key: cord-0049999-cnc0fqmj
authors: McCullough, Danielle; Gotian, Ruth
title: Making anaesthesiology more inclusive: the time for action is now
date: 2020-09-15
journal: Br J Anaesth
DOI: 10.1016/j.bja.2020.08.037
sha: 7307a953ae8de19c950ab0a90df3ecd3985c4ebe
doc_id: 49999
cord_uid: cnc0fqmj

nan

EditordThe oft-mentioned 'American Dream' is the idea that, with enough gumption, anyone can advance in society. The recent killings of George Floyd, Breonna Taylor, and countless other Black Americans by authority figures, however, echo a centuries-long pattern of dangerous systemic bias in the USA. The fantasy that equal opportunity exists has been revealed as a false narrative, but protests in all 50 states show that society is ready, even aching, for change. It is imperative that institutions turn a mirror inwards to dismantle entrenched injustices, and academic medicine is by no means exempt from this prescription. 1 How can anaesthesiology move towards inclusion? The problem seems daunting at first. It is difficult to take an accounting of academic anaesthesiologists by race, as it is a selfreported measure; many abstain from answering the question. 2 It is estimated, however, that Black physicians comprise 3% of the academic anaesthesiology workforce (13% of the general population) 3,4 and under-represented in medicine (URiM) physicians 6% (34% of the population). In 2017, there were fewer URiM anaesthesiologists in leadership positions than women. 2 Increasing representation is crucial, but so are promotion and retention of URiM faculty; these improvements require fostering a workplace where everyone belongs. How though do we begin and who should be accountable? In short, we begin today, and everyone is a stakeholder.

Anaesthesiology departments are in a unique position to be at the forefront of change. We care for patients from every corner of the hospital in multidisciplinary teams, interacting with a range of specialists. Our far-reaching influence on hospital culture confers a moral responsibility to implement solutions to inequality, but evidence shows that increasing diversity can improve efficiency and profits as well. Further, a diverse physician workforce correlates with better outcomes for minority patients. 5 Thus, in the era of glaring racial disparities, in COVIDe19, institutions ought to attract employees from URiM backgrounds. There are numerous ways to overcome obstacles that exist in developing an inclusive workplace, and several departments and chairs have already made a Herculean effort in this regard. 6 Every person from resident to chair can take an active role in changing the landscape of anaesthesiology. We offer some tips that can be implemented immediately to proactively make departments more inclusive and help marginalised staff, residents, fellows, and faculty feel accepted. We recognise that there are varying department sizes, models, and foci, and not all suggestions would be appropriate for all institutions.

Anti-bias training works best when the participation is voluntary, as people feel more engaged and internalise the lessons learned. 7 In a busy department, effective training should be brief, and participants should feel free to engage without fear of retaliation. The Implicit Association Test (IAT) 8 uses categorisation tasks to reveal hidden biases of the user in about 30 min and is available on the Project Implicit website of Harvard University (https://implicit.harvard.edu/implicit/). Participants are prompted to categorise photos and words representing certain groups as either 'good' or 'bad'; the test measures reaction time and purports to reveal biased thinking when users are slower in categorising certain groups (e.g. Black Americans) as 'good'. Consider making this website available to all staff and allow them to examine their own biases in private. Many will recommit to supporting diversity afterwards, regardless of the results. The act of volunteering makes them stakeholders.

Look at the hallways and website of your department. Who are the people featured? Does it represent the faculty and nonacademic staff at large? If a prospective under-represented faculty member walks down the hall, will they see a photograph of someone who looks like them? If not, consider what message this is sending. Whilst having images of previous leaders is a long-standing tradition, there are more inclusive ways to showcase a sense of community. Consider displaying photographs in your hallways and break rooms from conferences, faculty meetings, holiday parties, and late-night calls. Ensure that these photographs showcase an appropriate balance of the diversity of people in your department, including varying ages, gender, race, and ethnicity. Sometimes, informal smiling faces are more appealing than formal staged photographs.

Did someone in your department win an award, serve on a committee, get a grant, publish a paper, or get accepted into or finish a prestigious course? There is a good chance that others in the department are not aware of these successes. Leverage your network by amplifying these wins, especially for those who are too often overlooked. 9 Talk about their ideas and contributions at meetings, give them a congratulatory remark on social media whilst mentioning their latest success, and introduce them to others. Try and take a photograph with the person whose voice you are boosting as it sends the message that you are throwing your full support behind them.

There are numerous times every year where we invite people to our institution. Before sending out invitations for grand round speakers or visiting professors, take a pause. Look at who you are inviting and compare that to previous and future invitees. Consider if these speakers are the true experts in their field or if there are others who are equally knowledgeable, yet often fall into groups that are often overlooked, such as women, URiM, and those who are differently abled. Ask others in the department for recommendations and curate a list of potential diverse speakers.

If we fear that which is unfamiliar, we must get to know each other. Black and other URiM employees experience chronic racial traumas of which their co-workers are likely unaware. 10 It is necessary to provide a safe forum for sharing these experiences. Consider organising a meeting for employees to share stories. Our institution recently held a Zoom meeting featuring members of the anaesthesiology, obstetrics/gynaecology, and psychiatry departments. Allowing space for volunteers to open up about their lives fostered feelings of empathy throughout the departments, the ripple effects of which are still being felt.

The ultimate goal is for faculty and every department member to internalise that we have a common task at hand, namely, providing the best possible care for patients. Utilising the diverse skill sets of staff from different backgrounds makes us more likely to succeed in this task. Although our specific life experiences are different, many of our emotions and motivations are universal. It is through continued exposure to colleagues different from ourselves that this realisation is possible.

To have a long-standing impact, there needs to be a system and culture of awareness and accountability. Developing a diversity admission and retention pipeline is a critical first step, but the responsibility should not fall on one person. Instead, there should be a group of people who are there to review policies and marketing materials to ensure that they are both welcoming and inclusive. This includes educational materials, objective structured clinical examinations (OSCE), internal policies, and departmental websites. This added perspective can help anaesthesiology departments recognise overlooked opportunities for recruitment and retention.

DM has nothing to declare. RG is a member of the associate editorial board of the British Journal of Anaesthesia.

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