Narrator:   0:01

Welcome to the Advancing Surgical Care Podcast brought to you by ASCA, the Ambulatory Surgery Center Association. ASCA represents the interests of outpatient surgery centers of every specialty and provides advocacy and resources to assist them in providing safe, high-quality, cost-effective patient care. As with all of ASCA’s communications, please check to make sure you are listening to or viewing our most up-to-date podcasts and announcements.

Mandy Hawkins:   0:27

Hello, and welcome to the Advancing Surgical Care Podcast. My name is Mandy Hawkins. I'm the president of the Ambulatory Surgery Center Association or ASCA, and the host of this podcast. My guest today is Dr. David Acosta, the chief diversity and inclusion officer of the Association of American Medical Colleges or AAMC. As many ASCA members know ASCA Board of Directors unanimously approved an initiative last year for the association to advocate for increased medical education and training opportunities, including new initiatives for historically disadvantaged and underrepresented communities. ASCA is also considering new education offerings for our members and their staff to improve their cultural competence, working with patients of many diverse backgrounds and lifestyles. As everyone in the healthcare world knows, the country is facing a dire shortage of physicians, nurses and other medical professionals. With our growing aging and increasingly diverse population, there's so much that needs to be done to educate and train a larger, more diverse healthcare workforce. And no one is immune to these concerns, hospitals, ASCs and virtually every other type of provider organization are finding it increasingly difficult to hire and retain doctors, nurses and other medical personnel in rural areas and many inner cities to problems even worse. Dr. David Acosta is on the frontlines of this growing concern, working on behalf of the nation's medical colleges to help overcome these challenges. And I've invited him to join me in a discussion today to learn more about what our medical schools are doing to meet this challenge. Dr. Acosta provides strategic vision and leadership for the AAMC’s Equity, Diversity and Inclusion unit. He is a family medicine physician who joined the AAMC from the University of California Davis School of Medicine and He previously served as the first Chief Diversity Officer at the University of Washington School of Medicine, where he established the Center for Equity, Diversity and Inclusion, and the Center for Cultural Proficiency in Medical Education. Dr. Acosta, welcome to the ASC podcast.

David Acosta:   2:36

Thanks for having me, Mandy. It's such a pleasure to be here with you today. So, thank you.

Mandy Hawkins:   2:41

Great. As I just mentioned, I was eager to have this discussion with you to learn more about AAMC’s efforts to admit and graduate a more diverse group of medical students. But I think it's also important to know that we not only need a more diverse medical workforce, we need a bigger workforce of physicians, specialists and surgeons to meet the future demands of our country. But before we get into some specifics of your diversity efforts, can you talk for a moment about the number of physicians we are currently graduating today, versus the number we are going to actually need in the near future?

David Acosta:   3:12

Sure. And I'll start with first saying, I totally agree with you the adage of the physician demand can the physicians demand continues to outgrow faster than the supply is still holds true today. And I think as we'll talk to us about some of those numbers, I agree with you that not only needs a larger physician workforce, but again with COVID, from the COVID pandemic. We also notice that we need a larger health professional workforce, especially nurses looking at the nursing shortage as we have today, in order to meet those demands on the healthcare needs of the society. So, in answering your question, pulling data from our AAMC workforce studies unit has projected an estimate shortage of between 37,000 and about 124,000 physicians by 2034. So substantial amount there. And when we disaggregate that data, we find that the projected shortfall for primary care physicians is about between 17,000 and 48,000. The projected shortfall for specialty care physicians is between about 18,000 and 48,000. And when we look at the projected shortfall in specialty care physicians, it's about 21,000 to about 77,000 as well, when you break down the specialty physicians into the surgical subspecialties, we're talking to shortfall of that 16,000 to about 30,000 physicians worldwide. So how are we doing with supply? Because it goes right along with how we're standing here looking at the shortages. The good news is that the number of graduates coming from medical US medical schools has really increased each year over the past decade. And I can tell you that back in 2013, 2014, the amount that we're graduating was about 18,000 graduates per year from our US medical schools. Today, the total number of graduates from our MD granting schools between 2021 and 2022 academic year was a little over 21,000 that are there. So again, I'll just end with saying, that's one way to begin addressing that shortage. And maybe later on, we can talk a little bit about to continue to address that shortage, it's going to be really important to think about the residency training positions that are also available in the United States, because that also impacts that shortage.

Mandy Hawkins:   5:31

Yeah, it's good to hear that you're seeing an increase. I know all of us, in this community are very worried about physicians coming into the industry. So, let's go back to the issue of diversity in medical education. Can you tell us where we stand today in terms of incoming medical school classes, and whether or not we're going in the right direction of admitting more people of color, more women and more students from diverse cultural and religious backgrounds.

David Acosta:   5:57

So I think that the good news is that the number of black, Hispanic, Latinx and women applicants and enrollees continues to slightly increase at the US medical schools in 22 and 23 academic year, women again, continue to gain ground, they're making great strides, they still make up about 57% of applicants to medical schools every year, and are maintained about 54% of the total enrollment in medical schools. And this is the fourth year in a row, that women make up the majority of these particular groups. When I focus on race and ethnicity, and we look at our black African American students, they make up about today about 10.2% of our matriculants into medical school, in 22 and 23. And that's up by about nine from 9.5% that we had an in 2020. I will say a skip 21, 22 because we had this this incredible fallout in where we had these exorbitant numbers during the pandemic sort of thing. And we were really trying to retrace back to find out why do we have such a surge or thing? Most of us were thinking, well, maybe because of the pandemic, I sensed people with a sense of altruism was coming true and warmer today, he needed to medical school. Well, as we look back and disaggregated, the data to try to figure this out, we found that we had more applicants solely because students who now had more time to fill out their applications since they were attending school from home, as opposed to being in the classroom at their at that place. So that excitement quickly whittled down. But we still did see an increase when we look at the real numbers prior to the COVID pandemic. And now, that seems to be the continuing trend that we have with that. So, with that, I think the important piece is, we went from about 9.5% of making up the total enrollment of African American students to about 10.2% today, so slight increase. We saw the same sort of thing with Hispanic, Latinx medical students as well. They make up about 12.3% of the total applicants in 2023 and that's up from about 12% in 2021. We do follow any kind of concern most concerned with American Indian and Alaska Natives matriculants. Because they have a continued decline since about that time. They basically now comprise about 1% of the matriculants and that's down from about 1.1% in 2021 as well, so.

Mandy Hawkins:   8:25

It sounds like we need to hit that population with some more opportunities in medical schools.

David Acosta:   8:29

Absolutely. Absolutely.

Mandy Hawkins:   8:32

Dr. Acosta, we're going to take a short pause to hear a brief message from our podcast sponsor, please stand by and we'll be right back.

Narrator:   8:39

This episode of the Advancing Surgical Care Podcast is brought to you by AMSURG, a national leader in the strategic and operational management of ambulatory surgery centers. AMSURG partners with more than 2,000 physicians and health systems and more than 250 ASCs operating in 34 states. Learn more by visiting amsurg.com.

Mandy Hawkins:   9:00

So, I shared with you and a discussion before we had this podcast that ASCA is in the early stages of developing our own advocacy efforts on Dei. We have three working groups made up of ASCA members and staff and they've been looking at data and looking at the efforts of other larger healthcare organizations. As we consider the challenges of not only improving the diversity of our workforce, but also growing the size, we quickly concluded that medical school capacities and medical school admissions are only one small part of this challenge. It's clear we must begin preparing more students, including more historically disadvantaged students at a much earlier age if we want to develop a larger pool of qualified applicants. Can you talk to us a little bit about this issue and what you have learned and how you think these interventions need to occur?

David Acosta:   9:47

Sure, let me try to do my best with that, you know, understanding of what and where the specific structural inhibitors are, that are embedded in the educational system and society is where everybody has to start to take a look at really understand the transfer today. And this is really about having a better understanding of what causes those leaps the pipeline, we have always heard that phrase over time, students can have a very big interest in health careers but suddenly, as they go through the trajectory, they tend to fall off and get lost and become invisible to the system. And so the specific issues that studies have clearly shown, I think we have a better grasp of it today than we've ever had, is the data is showing that especially for the issues for the K through 12 group, we're finding some of the following that I'll just touch on, because we could probably talk for hours about this. But number one, the low expectations and the support that these students have, from their families, from their friends, and even from their teachers to pursue health careers, is very, so much alive today. There's still these fixed mindsets that people have about these students that are based on public perceptions, and the stereotypes and bias images that they have of students, especially students of color as well. We still continue to have these underperforming K through 12 public schools due to their poor and limited resources they have that includes good support financial support for school districts, in some of these particular zoning areas, the lack of support that the teachers have, in being able to have the financial resources they need, in order to support have supplies for their particular schools as well. But also understanding that this particular population group, many come from parents who don't have a background in having college education at all, students, as a result, students have this limited knowledge about how to even begin pursuing their health career pathway if I wanted to be if I wanted to work in health professions as well. In addition to that, even despite trying to have support systems such as high quality advising, we find along many of the trajectory spots for the impact pivotal points that are there, we find that some of those high-quality advising areas are missing, especially in our community colleges, especially in our tribal colleges as well. Four year institutions are a little bit better at that but it depends on location at that particular school, their funding, whether a selective or a private institution, versus a public institution, as well. And probably the most important salient thing that our audience sees a walk away from, there's an adage that many of our students that come from these disadvantaged backgrounds really believe that they tell us time and time again, these pathway programs that I personally have served on is that if they can see it, they can be it. And that's really important that that take home message because to them, there's an invisibility or poor access to really the role models and the mentors that they need to have along this journey on a continuum. And if they don't see it, there's that belief that well, maybe I don't belong here. Maybe I'm a misfit and I should think about something else that's there. So as I thought about the question, I was thinking, so how can an association like ASCA really help. And I think the important piece is that K through 12 education of the dysfunctional educational system we have is too big of a thing to grapple with and handle. But I think the important thing that an association like yours can do is start with that adage, if I can see it, I can be it. Need to establish a presence. How can in one way as you can do that as think about leveraging those ASCA members that come from the similar diverse backgrounds that many of these students come from, and make them visible. I would suggest such as things using social media in encourage these particular members of color to continue to encourage them to tell their story, tell their journey because many of the there's a lot of similarities in that jury, that students need to hear that you know, something they grew up in neighborhoods like I did come from communities like I did as well, and look how successful they are today, to make believers out of them that they can do this. Secondly, I think depending where you're located, the reality is that the members of the ASCA can also connect with their local pre health pathway programs, and really be proactive about thinking about participating in their program, become speakers at their sessions during those pathway programs during the summer, offering shadow opportunities at your facilities, even your simulation centers, a lot of our students are really engaged with technology today. And the fancy devices that we use in our utility are something that gets them very excited about this as well. But I would also provide the opportunity for the students to meet your staff. Because sometimes the reality is working as an allied health profession, a lot of the staff basically and also share their stories and their personal stories about their journey, and how they landed to work at this Ambulatory Surgical Center. What they had to do to get the training for that, how much money they're making, what time does it take, and that may be a pathway into medical school and nursing school or other health professions as well. You don't have to jump immediately to go into medical school. You can take this journey and follow the same path that even some of your staff have even had to even thinking about having your staff function as mentors for some of these students in the summer programs as well, you know, again, they're closer of age, right? To understand their journey and their story, it was really helpful too. And the last I would say is think about connecting with your local teachers, you know, at the high school level could be even middle school, if needed. But there's a lot of health academies that are out there as well, that are really focusing on health careers for some of the high school students as well. So teachers are very thirsty or very hungry and looking for ways to get assistance to help them get their students interested in health careers. So I'd say the members should be proactive knocking on the teachers door saying, How can we help? What can we do. And I'll just give you one quick example. As we move on, when I was at in Seattle, the Hutchinson Cancer Center there, basically would donate some of their mind electron microscopes, their slides on DNA, those sorts of things with the local schools so they could use them during their curriculum. And their studies as well that a lot of the schools in our area, especially those poor school districts didn't have access to. But because the Fred Hutchinson center was increasing their devices and upgrading things, you know, they basically kept this stuff in the warehouse. But they were able to kind of collide and cooperate with the teachers and said, Teacher said, we'd love to have this. So the students can actually look at prepared scopes with DNA looks like all the different types of microscopic features and specimens that they had, that they would have never had otherwise sort of thing. So, there's wonderful examples that are out there like that.

Mandy Hawkins:   16:30

Those are all great ideas. I know social media is really shaping our industry a little bit more than we thought it would. And surgery centers are such efficient workhorses. I like the thought of having us take the time and have some type of a shadow or mentor program to get some of these younger kids into the school, into our centers. So they can learn a bit a little bit more about what's out there. And I almost want to expand a little on I love how the US Department of Education has the STEM programs in schools, it's really providing more opportunities, encouraging and educating our students that there are other, there are other opportunities, other professions out there for them and kindergarten through 12th grade.

David Acosta:   17:11

I just want to say that the nice part is when people get the news that you are looking, you'll be amazed how many will be contacting you as well, which is a good thing could be a bad thing. But it could be a really good thing and that sense of really kind of spreading that news, I think the important piece is here's a chance for ASCA to be an exemplary model for other associations of what you can really do in which you can even and publish outcomes. Once you start doing this, it becomes really important because people are so outcomes based these days, it could really help spread that moment.

Mandy Hawkins:   17:40

Well, Dr. Acosta, I think it's clear that we need to make a much bigger investment in educating our medical workforce in the future. So at ASCA, we're just evaluating our proposals to expand educational opportunities. Are there any legislative or proposals that AAMC is supporting that you think that ASCA should also support?

David Acosta:   17:59

First of all, again, I want to applaud your efforts and making this making DEI work a priority for you. And I think that's really critical. And it's my hope that you can set that example for others I've had I have said, we've you know, we've already touched on a few of these, but basically I want to research and talk a little bit more about them possibly. But I would also want to encourage the ASCA members to really consider taking advantage of a newsletter that the AAMC puts out on a regular basis called the AAMC Washington highlights. It's a newsletter that really summarizes all of the legislative activities, statements proposal as a double AMC is Office of Government relationships are addressing, it's free and it can be accessed on our website. And that's at www aamc.org/advocacy/washhigh/. But as it basically really gives you an up to date when we working on what are we looking at not only just workforce development, but for other areas related to health is very helpful in that sense. So, at the present time is the things that really come to my mind today, right now, as we're talking about this. The SCOTUS decision on affirmative action is top of mind right now. And again, my ask with the ASCA members would be to familiarize themselves so they can develop their narrative around this when asked familiar themselves with the amicus brief that the AAMC submitted and half of the organizations and associations signed on to is to really understand the argument about being supportive of affirmative action, as the US Supreme Court begins to look at this and make that decision. The decision is hopefully going to be coming out by mid-June is what we're anticipating. And the important piece between now and then, is really meeting as a group to decide so how are we going to respond to this sort of thing? If we really try to go leaving the value proposition of diversity, how important that is in the workforce? What can we as an association, and I would probably address these to all associations. What can we do collectively to support this? The hard part is we don't know where the decision is going to really go. But again, I would just invite you to work with the AAMC as you are today. Because we have prevailed, we have presented a plan a contingency plan for five different scenarios that can happen. And we're there to basically help share that as well. Again, members can go to our site, we have a wonderful site on race conscious admissions on there, if you just Google AAMC, race, conscious admissions, you can get right to the page. It has lots of resources for people, including access to those amicus briefs that we have written. The wonderful thing about amicus briefs is that they're usually a summary for the case of why diversity is really important. And so it allows people to develop that narrative with some of the data points that we've had. One of the things I'm really proud of is we also have a section of frequently asked questions around the SCOTUS decision. We've been collecting questions over time from our constituents of what they're most worried about. But we've been able to answer that so people can develop that messaging that becomes so important. This becomes even more important for your communications department as well as they decide what's the narrative for ASCA once that SCOTUS decision comes out. So I think that's important. The second one I would talk about too, and I mentioned it just briefly about this whole notion of how you handle the shortages. And that's that whole thing about we need more residency training slots, there was a freeze on these Medicare funded residency training slots back in 1997, we made a little bit of a breakthrough legislatively, because in 2020, we are able to, for the first time, in 25 years, they passed legislation to create 1000 new training positions by 2025. We also found that's a terrific place to go in the right direction. But there's some new legislation that's out there that I would recommend your association taking a look at. And that's called the Residency Physician Shortage Reduction Act of 2023 and this was introduced recently by Representative Terri Sewell, a Democrat from Alabama, and Brian Fitzpatrick, a representative from Pennsylvania. So bipartisan bill to really increase the number of residency slots by 2000 annually for the next seven years, because that may make a bigger difference for us and be able to really address the shortages that we're talking about. So those are the two really quick off the top that ultimately, I think that you could address from a legislative standpoint.

Mandy Hawkins:   22:35

We definitely need more than 2000 spots. So that's something we need to look at. Okay, we have time for one more question. And I'd really like to talk to you a little about cultural competence. I know from our prior conversations that AAMC kind of characterizes this a little different. So I wanted you to be able to share that with us. Can you talk a little bit about that?

David Acosta:   22:53

So you know, I think cultural competency, a number of years back was really important as we became thinking about at that time, how do we provide the best culturally and linguistically responsive patient care, and we thought that cultural competency was going to be the thing sort of thing. And so I think we've utilized but I think it has limitations that we'll talk about in a minute for our viewers, I think, providing that type of response of care. And being conscious of both culturally and linguistically about for our patients. It does today, we're really emphasizing the important practice of cultural humility, for those audience that are listening in cultural humility is not new. But it was first coined by Dr. Oz trival on and Maria Garcia back in 1998. And it really includes the following elements. And I think this will resonate with a lot of listeners as well, because some of you are already doing this. But cultural humility says it requires is ongoing self-reflection, to continue to examine your own stereotypes and assumptions that you bring to the table that basically help you formulate and influence you how you see families, how you see patients that you encounter. And it really brings in some of those stereotypes or challenges, those stereotypes that you've may have developed over time. And the important piece about that reflecting on that and knowing how and where they formed, is a really a critical component of this as well. Cultural humility also requires developing and perhaps even rediscovering the meaning of being open-minded. And that is, what we know with our patients is that there are cultural differences that our patient encounters, they have different world perspectives and views and that we have and so this this is about us having a skill of having a respectful attitude towards listening towards listening, but also understanding people's differences as well. And it also requires physicians, any healthcare provider, recognizing the power, the authority and the privilege that they have, that they bring to the table that sometimes influences decision making. And when you're dealing with different cultural groups, different population groups, there's so much respect for the physician, because of their stance of authority and power, that sometimes they will not challenge those particular stereotypes that you may have, and will not call you on it out of duty respect. But it also doesn't allow them to fully express their lived experiences, about their illness as well. So cultural humility is really about legitimizing alternative ways of being. And alternative ways of thinking, doesn't mean because you consider it that you agree with people, it just simply means that you have a conscious awareness about the others perspective, and the others have lived experiences as well. And as this willingness to learn on a continuous basis, and the ability to be enlightened by folks, even if let's say you take care of a particular population group, from a particular community, or a particular country in the world, it doesn't mean you're always the expert. Because the other thing that cultural humility does, it basically forces us to really understand the patient's perspective. And what I mean by that is the following. I can have two patients from a similar population group, and I can even be a physician from that particular patient group. But it doesn't mean that each of us follows the same traditions, cultures and customs, that cultural competency says this is what this particular population gave practices and beliefs. Because each of us as an individual have different lived experiences within our community, and also come from different places from that particular country you come from, so that in the individualism is so important of understanding that different perspective of books and as with cultural humility, says, cultural humility basically approaches, in a sense telling you about your lived experience of from your population group, in that community, in your neighborhood in your family, how do you see health? How did you formulate the foundation? What healthy really means? But how, what's your foundation of how you understand your illness? How did you come to know it, as well, because a lot of that knowledge foundation is so important for us to understand as healthcare providers of how did people get here? Why don't they take a particular treatment? Why did they go to a traditional healer? why did why did it take them so long? How did they develop mistrust and distrust for the system as well. So that's what I meant when I was talking about cultural competency can sometimes be limiting to us, and really contribute to the biases and stereotypes as we learn about different cultures, it boxes us too much as well. And we think it's a great place to start. But an extension of that would be to add cultural humility to it in order to find out what this person's individualized lived experiences, and how do they see health and illness in their own way.

Mandy Hawkins:   27:48

We see this every day in our centers, and I'm sure they're across the industry. And I think understanding our patients’ beliefs is really going to improve the way we care for patients and the patient's perception and wanting to accept that care and be compliant.

David Acosta:   27:49

Exactly.

Mandy Hawkins:   27:51

Yeah. Well, Dr. Acosta, you are so passionate about DEI, and it's encouraging to know that AAMC is committed to meeting our country's medical education needs. I am glad that you are at the top and the forefront of this. You've been generous with your time and expertise and I want to thank you for joining me today. I'm sure members of both our organizations as well as others will benefit from this podcast. So, thank you again for sharing your views and insights and all the efforts of the AAMC.

David Acosta:   28:19

Thank you so much for the opportunity, Mandy. It was a pleasure to talk with you and look forward to continue to work connection from both of our associations in the near future.

Mandy Hawkins:   28:30

I want to remind everyone listening that you can find more information about ASCA’s, workforce and diversity initiatives on the ASCA website. And finally, before closing, I want to once again thank our podcast sponsor AMSURG, a leading ASC management company with more than 250 ASC partners in 34 states. To learn more visit amsurg.com.