So, I've been an ANA since 99 or 2000, and if you had asked me to give this talk in 2000, it would have been a short talk, and this would have been it, and I hope that shows. Okay, and I would have taken questions and sat down. Okay, so fast forward 21 years, and we can expand this a little bit more. It is not going to be as eloquent as Rick Ryu, but we will cover some important topics. ANA does now have a diversity and inclusion statement that you can read online. This is something we worked hard on to be inclusive. You will hear a lot about meritocracy. You will hear a lot about inclusion, and if there are things that you think need to be adjusted or changed, that's why we want you in this room talking to people that have come through the same pathway that you're now on. Is this really a thing? Rick talked about this, Brian Cole, our outgoing president, talked about this, and this is something that, you know, if it doesn't kick you in the gut, it should. This is not what I think we want our profession to look like, and this is something that is now on social media in various forms, Instagram, Facebook, Twitter, and if you want to read something impactful, go to these hashtags, and you will see that not only are some of these dating back years, but some of these are recent, you know, ongoing things with harassment and abuse, and I don't think this is what we want our profession, our ANA, our practices to look like. Diversity in our orthopedic profession could stand some improvement. When you look at medical school, you can see the numbers for men and women, white and non-white, hover around 50%. As soon as you slide one to the right, to orthopedic residency, white males tend to dominate, and then that's been mentioned by multiple speakers. When you look at AAOS, our kind of overall umbrella orthopedic academy, the percentages there essentially match what we see in ANA, and it's interesting that over the years, there has not been a significant increase in percentage in anything but our female membership. Our women members have increased slightly in ANA, but the other non-white minorities have not. These are our patients. This is why it's important. Our patients are diverse. So what is healthcare diversity? That's Justice Potter Stewart on the left, and if you don't know who that is, he was a Supreme Court justice who in 1964 made an amazing comment that still resonates to this day. He was involved in a lawsuit, in adjudicating a lawsuit by someone named Jacob Ellis, I believe, versus Ohio, and this person ran a theater, showed a movie called Les Amants, and that was deemed to be pornographic. And so it made it all the way up to the Supreme Court because this movie tavern owner was fined and essentially put out of business for showing this movie, and he was making all the claims you would imagine. This is freedom of speech. This is not pornographic, and the Supreme Court ultimately ruled that it wasn't pornographic, but the genius of Justice Potter Stewart at the time was he said, look, I don't know. I'm not going to define porn, but I know it when I see it, and I think that's a relevant comment here because diversity is not something you can always see. You can see me, but you can't see many of these other criteria, these other characteristics that are included under the umbrella of diversity. It is not something you can just see, and that is why we talk about conscious bias, unconscious bias, and many other things that we'll touch on shortly. This is our profession. This is our orthopedic surgery profession. We have the lowest percentage of females and minorities, not just because we're a surgical specialty, but when you look at all surgical specialties, we're still the lowest, so again, there is room to improve. This graphic on the left is from the University of St. Augustine. It nicely summarizes some of these concepts, and the question is, does it really matter? Do we really need to be worrying about this at all? And there is a lot of data. A lot of research goes into looking at this concept in the business world and now in the healthcare arena as well. And what we know is that diverse organizations, like ANA, attract and retain more talent, they are more productive, they are more creative, they have better reputations, they problem solve better, and they report less doctor burnout. From the patient side of the equation, diverse organizations are better for multiple reasons as well. Patients report higher satisfaction, there is increased patient trust, there is more patient compliance, there are reduced healthcare disparities. You would be surprised how little data there is in the sports medicine world on outcome differences based on social determinants of health. This article that's going to be published in ANA, it's in the publication pipeline right now, is one of the few articles looking at ACL tears and looking at how some people with certain social determinations, like black race, Hispanic ethnicity, public health insurance and lower socioeconomic status have decreased access to care, which may play a role in why they have a meniscus tear now plus an ACL tear now and why it now takes six months to see a doctor instead of two, and why their outcomes at that point may be worse. And so we don't really have a full definition of the problem at this point. This is from Barack Obama, and what I want to focus on with this quote is towards the bottom. What we are talking about, what I am talking about, is providing access to opportunity. I am not trying to guarantee outcome, I'm trying to provide access and education that there is an opportunity available for all of you in this room. We all, we all have biases. If we want to be better, if we want to do better, if we want to provide better, then we need to identify our biases. Okay, so how do we identify our biases, Donny? Well, there is one way. This IAT, the implicit association test, is the most commonly studied and cited method of identifying biases, and it's now gotten to the point that it's online, it's free. I use that little bufor.info as a quick way to find the website. You have to be very careful, because if you take the test one time and it's a bad day, you may come away from that thinking that you're a raging, racist, misogynist pig. Okay, so you have to understand that this test is controversial, and it is really designed for populations, and they still argue about how applicable it is for an individual person to take one time. But nonetheless, I still think it's interesting. There's a whole list of things you can take on the side in those blue boxes, and if you're going to do that, before it sends you into a tailspin, take it a couple times, take it over different periods, and kind of look at your aggregate. It's like your blood pressure. You don't just take your blood pressure once and say, gosh, I'm perfect. You don't just take it once and say, I'm hypertensive. Your internist is going to want you to take it over time. So how can you minimize your biases once you've identified some of them? Well, this is from our family practice colleagues. This is a little bit busy. Being orthopedic surgeons, we like small, medium, large. If our scales go above four, it gets a little bit worrisome. And so, what can you do personally? What can you do personally that's easy to remember that you can take home Monday? And what I would say, and what I've come to at this point in my practice, is I reflect first on my own biases. What am I bringing to the table? And once you get to that point, sit down with the patient. And I mean that literally. Sit down with the patient. You've all heard that before by now. Sit down, find a place in the exam room to make a comfortable spot for yourself, and sit down. Make no assumptions. I think that's a big one. We all make assumptions. I'm guilty of it every week, even at this point. I do a lot of orthobiologics. It's cash pay. I find myself all the time, in my mind, when I walk into the room, and I look and I see their address, and I see what other doctor they're referred from, or if they're work comp, especially work comp with orthobiologics, I make assumptions that I should not make. Listen, listen, listen. And give patients what they've come for. I'm always asking, have we covered everything you wanted to cover today? Give me your problem list. If you had to rank things that are bothering you, forget orthopedic surgery. If you have to rank things right now that are bothering you, what's on that list? If you're bad knees number three, tell me about one and two, so we can help you make some decisions about what's the best thing for your knee. Be an educator, not a lecturer. I don't lecture to patients. I have a whiteboard in every room, and by the end of most of these new patient visits, that board is full of options and full of discussion points. My office visits have gotten three times longer than they used to be when I first started in practice. Let patients pick their path. I see myself as a guide. I feel fantastic if when they leave that 15 or 20 minute new patient visit, they have as much knowledge as I do on the subject, at least enough to be actionable for them. I have to recognize the fact and check your humility that even though they may have a meniscus tear to stay on that example, the fact that I can put in two great vertical mattress sutures may not be what they need to support their family the next year. So what do we do as an organization, as ANA? For all of you in the room that are emerging leaders and on this path, reflect on ANA. Communicate with other like-minded members. Find out where there's gaps, where there's areas to improve, and be the thought leader in that area. DEI is diversity, equity, and inclusion, so we need to institutionalize that. We'll get to that in a minute. We need to equalize access to leadership, committees, the presidential line. We need to equalize access to education and educators. And what I mean by that is many of you in the room can be master instructors at the OLC. Many of you need to be leading these committees. Many of you need to be teaching, running podcasts, doing these other things. And you need to know that that opportunity is available. Mentorship. I'm always being mentored. The top picture were my initial mentors, my parents and my two brothers in both positive and negative ways are mentors. The middle guy, Joe Toro already talked about Steve Schneider, I literally wouldn't be here at the podium without him. Met him in 1982, was a 17-year-old. And fast forward many, many years, and I end up doing the same thing he does, basically. And then my wife. I literally wouldn't be here at the podium either without her. She'd be over here across the street right now. So mentorship is important. Find somebody like-minded who does things who you respect and approach them. One thing I found in my 21 years at Anna is we are all approachable. We are all approachable or we wouldn't be here. Can unconscious bias be eliminated? That's a tough one. Because even in 2021, I would argue that there's still plenty of conscious bias. Unconscious bias is probably not going anywhere. There's still enough conscious bias that is concerning. And so as a result, I think we need to design our individual practices, our healthcare facilities, so your ASC, your hospitals, wherever you work, our Anna, our organization, and our profession so that bias simply cannot operate. What I'm saying is we should assume that there's implicit unconscious bias in all of us and structure our facilities where we work, where we take care of patients, and where we learn as colleagues so the bias can't have a role. We just take that out of the equation completely. One person can make a difference. Each one of you in this room can make a difference. Our outgoing president, Brian Cole, established this diversity and inclusion task force. And he called me one day, I'll never forget, it was mid-COVID, and I was on the way to the bank, and he made that call and said, hey, Donnie, I have a couple questions to ask you. Do you have a minute? And I said, sure, because I would never say anything else to Brian. He's a good friend and I respect him as much as I respect anybody. And he said, I'm thinking about doing this task force. Would you consider chairing it? And again, first word out of the mouth, yes, of course. And then after hanging up the phone, after having a good conversation, sat with my wife and said, how am I going to do this? What does that mean? And it's something that over the course of the year, I think we got a lot done. I think we really got a lot done. We have an annual meeting lecture. We have a diversity research award, and we had a lot of discussion about how to implement that in a way that wasn't an affirmative action plan. So we have a lecture that has to be approved by the education committee. Once it's approved, then it goes, if the author wants it to, to be considered for a diversity research award. And now we're going to be bringing in young orthopedists and future orthopedists into the OLC. So that was all done because somebody had vision, because Brian had vision to do that. And each of you have that capability if you get fired up about something that can help us as a profession and as a specialty. So number one, increasing diversity, equity, and inclusion at ANA will have immeasurable longstanding benefits for ANA and for the patients we care for. It's too hard to measure the positive outcome from this. We must recognize and embrace and encourage our human diversity if we want to be better doctors, teachers, leaders, and institutions. And then finally, this is not an end point. We are not striving to be perfect. We're not striving to be a perfect institution. I think Dr. Cole made that point. This is a journey to be better, to constantly improve, to constantly provide the best care to a diverse patient population. So thank you for your attention. I hope you can take some of this knowledge back to your practice to craft it in a way that you think is appropriate. We need you to think about this as you become leaders in ANA to shape this organization as we move forward. And remember that our goal is to better our patient care, and we need to think about these interesting and sometimes difficult topics to make sure that we're providing culturally competent care. So I thank you very much for the invitation.

diversity and inclusion

orthopedic surgery

underrepresentation

patient satisfaction

cultural competence