Introduction

The importance of diversity in the workforce has been well established in literature across multiple disciplines. Primary benefits of diversifying a team beyond the moral and ethical obligations to do so include increases in creativity, productivity, and improvements in outcomes [1, 2]. Specifically in medicine, however, studies have shown that the diversity makeup of the surgical workforce lags far behind the makeup of the American population [3, 4]. This discrepancy is further emphasized as one looks higher in the ranks of professional societies and academic institutions [3, 5,6,7,8]. With the growing emphasis on diversity, equity, and inclusivity (DEI), some small but positive changes have been seen in the surgeon workforce with increasing representation of women and individuals underrepresented in medicine (UIM) [7, 9,10,11]. However, much work remains to be done.

Professional societies were developed in part to form avenues for like-minded people to develop networking opportunities. Some of the values of these societies include the centralized educational and mentorship opportunities for surgeons of all levels, leadership positions, and sponsorship and recruitment of growing professionals [12]. However, there remained limited forums for discussing common concerns faced by minoritized individuals, such as addressing challenges encountered in academic advancement and promotion, developing more specific networking opportunities, and tackling unconscious bias. These needs resulted in the development of additional professional societies dedicated to representing a breadth of surgeon voices—the Association of Women Surgeons (AWS) founded in 1981, the Society of Black Academic Surgeons (SBAS) in 1987, the Society for Asian American Surgeons (SAAS) founded 2011, and the Latino Surgical Society (LSS) in 2017 [13,14,15,16]. In more recent years, the recognition for collaboration and DEI work in the larger professional societies subsequently led to the development of many prolific DEI task forces [17,18,19,20].

The Association for Surgical Education (ASE) was first established in 1980 to fulfill the role of a professional society for persons dedicated to surgical education. Since its inception, the ASE has been a proponent of establishing an open and nurturing culture. Indeed, Royce Laycock, the founding ASE president, described the annual meetings as open to all interested attendees and were deliberately designed to assist participants in gaining skills in teaching and education science research [21]. The ASE currently has a membership of 1117 individuals, welcoming members from multiple surgical specialties and numerous training backgrounds in education. Consistent with its original core values, the ASE has strived to maintain non-exclusivity through several mechanisms: (1) membership is open to “anyone with a passion for surgical education”, (2) any member can join a committee via the ASE open committee structure, and (3) positions on the Board of Directors have been created for trainee representatives [22]. There are also transparent leadership opportunities: (1) all committee chairs are voting board members, (2) all committee co-chairs are non-voting board members.

Despite these intentional efforts, the ASE leadership realized that more focused DEI attention was needed. In 2018, ASE president Amalia Cochran entitled her seminal presidential address, “ASE: You Belong Here,” which emphasized that “one of the most important ways for us to ensure the wellness of ourselves and the next generation of surgeons is to create a climate of belonging” [23]. Subsequently, in 2019, ASE president Ranjan Sudan established the ASE DEI task force. The task force is: “committed to improving cultural awareness and increasing diversity, equity and inclusion in our organization. As surgeons and educators, we seek to improve the care of our patients as we strive to educate ourselves and champion causes to advance diversity, equity and inclusion in surgery” [24].

One of the most apparent needs identified by the DEI task force was to examine the current culture of the ASE more closely. This study aimed to assess experiences and perceptions of ASE members regarding inclusivity, collegiality, transparency, and discrimination, with the intention of characterizing the current DEI climate and identifying areas for improvement to guide future ASE efforts.

Methods

Study and survey design

This study utilized a mixed-methods, cross-sectional survey design to assess the ASE culture. The survey was a modified version of the previously published University of Michigan’s climate survey [25]. Modifications were made using consensus decisions by the DEI task force in consultation with an investigator (D. Telem) with prior experience using this survey for national surgical organization purposes [17]. The survey assessed various components, including demographics of the respondent (age, gender identification, sexual orientation, location, ethnicity, and membership category), overall experience within the ASE in various domains (satisfaction, value, camaraderie, ascendancy, and transparency), experience with discrimination (sexual, age, race/ethnicity, gender, or membership category), and consideration of leaving the society and reasons why. Demographics questions were categorized according to currently accepted terminology [26]. Quantitative data were collected using a Likert scale with responses from 1 (completely disagree) to 10 (completely agree). In addition, four open-ended questions were included, which asked: (1) recommendations to improve member involvement, (2) recommendations to improve diversity and recruitment, (3) recommendations for the DEI task force this year, and (4) anything we did not ask/additional comments. This paper was reviewed and approved the ASE DEI task force and Board of Directors.

Data collection

The survey was prepared for dissemination using SurveyMonkey® and first pilot tested with all ASE executive committee members. After receiving approval from the ASE Board of Directors, the survey was then distributed to all ASE members using the membership listserv beginning November 13, 2020. The distribution list included 1117 members, consisting of physicians, trainees, non-physicians and emeritus members. Three reminder emails were sent at weeks 1, 2, and 3. Additional efforts to obtain responses included a targeted email to all ASE committees and the ASE Board of Directors in December 2020 and dissemination during the Annual Meeting Presidential Address in April 2021. The survey closed on June 28, 2021; a total of approximately 7 months was allowed for data collection. Survey participation was voluntary and anonymous unless the respondent intentionally provided their name and contact information.

Data analysis

Descriptive statistics were used to analyze quantitative data. Percentages were used to describe frequencies and means were used as the measure of central tendency. Data from open-ended questions were analyzed using qualitative content analysis [27,28,29,30]. A conventional approach with iterative data review, and resulting inductive coding was performed to derive subcategories. Coding was performed by MN, a female surgery resident (3 year involvement with ASE, 1 year as a DEI task force member). Secondary review for consensus building was performed GS, a research scientist with expertise in qualitative research (8 year involvement with ASE, 4 years of leadership roles). Subcategories were grouped into categories based on further consensus review.

Results

Demographics

The survey response rate was 20% (220/1117) and the demographics of survey respondents are listed in Table 1. There was a largely equal representation of male (45.5%) and female (44.5%) respondents, with otherwise a large percentage of heterosexual/straight (85.4%), Physician (80%), white (65.3%), national (94.8%), and non-disabled participants (88.8%). Of those who selected multiple ethnicities (n = 16), 87.5% were a mix of White and one or two other ethnicities. The average age was 48.3 (range 25–81). The vast majority (94.8%) were from the United States (US) with the most prevalent states including Massachusetts (10.3%, MA), New York (9.2%, NY), California (8.0%, CA), Georgia (6.3%, GA), and Texas (5.2%, TX). The international respondents represented 5.2% and were primarily from Canada, Japan, and Pakistan.

Table 1 Demographics of the survey respondents
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Overall experience

Average ratings for each question regarding the overall ASE experience were strongly positive (Score > 7). Respondents gave the highest ratings particularly for the statements “My ASE colleagues are supportive of one another” (8.4), “I get along well with my ASE colleagues” (8.4), “My ASE colleagues respect me as a person” (8.3), and “Overall I am satisfied with my ASE membership” (8.0) (Fig. 1).The lowest ratings, despite still scoring highly positive, were for the statements “I feel as though advancement options in the ASE are open to me” (7.3), “I feel that the ASE is transparent” (7.5), and “I feel I fit well in the ASE society” (7.7).

Fig. 1
figure 1

Comparison ratings for overall experience at the Association for Surgical Education. Responses ranged from 1 (completely disagree) to 10 (completely agree)

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Discrimination

Average ratings for each question regarding overall discriminatory experience in the ASE were strongly supportive (Score > 7, Fig. 2). Respondents gave the highest ratings particularly for the statements “ASE does not discriminate on the basis of race/ethnicity” (8.7) and “ASE does not discriminate on the basis of sexual orientation” (8.6). The lowest ratings, despite still scoring highly positive were for the statement “ASE does not discriminate based on membership category (Example: Emeritus, Physician, Non-Physician, Trainee)” (7.8).

Fig. 2
figure 2

Ratings of discrimination experience in the Association for Surgical Education. Responses ranged from 1 (completely disagree) to 10 (completely agree)

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When asked if some ASE members had condescending attitudes to certain demographic groups (scale 1-completely disagree to 10-completely agree with concern considered a score > 5), 28% of respondents expressed concern of condescension towards women, 23% towards the LGBTQ + community, and 22% to racial/ethnic minorities (Fig. 2).

Of those who responded to the survey, 96% reported never personally experiencing discrimination, while 4% (n = 9) reported they had (Fig. 2). These respondents were 56% physicians, 56% white, and 67% female. When prompted as to the focus of the discrimination (multiple selections were allowed), 67% (6/9) reported discrimination by membership category (three physicians, three did not wish to disclose their membership category); 67% (6/9) reported by gender (five were women); 44% (4/ 9) reported by age; 11% (1/9) reported by sexual orientation (orientation not specified).

Analysis of the free text comments included recurring positive comments: ASE is a safe place, no experiences of recognized discrimination, inclusivity and collegiality, and revised membership categories are more inclusive. Concerns included: all male executive committee, lack of international collaboration, age discrimination, lack of LGBTQ + representation, lack of Black/African representation, logistics of joining open committees, and a single witnessed sexual harassment event at one conference.

Consideration of leaving the ASE

When asked if the respondent had ever considered leaving the ASE, 12.0% (n = 25 of 209 respondents) responded in the affirmative (Fig. 3). When these respondents were prompted for their reasons (scale 1 = not at all to 10 = a great deal), they equally desired more leadership opportunities (rating = 5.1), to participate in a society more welcoming of all members (rating = 5.0), and to have more visibility within the organization (rating = 5.9).

Fig. 3
figure 3

Comparison ratings for reasons for leaving the Association for Surgical Education (data are shown for 25 respondents who reported considering leaving the ASE). Responses ranged from 1 (completely disagree) to 10 (completely agree)

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Comparison of responses for those who had and had not experienced discrimination

Compared to members who had not experienced discrimination, those who had experienced discrimination more often rated the overall experience lower, recognized more discrimination, and answered more strongly in support of the reasons for leaving the ASE.

Regarding overall experience, ratings by those who had experienced discrimination ranged from 2.3 up to 5.3 points lower on the Likert scale. The questions with the highest discrepancy in ratings included “I feel that the ASE offers equal advancement opportunities” (2.4 vs 7.7), “I feel that the ASE is transparent” (2.9 vs 7.7), “I feel as though advancement options in the ASE are open to me” (3.1 vs 7.5), and “I feel that my voice and opinions are heard within the ASE” (3.6 vs 7.5; Fig. 1).

With regards to discrimination, discrepancies in responses ranged from 2.7 up to 5.3 points on the Likert scale (Fig. 2). The questions with the highest discrepancy were “ASE does not discriminate on the basis of gender” (3.4 vs 8.8), “ASE does not discriminate on the basis of age” (3.7 vs 8.6), and “ASE does not discriminate based on membership category” (3.1 vs 8.0).

Of the 25 respondents who had considered leaving the ASE, seven (28%) had experienced discrimination, whereas 18 (72%) had not. Compared to members who had not experienced discrimination, those who had experience discrimination rated the reasons for desiring to leave anywhere from 1.5 to 2 × higher on the Likert with the highest rated reason being the desire to participate in a society more welcoming of all members (7.9; Fig. 3).

Content analysis of the open-ended questions

Analysis of responses to open-ended questions resulted in the identification of five categories: recruitment, retention, reporting, structural changes, and education. Categories and illustrative quotes are provided in Table 2.

  1. (1)

    The recruitment category referred to the intentional outreach to a particular demographic, methods for outreach, and incentives to future members. This incorporated underrepresented member targets within the organization (i.e., medical student, smaller programs, doctors of osteopathic medicine, international members, LGBTQ +) as well as novel strategies for recruitment, such as personalized letters, developing alliances with existing organizations, and membership options to offset funding.

  2. (2)

    Retention were methods of fostering an engaging environment to maintain membership, including developing mentorship and advancement opportunities.

  3. (3)

    Reporting referred to transparency and accessibility of communication from the organization. This was specifically with regards to the website organization, committee involvement, building a membership directory, networking opportunities, safe reporting services, and the transparency of the findings of this study.

  4. (4)

    Structural changes were defined as evolving the current organization of the ASE leadership and committees. Respondents identified concerns including the all-male executive board, and the limited representation of minoritized groups in committee leadership, speakers/panels, and award recipients.

  5. (5)

    Education was defined as future endeavors to develop and disseminate best practices in surgical training with particular attention to DEI efforts.

Table 2 Content analysis of open-ended questions with illustrative quotations
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Discussion

In light of the ASE’s efforts to establish a DEI task force and identify targets for improvement, this study aimed to provide insights into the current ASE climate. The results were encouraging, with an overall sense of positivity demonstrated by high ratings for feelings of respect, satisfaction, and camaraderie within the society. Simultaneously, the data identified numerous targets that will help inform the future efforts of the ASE DEI task force.

Given the size and scope of the ASE, it is reassuring that the vast majority of respondents reported having an overall positive experience within the association. In fact, the highest scoring statements included “my ASE colleagues are supportive of one another” and “my ASE colleagues respect me as a person.” Open-ended responses also recognized collegiality, and the growth in the ASE over time both with regard to transparency and the inclusivity of the membership categories. These themes of support, respect, and growth are core values of the ASE and are consistent with the ASE’s mission and strategic plan [31].

Even with the overall positive feedback, we recognized several areas that need improvement, including addressing discrimination. While 4% of individuals reported having experienced discrimination in the ASE is similar to rates reported by other surgical organizations, the ASE is even more committed to inclusivity and our goal would be that no member would experience discrimination [17].

Our data indicated a substantial negative impact on satisfaction for those who experienced discrimination. Even though individuals who experienced discrimination represented only 28% of respondents who had considered leaving the ASE, these individuals rated their experience and satisfaction much lower on all questions and their reasons for leaving much higher (Figs. 1, 3). In addition, this group may feel relatively vulnerable, as none provided contact information for potential follow-up.

Of the five insightful recommendations and categories that arose from these data, three major categories emerged as ideal targets for the DEI task force’s work: recruitment, retention, and reporting.

  1. 1.

    Recruitment: The open-ended responses allowed for rich ideas to emerge surrounding DEI recruitment groups and strategies. Groups that were emphasized included medical students, residents, DO programs, smaller programs, non-surgeons, international members, surgical subspecialties, ethnic minorities, and the LGBTQ + community. Some suggested recruitment strategies included collaboration with representative societies, such as AWS, SBAS, SAAS, and LSS, having personalized invitations from existing members, and improving membership and meeting accessibility (institutional memberships, joint society memberships, scholarships or discounted meeting rates, and childcare options). Indeed, discussions between the leadership of the ASE and both AWS and SBAS have been initiated, and an ASE International task force has been established.

  2. 2.

    Retention: A key identified concept was not only intentional recruitment to support the DEI efforts, but possibly more importantly retention in terms of meaningful involvement and value in being an ASE member. Retention efforts and recommendations focused on active recruitment of new and existing members into ASE committees to enhance member involvement and opportunities, creating a centralized mentorship/sponsorship network, diversifying the leadership of the society, providing more intentional consideration to underrepresented groups for speaking roles, grants, scholarships, and other awards, and promoting DEI education for ASE members. Over the past few years, self-nominations for leadership positions were adopted; more deliberate efforts to make members aware of these processes and provide opportunities for our growing membership are likely needed.

  3. 3.

    Reporting: A repetitive category recognized was the need for ongoing and transparent communication. One often cited request was for transparent communication regarding the results of this survey, which we hope has been addressed in this paper. Other requests seemed to seek improved communication surrounding available opportunities for current members to engage and network with other ASE members with similar interests. While some requests involved establishing a system for safe reporting, this may be outside of the ASE’s scope. The ASE Membership Committee has initiated work to establish a membership directory to foster increased transparency of the ASE member makeup and enhance communication between members. The ASE has continued to embrace its open committee structure and recently implemented a new process for “joining” these committees to facilitate communication. In addition, the ASE is establishing a Communications Committee to explore and address many of these issues.

The authors recognize some limitations with this study. First, there was a 20% response rate with limited reporting from underrepresented members, including some ethnic groups (Black or African American [0.9%], Alaskan Native or Native American [0.9%], and Native Hawaiian or Other Pacific Islander [0.5%]), LGBTQ + members, international members, and disabled members. This lack of representation can contribute to sampling bias. However, we believe the data still serves its original purpose of widely identifying areas for improvement. Second, the survey allowed components to be left blank which in some cases possibly underrepresented the respondents. Similarly, only 33 to 56 people responded to the open-ended questions, which provided valuable insight albeit from a limited cohort. And finally, there may be instances of subconscious bias or microaggressions that may not be identified in a survey such as this one which asks more towards overt evidence of discrimination.

Regarding the geographic distribution of respondents, our data are relatively representative. For instance, according to our ASE member database, 93.8% of members are from the US, which is relatively similar to the 94.8% of our survey respondents. For international members, the top two survey respondent countries were Canada and Japan, which mirrors our top two international member countries. Four of the five top responding states were also within the top five member states (MA, NY, CA, and TX). The geographic distribution of respondents was quite similar to the distribution of ASE members, with the top three regions being the Northeast, Midwest, and South. Thus, despite our overall response rate of 20%, our data seem to accurately reflect the geographic distribution of our members.

Conclusions

In efforts to guide the work and targets of the ASE DEI task force, this Climate Survey provided valuable insight. Overall, the data support a positive culture reflecting ASE tenets, such as respect, support, camaraderie, and inclusivity. Despite small numbers of reported discrimination, these vulnerable members had lower ratings for overall experience and these findings were particularly enlightening. Key targets for future action include the need for targeted recruitment, retention and diversification strategies, and the development and maintenance of transparent and open communication.