culturally insensitive encounters, harassment or discrimination and to receive timely support when these incidence occur.” (Stanford) – “… In the upcoming academic year, we will initiate a ‘Cultural Complications Curriculum’…understand how bias and prejudice can influence how we care for patients, interact with each other, and educate our learners.” (Medical College of Wisconsin)	“Create a pipeline for future diversity in faculty recruitment by establishing our residency and fellowship training programs as hubs for diversity and career development pathway.” (University of Alabama at Birmingham) – “Education to members of the department through efforts such as diversity Grand Rounds and diversity newsletters.” (Penn State) – “Cultural Complications Curriculum… Grand Rounds Speaker Guidelines…Civility Champions…” (Duke)	“Justice, Equity, Diversity and Inclusion Projects (JEDI Projects)…fund 5–10 projects a year of $1000-$5000, with year end JEDI Project Presentations to share project outcomes.” (Stanford) – “…(STEM-Out) Mexico program, funded by the Provost’s Global Faculty Awards, which provides training for UChicago graduate students and postdoctoral fellows in STEM communication and outreach in an international environment.” (University of Chicago)

Results

Of the 251 departments studied, less than 16 percent of departments (N = 41) included DEI-specific information on their website and/or a dedicated DEI webpage. As outlined in Table 2, further results focus on the specific DEI information presented within the 41 departmental DEI websites. Departments with DEI-related website content were scattered throughout all US regions: Northeast (34.1%), South (29.3%), Midwest (24.4%), and West (12.2%). Out of the 41 departments, 73 percent (N = 30) had a dedicated DEI webpage as part of their departmental website, the remaining departments had DEI information on their general departmental site. Most departments displayed DEI mission and/or vision statements (N = 40). 16 departments listed a range of DEI-related resources, while 5 departments listed departmental and/or committee goals (See Table 3 for extracted themes). Events and initiatives were documented for 7 programs, which offered a total of 169 events or initiatives (M = 24, range = 1 to 131). Two programs offered DEI-specific social media. Data from the ‘additional information’ variable found one DEI website included a statement addressing the events of 2020 and 2021, while another department that did have a committee also listed sub-committee goals specific to department staff.

Table 2.

Diversity, equity, and inclusion content on academic department of surgery websites

DEI Content		Departments of Surgery with DEI (N = 41)	All Departments (N = 251)
	N	%	%
Dedicated DEI Webpage	30	73.17	11.95
Mission/Vision Statement	40	97.56	15.94
Resources	16	39.02	6.37
Departmental/Committee Goals	5	12.20	1.99
Events/Initiatives	7	17.07	2.79
Social Media	2	4.87	0.80

Committee Involvement	N	Departments with Committees (N = 17)	All Departments (N = 251)
		%	%
Listed DEI Committee	17		6.77
Listed Founding Year	2	11.76	0.80
Listed Goals	5	29.41	1.99
Interdisciplinary	9	29.41	3.59
Trainee Involvement	7	41.18	2.79
Indicated # of Members	8	47.06	3.19
Listing of Leaders	11	64.71	4.38
Chair/Leadership Involvement	7	41.18	2.79

DEI diversity, equity, and inclusion

DEI Committees

Among the 41 departments with DEI information on their websites, 17 departments reported committees or task forces (see Table 2). Only two of these departments indicated the year in which their committees were founded, both of which were established prior to the catalytic events of 2020 that resulted in increased attention and commitment to DEI in academic medicine. Of the 17 reported committees, slightly over half were interdisciplinary, and less than half indicated trainee involvement. While only eight programs indicated the total number of committee members, membership varied greatly, with an average of 22 members and a range of 4 to 45 (SD = 11.6) Websites indicated that department chairs or other departmental leadership were involved in 41 percent of DEI committees.

Public-Facing DEI Efforts

Ten percent (N = 4) of the departments with DEI-specific information on their websites, included information to meet greater than 50 percent of the twenty variables considered in the current study. These programs, summarized in Table 4, reflect the breadth work of their DEI committees and task forces through a variety of available content. For example, Stanford Medicine Department of Surgery has four sub-committees (Faculty, Research, Staff, Trainee), an overview of their DEI-specific progress dating back to 2001, and other resources such as events, community programs, and research funding. Both Stanford (est. 2019) and Duke Departments of Surgery (est. 2017) formed committees prior to the events of 2020 and 2021. Medical University of South Carolina invites the community to engage in mindful conversation and questions that cover multiple topics (i.e., Native American Heritage Month). University of Chicago hosts a podcast, ‘Deep Cuts: Exploring Equity in Surgery’, which is a resident-led series that discusses health disparities in the patient population served by the university’s care teams. While meeting 50 percent or less of the variables of interest, other institutions did also indicate interesting and important DEI work on their webpages which could warrant future study and information sharing.

Table 4.

Departments of surgery with the most publicly available diversity, equity, and inclusion content

Institution	Publicly Available Variables (N = 20) N (%)
Stanford Medicine	20 (100)
Duke University	14 (70)
Medical University of South Carolina	11 (55)
University of Chicago	11 (55)

Discussion

While DEI has received more specific focus within academic medicine in recent years, less than 20 percent of academic departments of surgery have indicated attention to DEI in a formal, public-facing way. Public representation of efforts to attend to diversity, and improve equity and inclusion may be important to the necessary and ongoing need to address cultural changes within, and between, departments of surgery. In 2018 the American Surgical Association (ASA) outlined key strategies for improving diversity, equity, and inclusion in academic surgery, which include improving healthcare providers’ cultural competence, identifying and eliminating implicit and explicit biases, creating councils which solidify diversity and inclusion as a departmental priority, and implementing validated tools to measure improvement within an institution (West et al., 2018).

To move the needle on equity and inclusion, departments of surgery must not only engage in thoughtful practices that address ASA recommendations, but that benefit the surgical community and the patients served. Public-facing information about departmental-specific DEI initiatives may provide information and set a tone of accountability, that could, for example, help to address some of the issues related to recruitment and retention of diverse faculty and trainees. Despite an increase in inclusion within surgical residency programs, most American academic surgical departments and societies have failed to prioritize diversity in their leadership. To promote inclusion, academic departments of surgery must prioritize departmental inclusion, education, and the recruitment and professional development of individuals who have been historically underrepresented in medicine (Mehta et al., 2021).

Departmental DEI websites may also allow for other institutions and programs to learn from each other. As indicated from the results of the current study, there are departments such as, Stanford and Duke, who indicate a clear vision and effort related to DEI within their departments. For example, these institutions have clearly appointed DEI committees, initiatives, and training and education. Academic departments of surgery across the country would benefit from learning from these efforts, and the committees/task forces and leadership that have developed and initiated them. Public-facing DEI efforts may also have downstream effects for clinical patient care, as research has suggested that workforce diversity is positively associated with clinical care outcomes (Gomez & Bernet, 2019). Future research should better understanding the nuances of DEI efforts within academic departments of surgery, how public-facing DEI information represents the culture and changes truly happening in academic departments, and the impact of DEI committees and task forces. Further studies should also seek to understand the specific goals, changes, and outcomes related to DEI that are occurring within departments of surgery, and leverage shared knowledge and mutual goals to shift surgical cultural at a national scale.

Limitations

The primary limitation of the current study is that is does not capture the full extent of DEI initiatives, committees, and related work that are occurring within academic departments of surgery. The focus of the current study on the public-facing information presented via departmental websites likely misses programs that have implemented substantial programs and policies, nor does it imply the current culture or experiences for those functioning within departments. The methodological approach utilized in the current study is unable to well capture the nuance and degree of impact of DEI-related initiatives within individual departments. While some programs are provide a great deal of public-facing information, the authors acknowledge this does not indicate correlation with departmental culture. Despite these limitations, the current paper is the first to outline the specific degree of publicly available attention to DEI within departments of surgery. Future studies should collect data directly from academic surgery departments and leadership to better understand DEI efforts and initiatives at a higher level.

Conclusions

DEI-specific education, action, and leadership is critical to creating necessary change within academic surgery, yet only a small percentage of academic departments of surgery in the US have outlined these efforts on their public-facing departmental websites. Leadership in academic surgery has a critical responsibility to prioritize DEI, improve departmental culture to truly foster inclusion, and create diverse departments where all members feel supported and able to bring their best contributions to education, science and practice. In alignment with the 2018 American Surgical Association white paper (West et al., 2018), which outlined the need for specific efforts to ensure DEI within academic surgery, the current paper serves as a call to action for academic departments of surgery to develop and implement clear, proactive, and culturally sensitive DEI initiatives that can lay a foundation for systemic change within, and beyond, departments. Finally, while this study was specific to academic departments of surgery, the findings are relevant to all areas of academic medicine.

Author Contributions

All authors contributed to study conception and design. Data collection and analysis were conducted by AV, MC, LG, CC, MG and MJ. AV, MC, and CC drafted the manuscript text, tables, and figures. All authors reviewed the manuscript, contributed substantive feedback, and approved the final manuscript.

Funding

No funds, grants, or other support was received.

Data Availability

Not applicable.

Code Availability

Not applicable.

Declarations

Conflict of interest

Authors Alyssa M. Vela, Michelle Callegari, Leah Goudy, Cameron Cozzi, Meg Gibson, Michael J. Rooney and Juan Carlos Caicedo declare they have no financial or non-financial conflicts of interest to disclose.

Ethical Approval

The Northwestern University Institutional Review Board deemed the current study non-human subjects research and thus was exempt from formal review.

Human and Animal Rights

Under declarations below there is indication that this study was not human subjects reserach and was IRB exempt.

Consent to Participate

Because the study did not include human subjects, informed consent was not required.

Consent for Publishing

Not applicable.