Proceedings From the Advances in Surgery Channel Diversity, Equity, and Inclusion Series: Lessons Learned From Asian Academic Surgeons

Abstract

In this series of talks and the accompanying panel session, leaders from the Society of Asian Academic Surgeons discuss issues faced by Asian Americans and the importance of the role of mentors and allyship in professional development in the advancement of Asian Americans in leadership roles. Barriers, including the model minority myth, are addressed. The heterogeneity of the Asian American population and disparities in healthcare and in research, specifically as relates to Asian Americans, also are examined.

Introduction

Steven Wexner, MD, PhD, FACS and Tracy S. Wang, MD, MPH, FACS

Dr S. Wexner: Welcome to this episode of the Advances in Surgery Program, our third in a series of very important awareness initiatives on diversity, equity, and inclusion. We started with two programs involving many of the American College of Surgeons (ACS) leaders and today I am very pleased to be able to introduce Dr Tracy Wang who, along with her colleagues in the Society of Asian Academic Surgeons (SAAS), is going to be discussing lessons learned from Asian academic surgeons. We do have many more programs planned in this series with ACS leaders, leaders from the Association of Women Surgeons, Society of Black Academic Surgeons, and the Latino Surgical Society, and CEOs from some of the leading institutions and corporations. But without further ado, I would like to turn over to Dr Wang who can chat with us a few minutes about both the SAAS and today's extraordinary program.

Dr T. Wang: Thank you Dr Wexner. I would like to thank, on behalf of SAAS, Dr Wexner for the invitation and the Advances in Surgery (AIS) channel for putting this event together. We are certainly pleased to be able to be a part of the Diversity and Inclusion series.

For those of you who are not familiar, SAAS was founded a decade ago at a time when there was a relative lack of leadership positions filled by Asian surgeons in American surgery and American academic surgery, despite having good representation at the level of medical students, surgery residents, and surgical faculty. The society was founded to provide a networking forum and also to begin to provide opportunities, both with scholarships and professional development courses that we have sponsored in our annual meetings to give surgeons the skillset they needed to progress as leaders in surgery. Over the past 10 years, we really strove to do that both within our society and as allies to other societies such as the Association of Women Surgeons, Society of Black Academic Surgeons, and the Latino Surgical Society. So we are really pleased today to be able to talk about some of the issues specific to Asian surgeons, Asian academic surgeons in the United States, and across the world but also some broader points that I think are applicable to all surgeons, irrespective of how they identify.

I would like to introduce our speakers. I will first be speaking on implicit bias and the model minority myth. This will be followed by a joint talk on mentorship and sponsorship, from residency to retirement, by Dr Anai Kothari, who is an Assistant Professor at the Medical College of Wisconsin and the SAAS Associate Councilor, and Dr Jennifer Tseng, who is a Professor of Surgery and Chair of the Department of Surgery at Boston University School of Medicine and the Past President of SAAS.

This will be followed by a talk on allyship and advocacy by affinity societies by Dr Kasper Wang, who is a Professor of Surgery at Children's Hospital Los Angeles and one of the SAAS councilors, and Dr Susan Tsai, a Professor of Surgery at the Medical College of Wisconsin and our current representative to the Association of Women Surgeons. The next two talks will discuss healthcare disparities among Asian Americans, by Dr Lillian Kao, a Professor and Chief of Acute Care Surgery at the University of Texas and one of the SAAS founders, and Dr Ankush Gosain, who will discuss racial disparities in research. Dr Gosain is a Professor of Surgery at the University of Tennessee Health Sciences Center in Memphis and the SAAS Recorder.

Finally, Dr Quan-Yang Duh, who is the first Vice-President-elect to the ACS will be discussing developing diversity in national and international surgical leadership. This will all be followed by a panel session by all faculties that will be moderated by the SAAS Secretary, Dr Eugene Kim and the President-elect, Dr Allan Tsung. Dr Kim is currently a Professor of Surgery and Pediatrics at Children's Hospital Los Angeles and Dr Tsung is a Professor of Surgery and the Chief of Surgical Oncology at The Ohio State Medical Center.

We hope that all of you will find the next hour and a half or so both stimulating and informative, and we are open to having discussions both during the session and offline about any of the topics discussed today.

Dr S. Wexner: Thanks again, Tracy. Looking forward to an incredibly exciting, informative educational program. I appreciate your efforts and the efforts of all of your colleagues who are putting on the program today.

Tracy S. Wang, MD, MPH, FACS

Good morning, I would like to thank the AIS channel and Dr Wexner for inviting us to speak this morning. On behalf of SAAS, I would like to thank the AIS channel for the opportunity to discuss implicit bias and the model minority myth and why it is a harmful construct for Asian Americans.

Implicit bias is the automatic or involuntary attitude that we have about the members of distinct social groups who unconsciously affect our beliefs and actions. It may lead to our own actions that are not in line with our explicitly stated values, and it is important to know that everybody has implicit biases. We tend to favor our own groups because implicit biases are formed over a lifetime of exposures and our own lived experiences. It is important to note that implicit biases are changeable, although this does require time and the intention to change. A model for this is the “ACTION method”, which includes the following steps: (1) Ask clarifying questions, (2) Carefully listen, (3) Tell others what you observe the problem to be, (4) consider the Impact for yourself and for others, (5) Own your response and your implicit biases, and (6) consider Next steps.

One method of assessing our own implicit biases is through implicit association tests (IAT). Project Implicit is a nonprofit organization that has a goal of educating individuals about hidden biases and to provide a virtual laboratory for collecting data. IATs measure the strength of associations between concepts and evaluations or stereotypes. On the Project Implicit website (https://implicit.harvard.edu/implicit/index.jsp), there are IATs that explore implicit associations for social attitudes (e.g., race, gender, sexual orientation, and religion) and health (e.g., exercise, anxiety, and alcohol). What does the IAT look like? As an example, I took the Asian American IAT; the IAT introduces pictures of White and Asian American faces and then images that are either American or foreign. They then flash photos and using your keyboard, you respond to whether you think the photo is foreign or American, White, or Asian American and your reaction time is measured to assess your implicit associations.

Why do implicit bias testing and why does it matter in healthcare? In a 2019 study, Salles et al. looked at both implicit and explicit gender biases in healthcare professionals and surgeons specifically.¹ They explored bias using the Project Implicit gender-career IAT and a novel gender-specialty IAT, using 1,000,000 records from Project Implicit and 131 surgeons. Healthcare professionals were found to hold both implicit and explicit biases that associated men with career and women with family, and similarly, surgeons implicitly and explicitly associated men with surgery and women with family medicine. Also, the authors found that women were less likely than men to have explicit biases associating men with career and surgery.

I am going to pivot to talk about Asian Americans and while I will focus on data in the United States, I think that the Asian experience in other non-Asian countries is probably largely similar. In the United States right now there are nearly 20 million Asian Americans, about 6% of the population, and Asian Americans are projected to be the largest immigrant group over the next several decades. The history of Asian Americans in the United States largely began with Asian immigration in the mid-1800s; immigrants were primarily male and laborers, many of whom built the transcontinental railroad. But during this same time period and over the next century, Asian immigrants faced multiple exclusionary laws and frankly racist policies, such as the Chinese Exclusion Act of 1882, the Immigration Act of 1917, the National Origins Act of 1924, the Japanese internment camps during World War II, and exclusion from the 1920 passage of the 19th amendment, which excluded women of color from voting rights.

Much of this changed with the Immigration and Nationality Act of 1965, which allowed the immigration of highly skilled and educated Asian immigrants, and this led to the idea of a ‘model minority myth’. This coincided with a time when there was a response by some Asian Americans to seek to assimilate into ‘American culture’ by being recognized for their family values and patriotism. The term ‘model minority’ was coined by an American sociologist in the mid-1960s who praised Japanese Americans for their assimilation and perceived successes and directly contrasted them to African Americans, thereby pitting minority groups against each other.

What is the model minority myth? It is a concept that characterizes Asian Americans as polite, law-abiding, usually apolitical, and as people who have achieved a higher level of success through an “Asian immigrant work ethic” and the perception of an inherent difference from other minorities. This is wrong and harmful because it views Asian Americans as a monolithic group, which we certainly are not. It also perpetuates the perception of foreignness of Asian Americans by assuming that there is some different work ethic that Asian immigrants have and implies that other minorities are different or ‘less than’ Asian Americans, and then uses that as a rationale for others' perceived lack of success rather than addressing institutional and structural inequalities and inequities. This leads to the stereotypes and implicit biases that we all hold, and that the model minority myth certainly plays into, and to the microaggressions and macroaggressions, and the perceived ongoing slights and racism that we are seeing today. And we have seen a lot of this in the past 18 months with anti-Asian racism events that have arisen because of coronavirus disease 2019 (COVID-19); again, not just in the United States but also in Canada, the United Kingdom, and New Zealand, just to name a few places in the world where there really has been a sustained increase in discrimination.

I think that it is this combination of a continued perceived otherness of Asian Americans and the model minority myth that has led to a lot of these anti-Asian hate incidents and why it is so important that we address it. In conclusion, I want to say again that we all have implicit biases. The challenge is to ask ourselves how this affects how we perceive others as leaders, as colleagues, and for our patients ultimately, and that is why it is so important in healthcare. As you hear the remaining speakers today and the panel session, I would like you to think about what your own implicit biases are, how this might inform the topics that the other speakers are going to speak about, and about the ACTION method and how you can apply this in your daily life, both personal and professional. So again, I would like to thank the AIS channel for hosting this session today and I look forward to the conversation. Thank you.

Anai Kothari, MD and Jennifer Tseng, MD, FACS

Dr J. Tseng: Hello, my name is Jennifer Tseng and I am the James Utley Professor and Chair of the Department of Surgery at Boston Medical Center in Boston University School of Medicine.

Dr A. Kothari: Hi, my name is Anai Kothari. I am actually in the midst of a transition. I just completed my fellowship at MD Anderson in Complex General Surgical Oncology and was previously at Loyola University Medical Center for General Surgery residency. I will be joining the faculty at the Medical College of Wisconsin in the Division of Surgical Oncology.

Dr J. Tseng: Great, so we are card-carrying members of SAAS and we are charged with discussing mentorship and sponsorship for this important course.

Dr A. Kothari: Instead of doing a typical PowerPoint presentation, we decided to engage in a discussion and have a conversation about mentorship and sponsorship. So, I get to ask the first question which is, throughout your career, as you have progressed, how important has mentorship and sponsorship been to you?

Dr J. Tseng: Sponsorship and mentorship have been incredibly important throughout my career, since before I actually understood what the words of mentorship and sponsorship have meant. I speak as somebody who may not have always pictured themselves as a surgeon, or thought they looked like a surgeon, or an Asian female could even be a successful surgeon. All the more, it was incredibly important to have people who picked you out, who helped you, and who you could ask for advice. Also later on, individuals who would actually propose you for opportunities and positions along the way. I have a large number of mentors who have helped me and I have never let any of them go, even if they wanted to escape me! I cannot underestimate them in my life. So I will turn it around to you and we can have a discussion. Anai, you have just finished training; how important is mentorship and sponsorship been in your journey?

Dr A. Kothari: Your point about even before you knew what the words mentorship and sponsorship meant is really so true. Mentorship and sponsorship were these things that I knew were valuable. Also, we talked a lot about them and trying to figure out how can you identify these individuals to lift you up. It seemed like a simple thing, and as I found over time, it is not always so easy. But once you find mentors and sponsors, it is incredibly valuable, it is super important. It is one of the most critical pieces of advancing as a trainee. But sometimes that step of actually identifying and making these things happen, is a little bit challenging. We will have an opportunity to talk about that more, about how to find mentors and sponsors. Right now, I feel exactly what you have said, which is that you “collect” these individuals and make them part of your team. Try to make sure it is bidirectional as well.

Dr J. Tseng: The odd thing about getting older is that you feel the awkwardness on both sides now. Being in a senior position with some visibility means that now I have people who come up to me that I do not know at all and say, “Hello, I am so and so; you do not know me but will you be my mentor?” Sheryl Sandberg in “Lean In” has a chapter on this and compares it to the children's book by PD Eastman where a baby bird asks all kind of random people and objects, “Are you my mother?”

Mentoring relationships can be assigned, say within BMC surgery, that is just a starting point and the relationship needs to be built organically over time to be a true relationship and as you point out, I think it is bidirectional. For junior people, I recommend you look around and identify people who you admire that you have something in common with. Then you try to establish a relationship without being annoying as best you can.

For instance, I identified your new boss, Doug Evans, early on, even before I had matched at MD Anderson for fellowship. I was always there; he basically kept tripping on me when he would turn around at the Pancreas Club. Poor guy probably thought I was a stalker. Eventually some opportunity arose. For me it was working on a paper with him on vascular resection. Although I knew nothing about the subject at the time, it sounded like a great opportunity to work with him, and the paper, and the plenary talk at the Society for Surgery of the Alimentary Tract (SSAT) really started off my career as an academic HPB surgeon. And gradually, it becomes bidirectional and can evolve later into a real friendship, one which I cherish.

Dr A. Kothari: Of all the pieces of advice that I can offer to anyone, especially early on, is to take advantage of the mentorship opportunities that are assigned when you start. Many training programs and societies have mentorship programs and the individuals who participate actually want to be mentors and sponsors. They usually have been successful in that role. Also, once you have at least established that relationship and see how that goes, you can be more intentional. Exactly like you said earlier, which is thinking about who or which individuals specifically may help you. So, what I would suggest is take advantage of the resources in front of you, for example, mentors and sponsors in a department and then try to think about it more intentionally; I think that combination is really helpful.

Dr J. Tseng: I do not think we can emphasize enough the importance of surgical societies. I did not understand that as a trainee I was not mentored in them. I worked for a basic scientist in my laboratory years and we presented at Gordon research conferences instead. I was lucky enough to stumble into the SSAT because I was desperate to present my basic science research in some forum and I was told that the SSAT Residents and Fellows conference was a great opportunity. I only was able to present at the ACS surgical forum because I may have let my PhD laboratory mentor and the great late Dr Judah Folkman each think that the other wanted me to submit! Also, honestly, SAAS, which really grew from the genius brain of George Yang, has become probably the most fluid in terms of leveling status. The number of department chairs and trainees that is in the room together is amazing! You can really talk in a relatively level fashion and it is more enjoyable for both for the “senior” people, which I have unfortunately become one of, and the junior people. It is not just someone trying to ask for somebody something but it is actually just getting to know each other.

Dr A. Kothari: Agreed, they offer an opportunity to really get to know each other and grow mentor-mentee relationships. Sure, there are internal relationships that you work to build out but the surgical societies, and I think SAAS is one of the best examples that I have been able to participate in and offer the ability to build an external network. You can share thoughts about what is happening, not just at your place but beyond, and that is what fun about it is.

Dr J. Tseng: Let us shift talk about what not to do as a mentor. We learn in surgery the whole “see one, do one, teach one” concept. So, not to take a dig at anyone, but what have you seen or seen done that you should not do as a mentor?

Dr A. Kothari: I like the see one–do one–teach one framework as it applies to mentor-mentee relationships because I think there are examples in each of those domains of what not to do. For the ‘see one’ part, a lot of it is observation. It is watching the individual and so you are seeing how they do things. So much of that are interpersonal relationships. How they treat the staff. Unfortunately, there are a lot of bad actors and very quickly, for me, it was figuring out those behaviors I just did not want to do. The “do one” for surgery is especially important, obviously. It is in the operating room and watching how people conduct themselves both technically and then handling the operating room environment. You can identify when there is something to be learned about what not to do and taking that very seriously. Then once you are doing, the next step is to teach. To do that most effectively, it is taking time to remember how it was when you were in the shoes of the mentee and paying attention to things in each domain where you can find examples of things not to do and hold yourself accountable to that. What do you think?

Dr J. Tseng: Yes, just like there are no perfect people, there are no perfect mentors. There are imperfect mentors also in the sense that somebody who you admired deeply for their technical skills or for something else may not actually treat somebody the way you want to be treated. So you can take the good from everybody and also take what works for you. What works for one of your mentors may not work for you because you have a different situation.

Dr A. Kothari: It is a nice transition because sometimes you will find things that may not work with you and a particular mentor, and it may be hard to either breakup or decide that you want to try to figure out how to save these relationships. So how do you navigate that? How do you figure out this is not working and whether you should keep working? And then how do you keep it?

Dr J. Tseng: I think for everything it is transparency. There is so much that is unsaid and then when you assume that you know what the other person is thinking you are often wrong. You are almost always wrong. So, if I think that someone is unhappy with me because of X, Y, or Z or someone is just mean because they put themselves first on a paper when I did the study. It is easy to sulk and think bad things about the other person. But instead, talk about it. Can this mentoring relationship be saved? But if you actually respectfully ask them what they are thinking and tell them what you are thinking, as hard as that can be, that can go a long way to trying to at least save the relationship or at least part amicably.

Are there any risks of mentorship? I saw somewhere important, like maybe on Twitter, that some men were saying they were not going to mentor women in the “Me too” era. I, of course, am fairly confident that none of these men were good mentors to women to begin with but are there risks? Are there people who are reluctant to mentor and find it risky?

Dr A. Kothari: Unfortunately, I do think people think about those things in their environments. Whenever we have built in hierarchies, and medicine is a perfect example of that, it has to be acknowledged that there can be situations where individuals become vulnerable. But, as a mentor, if you are worried about a perceived risk to the type of interaction you are having or could have, and if you are thinking about it too much, maybe you are not the best mentor for that person to begin with. So, to me, a solution is encouraging psychological safety in these mentorship relationships and making sure you are thoughtful about it but not to be overly worried about it.

Dr J. Tseng: How do people mentor people who are different from them? Try to find out what you have in common and start there. Try to understand how they may be different and try to be helpful, or at least acknowledge that you do not understand. Almost all of my early mentors were men and they were generally men who had incredibly brilliant wives who stayed at home and raised the children and did everything at home. Well, a couple of my mentors really express to me that they could not understand how my husband and I could have the careers we wanted and still have a family life, but they have watched it unfold and they respect that honestly. I did not go to them for lessons about work life balance. For those issues, I found other people in other sources and also just figured it out for myself and from peers. That is, where acknowledging areas in which you differ is crucial. Again, transparency is important.

Dr A. Kothari: I was just going to say that same thing. Transparency and openness about things and being willing to talk about them—those are the best and strongest mentor-mentee relationships. When we can be honest with each other, when we can have the tough conversations in the office, or wherever we are and really trust each other. And once you have reached that with a mentor, which is the aim. Those are people who you hold onto really, really tightly. This next question is important because we have talked a lot about mentorship. But, when you start shifting into more of that sponsor-type role and how do you do it?

Dr J. Tseng: Start as early as you can! For example, when you are a senior medical student at BU School of Medicine, you actually sponsor junior medical students who are interested in surgery. Our residents, the senior residents, or the research residents teach the interns. It is the same way in a surgical career. Early on when I was a young faculty member, I would be sponsoring my residents to join societies. Simultaneously, people would be sponsoring me. When Selwyn Vickers became the Treasurer of SSAT, David Rattner used his presidential appointment to move me up to Selwyn's vacated membership committee chair. Doug Hanto advised me on when to ask my then-Chair to propose me for the American Surgical Association. Remember, it is bidirectional. Actually it is multidirectional. There are people who are younger than me who are pulling me into things. For example, you may have pulled me into this! And, there are people who are older than me who are still helping me. You know Doug jokes that someday when he retires from MCW, he is going to come work at BU part time and sail. He states he requires Fridays off in the summers to sail but in the winter he is going to take acute care surgery call (ha ha). It is strange when you start to actually be able to help people who are senior to you; it gets relatively fluid, and it feels good.

Dr A. Kothari: It is funny and it is really ongoing. And something that I have forgotten is that it just happens. All of a sudden, you shift from the mentee to the mentor or the beneficiary to the sponsor. It is looking for those opportunities and identifying individuals to help.

Dr J. Tseng: My final thought on this is we need an environment of mentoring. The sooner that you as a mentee or as a junior person think about what you can do for your mentors, and other people who are “below you”, the transition will be organic. If you are already trying to help in whichever way, if you continue to pay it forward and pay it up, pay it down, you will grow naturally in the role. Also, just as you help others, they will help you. It goes back and forth. The most important part is that this is an active process and that comes at all stages of being a surgeon.

Dr A. Kothari: My final thoughts are identifying a mentor, becoming a mentor, and being a sponsor can be fluid. But you have to seek these opportunities out: External societies, within your department, and outside of your department. Especially early on, really need to work on it. And then, once the momentum is built, some of these relationships happen more naturally. My residency had a process to pair new residents with mentors. It was mostly random. I clearly remember sitting down for the first meeting, staring at Gerard Abood who became one of the most impactful mentors in my career. I sat down in front of him and just waited. Expected to be mentored. And at first it did not work. Fortunately, he wanted to be a mentor and sponsor and invested the time. He taught me to be intentional about it. I was open about what I wanted and how he could help. I think those are all really important pieces.

Dr J. Tseng: This has been fun. Next time, in person!

Dr A. Kothari: Thank you so much. This is a lot of fun. Really appreciate the invitation and the opportunity and I will look forward to seeing you all soon again.

Susan Tsai, MD, MHS, FACS and Kasper S. Wang, MD, FACS

Dr Susan Tsai: Hi everyone, my name is Susan Tsai. I wanted to thank the AIS channel and SAAS for inviting myself and Dr Kasper Wang to share our thoughts on Asian American and Pacific Islander (AAPI) allyship and advocacy by affinity societies. In this session I will be covering some fundamentals of allyship, including how to be an ally and what the specific challenges are that are faced by AAPI surgeons and talk a little bit about what individuals can do to be allies. Then Dr Kasper Wang will conclude by discussing the role of allyship within and between organizations.

There is a close relationship between the concept of privilege and allyship, and I think, broadly speaking, when we talk about privilege, it is having an advantage over others in some area. This can be financial or social or physical, or other advantages not listed. It is important to note that privilege does not necessarily mean that there are global advantages. So, it is possible that people can be privileged in some ways but disadvantaged in others. And I think often times people may feel uncomfortable with the term privilege because it implies that all their experiences have come easily and that is not the case. I think having privilege does not mean that one has not experienced challenges in one's life. It just means that you have a toolkit that you can access that others do not have, and so allyship is understanding that you may benefit from some types of privilege and can use that position to improve outcomes for others.

I think it is very true that allyship is not a state of being but it is a verb. It starts with building trust, which is a foundation on which all relationships are built, but it really depends on consistent action and accountability. It is helpful to have not only just words but actions to reinforce those statements. So what actions can an ally perform? Advocacy for others is the foundation of allyship, and this includes being able to share growth opportunities and to recognize and work to rectify areas of inequalities both systematically or anecdotally.

It is important to believe and promote under-represented minority experiences as true and valid.

This requires a lot of listening, self-reflection, and a willingness to potentially change your perspectives. Finally, this culminates as others identifying you as an ally, when you have really achieved allyship. It is not something that is self-defined, it is something that others define you as.

So within the AAPI space there are some specific allyship challenges that were touched on in previous talks. I am just going to touch briefly on three. The first is that Asians are not perceived to be under-represented in medicine and up to 1/5 of incoming medical students are of AAPI heritage, but I think what is not recognized is that there is a significant diversity within the AAPI population. I think this is really becoming understood in the LatinX community but that heterogeneity also extends to the AAPI community as well. It is important to understand and to reach out at an individual level and away from stereotypes. Dr Tracy Wang spoke about the model minority myth, the idea that AAPI surgeons are successful, they are industrious, and they really do not need any additional help because they are very self-motivated. But those who do not fit into that stereotype are often stigmatized, and I think again, moving away from stereotypes and moving toward understanding individual experiences and perspectives is very important.

And finally, the bamboo ceiling, which is the lack of AAPI leadership across academic medicine, I think, has been touched on in other sessions, but this idea is that individuals who are Asian are passive; they are not risk takers and they are not really meant for leadership positions. These are often assumptions, and if we get to know individuals and ask them what their goals are and if they are interested in leadership, we find that they have ambitions very similar not unlike non-AAPI persons.

I am going to conclude on some personal actions that individuals can take for allyship, and these apply to AAPI but also all under-represented minorities. Be an advocate in the representation and recruitment of individuals for leadership. I think that either re-examining the workflow or the recruitment process is essential to create a pipeline for individuals. Evolve from being a bystander to an upstander in terms of advocacy when witnessing microaggression or macroaggression. Seek out diverse AAPI perspectives. As we discussed earlier, it is a very heterogeneous group, so it is difficult to apply one perception to all individuals of AAPI heritage.

And finally, this I think culminates in just continuing self-reflection and examining of your own biases, which we all have our own biases. Learn to self-reflect and be willing to change. And with that I will turn it over to Dr Kasper Wang.

Dr Kasper Wang: Thank you, Dr Tsai. To follow along with your thoughts, it is important to think about allyship in the construct of your organization. What are the things that an organization can be encouraged to do? Or what should an organization do to be supportive of under-represented minorities in terms of diversity, equity, inclusion, and allies?

First, I think it is important to critically review the current state of diversity, equity, and inclusion within one's organization. Consider using external surveys as exists through the American Association for the Advancement of the Sciences (AAAS) SEA Change Program or participate in diversity, equity, and inclusion courses as are provided through the Association for Academic Surgery (AAS) and the Society of University Surgeons (SUS). It is important to standardize diversity, equity, and inclusion education within an organization, in part through implementing routine unconscious bias training, modifying recruitment methods to be more inclusive with intent to diversify, and screening candidates for a position blinded to race. It is important to standardize interview questions which otherwise might introduce implicit bias into the evaluation process of a candidate.

Very importantly, one should avoid tokenism, or in other words, the practice of actually doing something in a superficial manner in terms of inclusivity. How does tokenism look? Perhaps by bringing in just one under-represented minority candidate. Instead, consider bringing in two or more. Do not just hire one. Instead, hire more. Look at this as an opportunity to bring in added layers of support. Diversity will ultimately strengthen an organization. The question also logically expands to, what can one do interorganizationally to support diversity, equity and inclusion and between organizations? I think it is critical to develop trust and consistency and accountability to avoid tokenism. We, the SAAS, have actually worked with other organizations in partnership to support them, and in turn, have benefited from support in a bidirectional manner. I think this mutual trust and mutual understanding of one another's experiences is critical.

In summary, it is pretty clear that diversity enhances everything. Become an ally. Be proactive. Do not be perfunctory. Avoid tokenism. There is this bamboo ceiling for Asians as Dr Tsai mentioned, and it is important for other organizations to be our allies in our battle to break through. Thank you very much.

Lillian S. Kao, MD, MS, FACS

Although often perceived as a “model minority”, Asian Americans experience disparities in access to care, preventive measures, diagnosis, treatment, and self-management of multiple conditions. In addition, evaluation of Asian American healthcare outcomes using aggregate measures often obscures significant disparities in subpopulations; Asians in the United States are a heterogenous group with origins from more than 20 countries and representation of many ethnicities. Such heterogeneity is manifested in both healthcare outcomes and in social determinants of health. Multiple strategies can be employed to reduce disparities including but not limited to cultural competency–based strategies, legislative advocacy, and research.