Von G. Samedi, MD, PhD
May 2022—The ineffectiveness of the U.S. health care system is well documented. The United States consistently allocates more resources for health care compared with other industrialized countries, while not holding the top spots for desired outcomes. A significant percentage of Americans is underinsured or uninsured, and access to quality care is widely asymmetrical among different racial and ethnic groups. Early in the pandemic, COVID-19 highlighted these health inequities in which Blacks, Hispanics, Native Americans, and immigrants were the populations to disproportionately experience disparities related to burden of disease and mortality.
In addition to the pandemic, in 2020, the video of the killing of George Floyd was a vivid symbolic reminder that inequities were not isolated to health care but pervasive throughout American society. These two events led numerous organizations and institutions, including in the health care industry, to enact policies and strategies aimed at broadly increasing ethnic representations in their respective fields. One frequently made argument for a diverse workforce among physicians is that the providers should look like their patients. This would presumably allow for empathy—advocacy among the former and trust from the latter.
As a mostly diagnostic medical specialty, pathology does not provide many opportunities for pathologists to interact with patients, so here equitable diagnosis seems to be more relevant than a diverse workforce. This would be incorrect, however, because providing equitable health care goes beyond patient contact. The pathologist can have an impact on health equity through education, research, establishment of reference ranges, the overall use of laboratory data, and broad advocacy. The CAP Foundation See, Test & Treat program is an excellent example of how pathologists can advocate for their patients. Many U.S. pathology professional societies, including the CAP, have long recognized the contribution and impact pathologists can make. While efforts to create a multicultural workforce and to address diversity in the workplace existed before 2020 in the pathology societies, these professional organizations have further invested resources in their existing and new initiatives related to diversity, equity, and inclusion (DEI). So how diverse, equitable, and inclusive is the field of cytopathology?
A 2021 study showed that fewer Black, Hispanic, Native American, or Alaska Native men and women are being admitted proportionally to medical schools than they were 40 years ago. While women are now entering pathology residency and fellowship training at rates equivalent to the percentage of women in the U.S. population, women make up less than 40 percent of practicing pathologists. The overall numbers and proportions of underrepresented populations in training, practice, or academia in pathology have remained essentially unchanged over 22 years, at less than five percent. According to the Department of Education, slightly more than half of Black and Latino (51.5 percent) students earned an undergraduate degree after six years, compared with nearly 70 percent of white students. This is a graduation rate gap of roughly 18 percentage points. Limited data are available on diversity among cytopathologists and cytotechnologists specifically. However, the overall pipeline for these two professional groups would suggest we are not where we want to be.
So where do we need to be? Diversity has many sides, including age, gender identity, sexual orientation, race, ethnicity, culture, religion, geography, disability, socioeconomic status, area of expertise, training philosophy, and personality types. The future and vitality of cytopathology depend on a workforce composed of diverse people, thriving in an inclusive environment, who can ensure creativity and innovation. The benefits of diversity go beyond fairness. There is overwhelming evidence that teams that include different kinds of thinkers outperform homogeneous groups on complex tasks, including problem-solving, innovating, and making accurate predictions. Furthermore, cytopathology, like transfusion medicine, is unique among other pathology subspecialties in that the diagnostic impression is provided by pathologists and cytotechnologists who have access to patients regularly. This makes it more urgent to curate a workforce that reflects the people it serves.
The events of the past few years have renewed questions about whether medicine is making progress in reflecting the full diversity of communities that physicians are called on to serve. Unfortunately, the data are clearly suggesting we are regressing, with a longstanding diversity gap that is widening. There is no quick recipe to reverse the trend, but we can take dedicated and purposeful actions to create a diverse workforce for the betterment of health care.
The flow in the pipeline for our field is critically low. Every year fewer and fewer U.S. medical school graduates are entering pathology. Multiple factors may be leading to the declining interest in pathology, but the decrease in pathology materials in the medical school curriculum has surely contributed. The CAP Pathology Pipeline Champions initiative (https://tinyurl.com/PathPipeline), one of four priorities of the CAP Pathologist Pipeline Ad Hoc Committee, is a wonderful way to reach out to prospective pathology trainees. The American Society of Clinical Pathology mentorship program is another platform to use to educate students in middle schools, high schools, and undergraduate colleges about career opportunities in pathology, including cytotechnology. Underrepresented communities should be the intended audience, regardless of the preferred outreach program.
The recruiting process can be a hurdle in reaching diversity if it is not designed to prevent implicit and explicit biases. Once a workforce is diverse, retention is best achieved through mentorship and sponsorship. The crucial glues to keep a diverse group of people working collaboratively are equity and inclusion for all. All these ideas are likely not new to most readers. In fact, many readers may be supportive of the vision of DEI, but perhaps fewer know how to move from a being a supporter to an advocate and an ally.
In recent years, most academic centers have begun to offer DEI classes or certificates. Many academic and nonacademic departments have created committees tasked to promote DEI. As a member of the profession, one should take advantage of these opportunities by signing up for a class or by joining one of these committees. The most important characteristic of a DEI advocate and ally is not his or her background, race, or ethnicity. It is the willingness to be open-minded and proactive in promoting DEI.
The inequities in our society go beyond the health care system, and it would be naïve to think we can reverse them with a few strategies. However, it would be irresponsible not to create strategies that could begin to do so. Over time, our involvement and engagement in DEI initiatives would bear fruit. Reaching DEI is more than about fairness; it is essential for our profession, for medicine, and above all for our patients.
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Dr. Samedi, a member of the CAP Cytopathology Committee, is associate professor of pathology, University of Colorado Anschutz Medical Campus School of Medicine, Aurora.