“There’s something much bigger than the business case for diversity, equity, inclusion, and belonging work. It’s the human case. How good do we want to be with and for each other?”

– Aiko Bethea

The importance of diversity in health care has long been recognized (Public Health Rep 2014;129:57-61; Anesth Analg 2020;131:1201-09; J Cardiothorac Vasc Anesth 2021;35:3148-9; Cardiothorac Vasc Anesth 2022;36:66-75; Curr Opin Anaesthesiol 2022;35:208-14). In 2020, following the murder of George Floyd, the world and the health care field had a re-awakening to this topic, and many institutions and specialties are now prioritizing diversity, equity, and inclusion (DEI) frameworks along with justice, belonging, and other related concepts (N Engl J Med 2020;383:199-201; Adv Exp Med Biol 2021;1334:39-53; J Gen Intern Med 2021;36:200-2). Beyond racial/ethnic representation, it is also clear that a variety of identities, particularly those that have been historically marginalized and/or excluded from medicine, make for a stronger, more effective team. Within the health care realm, the benefits of a diverse workforce is well-documented (Anesth Analg 2022;134:1166-74). Not only are patient care/outcomes improved and health disparities reduced (as noted by Betancourt, et al.) when the care team reflects patients’ identities and lived experiences, it also contributes to more effective health care teams, reduces burnout and turnover among staff, increases job satisfaction, and even improves profitability, as noted in a review by Nwokolo and associates (Mt Sinai J Med 2004;71:314-21; Anesth Analg 2022;134:1166-74).

As the lead physicians in perioperative care, anesthesiologists are responsible for quickly garnering information about an array of medical problems. Anesthesiologists are required to have a breadth and depth of knowledge of different medical and surgical diseases as well as elements specific to the specialty. Similarly, anesthesiologists provide care for individuals of different ethnic, phenotypic, and genetic backgrounds, necessitating skills, flexibility, and awareness to provide care equally for diverse patients. There are reports of racial differences in the assessment and treatment of pain by anesthesiologists as well as inadequate pain control in certain vulnerable populations (J Natl Med Assoc 2021;113:541-5; Sex Reprod Healthc 2014;5:188-94). To provide excellent anesthesia care, anesthesiologists also need to be aware of well-known pharmacogenetic differences that require attention (Pharmacogenomics 2018;19:285-98). Variability of anesthesia needs in diverse patients comes from multiple factors (environmental, genetic, metabolic, drug efficacy) (Front Med 2022;9:809393). Appreciating these differences and soliciting them from patients’ previous experiences requires the ability to overcome some of our implicit biases that may be innately present in our interactions with patients and the perioperative care team. Anesthesiologists must be able to care for and interact with vulnerable populations without the influence of bias (Int Anesthesiol Clin 2021;59:81-5). Thus, attention to diversity is important to ensure both empathy and meaningful communication (Curr Opin Anaesthesiol 2022;35:208-14).

We will now focus on areas related to the individual level (representation, recruitment/retention), systems level (e.g., workplace climate/environment), and patient care.

At the individual level, we need to evaluate and inquire about whose voices are “at the table” and whose are missing. Individually, anesthesiologists can be at the forefront of expanding the STEM workforce and numbers of talented diverse people who can join the specialty. Recruitment and retention must start at the earliest stages. Opportunity gaps across racial and socioeconomic lines exist starting in the early childhood years (asamonitor.pub/3FmeAvq). Lack of professional representation means that children and young people don’t see themselves in health care positions, particularly as clinicians. This may be especially true in anesthesiology, since most children’s interactions with doctors are in pediatrics, not anesthesia. Pathway programs that begin in middle and high school can address these gaps by providing knowledge about the different professions within medicine and encourage relevant STEM skills development. Partnering and engaging with groups who recruit from high school and undergraduate levels can expand the pool of future trainees and improve professional satisfaction (J Clin Anesth 2021;70:10192). In one instance of outreach, in the personal experience of one author, a group of high school students borrowed an old ether mask and an anesthesia machine to review the way anesthesia can be safely administered when comparing it to the first use of ether with an open mask. These interactive “show and tell” sessions expose younger generations to the principles of medical care.

Once individuals are in the workforce, we need to focus on retention. This requires evaluation of our environments and systems. Do they function to support individuals as their authentic selves? Do we and they feel like they belong? Belongingness is a human drive to form and maintain lasting, positive, and significant interpersonal relationships. It has been shown to be a critical component of the workplace climate. It includes the individual’s ability to be comfortable with bringing their authentic selves to work. If employees feel they are part of a team that sees and appreciates each other for who they are, they are more likely to feel comfortable sharing their authentic identities at work. Downstream, belongingness has also been shown to relate to lower turnover and improved performance and productivity. So, if belongingness falters, recruitment and retention, particularly of those from diverse backgrounds, may also be negatively impacted.

As recruitment and retention efforts expand, departments are likely to be faced with new perspectives that conflict with the “usual ways” of doing things. Systems must adapt to be more inclusive and reflect not only the population they serve but also the employees that comprise them. Affinity groups composed of individuals with shared identities and interests (e.g., Black, Indigenous, People of Color [BIPOC], LGBTQ groups, etc.), can be helpful to newer and seasoned employees alike in processing their experiences in the workplace. This support can help with transition stress, conflict, and microaggression management.

Finally, mentorship is a critical retention component. As individuals are mentored throughout their career, leadership opportunities will arise. Care must be taken to avoid what many professionals experience as the “minority tax” (originally known as “cultural taxation”), in which those who are most affected by inequities may also be asked to solve them, and thus burdened by extra emotional or practical labor (BMC Med Educ 2015;15:6; Educ Res 1994;23:24-7).

Anesthesiologists, like most physicians, often work within a larger hospital system. Active leadership at the systems-level (e.g., department, university, hospital-wide efforts) is warranted. Piloting and implementing initiatives that create a supportive, inclusive climate are central to creating a thriving, diverse workplace.

While some may feel that work-life balance in anesthesiology may be more positive than other specialties, the COVID-19 pandemic and sequelae challenged most of us. Consider the heterogeneity of impact across your teams. For instance, do those who also have caregiving responsibilities feel the same way? Are BIPOC, LGBTQ, or other minoritized anesthesiologists having the same experiences as their majority counterparts?

COVID-19 created some of the most emotionally and practically challenging experiences of many physicians’ careers. Many delayed or never processed those experiences at all because of the immediacy of need for providers and urgency of action. So, learning from this, how will we put support systems in place during traumatic circumstances or difficult cases? The University of Minnesota Department of Anesthesiology established a buddy system like that in place for our country’s defense teams. One of the department members collaborated with the Department of Psychiatry and Behavioral Sciences to establish and then publicize the model in a widely read anesthesia journal that received thousands of reprint requests (Anesth Analg 2020;131:43-54). While these supports were developed in the face of (and focused on) the impacts of the COVID-19 pandemic, they represent a model that can be applied more broadly across other critical and challenging experiences, and in other departments and fields as well.

When faced with staffing shortages across the board, increased tensions may develop. Supporting caregivers during their stressful experiences is important. Belongingness is most effective when interactions are frequent, pleasant, and take place in a stable and enduring framework of concern for one another’s well-being (Psychol Bull 1995;117:497-529). Therefore, belongingness can become a challenge when a team is less cohesive. While conflict can certainly be a barrier to cohesiveness, less egregious factors such as hybrid and remote work, working across multiple sites, and an increase in the ubiquity of locum tenens providers can also interfere with a team’s belongingness.

We can also expand the construct of what “healthy” looks and feels like by:

  • Building increased flexibility into the role (i.e., balance the benefits locum tenens positions offer)
  • Facilitating opportunities to expand positive communication skills and create a shared language
  • Building a work environment in which good intention is assumed, mistakes are acknowledged with compassion rather than judgment, and performance is positively acknowledged.

All these efforts will support a positive climate in the workplace.

While the specialty of anesthesiology is unique, it is still possible to build strong bonds with patients despite the sometimes limited interaction available for anesthesiologists. This brief pre-anesthesia meeting is usually intense but extremely important and necessary for sharing information. It’s the time where one can demonstrate caring by paying detailed attention to individual medical and social issues. A personalized and safe care plan addressing all concerns will then need to be agreed upon.

In conclusion, for best practices in health care and in research, efforts toward increasing diversity and ultimately ending racism are critical, as emphasized recently by Nobles et al. (Nature 2022;606:225-7). Diversity and inclusion efforts across our trainees, physicians, and all members of the health care team are important for maintaining unity. Within our own health system, we promote the code of working in partnership and without bias. We strongly feel this is the wave of the future, and we can only make the future happen if we practice this fully in the present.