Dr. Dennis Spencer - Promoting Academic Medicine Workforce Diversity through Pre-Faculty Development

Good morning. It is my absolute pleasure to introduce Doctor Dennis Spencer as today's Department of Surgery grand round feature. Doctor Spencer graduated from Morehouse College with a degree in biology prior to, uh, prior to graduating from the Weill Cornell Rockefeller Sloan Kettering tri-institutional MD PhD program, where he earned a PhD in microbiopathogenesis and immunology from the Rockefeller University. Following medical school, Doctor Spencer trained in pediatric at Stanford University's Lucille Packard Children's Hospital and subsequently completed his fellowship in pediatric gastroenterology, hepatology, and nutrition here at Boston Children's Hospital. Doctor Spencer remained on staff, luckily, and among his many roles as clinician, administrator, and educator, has found the time to serve as the director of Equity, diversity and inclusion for the Boston Children's Hospital Division of Gastroenterology, and is also an associate Program director for the Boston Combined residency Program. Doctor Spencer is additionally a founding board member of Building the Next generation of academic physicians, and we are incredibly excited to hear his talk today. On promoting academic medicine workforce diversity through pre-faculty development. Without further ado, thank you, Doctor Spencer. All right, everyone, thank you for the introduction, and I'm so, um, I feel it a privilege to be here to talk to my surgery colleagues. I look forward to seeing you guys the first week of the new year when I'm back on service, so please be kind. But, um, as you see, today's topic, I'll be, uh, just to start off, I was curious about what it is that might be interesting to my surgery colleagues cause I, um, You know, I wanna make sure that this is a discussion, you know, not just a lecture, um, that you would find, um, useful, that you might find interesting, but also, um, that I could really highlight some of the topics that I have particular passion around, some of the work that some of you are familiar with me doing here, um, but also some work that many of you may not be as familiar with that I'm involved with. So, hopefully, I've struck a decent balance, but I am definitely hoping to encourage a bit of a conversation. Um, just to start off here, I don't have any, um, disclosures to note for financial disclosure, but as mentioned, I will be talking about some of the work of the nonprofit that I, um, helped to found and that I continue to be the treasurer for, um, for which I've received no financial compensation. To kind of start a conversation, I think it's really inviting to talk a little bit about, you know, More of why I think the way that I think, why I'm passionate about some of the things that I do. And I think it's also just nice to get to know each other. So, when talking about these topics, I like to give a quick little um bio of myself, um, again, encouraging our conversation. So, I am from Baltimore, um, born and raised in Baltimore City. And with that, I always just say that I always look at myself as some, you know, some dude from Baltimore that grew up in, I think, a very interesting time in the city. Um, it was right soon after the close of industry, Bethlehem Steel being the number one employer of my city, um, everyone Over 50% of the city kind of had something to do with that particular industry when that went away. It's also around the same time as when crack entered the city. So I remember seeing my community changing. I remember growing up with um really seeing urban sprawl. It's like the end of the 70s, early 80s where I just had friends that were gone, and I wasn't quite sure what was happening, but There were all these things that I was too young to better understand, but I could feel in my family, some people who, you know, fell victim to the horrible disease of substance abuse. I In middle school, I remember having friends of mine who, um, unfortunately, were killed in relating to drug violence. And this environment really was important for my own identity formation because while I really wasn't understanding what was happening, I felt the need to feel some way, how could I help? And, um, with my parents as very strong advocates for being active in the community. My father was a person that was a part of the local administration, um, in Baltimore and his work with youth just made me think, OK, I wanna do something. I don't know if I wanna do what he's doing, but I wanna do something. But I also became aware that there are kind people in the world. There are kind, kind philanthropic groups in the world, and I became someone that was a product of philanthropy. I was a part of a project through the AB Foundation that was trying to Introduce science, introduce research to inner-city youth, and with this, I was able to um learn about what a scientist could be. I, in high school went to the Center of Marine Biotechnology, a part of the University of Maryland Biotechnology Institute. Where I was taken out of high school half the day to work in a laboratory. So I was able to work on projects that allowed me to be published by the time I started college from my own high school research. I submitted to the Westinghouse Science Talent Search back then, so I was able to do all these things that most of the people who I grew up with had no idea existed, including my parents, and that really put me on this path thinking, OK, I kinda like this science thing. But is that something that'll allow me to be useful in the world? Maybe. Maybe I can be a scientist and discover something great. Went to college, went to Morehouse. While at Morehouse, I was there when, um, David Thatcher had just finished his term as the surgeon General for Bill Clinton, and when he came back to then be the president of Morehouse School of Medicine. Someone said, you should meet this guy. So I met with him and he was the first MD PhD I'd ever met. And he just said, this is a cool thing that I do. Like he, he presented it as like something he just happened across. Turned out later that I realized just how awesome he was, but his nephew was also an MD PhD and he said he's also a scientist, he's also a a an astronaut. So his nephew is a biomedical engineer, astronaut, MD PhD, and I was at that time on a NASA scholarship. So I was thinking, this sounds like something I wanna learn more about. Did some more exposure while in college doing some lab work but also working at NASA. I went to another, um, kind of pathway pipeline program with the Cornell Rockefeller System that introduced individuals as undergraduates to MD PhD, so I was able to do that and again got more exposure, got more mentorship, decided to pursue that degree path which was already mentioned. I did the Tri-I Institutional MD PhD program. But between this point where I'm at my MDP PhD program and actually really when I was in my PhD I really started feeling, one, this is a career path I think that I'm excited about and I want, I wish others were familiar with it, one, but two, there was also that sense of being kind of like the only lonely. There were a couple of people who were some years ahead of me in the MD PhD program who kinda had similar identities as mine, but There was that sense of isolation and that did cause some trouble. I ran into some challenges with some of my um My colleagues, my, um, co, um, students, but also within faculty. It was just a, a weird situation where when things came up, for instance, another part of identity formation, um, I remember when Katrina happened that was a huge deal because I was having to kinda, I feel. Explained that it's hard to be reasonable in an unreasonable situation when my colleagues were calling some of those victims savages, like how they're just breaking things, like how can we put all this money to people who are acting like animals, and I was feeling very strangely required to like speak up. I have no connection to Louisiana, but the empathy that I grew up with made me realize that this is not OK and I was upset that this would happen in lectures and no professor would speak up. And so I felt. This kind of sense of burden, but this was something else that allowed me to really step into becoming a leader. I met with other individuals who at the same time were feeling similar challenges where they were training, and we then decided to create a nonprofit that was to try to fix that situation. Why don't we have faculty at the numbers that we were hoping for, um, that had similar Passions, maybe similar backgrounds, but not even really more just having kind of those values aligning that we would love to have seen as mentors. So we created this idea of how can we establish something to help with that pathway, that pipeline that created big gap and at this point, that was 16 years ago and it was something that um really became a huge part of my own um further identity formation as well as A passion that really helped to catapult my focus, not only from a research perspective but also from an advocacy and administrative perspective. So, that's where I'll end in terms of like that bio, but just to give you a sense of, you know, It is important for us to think about what is that workforce look like for not only the students but also for the faculty staff. Um, where are the stories, what are the perspectives, um, the insights that we lose when we don't have as much emphasis and also, to be frank, What can it look like when we're approaching this from an actually a scientific, um, more intentional perspective because we've been talking about diversity for 40 years. And there's a lot of great work that's happened. There's a lot of great people with the great intentions who've created programs, but most of which has not been evaluated. Most of this work has been done out of the goodness of our hearts, but maybe not really following pedagogy to think, how can we train, how can we create something that's longitudinal that we can then, you know, go through iterative cycles and see, did we work, did it work? What should we change? OK, how do we know what metrics are we using to know that we've done something? So all of that was part of also um what I helped to be able to bring to this kind of discussion. So today, I'm gonna talk a little bit about You know, the topic that many of us are familiar with. I just wanna make sure that we are kind of levels setting, but we'll talk about the concept of diversity, how I view diversity, and think about that in the context of academic medicine careers, describing a little bit about what we've been doing in BIN Gap, building the next generation of academic physicians, and then talking about this concept of pre-faculty development and its relevance for how this might be a way to think about our academic workforce and the preparation to be successful in that career path. So talking a little bit about, you know, the fact that we are in a population that Projections have been stating for years that it's gonna continuously become more diverse. And we see this around us, and this is something that, you know, There's another side note, I'm gonna try to avoid too much political discussions today, um, but we know that as a, um, nation, there is an ongoing conversation about if diversity is a good thing, is it a bad word, and, uh, you know, differing opinions. But from projections from the census by 2045, there is the expectation that it will be a minority-majority country that we live in and the some of the projections, um, that have been, um, Discussed Now, with this discussion, many of you, if you've heard about our thoughts around challenges around diversity when it comes to medicine and specifically academic medicine, it's been this discordance between the US population and the composition of our physician staff. So, looking here with a um focus in 2023, we have this population where um There is 59% of the country self-identified on the census as being white, whereas 13.6% were black, Hispanic was 19%, Asian was 6.3%. Now, when we look at the percentage of individuals who were a part of the med school graduating class in 2023, um, those identified as black, um, represented 70.7.6% of that class, which is roughly half of its representation in the US population. But then when we look further about those who then are, were actively residents in 2023, 6.3% You know, it's a little bit beyond the standard of error to say that that's a little bit different than those who graduated, which gives us a concern, and there's further discussion, we could talk about attrition. But then looking at those who then were practicing um US physicians, the data in this case is from 2022. There's a little bit of a drop off. Some people, you know, train and then go into other industries, that's fine. But then you see those who then are part of the medical school staff, um, faculty, that's 4.3% in that year. So we do see from what we look at the population to those who are teaching our next generation of um physicians that there is that lower percentage. Not surprising to anyone, but I just wanted to show the data from that and then seeing that similarly there is a similar um discordance from Hispanic identified individuals, 6.2% being a part of the workforce as well as the faculty force relative to the 19% of the population. Now, I often talk about this in the context of, you know, I'm a GI doc and I am constantly trying to figure out how can we get better data to inform where intervention should be within GI. So one of the other hats I hold is within NASA, our national organization. I founded the a diversity Committee, so we are now officially a committee on the board, and I'm trying to collect the data on our workforce because we have not regularly been. tapping that information in our workforce, um, surveys. So the data for pediatrics is a little bit lacking when it comes to who is part of the active working force, but similar to what we can see in the adult data, and most recently that was published in 2019, um, that there is a decrease in those, um, practicing gastroenterologists relative to the population, um, but When looking at the faculty, there's also been a stagnation. Now, this goes from 2010 to 2017. I can tell you that, um, again, unfortunately, I know that AGA right now is doing another deep dive to get more data on the faculty, but there has been for a while, a bit of a flat line, and you can see on the red line here, I'm sorry, the blue line is um those who are white identified. The green here is Hispanic, and then African-American, which is slightly below the green, um, is those identified as African-American. These lines have been pretty stable around like the 5 and 6th percentile for faculty and GI. So similar to the workforce, the actual practicing work workforce who are in academic medicine. But when looking at, you know, that adult data, I wanted to say that we certainly are finding similar challenges in pediatric. We're not, um, exempt in this case. So since I know this is a joint, um, grant rounds. Looking at Anesthesia, and this is from 2025, so this is the most recent data from the AAMC. Those who are a part of the training, um, so residents and fellows who are anesthesia, pediatric anesthesiology, um, has About 7.3% who are black identified who are currently training um in anesthesia, uh pediatric anesthesia rather. And then if you look at um Cardiac anesthesia for pediatric, um, there actually is, um, just a smallern, but, um, you can still see that there's still a little bit of dis dis discordance from the population for those who identify as, um, black, and then similar, we see the same kind of trends for those who identify as Latino, Hispanic and Latino. Um, for surgery. So we'll see 7.7% are black identified and 10.5% are Hispanic identified who are in the surgery, um, general surgery residency, but when we look at fellowships for peed surgery, we see that there's a very similar percentage, actually, as the residency. 7.1% are black identified, 9.4% being Hispanic identified. Um, but, um, What this is all just showing is that these numbers are not isolated, that we are not exempt in pediatrics to see that there are some disparate, um, challenges when we're looking at race and ethnicity. There's also data that will Some of which I may show today, um, that talk about gender. Um. Gender parity has been something that we've certainly seen in the entering classes of medical school. If anything, actually, um, those who identify as, um, female are the majority of those who are starting medical school right now. They are a little bit over 50%, it's like 51, 53%, depending on which year you're looking. Um, but you'll see that when you look at certain specialties, there is still a drop-off from gender in terms of those who are active residents. But then when we talk about faculty, that's a whole another story that I'll talk about for sure a little bit. Zooming in what's happening here at HMS. We look at those who we have identified as underrepresented in medicine who are training with us, that they are less likely to transition to faculty here at HMS. Now, we have most recently looked at this data in 2020. I'm, I'm part, I was a part of this committee. Um, we look at how in um, 2018, for instance, 4,776 individuals were um People who graduate who are actively being trained um at uh within our different training programs. It's both residents and fellows across our affiliated hospitals. Of those individuals, 484% identified as being a part of underrepresented in medicine. In this discussion, when I'm mentioning underrepresented in medicine, I'm using the AAMC and the NIH's former definitions of underrepresented medicine. So Black, Hispanic, um, Native American, um, Asian, who are Pacific Islander, um, identified. So, Roughly 10% of the trainees in the Harvard system identify as being a part of those categories. But 289 actually transitioned to faculty in 2018. And of that 289, 5.2% of them, so total number, 15, um, identified as being underrepresented in medicine. So, this is showing that, uh, 15 out of 484 individuals, um, so that's much smaller than the 5.2% here, um, were transitioning into faculty positions, which is a decreased percentage than um their non-URIM um counterparts. And this is something that, um, when looking across years, we typically see this drop off. Again, the 23 is again, just 8.3% of the 278, but if you look at just from the total number of um Actual trainees or the total number of those who identify as underrepresented medicine, um, this is a much smaller percentage than their counterparts. But this is another opportunity of thinking, OK, so why are some trainees more likely to stay than others? And this is something that we've been, um, looking into, um, especially those of us in GME across the HMS system. But just to also give just some more granularity cause I was, you know, this was not easy data to attain, so we were very proud that we were able to get this from faculty affairs um within Harvard, um, looking at the absolute number of faculty across years, so from 1990 through to 2020, looking at those who um identified as Hispanics, so they're more Hispanic identified um faculty who are full-time or part-time in the HMS system than those who are black identified, there's been Some fluctuations. I will note that we all saw in the first Trump term, there was a number of people who left academia for a number of reasons. Um, so that's where you see these kind of jumps or or decreases, but then you do start to see a slight rise, um, around 2020. Um, but we've Been actively looking at more newer data on this. Um, the data's been a little bit challenging, um, for some of the, the way that we are obtaining data, um, has made that a little bit challenging for like a number of reasons. But we are looking at these to see, are there new trends that we can identify? cause again, I want us to be data-driven as we are looking at how to make any interventions, if there's anything appropriate and if there should be any targeting of our efforts. This is also looking across the country to show just the the fact that there is a total, there has been a, there has been a rise in the number and percentage in this case of faculty who are who are understa who are identifying as underrepresented in medicine, but you're still seeing that combined, we're looking at 9.6% of the workforce when the actual population being roughly that 13 + 9%, so like 20-something% of the population being those who identify underrepresented. So there's still this discordance, but thankfully there has been a slight increase that you can see of almost 2% points over the last 20 years. Um, but it just shows us where we are and what we can try to focus on. And other things, especially in this discussion around And academics specifically, there is. You know, maybe not surprising to anyone here that as you go higher in the ranks, there is a further not only plateauing but significant um decrease in diversity. Now, this data from 2013, you know, is dated. I'll admit that. I was hoping that there'd been a larger comprehensive study of this that had been published. I know more of specific fields that I can speak to around um what that percentage breakdown among different demographics are. But in 2013, it was very sobering to notice, for instance, that, you know, while we talk about, and I have focused a lot on Black and Hispanic, there are other groups that are also not seeing the same sort of academic success that we may need to focus on and understand. So in this case, I've zeroed in on how our Asian identified um faculty who are Overrepresented based on percentage in the US and those who go into the academic medicine workforce, they have not been as successful in taking on some of the highest, um, positions. Now, again, this is 2013 where there were no Asian identified deans of medical schools and allopathic medical schools. In 2023, the number went up to 5. So we do have 5 who are self-identified as Asian-American. Um, but that is still a far cry from the over 20% of the medical school class that identifies Asian American. This has been coined by some as a bamboo ceiling. I know that, um, APAMSA and some other groups have been focusing on this. Similarly, looking at chairpersons, we saw that I mentioned earlier, there's parity now in the workforce for women in medicine, but in 2013, only 9.2% were chair chairpersons of uh uh academic um department. In 2023, that number has significantly improved. It's now 26%. But still, for 50% of the workforce, there's still work to be done. Similarly, when it comes to deans, um, the number is also around, um, 25% as well. But then when you look at osteopathic schools, actually, the number goes to 33% who are women, who are chairs of the departments. So, there's still discordance, but we do see that depending on the school type, there's a difference. And why is that? We also see regional differences where you're more likely to see women in leadership at Dean and chairpersons levels on the West Coast and in Puerto Rico, and you're least likely to see it in the Northeast. So these are some of the trends that have been published and um we have to continue to look at. Finally, just talking about applicants, um, some may be aware cause there was a lot of discussions um around like 6 to 10 years ago around um the decrease in applications that have been observed across certain demographics where there was one study showing that In 2005, there were fewer African-American men applying to medical school than there were in 1976. And that was something that was seen as a huge concern and thought that it'd be something that was really showing um that despite 40 years of this conversation, there was something that was clearly not working. Now, looking at these numbers, there has been an increase, um, especially for those who identify as, um, black but is represented by a gray line that's kind of being, um, overlapping with the Hispanic, um, yellow line here, but that number still has not, you don't, you don't see a large slope here from those years we saw that kind of disparate number. And then for the matriculants, um. We see that for the um blue line down the bottom of the graph here, that that number of matriculants has really been very stagnant for, again, almost 30 years um for those who are black identified going into medical school and then Hispanic identified as well with a couple of blurbs every now and then. There was this idea, especially when looking at new institutions who are trying to create new schools, um, thinking that as we increase the number of slots, maybe this will improve the diversity question. And between 2000 and 2023, 60 new schools opened in this country. Many of them are osteopathic, but some of them are allopathic. But I'm not gonna spend for the purpose of time too much on looking at this, um, specific data, but if I take your attention to the, uh, middle, um, bars here, you'll look at those who existed before 2022, this kinda, um, lighter blue, um, color, then there's a bar right beside it that shows that those are the new schools, and you see for these different demographics that if anything, in some cases, the number goes down. There is a bump for Hispanic identified individuals and some of these um newer schools have been created out West and areas that are more um. Hispanic serving institutions, um, but still, even with these new schools I already showed you the data that shows that, you know, the absolute percentage of workforce has not changed all that much, so for the most part you really don't see that this has made a significant change. The numbers for those who are identified as white, for instance, between those newer schools and the older traditional schools, 52.5% versus 52%, no difference. So, really, that didn't change too much. One thing that has changed things is that we had a new ruling from the Supreme Court where looking at race and ethnicity was something that was not to be taken to account for our admissions. And there was a lot of concern of how that would impact um the um workforce. Now, looking at 2024, 2025 versus the prior year. We do see that there was interestingly an increase in applications from those identified as Hispanic and Black as well as an Asian, and there was a relative decrease um in those who are Native American and um white identified. But then when you look at the actual matriculants, there was, as we expected, a decrease for those who are Hispanic and um black identified, 10%, 11%. And this is something that when we look locally, um, was certainly very troubling for certain institutions. Harvard, we actually did OK. We went down, but the percentage that we went down was less than we expected. Whereas Tufts, we look at the campus in Boston and the campus in Maine. a larger, much larger class than us, say about 270, 280 students. And before the class in 2023, their class, I'm specifically thinking about the African American class, they had about 27, I think, between the two campuses, African American identified. Between the two campuses in 2024, 20204, 2025, 1 black identified person was in Maine, one black identified person was in Boston. So you went from 27 to 2. In that one year after this ruling. So we, it definitely has been felt here and when talking about the environment for those two students, um, this was an area that was a part of focus for my advantage even at Harvard in academic affairs, or student affairs, because we were doing a lot of outreach because we were hearing just how much challenge they were having being so isolated. So, real life consequences to these things. So, transitioning, I did spend a little bit longer there than I meant to, but, um, you know, I think that it's a lot of noise we hear about people speculating. When we have data, I think it's important for us to know the data so we understand that policies. Have they matter. But looking at um what can we do about this workforce piece in terms of people who want to stay in academic medicine to be faculty like those in the room here. Um, one of the things that my group had noticed, um, years ago was that students who come into med school. When you look at the metricating student questionnaire from AAMC, um, they are You know Kind of interested in negative medicine based on this data on on that survey, but there's a lower proportion of those who identify as minority, um, who express interest when they start med school. But then over time, That even worsens among those who are identified as underrepresented medicine. And there was not great understanding of exactly why there's a, over time, a decreased interest in staying on board to be faculty, but we already saw that there's a drop off in the data, so we know what's real. And wondering, like, maybe it gets better in residency. Maybe they see us as faculty walking around so happy, and they think, OK, maybe I wanna change my mind, but nope, that's not the case. It even gets worse. So, this is something that for my group and Vend Gap, we want to understand why. So And recognizing, like, again, why even care? There's many reasons um for why diversity matters. And this is, again, looking at all the dimensions, all the lens of diversity. You think about um the fact that there's plenty of data that shows the improvement in outcomes, um, patient satisfaction when there is, um, a culturally competent concordant, um, or someone who just, you know, is familiar enough to where you are seen as an ally. The way that the patients are more compliant, um, they are more feeling like it's a team as opposed to, um, feeling like they are being acted upon, um, that this also improves institutional excellence based on one, Overall workforce satisfaction makes for more productivity. Um, also, the overall agenda from a research standpoint, you know, thinking about the questions that may otherwise have not been considered, um, and just because we all have our biases and our focuses, we need to have people who have, you know, a more expansive focus. And all of this had encouraged our, um, sponsoring organizations to think we need to make sure that we are being actively Actively telling programs to think about the importance of um your workforce. And there was, that's even rose in 2019 to be a part of the Common Programor of Requirements for the ACGME. Now, while again, this was something that had been recognized for the ACGME as well as for LCME for med school to think how can we be more active in ensuring that our education is allowing materials that can allow for a more informed workforce, but also for a workforce that also is uh more inclusive. Um, while that was something that was seen as important then, there have been, again, more recent changes to that perspective. Um, so, in the beginning of this year, in, well, I guess last year, well, September, I'm sorry, September, so a few months ago, there was a recent letter from ACGME that mentions that while this was something that had been a core requirement due to recent, um, directives, that there is now a prohibition for accrediting bodies to require or even suggest, um, focusing on these areas. So, To stay in alignment with this, they have retired that accreditation standard, so that is no longer a requirement as of this fall. And ACGE is also closed, um, the Department of DEI. And that they do mention that, you know, while these requirements don't exist, that there is flexibility among programs to really do as they wish in alignment with their own values. And this led um myself and Jennifer, the GIO for um Boston Children's to coin a letter just to re-emphasize that in response to this, we are doing our own. Self-analysis of the work that we've been thinking around diversity and that we are gonna continue to follow, um, What are things that we think are in line with the mission and values of Boston Children's Hospital. So, but again, this has caused us a lot of us from an institutional standpoint to think, what can we do? What should we do? What are we permitted to do based on our general counsel? But that I think is just even more emphasis um for me to think about outside of what restraints I have within the Harvard system, what restraints we might have at Boston Children's. Are there other tools that we can implement that, you know, Are things that um we don't necessarily need those permissions but still allow us to remember how important it is for us to consider um the learning environment and the workforce that are part of our academic medicine career um path. So, Ben Gap, as I mentioned, was something that um was encouraged by myself as well as others who had noticed this issue, you know, over 16 years ago. Um, we came with a strategic plan of thinking about how can we approach this scientifically? How can we look at what's already happening? What, how can we How can we look at that data that I mentioned that showed this decreased interest over time and understand it? You know, we did not want to go from the anecdotal, but rather, we wanted to get some data to support what the next step should be. So we created these, um, focus groups. We created an instrument, um, just for surveying students, residents, as well as even junior faculty to understand, um, their interests over time. So, in assessing the diverse perspectives of individuals who are in that pathway, that pipeline, um, we went through a sample of convenience, going to national meetings, um, that were being sponsored by a lot of medical organizations. Uh, we had, um, The Miranda's of understanding with these groups to be able to sample their populations. We designed, um, again, different ways of collecting this data. We've published on this, and one of those, for instance, that we published in academic medicine looked at, um, 601 students, saw that there was an interest in this group which we recognize is probably because they're already part of medical organizations. This may not represent necessarily your typical student who is just trying to get through. So we looked at the caveats of the fact that we are interested, we're talking to an interested group, but we recognize that they also are describing certain obstacles in this interesting group of those who um think that it might be challenging to be successful in an academic career, and they had listed some of these that are listed here, including obstacles around the promotion process. So, in our qualitative, we found some themes that um actually came across different groups. So these are three different publications that I've quoted down here, but this was In part, looking at our um particular study with our Asian medical students and talking about um challenges that, you know, this um individual talking about impact of family. So that there is a socio um Component to some of these pressures that may make it challenging for some to feel like they could be successful. The idea of self-doubt, imposter syndrome, we know is very prevalent, and this is both for race and ethnicity as well as around gender. And then those who may identify as like gender minorities, there's even more challenges around finding one, places where they can feel safe, challenges where they can find mentors. So these were themes that came up. In preparation for today, I was trying to get some more clarity on, you know, what are some of the nuances that impact, um, both race and gender in surgery. Um, this particular study I thought was interesting because in many fields, and also as a program director, I will notice that there is this concern around being scholarly, scholarly, um, productive and as a medical student. And that that has been seen as a barrier, especially seen worse in those who identify as underrepresented in medicine as well as in gender across many fields. But when I looked at this, um, recent study in the Journal of Surgical Research from 2024, they did not find that there wasn't much difference. They felt that those who were, um, women were found to have the same number of scholarly public, um. Productivity, um, number of publications really was no different from a gender perspective. Um, so I thought that was interesting because again, it just to me highlights the fact that we need to understand certain subgroups of med students who are going into these academic, um, residencies and then figuring out what's happening when they get to residency because as we also saw, interest further wanes. So, There may be a different approach for general surgery, for instance, than there might be for um pediatrics, general pediatrics. But as we learned more about these subgroups to target interventions, then we wanted to figure out, OK, now that we know the challenges, how can we develop educational interventions to support, um, kind of this pre-faculty pipeline. And I say pre-faculty because this is something that we coined, um, and you'll see, hopefully in more publications, this idea of before you are faculty. As you progress to academic medicine, you are hopefully recognizing that you're gaining competencies, you're gaining skills that are preparing you to be faculty. Some people are receiving this information in a way that's very obvious and deliberate, while others may not realize that the activities that they're doing would support an academic career. How do we fill that gap? How do we also make sure that everybody is receiving some of those competencies and skills in that pathway? So we, when we ever, anytime we walk and talk to medical students, anytime we talk to even college students, we Acknowledge them as pre-faculty and everything that you're learning here can support that career. So start thinking about it in that context and think about what skills you feel like you may need to be successful and then eventually being able to be promoted. So in creating these seminars, we have created one that is specifically for those who are college and postdoc students, and this has also supported a textbook that we've written. Um, then looking at those who are already medical students and residents, we've created another set of seminars that hone in on certain additional skills that at those levels you are receiving and we can be more intentional in teaching. That also um resulted in another textbook. I was really happy without me pushing that this was a book that I found in student affairs at Harvard. I was like, oh, you guys bought this. Uh, you guys know I wrote this, right? I love it. So this was a very, uh, cool thing that it's getting out there, um, in the community. But then looking at when you are really thinking about as a medical student, as a resident, as a fellow, your leadership competencies in particular, we have a whole curriculum seminar around that. And then for when you are looking for your first appointment, um, these are other just critical transitions that, um, there are specific competencies that are not always very intentionally, um, being taught or you don't recognize it as a competency. So we have created these workshops. This is just, um, some screen captures from a couple of years ago, but these are things that if you are a part of my committee on Jimmy here, you may hear me sometimes highlight. Uh, because in many cases, these are offered free and we are, you know, doing this around the country. So then looking at, again, from a more scientific critical lens, how are we assessing that we're doing something in these interventions? Cause we recognize people have been talking about diversity forever and we don't necessarily know. Why some of those programs didn't work because they're not evaluating their work and many reasons because many of them were created in a way that doesn't make it easy to longitudinally evaluate, but, uh, we wanted to make sure that everything that we're doing, we have that opportunity to look. So looking at some of our, um, educational innovations, um, these seminars I talked about, um, we've had. A number of learners. We've had for those who are in that college post-doc trainees, we've had about 1100 learners. This is, um, we've had 23 implementations of that particular seminar around the country. This is the breakdown, but as you may notice, we are very intentional in talking to, um, To deans, talking to advisors and trying to encourage um that many of the groups that may not already be getting this information are present. So we do have an overrepresentation of those who are like African-American identified or those who are Latino um identified. Um, we also make a big point to um, make sure those who are sexual gender minorities or part of the LGBTQ community are As present as possible if they are willing to disclose. So these are, um, just some of those metrics that we've measured of who's coming to our seminars for the pre um pre-med and postdoc, looking at the med school, um, students, um, the residents, fellows, we have about 2500 learners, um, and then those who are going through our leadership, um, seminars, about almost 700 learners. But we've been very proud because again, we are very intentional and trying to recruit as many. We are very inclusive, so anyone, everyone can and should come to our workshops. We think these are competencies that work for everyone, but we do recognize that there is in some cases a perception of an unwritten curriculum that some people feel that others are just getting and they were not privy to. So we're trying to make sure we're filling that gap. And also, another thing that we noticed was, again, the concern around a competency for being able to show academic productivity. Understanding that um for those who are applying for med school into residency that a shortcoming had been seen across many demographics of being able to publish. So we've talked about how can we improve that. So we certainly bring in our learners to be a part of um the studies that we're doing. We bring them in as co-authors, so At this point, we've um have about 55 journal articles and book chapters with 261 co-authors and once again, we're very intentional in trying to make sure that it's as diverse as possible. But again, it's good for teaching these skills, but also recognizing that it's gonna be helping them to be more competitive when they're applying for not only um residency fellowships but also for that first academic appointment. We've created a National Center for Pre-faculty Development, and these are some of the institutions who have come on as National Center members. Um, but one of the offerings of this, um, National Center is our Academic Medicine Writing Fellowship. And this has allowed for people to learn specifically how to publish in medical education. We've partnered with associate editors at MedE Portal to help us to develop this specific competency because if you've ever read MedE Portal or published in it, you know, that they are very particular and quite different than. And many of the other academic journals. So we felt that this was uh one way that we can support learners who sup are interested in education but never learned how to be educators, never learned how to write about educational content as, um, you know, earlier in the pipeline. And as I mentioned at the beginning, I am the co-director of a. Kind of a spin-off of this, but the National Board of Medical Examiners were excited about this initiative, and they now also are supporting their sponsoring, um, writing, active medicine Writing fellows. Um, so that's an application that you can apply to through BEN Gap to be NBME Active Medicine Writing Fellowship, and I'm the co-director of that. Finally, As we continue to think about how can we better understand our interventions, how can we create newer interventions based on what we've learned over the last 15 years, 16 years, um, we have, um, discussed with Josiah Macy and they've, um, supported us in Um, creating a new program where we are really looking at these pre-faculty competencies that um we've developed and that we further refine through a modified Delphi, um, process to figure out what are the core pre-faculty competencies that are needed to become a leader or a successful in an academic career. And now that we've established these foundational competency domains, and then with some certain focused comp competency domains around um some of these topics that again came from educational leaders, so deans of medical schools, um. Came from chairpersons of departments. Um, we are now finding ways to make sure that each of these competencies can be assessed by our learners who become a part of our study, and we're doing that through creating a a performance dashboard, that dashboard, um, that we've established where people are entering this as they would enter new activities on their CV. But then they get banked into a particular competency that that particular activity would support. So this publication could support um one of our focus, um, competencies around, um, productivity, but it also may support, if it's something that you did where you were working with a medical student, your ability to be a good mentor. And, you know, we It's very nuanced to have someone go through it the first time. We have looked at it, it takes about 2.5 hours, so it's actually quite involved. But once it's established, it's something that as you're adding to your cert, your CV and there's one button you'll push that'll pump out your CD CV, but then another button you'll push will pump out, um, specifically around these competencies, areas where you may be still viewed as a beginner, an area where you're seen as like kinda midway through, and then the area that you are truly competent. And This is just in our, our way of trying to see how can we demonstrate that when you go through our materials, that when you go through our trainings and that when you are doing the work that you are already doing and not even realizing this is a pre-faculty competency, how can we actually evaluate it, demonstrate it, and know where your weaknesses are and where your strengths are. So these are some of the things that we're doing. We view this as an innovation. Um, this is still quite new, so we are still piloting it. Um, but You know, this is again, from my perspective, how can we take a more scientific, really regimented, um, critical approach to seeing how can we support our learners who've told us that they have obstacles, perceived obstacles, but we want to hopefully think that if we can address some of these Areas of angst of angst, some of these areas of perceived barrier that it may improve interests in staying in the game, and staying off the faculty and continuing to be a part of what we think is a solution to some of the challenges that we've identified earlier, um, but it's still ongoing work, but it's very exciting. We're very excited about, um, this potential, this idea of pre-faculty development that's intentional. That in some cases are a little bit more targeted, but we do think that this is an inclusive innovation that not only supports a diverse workforce, but also for many individuals who we feel we are failing as medical educators as well. So, this is something that, um, hopefully you'll hear more about from me. Maybe you'll be able to um see some of our publications, um, but, um, in summary, these are things that, um, Uh, I'm hoping will be of shared interest, something that I also will encourage any of your residents and fellows to, um, reach out to me, reach out to my organization to see if we, uh, you know, can be. A part of their academic journey and hopefully their success. Um, this is our board here of, um, a myriad of educators and, um, leaders in their own right that I've been so blessed to be able to work with over the last 16 years. And with that, I will stop. I think that we are almost out of time anyway, but I would love any questions. Thank you. Dennis, thanks so much for, uh, sharing your experience, uh, and your, and your vision with us, and I'd be remiss in not thanking you for the excellent partnership, uh, you provide in the care of our patients, and we look forward to the upcoming week, and we need you to treat us well too. It's a, a bidirectional deal, um, and, uh, uh, on behalf of, uh, um, the surgical anesthesia and perioperative community, really thank you for your leadership in, in the areas you talked about today, um. Uh, um, I had known all of your backgrounds. I always think it's helpful when people give a little bit of sort of their, their personal stories. So we're like where we come from, uh, uh, affects, you know, what we do and what we are. You've taken a very data-driven approach. It's clearly like this is, this is data driven, um, to solve the ongoing challenges. It's pretty discouraging to see what your surveys have demonstrated about um those who have had slightly increased opportunity but then losing um um the the the the the falling out of the pipeline and and uh. Are there, is there any data to, uh, I know it's survey data, to explain why, um, uh, from your personal experience, you described sort of the Katrina experience, like, it's not fun to be in a place where you don't feel the same or welcome. Are people expressing they're, they're just like, I don't feel welcome here and it's just not comfortable for me, so I'll go do something else, or is there, is there any data that explains why people would Uh, will walk away from a path that they, you know, um, had the opportunity for they thought might have, they fought to get, um, and, um, I walked away. Yeah, I mean, there's definitely differing thoughts among. The people that we survey. Some of it is this sense of If Agn medicine doesn't want me, why am I gonna try to muscle my way in? There's certainly that perspective of not feeling welcomed, and that's where, you know, this idea of inclusion that I feel is often kind of said in a very willy-nilly way that almost becomes, to be honest, a little annoying, cause like, what does that mean? It's like, wellness, what does that mean? But, uh, there is something to be said around if you don't feel like you belong. Why am I going to beat my head against the wall to be there? And what does belonging mean? What does it look like? And some of it is a very explicit reaching your arm out to say, we want you. This is also where, you know, recruitment and stuff matters. But then once you bring in someone, what kind of environment have you prepared them for? If you're in an environment where people are toxic, where people are being antagonistic, um, Then it's hard to do the whole retention piece. And retention is the area that I was showing for the HMS status specifically. Like, we are trying to dive deeper into our HMS affiliated hospital trainees specifically, like, why are you leaving? And I can tell you that a number of us program directors are trying to ask those questions, like exit interviews and things, but um, There is a myriad of reasons. A lot of it does still come down to Why am I trying to be at a place where I'm not wanted? And uh. I do feel like we want them. I do feel like our leadership, like we do not want that to be the perception, but how do we change that perception and what, what should we be doing, um, to make a more inclusive, welcoming environment. And that's where, again, I'm trying to follow the data, so we're doing interventions that don't make us feel good, but also are addressing their concern, but the data is ongoing. Thanks so much. This is awesome, and I appreciate that data-driven approach that you're bringing and swimming against the stream as you are right now with the environment we're in. Can I just ask about leadership? Um, uh, it's always a little confusing to me because it seems like you present the data on where we're at right now with percentages of underrepresented individuals and say gender. Um, when you talk about people that are in, say, chairmanships, though, those careers started 30, 35 years ago and developed the credentials to be a chair. So at that time, I would propose that the percentage, specifically of women would have been a lot lower than it is now, underrepresented individuals, I'm not sure about, but the current makeup is 50 or more women. And we see a progress as you presented in women in leadership positions. Let's take that example. Would it be not fairer to say, um, we would compare like and like in terms of epochs of their career, so it would be fair to say, look down the line at where leadership. Percentages are 30 years after a given time period to know whether or not progress has been made, because it's a little unfair to say they're underrepresented right now, but to look at the time frame that they would have started their career, there were very few women. Does that make sense to you? I mean, for sure, and that's a criticism that's um brought up, um, but to that. There are parity studies that will show that a woman who's been in the same position or been a faculty member for 20 years, that their likelihood of being promoted is still different than their male counterpart. So when you're doing that side by side comparison, is that an issue of bias of those who do the promoting process to where they were not even in that associate or full professor ranking to be considered for a chairperson, um, despite having been working for this amount of period. So there's It is a fair argument to say that, you know, if they were smaller and, then certainly you would not expect there to be parity all of a sudden and that you would look at where you are in your career, but there's nuances to that too that demonstrate that there's either implicit biases that impact promotion or even some of the self, um, challenges where you may not be as aggressive in promoting yourself due to maybe a lack of some of these competencies to know how to promote yourself. So like, It's a messy question, but it's a fair one that some of it is maybe slightly disingenuous, but there's still a problem there, and we need to figure out how can we address those numbers, um, despite the fact that some individuals might have had a head start. I mean, And uh, there's certain groups that are specifically really focused on women, uh, MAC, and, um, WAMC has, I'm sorry, WAMC has another group that I'm losing the name right now, but um they're they're. Annual meetings, um, go more into detail about where, um, despite the fact that now parity has been in place only for the last like 1520 years, that there's still specific needs that our institutions need to do and, um, I would encourage you to look at those or those who are also interested to look at some of those recommendations that have been made because that exact question has come up like how do you. How do you really do this comparison in a fair way, but recognizing that even with Adjusting for all the different variables, there's still things that we should be actively doing, and I just think that with time, things just get better cause unfortunately they don't, they don't. Maybe one more question. Dennis, excellent presentation. You're certainly to be uh recognized for the effort you're making in this area, particularly when our government in Washington seems to be doing everything to Bree. Prevent any progress from doing away with diversity from the college level to medical school on up and then the decimating of of postdoctoral fellowships which are the academic breeding ground if you will, for future academic physicians. I, I have one question. Um, many medical school graduates now come up, come out with a boatload of, of debt, um, and. Uh, since academic medicine is seen as a less lucrative field, if you will, than, than private practice, what, what sort of role have you found the personal finances have on people's decisions against going into academic? Absolutely, and that's an important one that comes up very frequently, as you can imagine. Um, especially for those who may come from some of the areas that really need an increased workforce, so rural areas, um, in certain demographics, especially Native American, um, there is a pressure to make money, and this is not seen as as lucrative as a field. So, we do have discussions specifically on how can you leverage um your position in academic medicine to create a fulfilling career, for sure, but one that also you can support your debt load and things of that nature. So, one, there is a lack of awareness still on some of the programs that are in place around like loan repayment. Um, or service. And some of these individuals, um, who identify their interests in community and going back to where they're from, not recognizing still that there are opportunities to go to some of those areas that are underserved and that then supporting you for loan reimbursement, um, some of that basic information is not necessarily known. And you would do that at An academic center that's in these disparate areas, which would not necessarily be the same money you'd be available for if you went to private practice. So, in certain fields, that is certainly a lack of understanding. But we have, like in the book, one of the books, uh, would talk about contract negotiation, or talk about how to consider things like consulting and other areas of additional income that no one talks about when you're in the pipeline. So you don't really know how to be savvy and think about how can I Do the great work academically, scholarly, but also find additional income, if that's of interest or need for you. So, a lot of that comes down to education. There will be those that probably should go into the most lucrative thing they can go into. We recognize that, but I think many of the group just are unaware of opportunities to make this work for them, and that's where we come in with this kind of, you know, curriculum. We're over time and, and, uh, to be able to get to the OR but we're gonna take one more question from Doctor Modi who runs our education. Dennis, thank you. Um, it's been great to see this work that you've been doing, you know, I've seen a lot of it through the GME office, office, obviously, and it's been, uh, great to see the impact already of the work you're doing and, um. I think one comment you made which is particularly poignant is that we need to specifically focus on preparing the environment as we work on this because if you have an environment that's toxic or antagonistic, it's, it ends up being a negative. Um, Two observations that I'm hoping you can maybe comment on, one, you know, it seems like efforts to fix this leaky pipeline. are sort of macro and micro. On a macro level, we have programs to try to bolster recruitment, if you will, but a lot of them seem to have a disconnect. And as an example, you might have a summer workshop where you invite underrepresented children to come learn about medicine, um, but you know, often those kids are working in the summer because their families need them to work, and there's a, there's sort of a disconnect between the efforts that are made and the ability for children to take advantage of them. To even get into the pipeline. The other is sort of micro, right? Sort of almost one on one, and that really has to do with role modeling and mentoring. Um, kids just don't see people that are like them in these roles and therefore there's no effort. There's an imposter syndrome, as you mentioned, to, to even think about going into. Medicine, let alone pediatric surgery or pediatric gastroenterology. And so I wonder if you can just comment on what efforts are being made or what kind of things we can do to improve both of those. Yeah, so certainly the issue of environment is super critical. And one of it is, to be frank, some of the things that, again, I think we may You know, speech, right, uh, roll our eyes on when we talk about, you know, wellness, or how can you be an upstander and things of that nature. It's like, We know that I'm going to take this position that people generally try to be, are good. I think that people generally don't wish to create a negative environment. Um, but we do not see our own biases, and I do think there has to be a time and a place for us to recognize this negative medicine or just in medicine and figure out how can we stop that, and that requires behavioral change that none of us think that we need to do. Um, so like, you know, the more that we pound these discussions around, you know, how do you call somebody in to let them know that, OK, that actually is not cool. And I know you meant nothing by it, but that has just now turned off this learner, and they're gonna finish this rotation, they'll never want to do this again. Um, how do we change that individual level? But then like institutionally, I do think that things that that people be seeing are important. And that includes, like, again, there's something that we're doing in GME we still need to be more intentional on is like, how do we recognize in GME Ramadan? How do we recognize that we got to break a fast and that you have learners who are on their feet all day, who are fasting, and then You know, we just act like nothing is happening, but yet we have a menorah and a Christmas tree up front. And so there are certain identities that seem to be cared for, welcomed more than others that we, again, no one is being intentional about it, but the lack of intentionality is really careless, so that we can just be better with. It doesn't require, like I said, you make a huge change, but like even just a verbal recognition or You know, we have cookies out for many other reasons. Let's do something to break fast. Like there's all these things that we can do, should do. I do think small things matter. And these are some of the things that honestly come from some of the surveys I've had with people on Exit Interviews. They just want some small gestures that we could do, but I don't think we think to do. So that's one way to invite, um, Environment, but like you said, micro and macro, there's the internal, there's institutional. I think that for most of us, we would do better if we knew better. So that's why I do think it's important for us to talk about some of these things more and for it to be said in a way that again recognizes that everybody wants to do well. Like we're, again, at children's, we're pediatricians or pediatrics and specialists. We are people who care, but we are still harming our learners in some cases. So how can we all get better because I know that we all want to get better. So, we have to think about how to do that in a way that is inviting. It's not displacing people, not making people feel shame about their own identities, but recognizing that there's room in the camp for everyone and how can we make it more welcoming. Well, thanks so much. Uh, obviously gone on for a long time. There's tons of interest, uh, in this, and, and you've, uh, generated many of us to, to think, think further and how, how we could do better. So, um, we'll, um, look to you for continued leadership and how we can help. Thank you very much.