Q&A: Create a more diverse, inclusive orthopedic specialty by being an ‘upstander’
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SAN FRANCISCO — At the Arthroscopy Association of North America Annual Meeting, Eric W. Carson, MD, FAAOS, FAOA, shared his experiences as a Black orthopedic surgeon and the importance of diversity, equity and inclusion within orthopedics.
From growing up in Roxbury, Massachusetts, during the forced desegregation of the Boston public school system to navigating his path toward medical school and becoming an orthopedic surgeon, Carson discussed his experiences with implicit bias, imposter syndrome and burnout, and the impact of his relentless mentorship and sponsorship of marginalized individuals toward a career of orthopedic surgery. He also presented possible solutions to help make orthopedic surgery a more diverse and inclusive surgical specialty.
“We must show compassion and empathy for people who are not part of the majority,” Carson, professor of orthopedic surgery in the department of orthopedics and division of sports medicine at Washington University School of Medicine and past president of the J. Robert Gladden Orthopaedic Society, said in his diversity guest lecture. “We must recognize that there are differences between us and that we can no longer be a bystander. We have to be an upstander and essentially use our voice going forward. We, as a profession, need to be allies for our colleagues and support them.”
Healio spoke with Carson about his diversity guest lecture at the AANA Annual Meeting, the lessons he learned from his life experiences and his advice on building a more diverse and inclusive specialty.
Healio: Can you please briefly discuss a personal experience related to diversity in orthopedics?
Carson: My life is an experience. The point of my diversity talk at the AANA Annual Meeting was the fact that I could have easily gone into all the semantics of microaggression and all these other various diversity, equity and inclusion (DEI) terms and not put it into a context, but everything that I did within that talk was all based off my life experience. Any of the many words of in the sphere of DEI, such as belonging, white fragility, white privilege and gaslighting, I tried to equate that to some of my “life experiences.” The experience that most people got caught off guard was an incident when a policeman accosted me, pushing me to the ground and placing a gun on me after the infamous Stuart murders in Boston in 1989. That’s the one that blindsided most of my colleagues. However, I tell people more clearly that’s the third time that the police have pulled a gun on me. So I’m lucky to be alive, and the correlation that I use with that is I’m a Black gentleman walking to work, wearing a white lab jacket with an insignia and the words of “Harvard University” on it clearly marked over my surgical scrubs along with a stethoscope in my pocket. Do I look like a killer? The answer is probably no, but could I be a killer for I fit the description of the potential killer being 6 feet tall and in his 20s or early 30s? The answer is absolutely yes. So, in general, that’s how that whole scenario played out. For a lot of my white colleagues, they were totally surprised. For my Black colleagues, they all had similar experiences at some point and time in their life. Although it sounds unique, unfortunately, being a Black person, it’s not that unique.
Healio: How can diversity and inclusivity in orthopedic centers or departments improve the work ethic of orthopedic surgeons, as well as other orthopedic staff?
Carson: That is the challenge of challenges. Before the murder of George Floyd, we had little dialogue going back and forth just because people weren’t talking. Post-George Floyd, I would tell you that people are talking, but each and every one of these conversations about diversity, equity and inclusion, involving gender, ethnicity or race, will be “uncomfortable conversations.” If they’re not uncomfortable, something’s wrong. So that’s the first thing. We all need to start talking more.
Number two, if you aren’t white or you’re not male in orthopedic surgery, you’ve had a different experience and path. My take home on the talk was to take a look at your colleague to your right, to your left, in front of you or in back of you who doesn’t look like you. Recognize that their journey is different from yours as a white man. Now we know that orthopedics, per some of the recent STAT articles, is presented as the “whitest surgical specialty,” the most privileged and the more legacy driven of all the surgical specialties. Believe me, a lot of my white colleagues who now have sons or daughters and grandsons or granddaughters who are orthopedic surgeons would disagree with that. They say their kids have worked hard to get to this point, but, honestly, they are “white” and that gives you automatically a step ahead of everybody else. The fact that your father may be an orthopedic surgeon gives you two steps ahead of everybody else. So, I’m not taking away from their hard work and what they’ve gotten to, and this is where we get into the whole concept of white privilege along with white fragility. A lot of my colleagues are mentoring young African Americans, women and Latino students who are incredibly strong applicants who don’t get looked at, and I have some of my colleagues whose fathers are orthopedic surgeons who have some of the lower scores in their medical school class who get a pass because they’re part of the club.
Then, the last thing I will say is if you look at what’s transpired in the business world, creating diverse work environments breeds success and significant profits. Studies show that when you have a diverse vs. nondiverse group of people innovation improves along with higher profits. Overall, the work environment is such that people feel safe and more productive. Also understand that we all have our blind spots, implicit and unconscious biases. The major point to be made is you just need to recognize you have these biases and you have these blind spots. Everybody has them.
Healio: How does diversity and inclusivity in the medical profession impact patient outcomes?
Carson: The medical literature has also proven that the more diverse environment that you have, the better the health care system is going to be, the better the clinical outcomes and the higher the patient satisfaction is going to be. Those are facts. We don’t just have to look at the business literature as there is enough in the medical literature that supports that also. But I could tell you a lot of my colleagues question those results and the need to diversify the surgical specialty of orthopedic surgery. They say, “Let’s stop talking about affirmative action, let’s stop talking about this, let’s stop talking about that,” and it gets old after a while. Post-George Floyd, there’s what I call a true “diversity fatigue.” People are tired of talking about the need for diversity and truly tired of going to mandatory implicit bias and unconscious bias trainings. People are tired of it, but the realization is: Are you going to change everybody? I am trained in implicit and unconscious bias training, and typically there are 20 people in the room. Of the 20 people in the room, there are probably about three or four people who don’t want to be there. You also have a number of people who are there who are interested in learning something and there are others who have no idea why they’re there and then they learn something. But the short version of the story is that you can’t change everybody’s thought process, whether it’s on race, gender or ethnicity.
Healio: In what ways can leaders in orthopedic surgery help make orthopedics an inclusive and diverse environment?
Carson: Some of the fundamental things that you can talk about is making some of these trainings as an integral part of the onboarding processes and such training be mandatory for all people of leadership. Doing this one thing will bring forth a fairer process for training, promotion, mentoring and a better overall understanding of those persons who do not look like the majority. This conscious change in the infrastructure of systems will be more open and fair. I don’t propose to have all of the answers to the questions, but I will tell you that most people believe diversity doesn’t matter. But we know clearly that those diverse teams outperform those of the nondiverse teams in general, on a regular basis, anywhere from 15% to 35%. Also, if you look at satisfaction and people’s job satisfaction, that goes up significantly. There’s typically more success that’s noted, we know there’s increased innovation and a lot of this is related to the fact that you get away from the homogeneous thought process and get more toward people bringing different concepts and thoughts to the table. So, again, doing some onboard training, recognizing people have their potential biases is important and just people communicating — that’s probably the most important thing — and everybody taking a look in the mirror.
Healio: What is implicit bias? How can orthopedic surgeons identify their biases and work to change their thinking?
Carson: There’s been a lot of point/counter point in regard to doing unconscious and implicit bias training which I will acknowledge. There are certain people who feel as though the gain with these is not as high as they once were. There are some experts who feel that doing this type of training will not be of any value to you unless you are open to it. I had proposed to the American Academy of Orthopaedic Surgeons about 4 years ago that everybody undergo some type of training with some modules to become a fellow of the AAOS. I thought that was important at the time, and I still think it’s important. I think it’s important that people of leadership in different organizations be a neutral party and see things as they are. I think working through those things are important. Then the other important facet is to uplift and support marginalized people and hearing them with their noted incidences of microaggression and other behaviors. This empowers a group of people who previously lacked a voice.
Healio: What are additional terms and concepts related to diversity and inclusion that orthopedic surgeons should know?
Carson: I call it the bystander/upstander. A lot of people are spending a lot of time thinking about this now and so looking at your colleagues, creating that allyship with your colleagues, is important, but most importantly, if you see someone who is being either gaslighted or you see someone who has microaggression being directed toward them, instead of just being a bystander, be an upstander. Get involved. Speak your mind. I typically will say that in 2022 those of us who are silent are complicit to institutional racial policies. If you’re not going to speak up, then you’re definitely complicit in that.
Healio: What advice do you have for orthopedic surgeons when it comes to making orthopedics a more inclusive and diverse area in medicine?
Carson: The numbers have not changed, which is of significance. If you’ve looked at the number of African Americans in orthopedics, we have barely budged. We have been at 1.9% and we drifted up to 2% maybe about 5 years ago, but that number has stayed low for over 20 years because this is the “good old boys” club. Women have definitely made an impact in orthopedics from the perspective that their numbers have increased, but does it match that of what is in the community? Does it match even that of who has graduated from medical school? Medical schools now graduate, I think, 52% women and 48% men. In itself, the numbers are not being represented appropriately, so I think there needs to be a new thought process and looking at how this process is going to play out. When you look at hiring practices in orthopedic surgery, there’s still the “wink-wink” in orthopedics and there’s not a fair process for people to diversify this field. The bias related to fit of the homogenous group is prevalent. For me personally, I’m trying to get away from the word of diversity. I’m trying to get more toward the words of “inclusion” and a “sense of belonging” because diversity you can make whatever you want. It’s like all the purple people, they’re being discriminated against because they’re purple. You can make diversity whatever you want to make it.
References:
Carson EW. Why diversity, equity and inclusion matters in arthroscopy and sports medicine in 2022: What I have learned. Presented at: Arthroscopy Association of North America Annual Meeting. May 19-21, 2022; San Francisco.
Empinado H, et al. Watch: A rebel with a cause: As a mentor and a leader, this Black orthopedic surgeon fights to diversify his field. https://www.statnews.com/2021/12/14/eric-carson-black-orthopedic-surgeon-fights-to-diversify-field/. Published Dec. 14, 2021. Accessed June 2, 2022.
McFarling UL. The whitest specialty: As medicine strives to close its diversity gaps, one field remains a stubborn outlier. https://www.statnews.com/2021/12/13/whitest-specialty-as-medicine-strives-to-close-diversity-gaps-orthopedic-surgery-remains-stubborn-outlier/#:~:text=STAT%20Conversation%3A%20The%20Whitest%20Medical%20Specialty&text=Guy%2C%20a%20white%20orthopedic%20surgeon,some%20criticisms%20in%20the%20letter. Published Dec. 13, 2021. Accessed June 2, 2022.
St. Fleur N. STAT conversation: The whitest medical specialty. https://www.statnews.com/2021/12/14/stat-conversation-the-whitest-medical-specialty/. Published Dec. 14, 2021. Accessed June 2, 2022.
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Carson EW. Why diversity, equity and inclusion matters in arthroscopy and sports medicine in 2022: What I have learned. Presented at: Arthroscopy Association of North America Annual Meeting. May 19-21, 2022; San Francisco.
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