“Diversity in Surgery” by ICSM's Surg Soc - an interview with Viraj Shah, organising chair

Imperial Medicine Apothekathryn Kathryn Chia

“Diversity in Surgery” symposium by ICSM's Surgical Society

On the 12th of December, the “Diversity in Surgery” symposium, organised by the Imperial College School of Medicine’s (ICSM’s) Surgical Society took place. It was an incredibly inspiring afternoon, where participants had the opportunity to hear from world renowned surgeons coming from an abundance of different backgrounds. From Professor Averil Mansfield CBE -- the first female professor of surgery in the UK, to Ms Lubna Bakr -- the first female Cardiac surgeon in Syria, all the exceptionally influential speakers and panellists are trailblazers in the surgical community. The speakers described their journeys towards success and recounted the challenges they faced along the way. Throughout the event, the speakers stressed the importance of perseverance and resilience, expressing that no challenge or obstacle was too great if we wanted to overcome it. Their tenacious mindsets, despite any discrimination they might have faced was truly encouraging!

Before this symposium, I honestly had never really thought about the barriers that female, BAME (Black, Asian and minority ethnic) and other minority groups of individuals might face in Medicine and particularly in surgery. The Q & A segment at the end of the symposium was also immensely helpful and interesting, as I had the opportunity to ask questions which were comprehensively answered by the panellists. I’m truly grateful for the insight I was given into Diversity in Surgery by attending this symposium. I found it extremely thought-provoking and intriguing. I hope that symposiums like these can continue to inspire the new generation of Doctors and Surgeons!

An Interview with Viraj Shah, the organiser of the event

Viraj Shah Apothekathryn
Photo of Viraj Shah

Q: Tell us a little bit about yourself!

Hi! My name’s Viraj and I’m currently a second year medical student at ICSM, a General Executive in ICSM’s Surgical Society committee and the organising chairperson of this year's “Diversity in Surgery” symposium.

Q: What inspired you to change the symposium from “Women in Surgery” to “Diversity in surgery”?

I want to first preface this by saying that “Women in Surgery” (WinS) is still a very necessary cause that needs to be championed. More than anything, this event really highlighted the extraordinary number of barriers that women from all backgrounds still need to overcome to succeed in surgery especially given the fact that the barriers they face just aren’t equivalent to their male counterparts.

More than anything, a roster of events this year including the Black Lives Matter movement, really shone a light on issues that have never been raised consciously in fields like surgery - again only one aspect of Medicine per se. I think it unveiled a lot of structural inequality and systematic racism at the foundations of society in general, of which healthcare is a core part. I think it's probably the right time to have this sort of event, given what is happening in the world of surgery at the moment, with the Royal College of Surgeons (RCS) currently conducting an independent Diversity Review and the newly-elected RCS council being predominantly made up of white cisgendered men.

Other minority groups in surgery like BAME individuals, people with disabilities and LGBTQ+ people are often not platformed as much because they’re not seen as “glamorous” minorities. I believe that there’s no other medical school event in the UK that really focuses on the wider picture of diversity and I think it’s time we change that - to explore issues like unconscious bias and, one that I’m really passionate about, intersectionality.

ApotheKathryn Kathryn Chia ICSM
A snippet of Ms Anthea Davy's talk

Q: Do you know how WinS began in imperial?

It initially began on a much smaller scale, as an in-person panel discussion, established as part of the RCS WinS network. We’d normally have a series of keynote speaker speeches, a panel Q&A followed by a wine and cheese reception afterwards. Many other surgical societies in the UK have also really started to engage with the RCS WinS network and create their own WinS events. We have been running this event for a number of years successfully, but due to the fact that there are honestly a lot of WinS events around the country and globe now, the format has been quite stale for a while - this is why we wanted to revamp and reimagine it this year.

Q: How did you manage to find so many different, influential and inspiring speakers?

ApotheKathryn Kathryn Chia Srugery
Speakers at the "Diversity in Surgery" symposium

To put it lightly, it was very difficult. As we were keen for our symposium to have a more diverse theme this year, we wanted to make our line up truly representative of all the different shades of people that are underrepresented in surgery. We actually have a long history of working with Ms Stella Vig for our previous WinS events and in speaking to her, we realised that she would make the perfect chair as she really understood our intentions and motivations with this event. Regarding Professor Mansfield, I think that almost everyone with any awareness of WinS knows about her at this point. She's a real trailblazer and we felt that her current perspective was just as valid as it might have been at an event 10-20 years ago. In terms of our other speakers, we actually heard a lot about Ms Lubna Bakr online and we’ve also gone to a few talks she’s given including her much larger presentation at UCL. Apart from that, we used a lot of networks including Black British Professionals & Melanin Medics -- both organisations with Instagram accounts that really champion successes of people who have broken barriers to succeed. We found a lot of people through their Twitter and Linkedin as well.

Just a word of warning, if you are planning an event, it’s not easy to find representative speakers. We would definitely have appreciated someone with a background in disability and someone who identified as LGBTQ+, but we didn’t appreciate how difficult they were to find. We’d welcome them next time with open arms! A lot of people were more responsive than I thought they’d be and a lot of people were willing to get behind our event. I think it was because our theme this year was so novel that they hadn’t really engaged with something like this before and so were perhaps more willing to explore it, as compared to something like WinS, where there are just so many similar events. The speakers can get bored of doing the same talks centric to outdated questions including “Can I be a surgeon and have a family/children?”, so I think that’s why we got a lot of response to this event.

Q: Do you think that the people more responsive to these issues are mainly those affected by them?

Imperial Medicine Kathryn Chia ApotheKathryn
Viraj at the ICSM Arts Dinner (2019)

I’m not sure. I would base my opinions on our cohort currently at ICSM which is already a very diverse community, not just in terms of ethnicities but in terms of people from all backgrounds (gender identity, disability, sexual orientation, worldviews). I’d honestly say ICSM is probably one of the most international and hence multifaceted medical schools in the UK and I hope that was also mirrored by the external students that came to our event. What I noticed is that we got a lot of positive comments before and after the event from people from the backgrounds that the event was attempting to reach out to, so I hope that’s a sign that it was well received by individuals from the backgrounds that we wanted to reflect in our symposium.

It’s important for everyone to hear these topics because I believe we cannot facilitate real change, in any situation, without cooperating with the whole team. We can’t make a minority group feel more visible and respected without the majority group empowering them. It’s very important for us to get behind the same aims even if we aren’t members of those communities. This actually stems back to a much larger point - that we cannot expect others to understand without educating them. As sad as it is, a lot of people in the world are still quite naïve and ignorant to these issues. In an ideal world it should be an individual’s responsibility to educate themselves and the onus should not be on minority communities to have that responsibility. However, I personally believe this isn’t a very progressive approach to take to achieve real change in the short term. Through refusing to engage with people who aren’t educated on these issues, it essentially creates a “them” vs “us” divide and I don’t think that’s what diversity is about at all. Diversity is about everyone coming together which is why I think we need to take a more “effective altruism”-esque approach.

On allyship...

I think that everyone has the ability to be an ally. For example, a white woman can be an actionable ally to a person of colour, a man can be an ally to a woman, a heterosexual person can be an ally to someone from the LGBTQ+ community, an able bodied person can be an ally to someone with a disability and so on. Allyship is a lifelong process of building relationships on trust, consistency and accountability. Working together really allows people to grow and learn about themselves and build confidence with others. These topics are things that need to be engaged with by other people because they need to know how to lift other people up by advocating for them and recognising the inequalities they face. This involves understanding the impact of microaggressions as well as believing other peoples’ experiences, and most importantly: listening, supporting and self-reflecting. Acting on all this will allow us to see change. I’ve always been a firm believer that small actions have a big impact and I feel that these changes can have a profound influence on altering the general dynamics in surgery.

Q: In the medical community, what are some things that people can do to help in supporting these communities?

There are lots of things we can work on. One of the most important things we can do is give a platform to other people who’ve had experiences that we might not have had, to lift them up significantly, through championing what they have to say and really engaging with them, listening critically and taking everything in holistically.

In terms of more actionable points, if you see discrimination, it’s your duty to call it out. Even in medical school, it’s your duty to educate the people involved if you are in a position to do so. I feel like you can only claim to be a serious ally if you take active measures to improve the lives of the people you say you care about affected by these issues - it’s really up to us as medical students to embrace diversity and foster an environment of inclusion, to involve everyone (even those in higher positions) in this. On the flipside, it’s not just about involving a lot of people from different backgrounds, it’s also about promoting some of them to positions where they might be leaders or have real impact - positions that might have been inaccessible to them before because of the “glass ceiling” we talk so often about. Other more first-level things to do include recognising our own unconscious biases - which, admittedly, is a process. Continued recognition, reflection and awareness of where these biases stem from is something I’m personally undertaking.

Another point I’d like to raise would be to use inclusive language. This involves avoiding terms that have a history of causing hurt and pain within these communities even if you may not actively believe them to be discriminatory at first glance - this is not our place to decide and is something that we should all make an effort to really change. Once we change this, we really change the whole dynamic. The last thing, which adds to my previous point, is to recognise and amplify representative voices. It’s not just about listening to them. You really need to raise them up and make people even hyper-aware of what they have to say - because some of these communities have very marginalised voices in wider society and it is up to us to understand the systematic and societal issues which may play a factor in our own upbringing and privilege. We should definitely use and acknowledge our own privilege to amplify those who don't have the same!

Q: Do you think this discrimination starts in medical school? Or does it really only get worse when you become a junior doctor/ surgeon?

I’d actually go so far to say that they happen before medical school itself. One of our speakers, Mr Jonathon Makanjuola said it was the constant comments that really demotivated him initially including “Why are you wasting your time being a doctor? You aren’t going to get into a medical school.” These comments might not appear racist on a surface level, but when you explore the deeper implications they have on the people they specifically target, commonly black men and women - it is clear there is much work to do. We should encourage all types of people to enter the medical profession because the medical profession is made to serve all kinds of people and we can’t say we truly represent all types of people without all types of people working in the profession. I feel that medical school can propagate these ideas further sometimes. For example, lots of skin conditions that we learn about are only shown on white skin. However, these conditions show up a lot differently on darker skin, which is a massive problem. When we eventually go on to become doctors, we don’t have the basic knowledge of what a condition can look like on black skin and therefore we are unable to do what a doctor should do (diagnose and treat!) - a major inequality issue. Thankfully, I think a lot of progress is being made in this area and, although massively overdue, it is very welcome. Essentially, quite a lot of things we learn about are Eurocentric with emphasis on white skin (PowerPoint slides, cadavers etc.) and, as a result, we do not get a rounded impression of what medicine actually looks like because things show up very differently on different skin tones. I feel that having a more diverse exposure to lots of skin types in medical school enables you to be more adaptable when it comes to practicing medicine.

Another example is that a black woman is almost never painted in a positive light in a medical school question (e.g. the angry black woman narrative - she is always “difficult to work with” and a bad “team player”). Situations like this can have a detrimental effect on a student’s development in medical school and I think it’s quite serious. There are still quite a lot of older people in the medical and, particularly, surgical profession who don’t really address this like younger people do.

However, I would say that there are specialties that are more progressive than others, like Psychiatry. Just by looking at the data, surgery is one of the least diverse specialities out there. I think that when you go to surgical wards (I don’t have a lot of experience but just hearing from my friends from older years), the comments and attitudes of many older surgeons speak for themselves.

These issues can get propagated after medical school and so when you become a junior doctor or surgeon, the undertones of “you don’t deserve to be here - this isn’t the place for you” are felt by many people underrepresented in surgery. That’s what I feel makes these challenges a lot more serious for these people from these communities and I think that it’s definitely something we need to address and act on more.

Q: Are people willing to “call out” those that discriminate against these communities?

I think that the culture is changing gradually, but I personally feel that medicine and surgery is very hierarchical, and because juniors don’t want to ruin their relationship with a senior, they may be scared to call them out. This is very fair, because when someone is senior to you, it’s very difficult for someone in a junior position to call them out because you don’t want it to affect your career and your progression within surgery, as these people will be on the boards determining your progression and things you might apply to. However, now that a lot of things are anonymised, a lot more young people are calling out workplace discrimination. Especially in the last year, there’s been a much bigger focus on this and, although a sweeping comment to make, I think it is generalisable that young people are much more aware of the privileges they have and how to use them for good. Even so, this doesn’t mean

that there still isn’t a lot of progress that needs to be made. A lot more can still be done to facilitate the ability to openly communicate and complain about inappropriate behaviour and action without having it affect your career and people’s perception of your ability to practice. I think that the medical community needs to do a lot more work on anonymising this (calling out others) and making self reflection and self improvement more standard. I don’t think they address issues like these enough, which is something I’d like to see.

Q: What are some changes you’d like to see in the medical and surgical community?

I’d like to see a much larger focus on individuals that aren’t really platformed right now. Women and BAME are very visible, but there are loads more minority groups that just aren’t that visible, like people with disabilities and those who are LGBTQ+, because there just isn’t a network in place for them. I’d also like to see a diversity in surgery network established in the same way that we have women in surgery, because I feel that the barriers they face can often be comparative and different to the ones women face. I don’t think that there’s an accurate representation or body that champions and advocates for their issues, so I’d love to see more networks for different communities so that they can work together. I hope that the “Diversity in Surgery” event inspires a lot more events like this around the country, to facilitate the conversation a lot more.

In terms of other things I’d like to see in surgery, I’d like to see surgery become a lot more cooperative rather than competitive. I feel that surgery attracts very competitive people, which can get destructive in terms of patient outcomes, as reflected by research & data, when they have the mindset that everything is a competition. I think the most important thing in terms of patient outcomes is to focus on working together for a common goal. When we do that, we can allow people to be unafraid to call out their peers or seniors at the same time. It’s important to realise that when it comes to a patient’s outcomes in surgery, everyone is on the same playing field and I think there’s a lot more to be done to work on that. I’d also like to see more diverse teaching in general - for example, by not having negative and historic stereotypes enforced on certain types of groups. For medicine, I think that diversity can be quite a checkbox exercise for people and it needs to be a lot more about working together.

Q:Do you think stereotypes and discrimination these minority groups face discourage them from pursuing surgery?

Yes absolutely. From what we’ve heard from our speakers, they were put off from pursuing their careers many times because of comments like, “Women should be GPs so they can have families” “You should try for a less competitive speciality” “You’ll find it hard to have a work life balance”, just because of their backgrounds. These microaggressions really compound the systematic barriers that are already in place and as a result people don't want to enter specialities where they feel that they won’t be respected. This is a reason why I feel visibility is so important. We need to amplify voices and make them visible and seen in surgical positions so that when people think of a surgeon, they are not just thinking of one specific type of person. If medical students see a broader range of people in surgery, they might begin to feel it would be a community they would be accepted into.

Q: Do you have any advice for medical students/ aspiring medical students from these backgrounds?

The most important thing is to realise that you can do it. I’m not sure if this would work for everyone, but I like to think that you should have a “prove them wrong” attitude. In terms of surgery, I think it's important to realise that surgery is for everyone and that you deserve your seat at the table and you shouldn’t let anyone tell you otherwise. To echo what Professor Mansfield said in her speech, it’s important to be a leader and a role model, but most importantly you need to recognise that you don't want to be like what's been in the past and it’s therefore important to be kind. She had four key points -- write, speak, find a mentor, be a mentor. This means not just finding a mentor to help you, but also being a mentor to help those who are coming up from even more marginalised communities. You have to be the mentor to them to encourage gradual and progressive change.

In terms of behaviour, having an awareness of leadership, being understanding, supportive and polite and using language in a positive way really helps. See obstacles as something to overcome and presume that there’s always a solution to something. It’s very important to stay true to yourself and believe in yourself, but also not to put pressure on yourself to recognise that you have to be the change. Everything comes in small steps and it's important to take those small steps to achieve a large jump collectively. It’s all about looking after yourself and others at the end of the day - we are medics after all…

Last Words…

I’d love to see much more focus on Diversity in Surgery. There hasn’t been a lot of research into it (from what I’ve seen working on my own research with a colleague about student perceptions of diversity in surgery) and I’d like to see a lot more than what I have from reading the existing literature and publications that are already out there. It’s just not something that has been brought to the forefront of conversation and I'd like to see it being spoken about a lot more!

K: Thank you so much for organising this symposium and doing the interview! It's amazing that you're speaking up and championing for these topics that need so much more representation :)


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