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Reaching back to enhance the future: the American Association for the Surgery of Trauma Diversity, Equity and Inclusion Pipeline Program - 8 July 2024

Original Research••

Reaching back to enhance the future: the American Association for the Surgery of Trauma Diversity, Equity and Inclusion Pipeline Program

Abstract

Objectives There are significant disparities in the surgical workforce in comparison with medical student demographics. Pipeline programs have shown to be effective in addressing gaps. The American Association for the Surgery of Trauma Diversity, Equity and Inclusion Committee designed a longitudinal pipeline program with high school student mentees and surgeon mentors providing an in-person hands-on workshop.

Methods The mentee demographics and socioeconomic status at the time of application were determined using overall percentages and the Area Deprivation Index (ADI). Program application essays were qualitatively analyzed for common themes. The pre-workshop and post-workshop and 6-month follow-up surveys were analyzed for mentee experience and areas for improvement.

Results Mentees selected were 30% male (N=3 of 10), 70% female (N=7 of 10), 50% black or African American (N=5 of 10) and 30% Hispanic or Latinx (N=3 of 10). The majority of mentees were in the most disadvantaged groups in their state by the ADI (N=8 of 9, 89%). Many of the application essays highlighted a personal loss as driving the interest in a health career with several of those losses based on ‘gun violence’. There was under-representation in medicine racial/ethnic or gender concordance for 80% (N=8 of 10) of the mentee–mentor pairings. In the pre-workshop survey, even those students with high-grade point averages and strong academic achievement in science courses indicated low confidence in their ability to succeed. Most students (N=7 of 10, 70%) reported a strong positive connection with their mentor in the post-workshop survey. There was a reduction in self-identified modifiable barriers to success for 83% (N=5 of 6) of the mentees. One-third of students who responded to the 6-month survey indicated that they had issues with maintaining contact with their mentors after the workshop.

Conclusion The pipeline program was able to reach the target demographic and increase interest in surgery. Positive mentee/mentor relationships were formed. There are improvements to be made in longitudinal components of the program to ensure lasting results.

Level of evidence III.

What is already known on this topic

  • There is a representation disparity of marginalized racial/ethnic and gender groups in surgery. Pipeline programs have been shown to address this gap.

What this study adds

  • This study analyzes the first longitudinal pipeline program for general surgery established by the American Association for the Surgery of Trauma Diversity, Equity and Inclusion Committee highlighting successful components, reduction in barriers to healthcare careers for 83% mentees and areas for ongoing growth.

How this study might affect research, practice or policy

  • Programs such as this are achievable and funding should be available to make them more widespread.

Background

The disenfranchisement of historically marginalized communities is woven into the fabric of the USA. It is, therefore, not surprising that these conditions extend into the field of healthcare. Racism in medicine is present on every level including medical education. Such prejudice and inequity are grounded in structural determinants, which are the institutions, policies, and practices that define the distribution or maldistribution of healthcare and ultimately affect healthcare outcomes.1 To overcome these shortfalls and target inequity, we must chip away at the foundational constructs that perpetuate their existence.

In terms of medical education, one of the major structural determinants in the USA was the Flexner Report. Published in 1910, this report aimed to improve and standardize medical education. However, it is also criticized for the introduction of policies that encouraged systemic racism and sexism. As a direct consequence of the Flexner Report, there was a rapid decline in black medical schools and nursing programs.2 Since occurring at a time when black students, women and other under-represented groups were not admitted to many medical schools in the USA, the Flexner Report directly contributed to lower numbers of physicians from marginalized groups. The vestiges of this report are still seen over a century later. As of 2019, African Americans represented about 5% of all practicing physicians, despite making up 13% of the population.3 4 Particularly in general surgery, the numbers of racially and ethnically diverse surgeons remain low secondary to the disparity in proportions of under-represented in medicine (URiM) students applying to, matriculating, and subsequently graduating from US surgical residency programs.5

The necessity for representation in the physician workforce is evidenced by multiple studies which show that healthcare outcomes are improved when providers and their patients have concordance in their racial, ethnic, and language backgrounds.5 6 With this in mind, it is imperative to reconstruct pathways in the medical education system that create opportunities for URiM students to combat and succeed against the existing limitations. Simply put, structural determinants of health are the upstream factors of social determinants of health. To make indelible change downstream in health outcomes, we need tools that target the source of the issue. Pipeline programs are such tools that can serve to overcome barriers that have been deeply rooted for decades, and to create new foundations on which health equity can blossom.

Multiple studies have shown that pipeline programs are associated with positive outcomes.6–8 While channeling a pool of prospective students into the field of healthcare, these programs provide students access to resources which are typically absent in their schools and communities. The many benefits of pipeline programs include, but are not limited to: fostering environments of inclusivity which helps to unveil and eliminate implicit biases, improving technical skills, teaching strategies in time management and introducing sustainable study tools and habits, and enhancing navigation of college and medical school application processes.5 8 9 The effect of pipeline programs on participant perceptions of the field and mitigation of pathway barriers, however, has not been thoroughly researched.

Pipeline programs are particularly important in the field of general surgery, surgical subspecialties and procedure-based specialties as disparities in representation are even more evident.7 In 2018, black medical students represented 8% of general surgery residency applicants but only 6% of those interviewed at a representative sample of 10 major programs. This discrepancy was somewhat attributable to a higher proportion of black medical students having less than a 220 score on US Medical Licensing Examination step 1 but not on overall application strength highlighting a need for well-rounded applicant assessments.10 Established programs such as ‘Nth Dimensions’ aim to increase the number of women and those historically under-represented in orthopedic surgery through a collaborative and strategic longitudinal program including scholarships, test-taking skills, mentorship and hands-on experience.7 The completion of the Nth Dimensions Orthopedic Summer Internship Program has increased odds of participants both applying and matching to an orthopedic surgery residency program.11 Nth Dimensions has also developed a series of best practices designed to assist orthopedic surgery training programs to recruit and retain diverse residents and ensure their success with similar results being exportable to other procedural fields.12 The longitudinal aspect of the program is critical to its success. In a recent study of undergraduate pipeline programs geared to increasing the number of URiM students, it was noted that the lack of longitudinal follow-up often limited a program’s ability to have a significant impact.13 Although there are successful pipeline programs in some fields, there are no established pipeline programs for general surgery careers, longitudinal or otherwise.

With this in mind, seeking early intervention and exposure to the fields of trauma and emergency general surgery, the American Association for the Surgery of Trauma (AAST) Diversity, Equity and Inclusion (DEI) Committee created a longitudinal pipeline program for high school students funded by the American College of Surgeons Innovative DEI Grant. The program is unique in that it pairs the students with a dedicated surgeon mentor, ideally of similar geographic, racial/ethnic and/or gender backgrounds, who provides ongoing support through their graduation from high school.14 This article focuses on the mentee selection process, program and workshop design and program assessment of the 2022 AAST DEI Pipeline Program.

Methods

Mentee selection, pairing and preparation

10 9th–11th grade students with an interest in healthcare careers completed an online application. Students were selected for participation after review by multiple AAST DEI Committee members based on demographics, school grades and a statement of interest. Many of the student participants were from the Medical Careers Exposure and Emergency Preparedness Program (MedCEEP), an outreach program for URiM high school students affiliated with the University of Chicago Medical Center. The mentees were preferentially paired with surgeon mentors of similar geographic, racial/ethnic and/or gender backgrounds who were recruited to volunteer from the AAST DEI Committee and AAST Illinois local membership. The mentee–mentor expected interactions included a minimum of four virtual or in-person meetings throughout each academic year in addition to a hands-on workshop. The AAST DEI Pipeline Program day-long workshop was held at the society’s annual meeting in 2022 in Chicago, Illinois. The students and their parents/guardians completed permission slips, and photo/video release statements and were provided with school excuse note for the workshop day.

Workshop design

The workshop was based on known student exposure level, career aspirations and research interests that were submitted prior by the mentees. For students who did not have parental transportation, a shuttle bus was provided from the University of Chicago Medical Center to the conference hotel. Students were provided with meals throughout the day, AAST scrubs and T-shirts, suture kits, tourniquets and scientific museum memberships. The morning sessions included leadership through speed networking-style brief topical interactions with volunteers including medical students, general surgery residents, AAST members, nurse practitioners, and pharmacists followed by an interactive exercise to guide students in generating a research question. In the afternoon sessions, the students had lunch with their mentors and then participated in a vendor-sponsored skills competition, suture practicum, tourniquet placement and wound packing didactic and a dissection lab. At the conclusion of the program, the AAST president visited with the students, then all students were safely transported from the program either with parents or on the shuttle bus.

Program assessment

The accepted students’ initial program applications were analyzed from a descriptive assessment of demographic factors. A qualitative analysis using Dedoose software was performed evaluating themes within students’ statements of interest assessing motivation for program participation and expectations.15 The full home address of each student was used to calculate the validated Area Deprivation Index (ADI) to measure overall home neighborhood disadvantage by census blocks.16 ,17 Students completed anonymous surveys both before and after the day-long workshop and at 6-month program follow-up. The survey conducted prior to the workshop focused on previous classroom and standardized test preparation, career interests and perceived barriers to advancement. The survey conducted after the workshop focused on utility of workshop sessions, connection with their mentor and plans to continue in the program. The survey conducted at 6 months focused on longitudinal follow-up and any issues with program participation. A mixed-methods analysis of survey responses was performed.

Results

Demographics

Mentees selected were 30% male (N=3 of 10) and 70% female (N=7 of 10). The racial/ethnic breakdown was 50% black or African American (N=5 of 10), 30% Hispanic or Latinx (N=3 of 10), one Asian and one who self-identified as mixed ethnicity. The vast majority of mentees were in the most disadvantaged groups in Illinois and surrounding states by the ADI (N=8 of 9, 89%) with one mentee not providing their full address for analysis. There was URiM racial/ethnic or gender concordance for 80% (N=8 of 10) of the mentee–mentor pairings. Mentees were mostly in the 10th grade (N=7 of 10, 70%), with only one student being in the 9th grade and two in the 11th grade. There was 100% survey completion with all 10 mentees completing the pre-workshop and post-workshop surveys. There was only 60% completion of the 6-month follow-up survey (N=6 of 10).

Thematic analysis statement of interest

The 10 application essays of the selected students were analyzed for major themes. Several of the essays highlighted a personal loss as driving the interest in a health career (N=5 of 10, 50%) with over half of these losses based on ‘gun violence’ (N=3 of 5, 60%). Consistent reasons for an interest in surgery were a desire to ‘help people’ but also the ‘responsibility’, ‘decision-making’ and ‘skill’ of surgeons. The essays written by female students were more likely to highlight ‘being the first’ in their family and a ‘need to give back to the community’. Half of the essays (N=5 of 10, 50%) indicated that a previous school class or program had initially sparked their interest in healthcare and was critical in developing scholastic confidence.

Pre-workshop survey results

All students reported that they felt as though they belonged in the medical field, with respondents most frequently citing interest in becoming a medical doctor as their desired educational goal (N=8 of 10, 80%). Despite positive feelings toward pursuing a career in the healthcare field, many students reported low confidence in their ability to successfully achieve this goal (N=7 of 10, 70%). Importantly, even those students with high-grade point averages, strong academic achievement in science courses, and competitive standardized test scores indicated low confidence in their ability to succeed. Most workshop attendees did not report that coursework was a barrier to their pursuit of a career in healthcare, with only one respondent citing it as a significant concern. In contrast, mentees noted that they felt as though achieving specific scores on standardized tests was a barrier to their success. To address this barrier, the overwhelming majority of students (N=9 of 10, 90%) indicated that they were interested in taking a preparatory course for national, standardized college admission tests. Most students did not have a mentor to assist with preparing for a career in the healthcare field prior to attending the workshop (N=8 of 10, 80%). Additionally, students noted that racial bias, language barriers, time commitments, citizenship status, and a fear of disappointing others were significant challenges to their ability to pursue a career in the healthcare field (N=4 of 10, 40%).

Post-workshop survey results

All workshop participants planned on continuing their participation in the AAST Pipeline Program. They cited the hands-on learning experiences, positive social connections, and safe environment as important factors for their desire to remain in the program. Importantly, participants were unanimous in their assessment of feeling comfortable while participating in the workshop. Specifically, they noted that the workshop mentors were willing to answer questions, patiently gave advice, and offered support to mentees. Most students (N=7 of 10, 70%) reported a strong positive connection with their mentor, with only one student indicating that they had a poor connection. Of the AAST workshop components, the skills competition, leadership session, meeting mentors for lunch, and dissection lab were most commonly reported as participants’ favorite activities. Students overwhelmingly endorsed the current structure of the workshop. They suggested additional topics for future workshops including in-depth lessons on suturing, information on blood draws and management, professionalism in the medical field, and additional surgical skills. After the workshop, students still unanimously reported a strong interest in having a career in the healthcare field. All students indicated that the conference increased their interest in these careers and noted that they would recommend it to their peers. Although some participants noted that the most common barriers to continuing in the AAST Pipeline Program were transportation to activities (N=3 of 10, 30%) and having other responsibilities (N=2 of 10, 20%), the majority of students did not report these concerns.

Six-month follow-up survey results

In a follow-up survey administered 6 months after the conclusion of the AAST Pipeline Program, mentees answered questions about their experiences of working with their mentor. This survey was completed by 60% (N=6 of 10) of the students who completed the pre-workshop and post-workshop surveys; the respondents included the student in 9th grade as well as both students in 11th grade. Two-thirds of students indicated that they did not have any issues with maintaining contact with their mentors after the workshop. For those students who had issues with continuing their mentoring relationship, schoolwork, time commitments, and issues in their personal life were cited as the largest barriers.

In the 6 months after the AAST Pipeline Program, students reported the frequency of meeting with their mentor ranging from zero to two times. One-third of students did not meet their mentor at all, half met one time, and one student met their mentor twice. All meetings between mentees and mentors were virtual. Despite noting some challenges with meeting virtually, five students (N=5 of 6, 83%) indicated that they were interested in attending a virtual meeting that included all mentees and mentors. Additionally, students suggested viable strategies to increase the effectiveness of the mentoring relationship, such as meeting in person to foster better relationships with their mentors and peers, increased access to their mentors, and the development of connections with mentors who lived in the same geographic area. All students noted that they would benefit from a mentoring relationship with a college student, medical student, or general surgery resident. Respondents noted marked interest in participating in any additional opportunities provided by the AAST Pipeline Program—including volunteering, scholarships, internships, and network building. Four of the students (N=4 of 6, 66%) reported having interest in working with their mentor on a research project. Notably, there was a reduction in self-identified modifiable barriers to success for 83% (N=5 of 6) of the mentees. Also, practical skills were achieved through the initiation of a research project/case for 50% (N=3 of 6) of the mentee–mentor pairs.

Discussion

Programs such as the AAST DEI Pipeline Program create a reality in which URiM students can become future surgical leaders. Several studies have demonstrated the critical importance of mentorship, allyship and targeted recruitment.17–20 The program surveys revealed that the vast majority of students reported a strong positive connection with their mentor who often shared URiM racial/ethnic or gender concordance. Being able to ‘see’ themselves in their mentors as a relatable (and now possibly attainable) goal helps to deconstruct pervasive imposter syndrome experienced by many students of color.19 As evidenced by the thematic analysis of the application essays, acknowledging personal loss, community empowerment and the effectiveness of current school programs is critical in their path to surgery.

In the pre-workshop survey, students noted on surveys that racial bias, language barriers, time commitments, citizenship status, and a fear of disappointing others were significant challenges to their ability to pursue a career in the healthcare field. These factors have also been determined to contribute to general surgery attrition.21 Yet, the ability to rise above circumstances is exemplified by our mentors, who, through the tenure of the program, can equip students with tangible and actionable methods to actualize their potential. In fact, evaluation of the surveys prior to and after the program revealed a reduction in self-identified modifiable barriers to success for 83% of the mentees. Other practical skills were achieved via the initiation of a research project/case with a mentor during program participation period for 50% of the mentee–mentor pairs. This finding goes beyond fostering relationships between the pairs as was seen in previous studies, but also builds translatable skills that students can use throughout their learning and future careers.22

Though this study has identified some benefits of the AAST DEI Pipeline Program, limitations of the program do exist. The selection of the majority of the mentees from the MedCEEP summer program introduces selection bias and limits the generalizability of the results to future cohorts. In subsequent years, to have a more representative cohort, we plan to recruit students from the broader school district affiliated with the location of the AAST Annual Meeting in conjunction with school district leadership. Additionally, as the study was focused on high school students, it is unclear whether the issues with ongoing mentor contact seen in the 6-month follow-up survey were based on participant age or more systemic barriers. We plan to better integrate into already established school curriculum and teaching staff in the future providing a participation credit to limit any extraneous efforts that would be expected of the mentee and increase in-person interactions. Another limitation to generalizability is the small sample size of this study at only 10 students, which skews ability to extrapolate. As the program continues, our number of participants will increase each year enhancing the power of our research efforts.

To specifically address the program components addressed in the 6-month follow-up survey, we will create a virtual curriculum with all mentees and mentors on topics such as resume building, personal statements, interviewing, research projects and the day-to-day lives of individuals at college, medical student and general surgery resident levels of training. Additionally, we will better integrate our medical student and general surgery resident facilitators into the actual mentee–mentor relationship to bridge the generational gap, help to build mentee confidence and enhance research opportunities at all levels. These program adjustments will increase relatability, consistency and expectantly connectedness with both the program and mentor. We aim to make the AAST DEI Pipeline Program a vehicle for students to grow, thrive, and one day, also give back themselves to future iterations of the program and the field.

The dearth of URiM students in the field of medicine, and particularly in surgery, is a consequence of historical systemic and structural racism whose vestiges continue to persist today.2–4 These discrepant social constructs have contributed to generating and maintaining excellence gaps even among subgroups of students performing at the highest levels of achievement.17 It is of paramount importance to address and close these gaps, by breaking barriers and creating bridges of opportunity for URiM students. Despite how smart, hardworking, or resilient a student may be, if their circumstances are devoid of opportunity, then their potential will remain unrealized. The AAST DEI Pipeline Program is more than a tool for enriching young lives. A longitudinal program such as this is a resource for starting to dismantle the inequity in the fields of medicine and surgery.

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