Hi, my name is Natalia Arizmendez, and I will be presenting to you Trainee Leadership of Diversity Efforts in Academic Medicine. I have no financial disclosures or conflicts of interest. I do have an invested interest in this topic, although I'm not an expert consultant in anti-racism work. So these are my objectives, to describe the social determinants of health, to discuss last year's action items that one can implement in their institution to create inclusive diversity, to compare the differences in ICU outcomes among different population groups, and identify trainee efforts in diversity, equity, and inclusion, and how to engage leadership support of these efforts. Robin D'Angelo defines racism as an ideology and a practice that produces a society in which some people systematically have less access to resources, power, security, and well-being than others. We witness these injustices. We hear the cries of our sisters, our brothers, and our communities. And all of these social factors, social injustices, continue to destitute certain populations, leading to increased morbidity and mortality, and leaving communities unseen and unheard. These communities tend to be Black, Hispanic, or Latino, Native, LGBTQ+, and those in lower socioeconomic status. And these populations have historically and strategically been disadvantaged by policies created under colonialism. Some of the earliest publications of inequities in healthcare are dated as far back as 1906, and we've seen the rippling effects of how a society fosters discrimination through housing, education, finance, media, employment, criminal justice, and healthcare. The past couple of years have been an awakening call to some in the medical community. We recognize our past and how the healthcare system has perpetuated inequities. We acknowledge how social determinants of health, medical recruitment, medical education, and the delivery of healthcare impacts the outcomes of our patients, but we do not accept them. In last year's SCCM, several sessions proposed options and solutions to diversifying, creating an inclusive environment, and bridging the gap in healthcare inequities, and I'd like you to reflect on the changes you have made at your institution. One may say critically ill patients are treated the same based off of guidelines and evidence-based medicine, and social advocacy and investment in public health is ultimately how we improve patient outcomes. Now, while I agree with the latter, as this likely explains the higher crude mortality observed in many studies, we continue to expose the systemic fallacies and critical care outcomes in patients of color as if we negate decades of disparity and inequity research. This is a systematic review of over 25 studies, with 20 published in the last 10 years, totaling to over 700,000 patients, and we see higher ICU mortality and mortality after post-cardiac arrest, severe sepsis, even when accounting for socioeconomic status, delays to initiation of antibiotics, and more. When hospital type was accounted for, these racial differences were eliminated. Now, hospital factors and type, meaning hospitals serving primarily Black communities based off of size, the setting of rural versus urban, geographical region, and profit status. Previously reported by Danzier and colleagues, longer lengths of stay in hospital and ICU mortality were observed in hospitals serving primarily Black patients. So, this is an interesting study in which Asch and colleagues investigated patient and hospital-level factors associated with differences in mortality rates among Black and white U.S. Medicare beneficiaries hospitalized with COVID. So, they ran a simulation of estimated mean event rates, and I'd like to draw your attention to the observed improvement in mortality if Black patients had been treated at hospitals where white patients received care. Now, of course, this is a simulation and reflects 1,000 replications of the estimated mean event, but this should make one pause and consider what hospital-level factors, things that we can do to evade the differences and outcomes. So, where do we go from here? Creating a diverse, equitable, and inclusive environment in community and academic centers. Well, our trainees have been leading the way for justice, equity, and diversity, and I wish I had more time to expand on the amazing work these people are doing. We have medical students diversifying medical education, Chidirbe Ibe, Malone Mekwende, several residents and fellows advancing healthcare delivery and equity by Dan B. Kang, Chosun Mikeji, Nauman Farooq, Jason Brotherton, Valerie Valbuena, and I'm so proud of all my colleagues, but all of this work cannot be placed on the trainees. We need leadership support and involvement. And why? Because policies, procedures, hiring and admissions, the recruitment, hospital, and ICU culture is predominantly influenced by leadership. This is why the ACGME has now incorporated diversity, equity, and inclusion into the program requirements. So, action items is my role as a diversity, equity, and inclusion officer in critical care fellowship and a champion in the GME's DE&I committee. These initiatives were made in collaboration with the Department of Critical Care Medicine and the DE&I committee to guide and support efforts in creating an inclusive and diverse environment for fellows, faculty, advanced practice providers, and staff, and to provide equitable and exceptional care to our patients. So, our specific aims include develop a strategic plan for restructuring medical education, enhancing cultural competence and safety in a hospital environment, to design an organizational process for faculty that provides cross-cultural awareness, fostering inclusive diversity, equity, and admissions to academic positions, and providing faculty with tools to confront and challenge malignant narratives and actions in health, advance health equity by evaluating disparities in the intensive care unit, and or mitigating a known inequity in critical care medicine, and to design a mentorship program with community partners as a health careers exposure and support system for high school students and undergraduate students. When the academic system values DE&I by restructuring medical education to be inclusive and anti-racist, I don't think retention of diverse workforce will be difficult. There are several institutions that have incorporated this education into their curriculum, such as the University of California, which offers specialized coursework, structured clinical experience, and advanced independent study, and even mentoring for students wanting to work in underserved resource areas. And at UPMC, we have a curriculum that's been developed specifically for critical care in collaboration with the GME. Now, to my knowledge, the published curriculum and evaluations are specific to internal medicine and surgery, but I think sharing and disseminating these resources is important, especially with the new ACGME requirements, which include community health and inequities in critical care milestones. There are also simulations and other workshops that can teach you the necessary skills to be an upstander. So there are different methods one can pursue for creating an organizational process to provide cross-cultural awareness, competence, and safety while fostering an environment of inclusive diversity, from routine presentations, annual workshops, either in collaboration with simulations or the Society of Simulation and Healthcare. Now, for sustainability, all these processes should be evaluated for acceptability and preliminary effectiveness. Now, many of us are unlearning to become an anti-racist. Now, that being said, do not rely on people of color in your department to lead these efforts. Show that you're committed. Learn and do the work, and if you need assistance, there are experts in this field. So to move towards recruitment and retention of a diverse workforce, I'd like to emphasize inclusive diversity and mentorship and sponsorship. The structural racism results in certain groups systematically having less resources and opportunities than others. We must reach out to our community, create partnerships and mentorship programs. Other programs, such as UNM, has a combined BAMD program for high school students all over New Mexico and the Navajo Nation who are committed to serving the area. Other schools, such as UC Davis, adjust for socioeconomic challenges in their admission criteria without accounting for race. Value equity interests and those with community college education. Active recruitment practices and loan forgiveness with appropriate career development and mentorship are necessary. Attrition rates for physicians of color in academic medicine, the salary disparities by race and gender are partly attributed to lower representation. It also results from the lack of or inadequate mentorship. So here are some key aspects to sponsorship, such as helping with advice, creating and identifying professional goals, meeting regularly and frequently, and assigning new tasks that build skills. So be engaged in our activities and provide constructive feedback, advocate for us, and promote our professional development skills, create networks and leadership opportunities, and challenge others' negative perceptions. And one of my passions, investing in health equity research and implementation science. We don't have to accept the status quo because we are better than this and our patients deserve better. How many more studies do we need that document the differences in outcomes in Black, Latino or Latinx, and Native populations? So we should sponsor community-engaged research, create equity dashboards. How do you disseminate the material and share your results? Also, do you provide funding of research and publications? And we need to make sure that we're tracking the sustainability of these efforts. So improving the quality of healthcare involves changing behavior. And how do we change behavior through new processes? This is where you come in. You are the leaders and we must get executive leadership support. The first steps in implementing organizational change are one, is your organization ready for change? And two, does the collective believe in change? I'll tell you, you have future generations in the community looking to us for change. And as quoted from Angela Davis, you have to act as if it were possible to radically transform the world and you have to do it all the time. So determine the barriers that will impact the intervention uptake. Design your strategy and evaluate implementation of these processes. This entire review entails crucial components of a DE&I curriculum for the critical care department. Now, preliminary studies are encouraging in that even with execution of an anti-racist educational curriculum alone, Neff and colleagues observed that participants valued formal curriculum and structural factors attributing to the health of our patients. And many participants viewed the patients from a different lens and felt reconnected to their initial motivation for entering medicine. Now, I believe that this was an internal medicine training program. But again, these studies are encouraging. There is no more sitting in silence or waiting for change to come without taking action. Statements without policy change is not equity. Increased representation without inclusion is not progress. So let's not let these presentations stay on the intangible web. It's time for change and to make this change fact and with results because everyone is watching. And trainees, we must hold our institutions accountable. I know that this is hard and to learn to navigate the culture of academic medicine and higher education. I'll be honest, I've had a couple of sit-downs myself, but as the words of the late John Lewis, this is good trouble, but necessary trouble. So thank you. Again, my name is Natalia Aris-Mendez. This is my contact information. I am more than happy to share my resources with you. And again, I'd like to thank you for your time and the opportunity to speak with SCCM today. Thank you.

trainee leadership

diversity efforts

academic medicine

social determinants of health

healthcare outcomes