Figure 1: Series of events associated with the DEI component of a preoperative clinic rotation.

Figure 1: Series of events associated with the DEI component of a preoperative clinic rotation.

Anesthesiology is faced with disparities between patient populations across the spectrum of surgical services, including orthopedics, cardiothoracic, and obstetrics, that plague the United States health care system (Global Spine J June 2023; Lancet 2023;402:1065-82; Ann Surg 2020;272:668; JSES Int 2022;7:44-9; Anesthesiology 2023;139:244-8; ASA Monitor 2020;84:49-50). These disparities result in significant differences in health outcomes, including diminished life expectancy, most notable among Black and American Indian or Alaskan Native populations (Lancet 2023;402:1065-82). A recent actuarial analysis found health care inequity accounts for $320 billion in annual U.S. health care expenditures, which is expected to balloon to at least $1 trillion if not addressed by 2040 ( To transform the future of American health care, anesthesiologists-in-training will need to participate in understanding and addressing these disparities.

Resident physicians within accredited anesthesiology training programs are now required to become versed in recognizing disparities and contributing to solutions with recently updated training milestones and competency domains (;; Anesth Analg 2021;133:353-61). This large, multiyear responsibility for residents and residency program leadership requires significant faculty and institutional support (Gen Intern Med 2021;36:2539-46). Fortunately, many avenues exist to accomplish these tasks, beginning with supportive recruitment of diverse future anesthesiologists and continuing with sustainable efforts to advance the field. One avenue that this article will highlight is utilizing the preoperative clinic to facilitate resident-led advancement of diversity, equity, and inclusion (DEI) within anesthesiology and beyond.

The Accreditation Council for Graduate Medical Education (ACGME) lists six domains defined as competencies that are required curriculum features for crafting trusted and autonomous anesthesiologists: professionalism, patient care and procedures, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, and systems-based practice. Within five of the six domains, the ACGME specifically incorporates components of DEI.

The ACGME’s professional domain requires residents to: demonstrate competence in cultural humility, respect and respond to diverse patient populations, and be accountable to patients and society. Alongside case category minimums, such as providing care to at least 100 patients under the age of 12 years old, the patient care domain requires resident competency in providing care that is equitable and effective in disease treatment and health promotion.

The domains of practice-based learning and improvement and interpersonal and communication skills are more explicit in their expectations of residents’ involvement with DEI. As a part of practice-based learning and improvement, the ACGME requires residents to reflect on their strengths and weaknesses in the same way they require residents to analyze and improve health care disparities with concrete changes. Interpersonal communication skills are required for effective and efficient communication with patients and their families during some of the darkest times they face, including interfacing across America’s broad socioeconomic levels, cultural backgrounds, and languages.

One of the most unambiguous requirements for DEI from the ACGME lives within the systems-based practice domain. Residents are required to understand the complex ecosystem within which patients receive care, including the structural and social determinants of health. The ACGME goes a step further and requires residents to know how to navigate these determinants to provide patients with the highest quality of care.

The preoperative clinic at our institution has a robust educational structure, supported by dedicated faculty, nurse practitioners, physician assistants, and nursing staff. The preoperative clinic affords residents the ability to better understand and prepare patients for their perioperative journey. In addition, patients also have the opportunity to provide feedback in relation to the patient-reported competence in the ACGME’s domains.

Residents begin rotating through the preoperative clinic as early as postgraduate year one, or clinical base year. This rotation allows residents to become familiar with preanesthesia assessment, venous access for phlebotomy, and perioperative counseling. The rotation also features a resident presentation on a DEI topic of the resident’s choice, often inspired by patient interactions. Previous topics have covered disparities present in pain management, LGBT health care, patients with dementia, and patients who are incarcerated. One resident reflected on a patient who was deaf and compiled resources for the clinic to better care for our diverse patient population. This work was accepted as a poster presentation and stimulated discussion with an international audience of anesthesiologists. Another patient encounter led to a discussion on how to ensure voting access during a hospitalization, resulting in a deployment of voting access and registration resources within the clinic.

From a resident perspective, these DEI projects are introduced during new anesthesia resident orientation. Once residents start preoperative clinic rotations, their projects stem from genuine patient experiences. As a result of these impactful encounters, residents are motivated to produce a thorough investigation and presentation on a specific DEI topic. These presentations finish with future project ideas that the preoperative faculty and clinic leaders embrace. While the incorporation of these DEI presentations is relatively new to the rotation, tangible changes have already been made, with more to come. As residents move from the preoperative clinic to other rotations, the didactic curriculum supports them with advanced DEI lectures to reflect on their projects and discuss DEI needs and efforts at a higher level. This chain of events helps residents not only meet the specific ACGME requirements but also the need to serve our entire patient community.

Figure 2: Featured DEI presentation topics produced during a preoperative clinic rotation.

Figure 2: Featured DEI presentation topics produced during a preoperative clinic rotation.

The need for DEI within anesthesiology and perioperative medicine is high. While this need must be met with a multifaceted solution, preoperative clinic rotations can help expand the horizons of how anesthesiology embraces DEI through resident-led initiatives. Innovative modifications to these rotations can help residents see first-hand why DEI is necessary, create solutions, and raise the standards of the specialty to best serve all patients.