Equity: The Importance of Promoting a Diverse Anesthesiologist Workforce

Despite advancements in medical science and the American health care system, significant disparities in health care outcomes persist, especially among marginalized racial, ethnic, and gender groups (Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care. 2020; ASA Monitor 2021;85:45-8; J Womens Health 2021;30:230-5; Dermatol Clin 2020;38:185-90). These disparities are largely attributable to systemic, upstream factors that include structural racism and social determinants of health (J Law Med Ethics 2020;48:518-26). However, even when controlling for sociodemographic characteristics like education and income level, insurance status, and clinical factors such as comorbidities and illness severity, minoritized groups still demonstrate worse outcomes (Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care. 2020). Promoting a health care workforce that mirrors the diversity of the population it serves is an effective strategy for addressing existing health equity gaps (Public Health Rep 2014;129:57-61; Int Anesthesiol Clin 2021;59:81-5). Research has supported this concept, as studies indicate patients generally fare better when cared for by more diverse teams; patients received more accurate diagnoses, reported higher satisfaction, and exhibited greater compliance (J Natl Med Assoc 2019;111:383-92). Increasing the proportion of underrepresented minoritized groups in the health care workforce also increases the frequency of doctor-patient race- or gender-concordant care, which itself has been shown to be of benefit (asamonitor.pub/46Aj2To; J Health Soc Behav 2002;43:296-306). For instance, studies have shown Black patient-physician pairs tend to develop enhanced communication and trust, leading to higher levels of preventive screening, vaccinations, and invasive testing, as well as substantial reductions in Black-White male cardiovascular mortality gap, Black infant mortality rates, and an increase in life expectancy (American Economic Review 2019;109:4071-111; Proc Natl Acad Sci U S A 2020;117:21194-200). Beyond enhancing health care outcomes, the diversification of the workforce offers economic advantages, as reducing health disparities among marginalized communities could save billions in indirect and direct medical costs annually (ASA Monitor 2021;85:45-8; Int Anesthesiol Clin 2021;59:81-5). Promoting diversity at the medical student level can also increase access to care, since students underrepresented in medicine (URiM) are more likely to commit to practicing in underserved communities in the long term, and Caucasian medical students who trained in the most diverse settings report feeling better prepared to treat minoritized populations (JAMA 2008;300:1135-45).

The growing diversity within the U.S. population, as evidenced by 2021 census data, highlights a pressing need for a more representative health care workforce. In comparison to the U.S. Census, the 2021 Association of American Medical Colleges (AAMC) physician workforce data paints a less diverse picture for the medical profession: only 37.1% of physicians are female and 36.1% identify within minoritized groups (Anesth Analg 2023;137:800-2). More specifically, 63.9% of the active physician workforce is Caucasian, 5.7% Black, 6.9% Latinx, 20.6% Asians, 0.3% American Indian/Alaskan Native, 0.1% Native Hawaiian/Pacific Islander, and 1.3% multiracial (Anesth Analg 2023;137:800-2; asamonitor.pub/3Fat9T5). This inequity extends to medical subspecialties, notably in anesthesiology, where just 26.1% are female and 31.3% are from minoritized groups (asamonitor.pub/48OiBGT; asamonitor.pub/3tnUVZL). While estimates suggest that sexual and gender minority individuals make up about 7.1% of the general U.S. population and approximately 21% of Generation Z identifies as LGBTQ+, data on sexual and gender minority representation within health care remains notably absent (asamonitor.pub/3Q8E9Xo).

A detailed analysis of each stage in the anesthesia training pipeline reveals critical disparities in representation for both gender and ethnic minoritized groups, as highlighted in the Figure. According to 2021 AAMC data, women comprise 52.7% of all U.S. medical students, yet only 33.9% of female medical school applicants opt for pursuing a career in anesthesiology (asamonitor.pub/45oDC8b). As female anesthesiologists progress in academic medicine careers, they become less likely to be promoted to senior roles, including Associate Professor and Professor rankings, compared to their male colleagues (Table 1) (asamonitor.pub/3Fat9T5; asamonitor.pub/3LVcLdc). Furthermore, female anesthesiologists continue to face systemic barriers to promotion, occupying fewer senior roles, department chairs, and editorial board positions compared to their male counterparts (Int Anesthesiol Clin 2021;59:81-5). Similarly, an examination of racial and ethnic diversity within the anesthesia pipeline exposes significant gaps (Table 2), where Black and Latinx candidates are notably underrepresented (asamonitor.pub/3Fat9T5; asamonitor.pub/3LVcLdc). This lack of diversity begins at the medical school application stage and continues throughout the training pipeline (asamonitor.pub/45oDC8b). Interestingly, URiM representation sees a relative uptick at the anesthesia applicant stage compared to White applicants. Nonetheless, the ensuing matriculating resident populations continue to be disproportionately White and Asian, suggesting additional barriers for URiM individuals in achieving equitable representation (asamonitor.pub/3LVcLdc). Lastly, among anesthesiology faculty, White individuals continue to gain increased representation at each progressive level of academic rank, whereas URiM representation diminishes (asamonitor.pub/3ZNZys2). This pattern of inequity has been a well-documented issue in academic medicine that has spanned across decades, underscoring the urgent need for effective interventions to rectify these disparities (J Surg Res 2013;182:212-8; JAMA 2000;284:1085-92).

Prior studies have consistently shown that the USMLE Step 1 score is a critical determinant in securing residency interviews, with most programs stipulating specific cutoff scores for eligibility. It is noteworthy that non-White male examinees tend to score significantly lower than their White male counterparts, which can be a reflection on the inequitable distribution of educational resources (asamonitor.pub/3rUn8H7; J Educ Perioper Med 2020;22:E646; Anesth Analg 2011;112:201-6; J Grad Med Educ 2013;5:276-83; Acad Med 2019;94:364-70). With the AAMC’s transition of the USMLE Step 1 exam to pass/fail in 2021, the subsequent impact on the representation of women and minoritized groups among selected anesthesia residents remains undetermined. Once matriculated into residency programs, however, Black and Latinx physicians encounter markedly elevated dismissal rates in comparison to their Caucasian and Asian peers (Curr Opin Anaesthesiol 2022;35:208-14). Concurrently, a survey conducted by Kraus et al. indicated that proactive recruitment and encouragement for female applicants in anesthesiology are deficient. Around 10% of surveyed female anesthesiologists would dissuade women from pursuing a career in this field due to challenges associated with motherhood (Curr Opin Anaesthesiol 2022;35:208-14). Presently, female anesthesiologists, like women in all specialties, generally earn less than male colleagues with comparable rank and experience. The impediments to the academic advancement of female anesthesiologists are multifaceted, encompassing issues related to childbearing and domestic responsibilities, the recognition of systemic hurdles, implicit biases, harassment, and a dearth of mentorship (Int Anesthesiol Clin 2021;59:81-5; Curr Opin Anaesthesiol 2022;35:208-14; Womens Health Rep 2022;3:414-9).

To foster greater diversity within the health care workforce, and specifically in the domain of anesthesiology, targeted initiatives aimed at recruitment and purposeful inclusivity are essential. One efficacious strategy is the creation of pathway programs designed to elevate the number of well-qualified URiM candidates who are motivated to join health care professions. Research indicates that over 70% of URiM students who participated in these pathway programs either matriculated into MD/PhD/master’s health programs or were on course to do so, with nearly three-quarters of these pipeline participants hailing from minoritized backgrounds (Health Equity 2021;5:512-20). Another proven approach to enhance representation is utilizing sponsored away rotations for underrepresented minoritized groups (Mayo Clin Proc 2010;85:723-7; Plast Reconstr Surg 2021;147:1229-33). Additionally, revising the applicant evaluation process by placing greater emphasis on Gestalt assessments, which consider clinical decision-making and offer a more holistic review, could also be beneficial, as opposed to relying solely on standardized tests (asamonitor.pub/3Fat9T5). For example, the Highland Diversification Initiative in Oakland, California, incorporated various elements such as the exclusion of USMLE scores, increased weighting of Gestalt scores, a diversified selection committee, greater resident engagement, and a designated diversity applicant week. Over a decade, this initiative led to a twofold increase in Black or African American and Latinx applicants, along with a nearly fourfold surge in Middle Eastern residents (Ann Emerg Med 2019;73:639-47).

Upon successfully recruiting underrepresented physicians into the field of anesthesiology, the focus must pivot to ensuring their retention and career advancement. Data from surveys administered to anesthesiology applicants and residents reveal that racial and ethnic minoritized groups, as well as women, disproportionately encounter discrimination and microaggressions in comparison to their nonminority male counterparts (Womens Health Rep 2022;3:414-9; N Engl J Med 2023;389:1258-61). These adverse experiences can lead to diminished job satisfaction and elevated staff turnover rates. To combat this, organizations should cultivate an environment that emphasizes interpersonal inclusion. This could be complemented by comprehensive education in diversity, equity, and inclusion (DEI), training in unconscious bias, and education on the social determinants of health. For female anesthesiologists, specifically, retention can be bolstered by implementing equal pay initiatives and adjusting tenure timelines to accommodate work-life balance (Int Anesthesiol Clin 2021;59:81-5). Other allyship actions include mentorship and sponsorship. These allyship actions have consistently been identified as vital elements in the retention and advancement of underrepresented and female physicians, particularly within the realm of academic medicine (BMC Med Educ 2014;14:26; Acad Med 2019;94:94-100). Mentorship provides a sustained relationship in which mentees gain professional guidance, skill development, and expanded networking opportunities (BMC Med Educ 2014;14:26; Acad Med 2019;94:94-100). Research has demonstrated the value mentees place on having mentors with demographic similarities, as this often implies a shared history and greater personal understanding. Additionally, the scarcity of diverse faculty presents an obstacle for residents in finding concordant mentors, thus highlighting the need for effective nonconcordant mentorship (BMC Med Educ 2014;14:26). However, mentorship alone may not be sufficient to adequately encourage URiM and female faculty to stay in academic medicine. The quality of long-term mentorship must also be high to exert a meaningful influence on academic progression, as evidenced by a qualitative study conducted at Johns Hopkins School of Medicine (BMC Med Educ 2018;18:108). Physicians with high-quality mentors experienced fewer obstacles in academic promotion, higher job satisfaction, and were more inclined to serve as mentors themselves (BMC Med Educ 2018;18:108). Moreover, the concept of sponsorship, wherein an influential individual provides high-visibility, career-enhancing opportunities to a protégé, is emerging as equally important to mentorship in facilitating career advancement (Acad Med 2019;94:94-100).

Enhancing diversity in the field of anesthesiology is imperative for achieving equitable health outcomes across all societal sectors. A diverse workforce enables the provision of race- and gender-concordant care, is preferred by patients, facilitates increased health care accessibility, and enhances the competency of physicians serving marginalized communities. While progress has been made in the representation of women, for those who are traditionally URiM and sexual and gender minorities, there remains considerable room for improvement across all levels of the academic and professional pipeline. As pointed out earlier, strategies for advancing workforce diversification include robust recruitment efforts via pipeline programs and reimagining the medical school admissions process to be more inclusive. Once recruited into the medical profession, their retention and advancement hinge on fostering inclusive work environments.

In summary, a multifaceted approach entailing initiatives to mitigate discrimination – as well as involving robust, long-term mentorship and targeted sponsorship – is essential to redress the disparities in career advancement opportunities for women and racial and ethnic minoritized groups.