In August of 2024, the American College of Surgeons enacted the term “Inclusive Excellence” (IE) to better define the evolution and importance of diversity, equity, and inclusion programs within our specialty. Despite evidence that structural racism contributed to inequities in the modern field of surgery and that health disparities and imbalanced access to care persist for low-resource surgical patients, misunderstanding persists regarding the core mission, values, and benefits of IE and why it is important for surgeons.1 To reduce the divide between its proponents and opponents, we are obligated to delineate and communicate the core mission and values of these programs. Surgery IE programs should aim to improve the delivery of care to marginalized patients, recruit diverse surgeons into the workforce, reduce bias in clinical decision-making, and improve organizational well-being and safety.1,2 Given the increasing obstacles to IE in the current US sociopolitical landscape, all applicable programs should strictly comply with federal and state antidiscrimination laws and regulations (such as Title VI). In 2022, we developed a structured plan for IE in our Department of Surgery,3 which yielded lessons learned about its potential impacts as we have expanded it. The mission statement for IE in our department is “To enhance the diversity of background and experience in our surgical teams, support programs and research initiatives aimed at eradicating disparities, and create an equitable environment where surgeons, staff, trainees, and patients of all backgrounds are valued and welcomed.” Surgery IE programs should apply to the wide range of communities underrepresented in surgery, not just race and gender. Others may include neurodivergent surgeons and trainees, surgeons with burnout and work-related stress, and first-generation trainees. They should also serve to identify and correct disparities in surgical care in poverty-stricken and marginalized surrounding patient communities. IE programs also help recruit and retain surgeons from diverse backgrounds and lived experiences, which can translate into improved care for the heterogeneous patient populations we are responsible for serving.3 The peer-reviewed literature supports improved outcomes with diverse surgical teams.4 A recent Annals of Surgery paper by Alverdy and colleagues5 reviewed mechanisms by which natural selection has evolved systems that are diverse, equitable, and inclusive, with the goal of cooperation, productivity, and sustainability. The impact of diversity when treating surgical patients supports this biologic theory. Worldwide, surgeons with distinct experiences and specialties work in teams to treat patients with complex diseases. Diverse teams may result in decreased decision-making bias, error reduction, increased objectivity, innovation, and enhanced resource utilization.6,7 In a recent population-based cohort study of 709,899 patients undergoing major inpatient operations, increased anesthesia–surgery team gender diversity was associated with better postoperative outcomes.8 Findings from a JAMA Surgery study analyzing data from 1,165,711 patients suggested that patients treated by female surgeons have lower rates of postoperative outcomes and lower mortality.4 Despite evidence of enhanced outcomes for operative patients, the true impact of diverse surgical teams requires further study, which can be achieved with active efforts through Surgery IE programs. We should identify and adhere to reliable metrics for IE programs, as we do for our clinical, education, and research programs. Surgeons meticulously track outcomes and adjust practice patterns and techniques to improve patient care. Determining which metrics track meaningful behavioral or outcome change for IE programs can be challenging and are still evolving. Those that hold our surgical leaders accountable for maintaining a culture and programs that support IE’s values are impactful for sustained progress.3 At our institution, our Department Chair presents our Surgery IE plan yearly at a school-wide symposium attended by departmental, health system, and university leaders.3 Formal feedback is provided by independent primary and secondary reviewers from the medical school’s Office of the Dean. A uniform rubric (5-point Likert scale) is used to score the plan and to determine the allotment of IE funding for the following year. Other examples used to measure progress in our Surgery IE programs include a “Report Card” that tracks completion of our objectives by quarter and calendar year, and quantification of long-term utilization under our expanded family leave and bonding policy for faculty and staff. National databases such as the American College of Surgeons National Surgical Quality Improvement Program and the Vascular Quality Initiative should continue to identify social determinants that affect care and persistent health disparities, helping focus our programs on patients in the greatest need of surgical care. A systems-focused approach to integrating IE principles into the overall mission and organizational culture helps these programs succeed. This involves the incorporation of IE principles into the policies, programs, practices, and procedures integral to the surgical organization. Operational resources, authority to facilitate change, and ideological and financial support from the medical school, health system, and surgery leadership can help appointed IE leaders initiate and develop programs. Financial, operational, and logistical support from institutional leadership in furthering IE programs is helpful but is highly variable based on the health system. We cannot forget the critical role that Surgery IE programs can play in tackling the overwhelming disparities present in our current system of surgical care delivery. IE programs must continue to focus on community outreach, promote socioeconomic reform, and foster pathways to attract, train, and retain surgeons capable of delivering compassionate and culturally sensitive care to diverse populations in need. An example of a newly developed IE program in our department, the Healing, Elevating, and Liberating Trauma Program, aims to provide equitable care to one of the most marginalized patient populations in our health system: trauma victims. This program aims to ensure humanistic, altruistic care for injured victims. Because there is a strong association with mental illness and accidental injury, Healing, Elevating, and Liberating Trauma addresses specific associated mental health and community needs. A psychology fellow to evaluate patients’ mental health needs has been integrated into the trauma surgery team. With the help of Surgery IE funding, the team has added 2 community health workers to assist in identifying, coordinating, and delivering outpatient community health resources to trauma victims after discharge from the hospital. Early data collected after implementation of this program suggest the estimated number of trauma victims with significant mental health issues admitted to our hospital has been previously underestimated by as much as 40%. More accurate estimation of preexisting mental health and substance abuse after hospital discharge will help connect patients with appropriate community health resources after release from the hospital. Other outcome metrics, such as tracking of hospital readmissions for discharged trauma patients, may be used to validate and improve this important IE program’s efficacy. Surgical specialties continue to demonstrate significant disparities in cultural background and gender for both trainees and practicing surgeons. Given the rapidly evolving age, cultural, gender, and socioeconomic demographics of the US patient population, Surgery IE programs are needed to deliver more focused and culturally competent care. Evidence demonstrates that traditionally underrepresented physicians have an essential role in caring for patients of similar backgrounds. A landmark New England Journal of Medicine study by Komaromy and colleagues9 analyzed data on physicians’ practice locations, racial and ethnic makeup, and the characteristics of patients they served. Communities with high proportions of Black and Hispanic residents were 4 times more likely to have a shortage of physicians. Black physicians practiced in regions where the Black population was nearly 5 times as high, and Hispanic physicians served in communities where the Hispanic population was twice as high as in the other areas analyzed.9 A recent Journal of Vascular Surgery study associated sociodemographic factors with major limb amputation in patients with peripheral arterial disease.10 Blacks and Native Americans demonstrated significantly higher rates of lower-extremity amputation compared with Whites. Hispanics had higher rates of amputation compared with non-Hispanics. The need for improved delivery of surgical care to these marginalized communities is clear. As leaders, surgeons must incorporate the principles of IE to drive impactful change that enhances equity of care for those in greatest need. IE remains a moral and clinical imperative for surgeons.
Jimenez et al. (Wed,) studied this question.