Operationalizing Equity, Inclusion, and Access in Research Practice at a Large Academic Institution.

INTRODUCTION: Healthcare advances are hindered by underrepresentation in prospective research; sociodemographic, data, and measurement infidelity in retrospective research; and a paucity of guidelines surrounding equitable research practices. OBJECTIVE: The Joint Research Practices Working Group was created in 2021 to develop and disseminate guidelines for the conduct of inclusive and equitable research. METHODS: Volunteer faculty and staff from two research centers at the University of Pennsylvania initiated a multi-pronged approach to guideline development, including literature searches, center-level feedback, and mutual learning with local experts. RESULTS: We developed guidelines for (1) participant payment and incentives; (2) language interpretation and translation; (3) plain language in research communications; (4) readability of study materials; and (5) inclusive language for scientific communications. Key recommendations include (1) offer cash payments and multiple payment options to participants when required actions are completed; (2) identify top languages of your target population, map points of contact, and determine available interpretation and translation resources; (3) assess reading levels of materials and simplify language, targeting 6th- to 8th-grade reading levels; (4) improve readability through text formatting and style, symbols, and visuals; and (5) use specific, humanizing terms as adjectives rather than nouns. CONCLUSIONS: Diversity, inclusion, and access are critical values for research conduct that promotes justice and equity. These values can be operationalized through organizational commitment that combines bottom-up and top-down approaches and through partnerships across organizations that promote mutual learning and synergy. While our guidelines represent best practices at one time, we recognize that practices evolve and need to be evaluated continuously for accuracy and relevance. Our intention is to bring awareness to these critical topics and form a foundation for important conversations surrounding equitable and inclusive research practices.

We Are Not All the Same: Implications of Heterogeneity Among Latiné/e/x/o/a, Hispanic, and Spanish Origin People.

There is great variation in the experiences of Latiné/e/x/o/a, Hispanic, and/or Spanish origin (LHS) individuals in the United States, including differences in race, ancestry, colonization histories, and immigration experiences. This essay calls readers to consider the implications of the heterogeneity of lived experiences among LHS populations, including variations in country of origin, immigration histories, time in the United States, languages spoken, and colonization histories on patient care and academia. There is power in unity when advocating for community, social, and political change, especially as it pertains to equity, diversity, and inclusion (EDI; sometimes referred to as DEI) efforts in academic institutions. Yet, there is also a critical need to disaggregate the LHS diaspora and its conceptualization based on differing experiences so that we may improve our understanding of the sociopolitical attributes that impact health. We propose strategies to improve recognition of these differences and their potential health outcomes toward a goal of health equity.

Outlining the Hidden Curriculum: Perspectives on Successfully Navigating Scientific Conferences.

Scientific conferences and meetings are valuable opportunities for researchers to network, communicate, and develop knowledge. For early career scientists, conferences can also be intimidating, confusing, and overwhelming, especially without having adequate preparation or experience. In this Perspective, we provide advice based on previous experiences navigating scientific meetings and conferences. These guidelines outline parts of the hidden curriculum around preparing for and attending meetings, navigating conference sessions, networking with other scientists, and participating in social activities while upholding a recommended code of conduct.

Unmasking disparities: the challenge of diversity, equity, and inclusion in Press Ganey surveys.

Data on minority group physicians from diverse racial/ethnic backgrounds is sparse and not reported by PG metrics at the national level. While PG metrics typically concentrate on the individual, patterns and trends are clearly discernible at the group level and comparison of groups to capture patterns may yield results hitherto unknown. One could even envisage using AI to capture any trends, differences, and comparative figures to build databases for the future. It is time to retool PG surveys to fit the modern U.S. healthcare workforce and be inclusive, and not selective at the individual level.

Engagement in rapid public health research among young people from underserved communities: maximising opportunities and overcoming barriers.

BACKGROUND: Inclusion in public health research of young people from low-income households and those from minority ethnic groups remains low. It is recognised that there is a need to change the way in which research is conducted so that it becomes more inclusive. The aim of this work was to identify novel and innovative ways to maximise recruitment and inclusion of diverse participants when doing co-production within very short time frames for emergency responses. METHOD: We conducted interviews with young people from low-income and minority ethnic backgrounds, and members or leaders of groups or organisations supporting or representing young people from underserved communities. RESULTS: A total of 42 participants took part in an interview. This included 30 young people from low income or minority ethnic backgrounds and 12 community leaders/service providers. Of the 30 young people, 26 participants identified as female and 12 participants identified as being from a minority ethnic background. Participants discussed a number of interrelated barriers to research involvement and identified ways in which barriers may be reduced. Prejudice and discrimination experienced by young people from underserved communities has led to substantial mistrust of educational and governmental establishments. Rigid and unfamiliar research practices further limit the involvement of young people. Four themes were identified as ways of supporting involvement, including: making opportunities available for young people, adaptations to research governance, understanding and acknowledging challenges faced by young people, and ensuring reciprocal benefits. CONCLUSION: This research explored barriers to engagement in rapid public health co-production. Working with communities to co-produce rapid recruitment and research procedures to suit the needs and the context in which young people live is necessary.

Genetic counselors' professional identity in North America: A scoping review.

Professional identity (PI) comprises attributes, beliefs, values, motives, and experiences by which people define themselves in a professional role and evolves through socialization with others in the workplace. While there have been several studies exploring the expanding roles of genetic counselors, few have specifically addressed PI. This scoping review aimed to describe the contexts in which PI has been discussed or examined in the genetic counseling literature. Articles were searched using PubMed, Scopus, and CINAHL with a priori terms including and related to PI. Articles based in the United States or Canada and of all study designs, commentaries, and speeches were included. Date of publication was not restricted. Using social identity theory (SIT) to formulate a definition of PI, multiple reviewers applied inclusion and exclusion criteria to all titles, abstracts, and full-text articles with conflicts addressed through consensus among all reviewers. A total of 5523 titles and/or abstracts were screened, and 467 full-text articles were evaluated and categorized as (1) focusing on PI specifically, (2) containing elements of PI although focused on another topic, or (3) not related to PI. Eighty-seven (87) articles were reviewed during the extraction phase. Ultimately, 41 articles were deemed to meet the agreed upon characteristics of PI. While empirical studies of PI among genetic counselors were limited, PI is being addressed in research focused on related areas, including professional development and diversity, equity, and inclusion, as well as in personal accounts, addresses, and commentaries. Sentiments regarding PI voiced by genetic counselors align with those reported among other health professionals. Given the lack of diversity in the field and rapidly expanding opportunities for genetic counselors, there is risk of some members of the profession feeling excluded, which in turn could negatively impact the collective identity of the profession and translate into impacts on patient care. Additional research regarding the PI of genetic counselors is needed.

Race, Ethnicity, and Other Cultural Background Factors in Trials of Internet-Based Cognitive Behavioral Therapy for Depression: Systematic Review.

BACKGROUND: There is a growing interest in developing scalable interventions, including internet-based cognitive behavioral therapy (iCBT), to meet the increasing demand for mental health services. Given the growth in diversity worldwide, it is essential that the clinical trials of iCBT for depression include diverse samples or, at least, report information on the race, ethnicity, or other background indicators of their samples. Unfortunately, the field lacks data on how well diversity is currently reported and represented in the iCBT literature. OBJECTIVE: Thus, the main objective of this systematic review was to examine the overall reporting of racial and ethnic identities in published clinical trials of iCBT for depression. We also aimed to review the representation of specific racial and ethnic minoritized groups and the inclusion of alternative background indicators such as migration status or country of residence. METHODS: Studies were included if they were randomized controlled trials in which iCBT was compared to a waiting list, care-as-usual, active control, or another iCBT. The included papers also had to have a focus on acute treatment (eg, 4 weeks to 6 months) of depression, be delivered via the internet on a website or a smartphone app and use guided or unguided self-help. Studies were initially identified from the METAPSY database (n=59) and then extended to include papers up to 2022, with papers retrieved from Embase, PubMed, PsycINFO, and Cochrane (n=3). Risk of bias assessment suggested that reported studies had at least some risk of bias due to use of self-report outcome measures. RESULTS: A total of 62 iCBT randomized controlled trials representing 17,210 participants are summarized in this study. Out of those 62 papers, only 17 (27%) of the trials reported race, and only 12 (19%) reported ethnicity. Reporting outside of the United States was very poor, with the United States accounting for 15 (88%) out of 17 of studies that reported race and 9 (75%) out of 12 for ethnicity. Out of 3,623 participants whose race was reported in the systematic review, the racial category reported the most was White (n=2716, 74.9%), followed by Asian (n=209, 5.8%) and Black (n=274, 7.6%). Furthermore, only 25 (54%) out of the 46 papers conducted outside of the United States reported other background demographics. CONCLUSIONS: It is important to note that the underreporting observed in this study does not necessarily indicate an underrepresentation in the actual study population. However, these findings highlight the poor reporting of race and ethnicity in iCBT trials for depression found in the literature. This lack of diversity reporting may have significant implications for the scalability of these interventions.

Where are we now? Evaluating the one year impact of an anti-racism curriculum review.

PURPOSE: Undergraduate medical education has had a call to action to acknowledge racist practices that are impacting learners throughout their training. In 2020, our school performed a detailed curricular review and provided recommendations to address racism in the curriculum. Many schools have now undergone a similar curricular review process, but little is known about whether suggested antiracist curricular changes impact faculty teaching behavior or the overall curriculum. MATERIAL AND METHODS: In 2021, as part of the medical school's annual educational quality improvement process, course directors were required to answer a question about the changes they made to address racism in their courses based on recommendations provided the year prior from an antiracism curricular review. The documented changes were analyzed for themes and then organized by course and curricular year. These changes were compared with the suggested recommendations to analyze the number and types of changes implemented after one year. To evaluate student perceptions of change the general comments from academic years 2019-2021 were reviewed. RESULTS: After 1 year, approximately, 74% of our school's 328 anti-racism curricular review recommendations were implemented in courses. Over 80% were implemented in curricular year 1. The greatest number of recommendations implemented were related to the theme of critiquing the strength of evidence in race-based medical practices. The least amount change was made around the theme of challenging the biologic notion of race. CONCLUSIONS: An antiracism curricular review followed by an embedded continuous quality improvement process can be an effective approach to address racism in medical school curricula. Addressing racism in medical education requires medical schools to regularly identify curricular gaps, faculty needs and monitor their progress.

Autistic Perspectives on Employment: A Scoping Review.

PURPOSE: Inclusive recruitment and employment of autistic adults has garnered recent attention in research and policy. To address a need to better understand the experiences of autistic adults in relation to paid employment, we asked the literature, what are the experiences of autistic individuals (from their perspectives) in competitive employment? METHODS: A scoping review was conducted to summarize and consolidate the findings across research to date. A systematic search and screen of the literature resulted in 32 relevant studies. FINDINGS: Key study characteristics, participant demographics, and thematic findings are shared, along with considerations and recommendations for future research and practice. Six key themes were described by autistic participants across the 32 studies: (1) accessibility of employment, (2) workplace relationships and communication, (3) role alignment, (4) sensory needs and/or mental health, (5) colleagues' knowledge and beliefs about autism, and (6) family and community context. CONCLUSION: It is anticipated that the results of this review will be beneficial for stakeholders engaging in discussions and decision-making across research and employment contexts.

Leveraging individual power to improve racial equity in academia.

Academia in the United States continues to grapple with its longstanding history of racial discrimination and its active perpetuation of racial disparities. To this end, universities and academic societies must grow in ways that reduce racial minoritization and foster racial equity. What are the effective and long-lasting approaches we as academics should prioritize to promote racial equity in our academic communities? To address this, the authors held a diversity, equity, and inclusion (DEI) panel during the Society for Behavioral Neuroendocrinology 2022 annual meeting, and in the following commentary synthesize the panelists' recommendations for fostering racial equity in the US academic community.

Addressing Barriers to Career Development Awards for Early Career Women in Pediatric Psychology.

OBJECTIVE: To provide person and system-level recommendations for supporting early career women in the field of pediatric psychology in writing and submitting National Institutes of Health (NIH) Career Development Award (K award) applications. Recommendations are provided in the context of common barriers, with a focus on practical solutions. METHODS: Publicly available NIH reporter data were compiled to examine rates of funding for Society of Pediatric Psychology (SPP) members. Barriers that women face when initiating programs of research are described and applied to the field of pediatric psychology. RESULTS: Of current SPP members, 3.9% (n = 50) have ever received an NIH K award. Approximately 88.5% of SPP members identify as women, including 89.0% of SPP K award recipients. A table of person- and systems-level recommendations is provided to offer strategies for mentees, mentors/sponsors, institutions, and national organizations to address the barriers discussed. CONCLUSIONS: By addressing gender-specific barriers to submitting K award applications, we hope to increase the number of women K awardees and support the scientific advancement of pediatric psychology.

Matters of the Heart: Examining Motivating Factors and Unconscious Bias in the Adult Cardiothoracic Anesthesiology Fellowship.

OBJECTIVES: The purpose of this study was to identify barriers to improving diversity within adult cardiothoracic anesthesiology (ACTA) and to provide possible strategies that could be implemented by evaluating the demographics of current ACTA fellows, examining motivating factors to pursue the sub-specialty, and assessing perceptions of unconscious biases during their application process and training. DESIGN: A survey was created by the authors and distributed electronically by the Society of Cardiovascular Anesthesiologists to the ACTA Fellows from April to June 2022. SETTING: A multicenter survey. PARTICIPANTS: Recent 2021 to 2022 ACTA fellows. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 68 fellows were included in the analytical sample; 37.3% were women, and 58.2% were men. Half of the participants in the sample were White race (47%), 26% were Asian, 8% Hispanic or Latinx, 5% Black, and 2% were Pacific Islander or Native Hawaiian. Most fellows indicated that the complexity of cases and/or competency in transesophageal echocardiography was "very important" in their motivating factor (74.0%). When examining sex differences, female fellows reported (p value <0.05) that their experience was impacted negatively by sex and was more often treated with less respect and courtesy. There were no statistically significant differences in perceived discrimination by race and/or ethnicity. CONCLUSIONS: This study identified several motivators to pursue ACTA and the perceptions of unconscious biases during the fellowship. Female fellows felt unconscious bias and a negative impact against them due to sex. Due to the small number of undergraduate enrollments, the results should be interpreted cautiously. Additionally, this provides support to complete further studies. Implicit bias training is one strategy that can be implemented to decrease unconscious bias experienced by ACTA fellows.

Emunas Chachamim (faith in the sages): A prenatal genetic counseling needs assessment of Orthodox Jewish clergy in Los Angeles.

The Jewish population's high risk for certain genetic conditions is well established. The Orthodox Jewish community, a denomination of the larger Jewish population, has distinct customs and cultural practices and a complex relationship with Western medicine and medical genetics. Clergy play a central role as stakeholders in the Orthodox Jewish community, and their input often informs key medical decisions for their congregants. Orthodox clergy have a unique structure for advising their community members, which is based on Jewish law. A qualitative research methods study was conducted to learn more about the needs of Orthodox Jewish clergy in the greater Los Angeles area with regard to prenatal genetic testing. The present study aims to understand the function of clergy, cultural implications in genetics care, and ways to improve cooperation between clergy and medical providers. 18 clergy members were recruited to join the study, with a 100% participation rate. Thematic analysis of individual interviews highlighted four major themes: the multitude of roles of clergy; pragmatic testing; a need for mutual respect; and interactions between medical providers and clergy. The existing community infrastructure may be used as the framework to provide a greater awareness of genetic care to this community. Future research should be conducted to explore how to improve interactions between genetic counselors and Orthodox Jewish clergy and the best practices for cultural competency.

The neurosurgeon workforce: a geographical gender-focused analysis of the trends in representation of neurosurgeons and choices in training over 70 years.

OBJECTIVE: Neurosurgeons frequently move throughout their careers, with moves driven by personal and professional factors. In this study, the authors analyzed these migration trends through a dynamic migratory map and statistical review, with a particular focus on differences in education and practice patterns between male and female neurosurgeons. METHODS: A list containing all board-certified and -affiliated US neurosurgeons practicing in 2019 was obtained from the American Association of Neurological Surgeons. The list was augmented to include demographic and location information for medical school, residency, fellowship(s), and current practice for all neurosurgeons with publicly available data. Migration heatmaps were generated, and migration patterns over 10-year intervals were plotted. A web tool was additionally created to allow for dynamic visualization of this database. RESULTS: The database included 5307 neurosurgeons with a mean age of 57.2 ± 11.3 years. The female population made up 8.93% of all neurosurgeons, and were found to be more likely to complete fellowships than their male counterparts, at 54.2% and 39.1%, respectively (p < 0.0001). A total of 39.5% of all neurosurgeons completed at least one fellowship. A large proportion of currently practicing US neurosurgeons completed medical school internationally in the 1990s. Recently, there has been a trend in neurosurgeons choosing to practice in the South, emigrating from the Northeast and the Western US Census regions. By population, the Western US region trained the fewest neurosurgeons at 1 per 115,000 residents, and the Northeastern US region trained the most at 1 per 49,000. The web tool provides a simple interface to visualize the database on a world map. CONCLUSIONS: Diversity, equity, and inclusion in neurosurgery have been a strong point of discussion in recent literature, with neurosurgeons comprising one of the most gender-disparate workforces in the US medical system. This study provides additional metrics to assess these disparities to help motivate further action toward a larger, more diverse neurosurgical community.

To leave no one behind in complex systems of health and education.

Now, as we emerge from the global crisis of the pandemic, the diverse community of practice of Medical Teacher readers and authors needs to jointly address the existing areas, contexts, and scales of inequity, exclusion, and discrimination in health workforce education and research, and implement the long-term strategies ensuring that we 'leave no one behind in health and in education'.

Culturally Centered Implementation of Video Telehealth for Rural Native Veterans.

Introduction: Native American Veterans are the most rural and experience heightened risk for mental health (MH) challenges while facing significant health care inequities and access barriers. Rural Native Veterans (RNVs) have experienced historical loss and racial discrimination, contributing to mistrust of Veterans Health Administration (VHA) and other Federal systems. Telemedicine, including video telehealth (VTH), can improve access to MH care for RNVs by addressing barriers. Understanding the cultural context and existing community resources can improve engagement and implementation efforts with RNVs. Objective: This article describes a model of culturally centered MH care and a flexible implementation approach, Personalized Implementation of Virtual Treatments for Rural Native Veterans (PIVOT-RNV), used to disseminate the model. Methods: Participants included four VHA sites serving large RNV populations where PIVOT-RNV was applied to expand the availability of virtual solutions, including VTH, for RNVs. A mixed methods formative evaluation tracked VTH utilization and used provider and RNV feedback to inform iterative process improvements. Results: Where PIVOT-RNV was used, number of providers using VTH with RNVs, number of unique RNVs receiving MH care through VTH, and number of VTH encounters with RNVs grew annually. Provider and RNV feedback highlighted the importance of addressing the unique barriers and cultural context of RNVs. Conclusions: PIVOT-RNV demonstrates promise for improving implementation of virtual treatments and access to MH care for RNVs. The integration of implementation science within a cultural safety framework helps address specific barriers to adoption of virtual treatments for RNVs. Next steps include expanding PIVOT-RNV efforts at additional sites.

Moving Beyond Words: Leveraging Financial Resources to Improve Diversity, Equity, and Inclusion in Academic Medical Centers.

Diversity, equity, and inclusion (DEI) efforts at academic medical centers (AMCs) began prior to 2020, but have been accelerated after the death of George Floyd, leading many AMCs to recommit their support for DEI. Institutions crafted statements to decry racism, but we assert that institutions must make a transparent, continuous, and robust financial investment to truly show their commitment to DEI. This financial investment should focus on (1) advocacy efforts for programs that will contribute to DEI in health, (2) pipeline programs to support and guide minoritized students to enter health professions, and (3) the recruitment and retention of minoritized faculty. While financial investments will not eliminate all DEI concerns within AMCs, investing significant financial resources consistently and intentionally will better position AMCs to truly advance diversity, equity, and inclusion within healthcare, the community, and beyond.

Negotiation and Career Advancement: How Can We Continue to Advance Women in Academic Surgery, What Are the Barriers They Are Facing, and What Can We Do to Overcome Them?

Despite increasing female representation in U.S. medical schools, women remain underrepresented in academic surgery departments across the country. Even as the gap narrows in academic surgery, female surgeons' professional advancement does not parallel that of their male counterparts. This article explores how to continue to advance women in academic surgery, first by considering the barriers women surgeons face, then offering actionable steps-on the individual, interpersonal, and systems levels-to overcome these barriers and work toward gender equity.

A tool to predict disparities in the timeliness of surgical treatment for breast cancer patients in the USA.

PURPOSE: Breast cancer outcomes are impaired by both delays and disparities in treatment. This study was performed to assess their relationship and to provide a tool to predict patient socioeconomic factors associated with risk for delay. METHODS: The National Cancer Database was reviewed between 2004 and 2017 for patients with non-metastatic breast cancer managed with upfront surgery. Times to treatment were measured from the date of diagnosis. Patient, tumor, and treatment factors were assessed with attention paid to sociodemographic variables. RESULTS: 514,187 patients remained after exclusions, with 84.3% White, 10.8% Black, 3.7% Asian, and Hispanics comprising 5.6% of the cohort. Medicaid and uninsured patients had longer mean adjusted time to surgery (≥ 46 days) versus private (36.7 days), Medicare (35.9 days), or other governmental insurance (39.8 days). After adjustment, Black race and Hispanic ethnicity were most impactful, adding 6.0 and 6.4 preoperative days, 10.9 and 11.5 days to chemotherapy, 11.1 and 9.1 days to radiation, and 12.5 and 8.9 days to endocrine therapy, respectively. Income, education, and insurance, among other factors, also affected delay. A nomogram, including race and sociodemographic factors, was created to predict the risk of preoperative delay. CONCLUSION:  Significant disparities exist in timeliness of care for factors, including but not limited to, race and ethnicity. Although exact causes cannot be discerned, these data indicate population subsets whose intervals of care risk being longer than those specified by national quality standards. The nomogram created here may help direct resources to those at highest risk of incurring a treatment delay.

A framework for addressing the lack of diversity in the Geosciences through evaluating the current structure of institutional efforts.

How can universities build institutional partnerships through supporting community geography projects? This paper details the case of university members seeking to achieve a community goal of expanding Geosciences education opportunities, while also targeting a long-range goal of improving diversity within the university Geosciences. Over the course of one year, two Ph.D students collaborated with community members affiliated with a local middle school to design and organize the School of Earth, Society, and Environment (SESE) Geosciences Camp for Middle School Girls, held in August 2019. This paper deconstructs and critiques the camp organizing process and its outcomes. The conclusion addresses what worked and what did not as a model for future attempts at more sustainable institutional partnerships serving community geography projects.