How important is 'equity' when you're getting heart surgery?
A screenshot was sent to me of a social media post by a CEO whose friend was having heart surgery. It read: "I talked to him about three hours before his surgery and his only concern was that he hoped his surgeon wasn't hired to fill a racial or gender quota." This sentiment crystallizes a dilemma currently facing the profession of surgery.
Diversity, Equity, and Inclusion (DEI) initiatives in surgery are ubiquitous. DEI has been embraced by innumerable departments of surgery and societies of surgeons as well as healthcare institutions. Vice chairs of DEI have been appointed, and DEI committees have been created within surgical departments, adding to a costly DEI bureaucracy already established in hospitals and universities. DEI no longer challenges the system; it is the system, and the public is aware.
Perhaps because of cancel culture, discussion of DEI within the ranks of surgeons has been limited. There has been no debate. As an alternative to DEI in academia, Abbot and Marino (two scientists) have proposed a different framework: Merit, Fairness, and Equality (MFE). An open discussion of the two systems, DEI and MFE, is warranted, in my opinion, in the field of surgery.
The basic unit of DEI is the group. Human beings are categorized by skin color or sex, with oppressor or victim status attached to each group, irrespective of individual life experiences. The basic unit of MFE is the individual, and judgment is based on merit. Excellence is considered the highest form of merit.
Perhaps the closest word to "diversity" is "variety." The variety of human beings participating in the field of surgery is enormous; it is a worldwide profession. Equity in DEI means equal outcome. Equality in MFE means equal opportunity. Equity in surgery, as in nature or society, is unachievable. Some surgeons receive more referrals, do more operations, and have fewer complications than others. Compensation among surgeons is also unequal because it is usually based on productivity. In general, surgeons strive to be excellent, not equal.
Inclusion is an admirable goal in surgery if it means inclusion with uncompromised standards. No surgeon would want to be perceived by a patient or colleagues as being "included" with inferior qualifications because of group identification. No party would be served well — patient, surgeon, profession, or institution. Furthermore, if the inclusion of one group is advanced by discriminating against another group, then exclusion is a more accurate term.
Merit, the first word of the MFE framework, is a traditional measure in surgery and other professions. Steve Jobs hired "A Players" at Apple. Jack Welch actively fired "the bottom 10%" at General Electric. Michael E. DeBakey, a founder of cardiovascular surgery, promoted excellence. In an interview in 1996, he stated, "Concentrate on excellence. ... I think you should put your money where the track record shows that it works best — in people who pursue excellence in the field."
A goal of individual excellence in surgery is fundamentally different from a goal of group equity. Though DEI has been rather quickly embraced by leaders in surgery, its general support by members of the profession is questionable.
The academic framework that produces the highest-quality surgeons will eventually prevail. The DEI framework, in my opinion, is so inherently flawed that it will fail. Patients, like the one above, expect their surgeon to be hired not to fill a group quota, but because of individual merit, which is the only reliable measure.
Dr. Roberts is chair of cardiac surgery at Baylor University Medical Center in Dallas.
Image via Pixnio.
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