Good day, everyone. My name is Joy Howell. I am a professor of clinical pediatrics, assistant dean for diversity and student life, and vice chair for diversity in the Department of Pediatrics at Weill Cornell Medicine in New York. It's my pleasure to have the opportunity to address the question of getting a seat at the table. Does representation matter? I have no relevant disclosures or conflicts of interest to share. Over the course of the next 30 minutes or so, I hope to define equity, diversity, inclusion, and representation, specifically as they relate to clinical practice and professional development. We'll identify gaps in representation in the healthcare industry. We'll talk about some of the disparities that are created because of those gaps in representation, and lastly, we'll close with some strategies that professional organizations and leaders can utilize to bridge or narrow said gaps. First by way of sharing some important definitions, diversity equates to representation. Diversity is typically measured numerically, considering race, ethnicity, gender, gender identity, age, socioeconomic strata, religious affiliations. Inclusion is the participation of those represented within the group. Inclusion usually is achieved when all members of the diverse population are invited to engage in decision-making around the policies and practices that impact the group. Equity requires the changing of structures of power, privilege, and oppression that historically result in some members of our society being locked out or underrepresented in certain circles. And lastly, belonging is that ongoing work of cultural enhancement, creating an inclusive climate across differences that really lead people to feel as if they are belonged, lead individuals to feel welcome and empowered to contribute to the group mission. Now that we've accomplished some level setting, let's review some of the gaps in diversity, equity, inclusion, and representation within the healthcare system. If we compare representation of certain racial and ethnic groups in the U.S. population to representation within the U.S. physician workforce, we will find that there are substantial gaps for certain groups. For example, if we look at representation of Asians in the U.S. population, they approximate 6% of the total U.S. demography, yet they represent approximately 17% of the U.S. physician workforce. I'll pause and say or acknowledge that the use of the word Asian is inappropriately broad. I don't know that it's necessarily appropriate to aggregate East Asians, Southeast Asians, yet I do so because that's typically how the numbers and proportions are presented in demographic and epidemiologic data. Latinx individuals represent 19% of the U.S. population, yet only 5.8% of the U.S. physician workforce. African Americans represent 13% of the U.S. population, yet only 5% of the physician workforce. European Americans or white individuals represent 60% of the U.S. population, and their representation in the workforce is pretty congruent at 56%. If we then move from the U.S. physician workforce at large to the academic workforce, we find even wider gaps, particularly for African American, Latinx, Native American, Alaskan Indian, Native Hawaiian, and Pacific Islanders. These groups remain underrepresented in medicine relative to their proportions in the U.S. population, hence the term underrepresented in medicine, UIM or URIM. If we look at all of these groups in aggregate, we find that there is significant attrition and leaky pipelines. Minority physicians experience lower rates of promotion than their non-minority colleagues, and more leave academic medicine altogether at every stage of the academic hierarchy. The pipeline appears to be most leaky for African Americans and Latinx individuals. On the next series of slides, I'll show you some graphs that depict not only representation at the attending or faculty level, but also some evolving trends over the past 15 years at the trainee level. If we were to narrow our lens from the U.S. physician or the academic workforce to specifically the critical care workforce, we see that there has been some progress that's been made with respect to gender representation. The greatest amount of progress has been made at the level of medical school acceptance, matriculation, and graduation for women, such that since around 2018 or 2019, women match or are just higher, represent a slightly higher percentage of medical school matriculants than men, on the order of 52%. The data presented here was led by one of SCCM's Congress co-chairs, Megan Lane Fall. She and her colleagues looked at trends in the critical care workforce pipeline. In this figure and those that follow, the black and off-black lines represent ICU fellows and trainees in specialties that feed into critical care training programs, those being anesthesiology, internal medicine, pediatrics, and surgery. In these figures, the blue lines represent medical school acceptance, matriculation, and graduation. And if you look at the trend over the past 15 years or so, you'll see that there's been slow but steady progress in female representation. However, we're still not matching the representation seen at the medical school level. If we look at representation by race and ethnicity, there's a tremendous amount of information in these figures. If I were to try to simplify the information, I would call your attention to the fact that the yellow lines represent the proportions of each racial or ethnic group in the U.S. population. The blue lines represent, again, medical school acceptance, matriculation, and graduation. And the black and off-black lines represent trainees in the critical care arena as well as those that could feed critical care training programs. The figure on the bottom right represents the representation of those identified as Asians. And you'll see that the blue lines as well as the black line fit well above the yellow line. Hence, the recognition that Asians are relatively overrepresented in healthcare. If you shift your attention from there to the top right figure, this figure conveys representation of individuals of European American or those we refer to as white. Note that both the black and the blue lines sit relatively close to the yellow line, so not much of a disparity in representation within the academic workforce. Moving on to Alaskan Indians and Native Americans captured here in the bottom right, we see what appears to be downward trends in the last several years in critical care representation. And if we move our eyes to the figure on the top right, conveying Latinx representation, we see that the blue, the black, and the gray line sit well below the yellow line that has been steadily rising in the past 15 years. Lastly, if we review trends in African American representation within the critical care workforce, we see a persistent gap over time between proportions in the population and proportions in the critical care workforce. You may ask the question, so what? There are many cases that can be made for diversity, equity, inclusion, and representation. There's a justice case, there's a moral case, there's a business case, an education case, a research case, and a productivity, but in productivity case, but in my mind, the most compelling case or argument for the need for more diversity pertains to health care disparities. By way of brief review, I share with you that since the federal government began documenting health information and health outcomes stratified by race and ethnicity in the 1970s, racial and ethnic disparities in health care have been noted. It wasn't until the late 70s that the Malone Heckler Report documented distressing disparities as evidenced by excess mortality in over 40 disease categories. Thereafter, resources began to be committed and coordinated to addressing these disparities. In 1987, the Department of Health and Human Services creates the Office of Minority Health to develop new policies and programs intended to eliminate disparities, to fund research and improve data collection, and to generate policies toward health equity. In 1999, Congress mandates the National Health Disparities Report and convened the Institute of Medicine to identify the contributors. Patient, system, and process level factors were identified, not the least of which was implicit bias. Since that time, not only has federal data continued to document disparities, but research from within the health care community itself identifies and documents differences in care that have been characterized as extensive, pernicious, and pervasive. Disparities that extend well beyond what can be attributed to access, clinical needs, or patient preferences. This data exists in the adult literature and in the pediatric literature, in the medicine literature, and in the surgical literature, and documents the ugly reality of unequal care. It is this excess burden of morbidity, and worse yet, mortality, that provoked the Institute of Medicine to characterize the diversification of the U.S. health care workforce as being in our nation's compelling interests. In a few moments, we'll review how much or rather how little progress has been made in the 20 years since these publications were issued. And if I were to take a moment to share with you two specific examples of problematic disparities, the first of which is that of maternal morbidity rates. You'll see in this figure that maternal mortality rates in these United States of America is more than double that of our peer nations. And if you were to investigate further, you'll find that this is largely attributed to wildly excessive mortality among African American and Latinx women. If we look at a neighboring example, that of infant mortality, again, we find problematic trends. In absolute numbers, you'll see depicted in blue for all racial and ethnic groups, red for African Americans, and green for European or white Americans, you'll see that over the past 80 years, the absolute numbers of infant deaths, the absolute infant mortality rate has fallen for all groups. However, I call your attention to the gray bars. The gray bars represent the ratio of black infant deaths to white infant deaths. Over that same 80 year period, you'll see that that disparity has only worsened. Minority populations often experience an undue burden of disease and worse yet premature death. Earlier, we reviewed the proportion of different ethnic groups in the U.S. population as of 2020. If we look at how the U.S. demography is evolving, we see that there are projections that indicate that by the year 2050, the proportion of non-white people in this country will exceed that of white people. In other words, the populations that we presently label of as minorities will represent the majority of the U.S. population. So you may ask, what exactly is the relationship between workforce diversity and healthcare disparities or healthcare outcomes? Well, I'll share some evidence from the medical literature. Racial and ethnic minority healthcare professionals are significantly more likely than their white peers to serve minority and medically underserved communities, who often suffer from worse access and worse healthcare outcomes. Recent work has demonstrated that increasing physician diversity is often associated with greater access to care, particularly for low-income individuals, racial and ethnic minorities, patients who do not speak English, and patients insured by Medicaid, making physician diversity a key strategy for reducing healthcare disparities. There's even been one randomized trial that found that Black men are much more likely to choose preventive services, in fact, invasive preventive services, if recommended by a racially concordant physician. Two notable publications that speak to the dividends of gender diversity include a study in 2018 by Greenwood et al. In that study, the authors found improved survival for patients presenting to the emergency department with myocardial infarction when their care was directed by a female physician, compared to when care was directed by male physicians. When female patients were cared for by male physicians, they were the least likely to survive. In 2019, Meyer and colleagues found that female co-team leadership was associated with a greater likelihood of return to spontaneous circulation and a greater likelihood of survival to hospital discharge. Data external to the critical care literature document not only improved physician communication, trust, and patient adherence to be associated with racial concordance, but there are also some studies that show palpable improvements in care when the physician has some degree of racial concordance with the patients. Work by William King and colleagues demonstrated that African Americans with HIV receive antiretroviral therapy substantially later than white patients with HIV when treated by white physicians. These same patients are more likely to receive initiation of antiretroviral therapy if they are treated by a racially concordant physician. In another study published by Greenwood and colleagues, they examined 1.8 million hospital births in the state of Florida between 1992 and 2015. These authors noted that when there was concordance between the race of the newborn baby and that of the physicians, there was significant improvements in the mortality for Black infants. This was particularly noted with highly complex deliveries and in hospitals that treat a large proportion of Black babies. I ask you to juxtapose these findings with the trends I shared a few moments ago about infant mortality. Despite steady advancements in science, in medicine, in health care overall, we have made remarkably little progress when it comes to representation in the health care workforce and mitigating certain disparities. Sometimes it feels quite frustrating as if the needle is barely moving. So what can we do about these disturbing trends? Despite the fact that some leaders who were formerly in high-profile positions tried to prohibit us from calling a spade a spade, the medical community is finally coming to grips with the ugly truth of structural and systemic racism. Declaring racism as an urgent public health threat is an important step in the right direction toward advancing equity in medicine and public health while creating pathways for truth, healing, and reconciliation. We are in desperate need of education, an education that crosses the spectrum between undergraduate, graduate, and continuing medical education. This education should seek to deepen our understanding of the sources as well as the consequences of systemic institutional and interpersonal racism as well as the strategies necessary to mitigate the adverse effects on health care and health care outcomes. The education needs to start with the truth about race, that race is a social rather than a biologic construct. Racism can be described as the systematic subordination of members of targeted racial groups with relatively little social power. In the United States, those would be African-Americans, Latinx individuals, Asian Americans, by members of the agent racial groups with relatively more social power, those being white Americans. This subordination is supported by the actions of individuals, cultural norms and values, institutional structures, the practices of society, and sometimes even our laws. At the individual level, racism operates through attitudes, beliefs, and behaviors. Thus, if we want to collectively effect change and climate and institutional or workplace culture, we have to start the work on the individual level. As individuals, we need to examine our own beliefs, judgments, practices, and acknowledge our social position and our roles in upholding systems of privilege and oppression to understand how these systems impact the patients we care for. Ibram Kendi describes that a racist idea is any idea that suggests one racial group is superior or inferior to another. If we hearken back to the Human Genome Project, which demonstrated a greater degree of genetic diversity within racial groups as opposed to that between racial groups, if we hearken back to the fact that rape is a social rather than a biologic construct, then we have to acknowledge that any differences in representation that we see are the byproduct of systemic and structural policies. Racism can be defined as a powerful collection of racist policies that lead to racial inequities because they are substantiated by racist ideas. In other words, every system is perfectly designed to generate the results it gets. If we're serious about accomplishing equity, we must be willing to acknowledge that differences in representation are simply the byproduct of our structures and systems. Anti-racism can be defined as a powerful collection of anti-racist policies and practices that lead to racial equity because they are substantiated by anti-racist ideas. Our education also needs to include cultural humility and structural competency. The term cultural humility was first introduced in the late 1990s and represents a dynamic and lifelong process focusing on self-reflection, personal critique, acknowledging one's own biases. It recognizes the shifting nature of intersecting identities and encourages ongoing curiosity rather than a defined endpoint to learning any particular content. Cultural humility involves understanding the complexity of identities that even in sameness, even within your own member groups, there are important differences and that any clinician will never be fully competent about the evolving and dynamic nature of a patient's experiences. Structural competence can be defined as the capacity of healthcare professionals to recognize and respond to health and illness as the downstream effects of broad social, political, and economic structures. I sometimes find myself saying to trainees that as intensivists, we need to do it like we mean it. We've made remarkably little progress in combating disparities and achieving equity and representation within the healthcare workforce. If we are going to effect real change, our systems and processes need to change. One way to do that would be to dismantle historically exclusionary practices that restrict opportunities for certain racial and ethnic groups. Another important strategy would be attention and resource allocation to building up the pipeline of critical care and in fact, healthcare trainees. Lastly, we're going to need to employ some bold maneuvers to move the needle at a pace faster than a glacier pace. One beautiful example of that is the practice of cluster hiring recently espoused by the NIH. So with that, I'm going to close. I hope I have effectively answered the question of why representation matters, and I would be happy to take any questions you may have. Thank you for your attention.

representation

healthcare

diversity

inclusion

equity

belonging