Crohn’s disease (CD) is a chronic and recurrent condition requiring long-term management. The American Gastroenterological Association (AGA) provides a risk stratification tool to guide treatment selection.1 Using this tool in claims databases is challenging due to missing clinical indicators (ie, anatomic involvement). Without medical record abstraction, assessing moderate to high (M/H) risk CD prevalence is difficult. This study quantified the proportion of CD patients meeting AGA-defined M/H risk criteria and described their demographic, clinical, and healthcare resource utilization (HCRU) patterns by risk status. This retrospective cohort study used the Healthcare Integrated Research Database (HIRD®), a large, nationwide claims-based real-world data source of commercially insured and Medicare Advantage populations in the US. Adults diagnosed with CD between 11/17/2019 and 8/16/2024 were eligible if they had an outpatient CD encounter with a gastroenterologist (most recent being the index date), were ≥18 years old on index, had 1 additional CD diagnosis during the year prior to the index date, no prior evidence of ulcerative colitis (UC), and ≥685 days of continuous enrollment prior to and ≥45 days following the index date. To address missing clinical indicators in claims, a subset of 700 patients underwent medical record abstraction. This enabled application of AGA criteria for M/H risk classification, as detailed in the figure legends. Patient characteristics and HCRU were assessed using claims data during the 1-year pre-index period and stratified by AGA risk status. Among 7,835 eligible patients, mean (SD) age was 49.2 (16.9) years, and 54.2% were female. Of the 700 abstracted patients, 490 (70.0%) were M/H risk. Compared to low-risk patients, M/H risk patients were younger (mean [SD] age 49.5 [17.1] vs 56.2 [13.8] years old), and less likely to be female (54.1% vs 61.4%). CD-related diagnostic testing and imaging (e.g., CT, MRI) were common (52.9% low risk and 63.7% M/H risk) and surgeries (colectomy, resection) were more frequent among M/H risk patients. Of the M/H risk, 257 (52.4%) received any advanced therapy during the same year (vs. 94 [45.7%] for those at low risk). HCRU was higher among M/H risk patients, including all-cause inpatient and emergency department (ED) encounters, compared to patients at low risk (Inpatient: 17.3% vs 10.0%, ED: 27.3% vs 19.0%). In this retrospective cohort study, 70% of CD patients met the AGA definition of M/H risk and 52.4% received advanced therapy. Patients with M/H risk had higher rates of inpatient and ED use, imaging, surgeries, and diagnostic testing than low risk patients. 1Sandborn WJ. Crohn’s disease evaluation and treatment: clinical decision tool. Gastroenterology. 2014 Sep;147(3):702-5. https://www.gastrojournal.org/article/S0016-5085(14)00918-4/fulltext. Figure 1:Baseline demographics Abbreviations: N/n, number; %, percent; SD, standard deviation; IQR, interquartile range; NH, non-Hispanic) Risk classification: Based on AGA criteria. M/H risk: Age at initial diagnosis < 30 years, extensive anatomic involvement, perianal and/or severe rectal disease, deep ulcers, prior surgical resection, stricturing and/or penetrating behavior. Patients not meeting M/H risk criteria were classified as low risk. * Cells with values of 1 to 4, or cells where values 1 to 4 can be derived, have been masked per Carelon Research privacy policies. The Northeast cell (>1,440*) was masked to prevent back-calculation of the of the value in the ‘unknown’ region.Figure 2:Clinical measures and healthcare resource utilization during the 1-year pre-index period Abbreviations: N/n, number; %, percent; SD, standard deviation; HCRU, healthcare resource utilization; CD, Crohn’s Disease. Risk classification: Based on AGA criteria. M/H risk: Age at initial diagnosis < 30 years, extensive anatomic involvement, perianal and/or severe rectal disease, deep ulcers, prior surgical resection, stricturing and/or penetrating behavior. Patients not meeting M/H risk criteria were classified as low risk. * Cells with values of 1 to 4, or cells where values 1 to 4 can be derived, have been masked per Carelon Research privacy policies. 1 CD-related imaging includes CT scans, endoscopy, MRI, and ultrasonography. 2 CD-related surgeries includes cecostomy, colectomy, endoscopic balloon dilation of the colon, fistulectomy/fistulotomy, incision/drainage of the colon, rectum, or anus, intestinal resection, placement or removal of seton, J-pouch formation, proctectomy, proctocolectomy, repair of anal fistula, or J-pouch, and stricturoplasty. 3 CD-related diagnostic testing includes abdominal MRI, any CT scans, colonoscopy, endoscopy, HRCT, magnetic resonance enterography, MRI, and ultrasound (abdominal, pelvic). 4 Advanced therapy for CD includes infliximab and biosimilars, adalimumab and biosimilars, ustekinumab and biosimilars, certolizumab pegol, vedolizumab, natalizumab, risankizumab, mirikizumab, guselkumab, and upadacitinib.

Background and Aims Digital health interventions may improve preventive care for patients with inflammatory bowel disease (IBD), but implementation barriers can limit effectiveness. We evaluated a multisite digital vaccine outreach initiative and identified implementation barriers and facilitators using the Consolidated Framework for Implementation Research (CFIR). Methods We conducted a qualitative case study across three academic medical centers from 2022 to 2024. Survey responses from clinical coordinators and principal investigators were coded within CFIR domains. The intervention used automated text messages with links to patient education and interactive health assessments. Results Patient engagement was limited at all sites. Pre-existing vaccination programs facilitated integration, whereas sites without established infrastructure faced greater difficulty. Institutional constraints, including institutional review board restrictions that excluded two-thirds of patients at one site, limited enrollment. Many patients distrusted unsolicited automated messages and perceived embedded links as phishing attempts. Weekly staff time varied substantially, and turnover disrupted implementation continuity. Despite limited platform engagement, the initiative increased provider attention to vaccination. Conclusion Digital vaccine initiatives require more than technology deployment. Successful implementation should include early assessment of institutional capacity, patient-centered design addressing trust and communication preferences, baseline needs assessment, structured implementation support, and clear gastroenterology-primary care workflows. Hybrid approaches combining digital outreach with communication from known clinicians or nurses may be more effective than fully automated messaging for preventive care in IBD.

Background:Gastrointestinal (GI) cancers are a leading cause of morbidity and mortality worldwide, accounting for a substantial portion of cancer incidence and cancer-related deaths. Randomized clinical trials (RCTs) are fundamental to the development of new therapies, as they generate evidence on efficacy and safety. However, concerns persist regarding whether trial populations accurately reflect the demographics of real-world patient populations, including variations by age, sex, race, and ethnicity. Underrepresentation of specific subgroups, such as older adults, racial/ethnic minorities, or those with distinct biological risk factors, can limit the external validity of trial findings and impede equitable treatment outcomes. As global populations become increasingly diverse and the burden of GI cancers continues to rise, identifying and addressing disparities in trial enrollment is essential for advancing precision medicine and ensuring that evidence-based treatments benefit all patients equally. This study aimed to compare the demographic profiles of participants in GI cancer RCTs with real-world data, and identify specific disparities in age, sex, race, and ethnicity that could undermine the generalizability of trial results. Methods:We performed a retrospective analysis of GI cancer RCTs registered in ClinicalTrials.gov between 2000 and 2024. Trials reporting demographic data on age, sex, race, and ethnicity were included. We categorized these trials based on cancer subtype [colorectal, pancreatic, gastric, hepatic, esophageal, and cholangiocarcinoma (CCA)]. The distribution of demographic variables was compared against real-world incidence data from the Surveillance, Epidemiology, and End Results (SEER) program. Discrepancies were quantified as the difference between trial participant proportions and SEER population estimates to identify under- or over-represented groups. Results:We observed consistent underrepresentation of older adults (>65 years) across multiple GI cancer subtypes, particularly those with higher prevalence in older populations. Male participants were disproportionately low in esophageal and hepatic trials. Racial and ethnic imbalances were most evident in pancreatic, hepatic, and CCA studies, with White participants overrepresented and Black, Asian, and Hispanic populations underrepresented. Conclusions:Significant demographic disparities persist in GI cancer RCTs, notably for older adults, men in certain subtypes, and racial/ethnic minority groups. These discrepancies threaten the generalizability of clinical trial evidence, potentially perpetuating gaps in care. More inclusive recruitment strategies and trial designs are essential to ensure equitable treatment outcomes for diverse patient populations.

Introduction: In the wake of racial reckoning in the USA and heightened awareness of health disparities that minoritized individuals face on a daily basis, the AAMC guidelines advocate for integrating diversity, equity, and inclusion (DEI) competencies throughout the medical education continuum. We aimed to assess the extent of representation in graduate medical education in gastroenterology/ hepatology by investigating the extent to which there is diverse representation in clinical cases in 3 large question banks published by major scientific GI societies. Methods: We reviewed the DDSEP+ question bank from AGA, the 2022 self-assessment test from ACG and GESAPX from ASGE offered for ABIM GI certification exam preparation. We only included questions pertaining to clinical cases in our analysis. We collected data on age, and socio-demographics (SD) such as gender identity, race, nationality physical and mental ability, job status, educational level, immigration status, sexual orientation, and marital or dating status (Table 1). Results: We reviewed a total of 1,602 questions. Once we excluded theoretical review questions, our study cohort included a final number of 1,544 clinical questions. 1,440 (93.3%) were adult patients. Median age was 48 years and ranged from 2 days to 98 years. 48.9% (n=753) were identified as women with she/her pronouns. 19 (1.2%) patients did not carry any gender identity. In total, 11.1% (N=171) cases included a description of any SD factors. In these instances, the correct answer was 85% more likely to be associated with these factors, whenever mentioned in the question stem, compared to questions that did not specify any SD (RR: 1.85 [95% CI= 1.51 – 2.27]). Conclusion: Despite AAMC DEI competency guidelines, GI board review questions continue to lack diverse patient representation. Failing to include diverse SD in clinical cases creates a non-authentic perception of our society. Addressing representation within medical educational cases will more fully portray the diversity of the patients we treat, and better prepare future providers to treat diverse patient populations. Stereotyping becomes more striking when the correct answer is usually associated with any of the rare instances a SD factor is mentioned in the stem of the question. In an effort to provide equitable care, we call on the major GI societies to ensure that their educational resources include DEI related competency-driven content in their board examination review questions and clinical scenarios. Table 1. - Characteristics of patients from clinical cases Characteristics N (%) ALL SAT 2022 DDSEP+ GESAP X Patients 1,544 293 808 443 Adults 1,440(93.3%) 292 (99.7%) 748 (92.8%) 400 (90.9%) Median age [range] 48 years [2 days – 98 years] 50 years [2 – 90 years] 45 years [2 days – 98 years] 54 years [4 weeks – 89 years] Gender identity Men with he/his pronouns 771 (50.1%) 146 (49.8%) 381 (47.2%) 244 (55.1%) Women with she/her pronouns 753 (48.9%) 146 (49.8%) 416 (51.5%) 191 (43.1%) Genderless 19 (1.2%) 1 (0.3%) 10 (1.2%) 8 (1.8%) Non-binary 1 (0.06%) 0 1 (0.1%) 0 Cisgender specified 0 0 0 0 Transgender specified 0 0 0 0 Race/Nationality/Ethnicity 54 (3.5%) 8 (2.7%) 28 (3.5%) 18 (4.1%) Black 15 (1.0%) 4 (1.4%) 8 (1.0%) 3 (0.7%) White 15 (0.1%) 0 6 (0.7%) 9 (2.0%)(incl. 5 Caucasians) Hispanic ethnicity 3 (0.2%) 0 1 (0.3%) 2 (0.4%) Has a job 37 (2.4%) 9 (3.1%) 21 (2.6%) 7 (1.6%) Immigrants 16 (1.0%) 0 12 (1.5%) 4 (0.9%) Educational level 11 (0.7%) 0 6 (0.7%) 5 (1.1%) Veterans 3 (0.2%) 3 (1.0%) 0 0 Prisoner 0 0 1 (0.1%) 0 Marital status Opposite-sex marriage 10 (0.6%) 2 (0.7%) 8 (1.0%) 2 (0.4%) Same-sex marriage 0 0 0 0 Opposite-sex dating 1 (0.1%) 0 1 (0.1%) 0 Same-sex dating 1 (0.1%) 1 (0.3%) 0 0 Spouse/partner of unspecified gender 4 (0.3%) 1 (0.3%) 2 (0.2%) 1 (0.2%) Sexual orientation 2 (0.1%) 0 1 Bisexual (0.1%) 1 Homosexual (0.2%) Sexual practices 2 (0.1%) 0 1 Penetrative and receptive anal sex 1 Anal receptive intercourse (0.2%) Physical or mental ability 4 (0.3%) 0 2 on mental ability (0.2%) 2 on mental ability (0.4%) Insurance type, housing, or language proficiency 0 0 0 0

Medical students report high levels of psychological distress compared to the general population, yet they also underutilize mental health services. Our Mindfulness-Based Art Workshops (MBAW) combine two established, formal interventions: (a) Mindfulness-Based Stress Reduction, an 8-week group series teaching mindfulness practices, shown to reduce self-reported measures of stress, and (b) art therapy, the use of art exercises guided by certified therapists, shown to reduce stress and anxiety in hospitalized patients and students. The goal of our study was to determine if a peer-led, virtual workshop series designed specifically for and by medical students may be a feasible and effective method of adapting these models to improve student well-being. We hypothesized that virtual, medical student led MBAW are effective in reducing measures of stress, anxiety, and depression in medical students and improving well-being scores. In 2020, 24 University of Maryland School of Medicine first- and second-year medical students were randomized to either the MBAW or no-intervention control group. Primary outcomes included (a) short-term change in State Trait Anxiety Inventory (STAI) scores and (b) difference in the perceived stress scores between intervention and control group immediately after, and 2, 4, and 6 weeks after a 6-session intervention. At specific time points, participants completed questionnaires, which included STAI and National Institutes of Health (NIH) Toolbox Perceived Stress survey. We compared the percentage of intervention participants who had clinically significant anxiety before and after MBAW for each session using a generalized estimating equations methodology and compared change from baseline scores between intervention and control groups using a mixed-effects model for repeated measures analysis. In the intervention group, post-MBAW STAI scores decreased by 16.2 (p = .0001), 5 (p = .1544), 13.7 (p = .0002), 13.6 (p = .0006), 12.1 (p = .0009), and 11.9 (p = .0011) points after sessions 1, 2, 3, 4, 5, and 6, respectively. Intervention group perceived stress scores decreased from baseline by 5.9 (p = .07) and 4.7 (p = .09) points more than the control group immediately after, and 2 weeks after the 6-session intervention. MBAW sessions are effective at significantly reducing short-term anxiety, and a 6-session MBAW workshop intervention shows trends toward decreasing levels of perceived stress lasting 2 weeks following the intervention, although these findings were not statistically significant. Future studies should evaluate a larger population to confirm the positive findings of this pilot study, which we hope will encourage medical schools to consider integrating and supporting such programs as a method of addressing the urgent need to aid student well-being, within logistical, time, and cost constraints of students and administrators.

Improving diversity in the biomedical workforce in the United States has been a long-standing goal.1Nickens H.W. Ready T.P. Petersdorf R.G. Project 3000 by 2000. Racial and ethnic diversity in U.S. medical schools.N Engl J Med. 1994; 331: 472-476Crossref PubMed Scopus (125) Google Scholar, 2Steinbrook R. Diversity in medicine.N Engl J Med. 1996; 334: 1327-1328Crossref PubMed Scopus (25) Google Scholar, 3Komaromy M. Grumbach K. Drake M. et al.The role of black and Hispanic physicians in providing health care for underserved populations.N Engl J Med. 1996; 334: 1305-1310Crossref PubMed Scopus (653) Google Scholar While efforts have been made, the needle has not moved toward this goal regardless whether this pertains to trainees, practicing physicians in gastroenterology (GI), or across all medical specialties.4Merchant J.L. Omary M.B. Underrepresentation of underrepresented minorities in academic medicine: the need to enhance the pipeline and the pipe.Gastroenterology. 2010; 138: 19-26Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 5Diversity in Medicine: Facts and Figures 2019. Association of American Medical Colleges.https://www.aamc.org/data-reports/workforce/report/diversity-medicine-facts-and-figures-2019Google Scholar, 6Carr R.M. Quezada S. Gangarosa L.M. et al.From intention to action: Operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology.Gastroenterology. 2020; 159: 1637-1647Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Benefits of growing and maintaining a culture that embraces, promotes, and actively pursues diversity, equity, and inclusion (DEI) have many positives for academic health centers, community practices, population and individual health, research, and innovation advancement to grow and sustain our biomedical research and healthcare workforce. Within academic medicine, diversity is recognized as key to excellence. As articulated by Dr David Acosta, “practicing conscious inclusion and equity-mindedness to achieve inclusion excellence — an environment where diversity is a strategic imperative, inclusivity is intentional, and exclusionary practices have been identified, critically deconstructed, and eliminated — will enable the bonuses of diversity to be revealed, actualized, and leveraged.”7Acosta D. Achieving excellence through equity, diversity, and inclusion.Association of American Medical Colleges. January 14, 2020; https://www.aamc.org/news-insights/achieving-excellence-through-equity-diversity-and-inclusionGoogle Scholar Among the many benefits are enhanced engagement and morale, increased productivity and job satisfaction, and increased trustworthiness and community responsiveness.7Acosta D. Achieving excellence through equity, diversity, and inclusion.Association of American Medical Colleges. January 14, 2020; https://www.aamc.org/news-insights/achieving-excellence-through-equity-diversity-and-inclusionGoogle Scholar A diverse faculty has a tremendous multiplier effect, including the ability to recruit diverse learners who view those faculty as mentors and role models. Underrepresented minority (URM) individuals, as defined by the National Institutes of Health and the National Science Foundation, are those whose racial or ethnic makeup is from 1 of the following groups: African American/Black, Hispanic/Latinx, Native American/Alaskan Native, or Native Hawaiian/Other Pacific Islander. Diversity provides tremendous benefit to patient care, particularly in underserved communities, when those who provide care are themselves diverse.8Saha S. Komaromy M. Koepsell T.D. et al.Patient-physician racial concordance and the perceived quality and use of health care.Arch Intern Med. 1999; 159: 997-1004Crossref PubMed Scopus (688) Google Scholar,9Takeshita J. Wang S. Loren A.W. et al.Association of racial/ethnic and gender concordance between patients and physicians with patient experience ratings.JAMA Netw Open. 2020; 3e2024583Crossref PubMed Scopus (148) Google Scholar A tangible aspect is better patient care, in part, because of improved compliance and trust by patients. There is also the impact of cultural competence10Blewett L.A. Hardeman R.R. Hest R. et al.Patient perspectives on the cultural competence of US health care professionals.JAMA Netw Open. 2019; 2e1916105Crossref PubMed Scopus (9) Google Scholar that contributes toward better patient-provider communication and trust. Importantly, the number of URM physicians who elect to practice in underserved communities is proportionately higher than other physicians.3Komaromy M. Grumbach K. Drake M. et al.The role of black and Hispanic physicians in providing health care for underserved populations.N Engl J Med. 1996; 334: 1305-1310Crossref PubMed Scopus (653) Google Scholar GI has had challenges in recruiting women and URMs. As of 2010, only 3.2% of GI fellows were African American, and 8.5% were Hispanic (Figure 1). For women, only 16% of GI fellows are women, despite 47% of U.S. medical students being women. By comparison, in the general U.S. population the racial, ethnic, and general comparisons are African-American (13%), Hispanic (11%), and women (51%).11U.S. Census BureauQuick Facts.July 1, 2021https://www.census.gov/quickfacts/fact/table/US/RHI725220#RHI725220Google Scholar Presently, there are 202 accredited GI fellowship programs with approximately 1735 GI fellows.12Brotherton S.E. Etzel S.I. Graduate medical education, 2019-2020.JAMA. 2020; 324: 1230-1250Crossref PubMed Scopus (41) Google Scholar Several interventions have been implemented to increase diversity within GI.13Carethers J.M. Quezada S. Carr R.M. et al.Diversity within US gastroenterology physician practices: the pipeline, cultural competencies, and gastroenterology societies approaches.Gastroenterology. 2019; 156: 829-833Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar,14Day L. Gonzalez S. Ladd A.M. et al.ASGE Membership and Diversity CommitteeDiversity in gastroenterology in the United States: where are we now? Where should we go?.Gastrointest Endosc. 2016; 83: 679-683Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar However, over the last decade we have not had much success is increasing the number of URM and female applicants to GI training programs (Figure 2).15American Association of Medical CollegesERAS statistics.https://www.aamc.org/data-reports/interactive-data/eras-statistics-dataGoogle Scholar The percentage of URM internal medicine (IM) residents applying to GI has been around 12.0% for the last 8 years, with a decline noted from 2015 to 2018 that has since improved (Figure 2).16Brotherton S.E. Etzel S.I. Graduate medical education, 2016-2017.JAMA. 2017; 318: 2368-2387Crossref PubMed Scopus (43) Google Scholar Alarmingly, profound declines have occurred among American Indian/Alaska Native and Native Hawaiian/Pacific Islander residents applying to GI fellowships (–37.5% and –25.0% annual change in applications, respectively) with only modest increases noted for African American/Black and Latinx applicants. With women, minimal changes noted in this number over the last decade (Figure 2).16Brotherton S.E. Etzel S.I. Graduate medical education, 2016-2017.JAMA. 2017; 318: 2368-2387Crossref PubMed Scopus (43) Google Scholar How do U.S. GI fellowship programs compare with other IM subspecialties and medical residencies as it relates to diversity? GI, in addition to pulmonary and critical care and hematology and oncology, are the only IM fellowships with a proportion of URMs under 10% (Figure 3A), and only 6 medical residencies (among 16) had a similar or lower proportion of URM residents when compared with GI (Figure 3B).17Santhosh L. Babik J.M. Trends in racial and ethnic diversity in internal medicine subspecialty fellowships from 2006 to 2018.JAMA Netw Open. 2020; 3e192048Crossref PubMed Scopus (39) Google Scholar Clearly, U.S. GI fellowship programs do not reflect either the U.S. racial-ethnic or gender diversity. Low numbers of URMs and women apply to and matriculate into GI fellowship programs, with little changes to these trends over the last decade.6Carr R.M. Quezada S. Gangarosa L.M. et al.From intention to action: Operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology.Gastroenterology. 2020; 159: 1637-1647Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Over the past decade, the American Gastroenterological Association (AGA) has begun to tackle lack of diversity in GI through prior programs that have reached a total of 2609 URM individuals at the medical student, GI fellow, and early career faculty levels. These programs established our ability to recruit individuals from URM backgrounds. In November 2017, the AGA both conducted online surveys and held interactive discussion focus groups of 20 early career URM gastroenterologists, hepatologists, pediatric gastroenterologists, and GI fellows. Surveys were designed to identify obstacles that dissuade or impede development of early career URM gastroenterologists and hepatologists. While many of the answers would be common to any physician interested in pursuing research (time, mentoring, departmental support), we also identified 7 areas in which URM GI fellows and early career gastroenterologists particularly struggle (Table 1).Table 1Academic Development Areas in Which URMs Struggle1. Lack of knowledge about how to become an investigator2. Lack of exposure to role models (ie, inspiration)3. Lack of mentorship4. Lack of sponsorship from mentors5. Lack of visibility within both the AGA and their institution for general leadership opportunities, not just leadership opportunities in the URM space6. Lack of programs within their home institution for leadership training7. Lack of support for pursuit of a career and personal identity as a physician-scientistData are derived from the AGA survey of URM GI fellows and early career gastroenterologists (5 years for fewer since completion of gastroenterology training).AGA, American Gastroenterological Association; URM, underrepresented minority. Open table in a new tab Data are derived from the AGA survey of URM GI fellows and early career gastroenterologists (5 years for fewer since completion of gastroenterology training). AGA, American Gastroenterological Association; URM, underrepresented minority. Three main themes emerged from these factors and were a lack of (1) research fundamentals, (2) leadership training, and (3) mentoring. Based on these lessons learned, AGA proposed a professional development program, through a competitive R-25 grant received from National Institute of Diabetes and Digestive and Kidney Diseases for early career gastroenterologists and GI trainees called the AGA FORWARD (Fostering Opportunities Resulting in Workforce and Research Diversity) Program that incorporates specific strategies to lower barriers and improve likelihood that URM physicians will pursue careers in biomedical investigation.18Anyane-Yeboa A. Balzora S. Gray 2nd, D.M. Improving diversity and inclusion in GI.Am J Gastroenterol. 2020; 115: 1147-1149Crossref PubMed Scopus (15) Google Scholar The AGA FORWARD program, through hands-on work with mentors and external coaches, trains URM physician-scientists with new skills and connections to successfully pursue research careers in GI. AGA FORWARD scholars develop skills in research and proposal development, planning for personnel, publications, and the timing of grant submissions. The AGA believes that this approach to integrating skills will provide a solid foundation for success. Other GI societies have also implemented programs to increase diversity in GI, including the American College of Gastroenterology’s “Prescription for Success” and #DiversityinGI social media campaign, the American Society for Gastrointestinal Endoscopy’s 5-year DEI Action Plan and the American Association for the Study of Liver Diseases’ global speaker database to guide nominations for committee assignments, speakers, and moderators for their programs. At the trainee level, the vast majority of programs recruit fellows through a national fellowship match progress. This time-tested process lends itself to the natural selection of candidates across a wide spectrum of backgrounds, experiences, and sexes. However, URMs represent only 9% of GI fellows in the United States.19Jackson C.L. Food for thought: opportunities to improve diversity, inclusion, representation, and participation in epidemiology.Am J Epidemiol. 2020; 189: 1016-1022Crossref PubMed Scopus (6) Google Scholar A structured trainee selection process would benefit from a keen eye toward attempting to balance race and sex when contemplating merit and other considerations. GI fellowship programs should consider URMs for leadership positions and members selection committees. Implicit bias training may help identify and address biases and lead to a more open-minded evaluation. A diverse fellowship program will ultimately improve faculty diversity through retention. In order for academic GI to be successful at creating a diverse environment, divisional leaders must make DEI initiatives a priority. Alignment with institutional goals is critical. A dedicated leadership position to focus on these initiatives, regular cultural humility and implicit bias training, collaboration with local agencies, and an infrastructure built to support and encourage research and mentorship of URMs is imperative for moving the needle in this realm (Figure 4). Conscious bias is relatively easy to identify and confront. However, unconscious bias is more insidious and probably more harmful, as the individuals delivering bias are often unaware.20Lewis D. Paulsen E. Proceedings of the Diversity and Inclusion Innovation Forum: Unconscious Bias in Academic Medicine. How the Prejudices We Don’t Know We Have Affect Medical Education, Medical Careers, and Patient Health. Association of American Medical Colleges, Washington, DC2017Google Scholar For example, women and African Americans may be labeled aggressive for the same behaviors that are called assertive in a White man. Therefore, before embarking on changing the recruitment process, some program evaluation is in order. Fellow selection is a process of balancing a candidate’s cognitive and noncognitive skills. Cognitive skills that are easily measured by grades, board scores, and papers written, tend to dominate. Noncognitive skills like interpersonal communication, maturity, commitment, dependability, and honesty are often assessed during the interview and may be biased by cognitive achievements, the so-called halo effect. Exam scores and research productivity are frequently used to determine whom to interview.21Hartman N.D. Lefebvre C.W. Manthey D.E. A narrative review of the evidence supporting factors used by residency program directors to select applicants for interviews.J Grad Med Educ. 2019; 11: 268-273Crossref PubMed Scopus (32) Google Scholar, 22Crowley A.L. Damp J. Sulistio M.S. et al.Perceptions on diversity in cardiology: a survey of cardiology fellowship training program directors.J Am Heart Assoc. 2020; 9e017196Crossref PubMed Scopus (14) Google Scholar, 23Lam C.C. Zimmern A. Colon and rectal surgery residency selection criteria: a National Program Director Survey.J Surg Educ. 2021; 78: 519-524Crossref PubMed Scopus (5) Google Scholar, 24Bonifacino E. Ufomata E.O. Farkas A.H. et al.Mentorship of underrepresented physicians and trainees in academic medicine: a systematic review.J Gen Intern Med. 2021; 36: 1023-1034Crossref PubMed Scopus (33) Google Scholar Yet, there is no firm evidence regarding what predicts success in advanced trainees. Speaking to the candidates’ referees to confirm areas of uncertainty is a good strategy. Interview bias may be decreased by blinding interviewers to a candidate's scores and letters; structuring the interview by asking everyone the same questions and scoring answers consistently; using questions that have no right or wrong answer but include a hypothetical that tests judgment, ethics, or team play21Hartman N.D. Lefebvre C.W. Manthey D.E. A narrative review of the evidence supporting factors used by residency program directors to select applicants for interviews.J Grad Med Educ. 2019; 11: 268-273Crossref PubMed Scopus (32) Google Scholar; having multiple interviewers, and requiring all interviewers to have implicit bias training. Reach out to colleagues at other institutions who are women or URMs and who may know of promising candidates. Develop relationships with programs that traditionally train more URM and female residents. Affiliate with Historically Black Colleges and Universities medical schools. For example, Veterans Affairs and Municipal hospital systems like Cook County, Chicago; Health + Hospitals system, New York; and Miami-Dade County also train larger numbers of URMs. Residents from these programs are often hardworking multitaskers who have mastered systems creativity in resource poor settings. The absence of faculty members who are women or persons of color can make your program seem uninviting. Talented candidates will not want to be pioneers navigating that system alone. They will need and want a cultural mentor whom they can trust. Well-organized and institutionally supported mentorship programs increase candidate satisfaction and aid in retention and recruitment.25Farkas A.H. Bonifacino E. Turner R. et al.Mentorship of women in academic medicine: a systematic review.J Gen Intern Med. 2019; 34: 1322-1329Crossref PubMed Scopus (92) Google Scholar While you may not be a cultural mentor, you can be an effective skills mentor. Grant writing, manuscript preparation, CV formatting, interview skills, and contract negotiation to name a few areas in which formal mentorship relationships can be made and built upon. In the private sector, a good recommendation is to take an actual picture of your organization to see who is literally seated at the table and to decide who you would like to be there (https://biasinterrupters.org). Invest in formal anti-bias training resources26D’Angelo R. White Fragility: Why It’s So Hard for White People to Talk About Racism. Penguin Random House, New York2018Google Scholar and embark on individual study to understand the history of bias in America and in medicine.27Washington H.A. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. Doubleday, New York, NY2006Google Scholar,28Stephenson-Famy A. Houmard B.S. Oberoi S. et al.Use of the interview in resident candidate selection: a review of the literature.J Grad Med Educ. 2015; 7: 539-548Crossref PubMed Scopus (94) Google Scholar We recommend a multipronged approach to diversification of the recruitment pool at multiple levels: in premedical education, medical school, residency, GI fellowships, and early GI careers: •Career development opportunities such as the AGA FORWARD Program. •Take a balanced unbiased approach to assessing cognitive and noncognitive candidate skills.•Implicit bias training for program directors, search committees, and selection committee members.•GI fellowship training program self-assessment on communities served; fellows’ opportunities for engaging community; curricular elements designed to enhance cultural humility and linguistic competence and amplify understanding of racism as a public health crisis, and social determinants of health. •Mitigate bias in job announcements by removing gendered language in job postings.•Competitive recruitment packages—assess for implicit bias in how these are offered.•Insertion of explicit statements that raise awareness of how the institution values DEI beyond an Equal Opportunity Employer statement.•Diverse search committee structure.•Well-organized mentorship program.•National Institutes of Health funding opportunities (eg, diversity supplements to existing supplements, Office of Minority Health).•Diversification of faculty and leadership positions.•Engage clinical faculty with faculty in research and academic endeavors. •Actively look for qualified candidates in programs who have historically trained women and URMs in large numbers.•Diversification of content in our journals in social media (journals, conferences, social media, listservs).•Post career opportunities in nontraditional sources (eg, social media and listservs). By employing these recommendations to improve diversity in digestive diseases, we will ultimately improve care for our patients. Espousing diversity in healthcare can lead to cultural humility and agility as well as the ability of providers to offer services that meet their patients’ unique social, cultural, and linguistic needs. The better our patients are represented and understood, the better they can be treated. Health equity is achievable through these proactive, short-term and long-term measures. As Owen Seymour Arthur (former prime minister of Barbados) is quoted, “For he who has health, has hope; and he who has hope, has everything” (https://www.quotetab.com/quotes/by-owen-arthur).

INTRODUCTION: In the setting of increasing attention to representation in medicine, we aimed to assess current perspectives of racial and ethnic workforce diversity and health care disparities among gastroenterology (GI) and hepatology professionals in the United States. METHODS: We developed and administered a 33-item electronic cross-sectional survey to members of 5 national GI and hepatology societies. Survey items were organized into thematic modules and solicited perspectives on racial and ethnic workforce diversity, health care disparities in GI and hepatology, and potential interventions to enhance workforce diversity and improve health equity. RESULTS: Of the 1,219 survey participants, 62.3% were male, 48.7% were non-Hispanic White, and 19.9% were from backgrounds underrepresented in medicine. The most frequently reported barriers to increasing racial and ethnic diversity in GI and hepatology were insufficient representation of underrepresented racial and ethnic minority groups in the education and training pipeline (n = 431 [35.4%]), in professional leadership (n = 340 [27.9%]), and among practicing GI and hepatology professionals (n = 324 [26.6%]). Suggested interventions were to increase career mentorship opportunities (n = 545 [44.7%]), medical student opportunities (n = 520 [42.7%]), and program and professional society leadership roles for underrepresented racial and ethnic minority groups (n = 473 [38.8%]). DISCUSSION: Our survey explored imperative and timely perspectives on racial and ethnic representation and health equity among professionals in GI and hepatology. The findings should inform future interventions to address workforce diversity and establish priorities toward improving health equity, ultimately serving as a springboard for professional societies, academic institutions, and other organizations that aim to increase diversity, equity, and inclusion in our field.

This month, the American Gastroenterological Association (AGA) journals, Gastroenterology and Clinical Gastroenterology and Hepatology, will embark on a common mission to highlight research in health equity and inclusion, with a strong focus on work conducted by investigators who are underrepresented in medicine and science. The endeavor is one aspect of the AGA Equity Project1 and expands the "Diversity, Equity, and Inclusion in Gastroenterology" ("DEI in GI") section launched in Gastroenterology in January of 20222 under the leadership of inaugural DEI editor Chyke Doubeni to another AGA journal, Clinical Gastroenterology and Hepatology.

The incidence of inflammatory bowel disease (IBD) is rising in racial and ethnic minority groups in the United States, and socioeconomic, racial, and ethnic disparities in IBD are increasingly being identified. In addition, there has been great appreciation for the social determinants of health as contributors to these disparities, and that upstream social determinants of health propagate downstream poor health outcomes in IBD. We propose strategies to achieve health equity in IBD that target the medical trainee, provider, practice, community, industry, and policy levels.

The American Gastroenterological Association (AGA) maintains a strong history of creating and sustaining impactful programming to support diversity and inclusion for physicians and scientists in gastroenterology (GI) and hepatology. After the inception of its Diversity Committee in 1993 (formerly the Underrepresented Minority Committee), AGA expanded its commitment to diversity, equity, inclusion, and justice in 2020 with the Equity Project. This 3-year equity strategic plan more concretely and systematically operationalizes the organization's diversity policy throughout the organization, identifying opportunities for greater impact by means of leveraging all levels and stakeholders in the society to be invested in the success of the project, extending beyond the scope of the Diversity Committee alone.1Carr R.M. Quezada S.M. Gangarosa L.M. et al.From intention to action: operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology.Gastroenterology. 2020; 159: 1637-1647Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar The AGA Equity Project's vision to achieve equity and eradicate health disparities in digestive diseases outlines an implementation plan across the following 6 domain areas, with desired future states (Figure 1): (1) Justice, Equity, and Education, with a just world free of health disparities in digestive diseases and free of inequities in access and effective health care delivery; (2) Research and Funding, with state-of-the-art and well-funded research that aligns with the realities of the current multicultural patient population and disease states; (3) Workforce and Leadership, with a world where it is expected and normal that both members and society leadership structures are diverse, and people of color and women are included in organizational decision making; (4) Recognition, with increased visibility and awareness of accomplishments of diverse leaders; (5) Bias, with an engaged AGA membership and staff educated about unconscious bias and committed to the eradication of racism and prejudice toward patients, colleagues, and communities; and (6) Engaged Next Generation, with a diverse, culturally and socially aware, large, and vocal early career membership that leads the field toward achieving this vision. This vision and plan were developed collaboratively, with important input from AGA staff, by a diverse group of members who now serve as the Equity Project Advisory Board, with representation from clinical and basic sciences, private and academic practice, and physicians and advanced practice providers, all with expertise in various digestive disease processes. Approved by the AGA Governing Board in summer 2020, the Equity Project was effectively backed with tangible resources that catalyzed mobilization of its collective vision and plan. Now in its third and final implementation year, the Equity Project has yielded meaningful results while continuing to drive the organization forward toward achieving its goal of equity and eradicating GI health disparities. This commentary provides a status update on the AGA Equity Project's objectives and identifies future directions for the organization to sustain momentum beyond the 3-year plan as a national leader in equity, diversity, and inclusion in GI and medicine at large. Reinvigorated national discourse on social determinants of health and their driving impact on disparate health care outcomes, in conjunction with broader recognition of systemic social barriers perpetuated by policy, have inspired even more robust participation in advocacy efforts among AGA members. In September 2022, an all-time high of 91 AGA members participated in "Advocacy Day," with a specific increase in representation of women and people of color advocating for policies that impact gastrointestinal health and increase access to gastrointestinal care for our nation's diverse patient populations. Overall, there have been 4 specific congressional briefings on DEI topics since summer 2020. This increase in congressional briefings produced a major policy victory in 2022, eliminating financial barriers to colorectal cancer screening by requiring private insurers and Medicare to cover the full screening continuum, which is critical to achieving health equity in colorectal cancer.2Huge wins for patients: CRC coverage continuum is complete. American Gastroenterological Association.https://gastro.org/news/huge-win-for-patients-crc-screening-coverage-continuum-is-complete/Google Scholar Preventive care is being challenged again, and AGA signed a joint statement led by the American Medical Association alongside 61 medical associations and societies to continue to advocate for preventive care access for all.3Physicians sound alarm on lawsuit threatening preventive care. American Medical Association.https://www.ama-assn.org/press-center/press-releases/physicians-sound-alarm-lawsuit-threatening-preventive-careGoogle Scholar In concert with its growing advocacy work, AGA amplified its efforts to enhance provider awareness of health inequities and tools to address these challenges through educational platforms, such as existing career development workshops and Digestive Disease Week (DDW) sessions, as well as via new platforms, such as the "Small Talk, Big Topics" podcast, which targets the GI trainee and early career community.4Small Talk Big Topics – An AGA Podcast. American Gastroenterological Association.https://gastro.org/fellows-and-early-career/small-talk-big-topics-podcast/Google Scholar In its first season, 16 episodes of "Small Talk, Big Topics" focused on topics most relevant to early career and future gastroenterologists, including building resilience, women in GI innovation, and GI health disparities. While amplifying provider education, AGA also invested additional resources to update and enhance patient education material, incorporating language diversity and a lens of cultural humility in its content.5Welcome to the AGA Patient Center.https://patient.gastro.org/Google Scholar A deeper understanding of the underlying causes and overall impact of GI health disparities will prompt strategic investment of resources and efforts that generate positive change. To accelerate the pace of knowledge growth in this area, AGA established a Healthcare Disparities Research Award for meritorious work in racial and ethnic health care disparities and created a fundraising event, known as "AGA Giving Day," which raised more than $300,000 earmarked specifically to support health disparities research with 9 pilot research awards, 38 abstract awards, and diverse investigators through an AGA Research Scholar Award supported by the AGA Research Foundation.6AGA Research Foundation.https://foundation.gastro.org/Google Scholar

Background Increasing the number of physicians who identify as an underrepresented minority (URM) has been a focus for decades. Despite the US Department of Health and Human Services establishing The Council on Graduate Medical Education focussing on the underrepresentation of minorities in medicine in 1990, US medical students in 1998-1999 were15.2% URM and twenty years later, URM students comprise only 14.6% of matriculants. This reflected our experience at University of Maryland School of Medicine despite our diverse community where over 60% of the population identify as Black or African-American. We share our strategies to mitigate bias in the admissions process and our resulting outcomes. Methods We implemented multiple interventions including interviewer training, recruitment strategies, holistic screening, changes in the interview process and increased racial, ethnic and gender diversity on our admissions committee. These changes were made over a two-year period initially focussing on the committee, followed by focussed interventions for interviewers. Results With these interventions, we demonstrated an improvement in the number of URM applicants that matriculated. In 2019, we had the first class that was in which no one ethnicity or race comprised the majority of the class, with 54% of matriculants identifying as students of colour. In 2020, in addition to sustaining a majority of the class identifying as students of colour, the proportion of URM students increased from 10%-13% for the preceding 3 years, to 24% of the entering class. Conclusion The number of physicians who identify as URM must be increased for the benefit of our patients and health care system. Unconscious bias training for interviewers, focused recruitment strategies, holistic screening deemphasising the MCAT, blinding interviewers to MCAT scores and GPA, and increasing admissions committee diversity are five concrete steps that yielded the desired outcome of increasing URM representation among our medical school matriculants.

Abstract BACKGROUND: According to recent estimates, the US transgender population has doubled in the last decade. Incorporating transgender competent care into medical education is a growing need, and a focus of the AAMC. Care of the transgender individual is multifaceted, and medical school curriculae on transgender care are limited and lack standardization. Similarly, strategies for measuring effectiveness and impact of these curriculae remain limited. Methods: Over 3 years, the use of a transgender clinical correlation in the endocrine section of the second-year medical student pre-clerkship curriculum progressed to the use of a triple modality intervention. This included (1) a self-directed written handout with terminology and the basic tenants of medical transition therapy with an optional podcast, (2) a traditional presentation covering social, ethical and multi-disciplinary transgender care, and (3) an interactive session with a transfemale and transmale patient. An anonymous 8 question pre-and post-intervention survey using an electronic clicker system was performed. Questions included interest level, comfort level with various aspects of transgender-competent care and resource awareness. Results: Prior to the intervention, 74% of students were interested in learning more about transgender competent care. After the learning intervention, in all questions focusing on knowledge and skills of transgender care, students reported a significant increase in their comfort level (Figure 1, p<0.5, all). This included reporting now higher comfort levels regarding goals of hormone therapy (8 to 63%), use of transgender affirming medications (19 to 44%), barriers to care (30 to 79%), and long term and multi-disciplinary care (8 to 63% and 13 to 71%, pre- and post-intervention respectively). At the end of the intervention, students felt they had more resources to access information about transgender-competent care (pre-23% to post-94% p= <0.05). Conclusion: Knowledge and skills in the care of transgender individuals is poor in the pre-clerkship medical school years. The interest to learn about transgender care is positive. This multi-modality intervention was successful in increasing medical student comfort and knowledge about comprehensive transgender care, and increased student awareness of available resources. Introduction of transgender care should be implemented early in medical student training. 1. Hembree WC et al. Endocrine Treatment of Gender-Dysphoric/ Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. Endocr Pract. 2017 Dec;23(12):1437. 2. Harris M, Johnson C. Only Human. Trans Kids Update: Dating, PMS, And, Yeah, Bathrooms. NYPR WNYC Studios, 2017. Figure 1. Change in student comfort across transgender competent care. * p < 0.05

In 2016, the American Gastroenterological Association (AGA) codified its commitment to diversity, equity, and inclusion (Figure 1)1National Multicultural InstituteDiversity Terms.https://our.ptsem.edu/UploadedFiles/Multicultural/MCRDiversityTerms.pdfDate: 2003Date accessed: July 8, 2020Google Scholar,2UC Berkeley Initiative for Equity, Inclusion, and Diversity. Glossary of terms.http://diversity.berkeley.edu/sp_glossary_of_termsDate: 2011Date accessed: July 8, 2020Google Scholar through the adoption of its organizational Diversity Policy.3American Gastroenterological Association Diversity Policy.https://aga-cms-assets.s3.amazonaws.com/2020327173230---COM20-009%20AGA%20Diversity%20Policy.pdfDate accessed: June 30, 2020Google Scholar Developed in collaboration with the AGA Diversity Committee, the policy establishes that the AGA aims to "reflect the interests of the diverse patient population we serve" and that the AGA is "committed to the "promotion of diversity within the practice of gastroenterology and in the individualized care of patients of all backgrounds," the "recruitment and retention of GI providers and researchers from diverse backgrounds," and the "elimination of disparities in GI diseases through community engagement, research and advocacy." Four years after the crafting of that policy, the AGA bolstered that commitment by condemning racism, bigotry, and discrimination in a Joint GI society statement with the American Association for the Study of Liver Diseases, American College of Gastroenterology, and American Society for Gastrointestinal Endoscopy.4Racism, social injustice and our pledge to lead change. Joint GI society statement from AGA, AASLD, ACG and ASGE.https://gastro.org/news/racism-social-injustice-and-our-pledge-to-lead-changeDate accessed: June 30, 2020Google Scholar The statement was in direct response to both the systemic racism laid bare by George Floyd's death at the hands of a white police officer and also to the burgeoning coronavirus disease-19–related racial health disparities.5Gray 2nd, D.M. Anyane-Yeboa A. Balzora S. Issaka R.B. May F.P. COVID-19 and the other pandemic: populations made vulnerable by systemic inequity.Nat Rev Gastroenterol Hepatol. 2020; 17: 520-522Crossref PubMed Scopus (140) Google Scholar Although the AGA had previously established diversity, equity, and inclusion as a major pillar of its organizational vitality, in the wake of these recent events, the specific inclusion of anti-racism initiatives is imperative to eliminate health care disparities and promote diversity within the practice of gastroenterology. Although AGA leadership and staff felt that they had been paying close attention to diversity issues, they deemed it essential (as detailed in this Commentary) to not only undertake a self-reflection in terms of its past and current initiatives, but also to establish a major equity initiative to further convert intentions to actions. The AGA has >16,000 US and international members who span the spectrum of academia, trainees, private, federal, and community-based practice; and industry. Its leadership is composed of both professional staff and volunteer members who serve on 18 committees (https://gastro.org/committees/). Of the 64% of full AGA members who have provided race and ethnicity information, approximately 11% are underrepresented minorities. Underrepresented minorities include American Indian/Alaskan Native, Black/African American, Hawaiian/Pacific Islander, and Hispanic/Latinx6National Institutes of HealthRacial and Ethnic Categories and Definitions for NIH Diversity Programs and for Other Reporting Purposes.https://grants.nih.gov/grants/guide/notice-files/NOT-OD-15-089.html 2015Google Scholar and comprise 0.2%, 4.6%, 0.03%, and 6.0% of the reporting AGA full members and 0.4%, 6.1%, 0.7%, and 6.4% of the reporting AGA trainee members, respectively (Table 1 and Table 2). Underserved communities additionally include those with disabilities and those who are economically disadvantaged. Although the AGA underrepresented minority representation mirrors the national GI underrepresented minority percentages, these numbers have plateaued over the past decade and remain well below the expected 30% based on national underrepresented minority population data when comparing 2010 and 2020 census data (Table 1).7Carethers J.M. Quezada S.M. Carr R.M. Day L.W. Diversity within US gastroenterology physician practices: the pipeline, cultural competencies, and gastroenterology societies approaches.Gastroenterology. 2019; 156: 829-833Abstract Full Text Full Text PDF PubMed Scopus (38) Google ScholarTable 1Racial and Ethnic Demographics of AGA Members and US GastroenterologistsRace and EthnicityAGA Full Members 2010 (US)AGA Full Members 2020 (US)US Gastroenterologists 2010 (US)aFrom the AMA Physician Masterfile, December 31, 2018.US Gastroenterologists 2018 (US)bAMA Physician Characteristics and Distribution in the United States, December 31, 2010. Percentages are of total reporting.US Population (%)n%n%n%n%2010cThe percentages add to 100.2 owing to approximation. The 2010 census data were obtained from: https://data.census.gov/cedsci/table?q=United%20States&g=0100000US&tid=ACSDP1Y2010.DP05.2020dThe percentages add to 100.1 owing to approximation. The 2020 census data are an estimate and were obtained from: https://data.census.gov/cedsci/all?q=ZCTA5%2012020&hidePreview=false&tid=ACSDP5Y2018.DP05.American- Indian/Alaskan NativeeUnderrepresented minorities (first 4 rows).80.2130.280.07150.120.70.7Black/African AmericaneUnderrepresented minorities (first 4 rows).1613.72834.64313.95634.412.312.3Hawaiian/Pacific IslandereUnderrepresented minorities (first 4 rows).10.0220.03N.A.N.A.90.070.20.2HispaniceUnderrepresented minorities (first 4 rows).2114.83706.07176.58476.616.417.8Asian92521.13177328.8253822.8355227.84.75.4Multiracial——————1441.12.02.4Other————3052.71230.960.20.2White307170.2372560.4711264752758.963.761.1Total reporting437753.5616664.211,11184.112,780—n.a.n.a.Total URM3818.766810.8115610.4143411.229.631Not reporting379846.5344035.8209915.9——n.a.n.a.Total8175100960610013,210100——309.4 M322.9 MM, million; N.A., non-available; n.a., not applicable; URM, underrepresented minorities.a From the AMA Physician Masterfile, December 31, 2018.b AMA Physician Characteristics and Distribution in the United States, December 31, 2010. Percentages are of total reporting.c The percentages add to 100.2 owing to approximation. The 2010 census data were obtained from: https://data.census.gov/cedsci/table?q=United%20States&g=0100000US&tid=ACSDP1Y2010.DP05.d The percentages add to 100.1 owing to approximation. The 2020 census data are an estimate and were obtained from: https://data.census.gov/cedsci/all?q=ZCTA5%2012020&hidePreview=false&tid=ACSDP5Y2018.DP05.e Underrepresented minorities (first 4 rows). Open table in a new tab Table 2Racial and Ethnic Demographics of AGA Trainee Members, 2020AGA Trainee MembersRace and Ethnicity2010aAs of July 2010.2020bAs of July 2020.n%N%American-Indian/Alaskan NativecUnderrepresented minorities (first 4 rows).20.240.4Black/African AmericancUnderrepresented minorities (first 4 rows).484.7646.1Hawaiian/Pacific IslandercUnderrepresented minorities (first 4 rows).0070.7HispaniccUnderrepresented minorities (first 4 rows).484.7676.4Asian38737.845143.2White53852.645243.2Total reporting102381.3104574.5Total URM989.614213.6Not Reporting23518.735725.5Total12581001402100URM, underrepresented minorities.a As of July 2010.b As of July 2020.c Underrepresented minorities (first 4 rows). Open table in a new tab M, million; N.A., non-available; n.a., not applicable; URM, underrepresented minorities. URM, underrepresented minorities. The AGA Governing Board includes 13 members who are charged with developing the AGA's strategic plan. The board is committed to making a significant impact on the goals enumerated in the AGA Diversity Policy and works with the AGA professional staff, a diverse staff of 101 employees, 30% of whom are underrepresented minorities, to achieve those aims (Table 3). Eighteen percent of the governing board are underrepresented minority members. Among AGA committees, underrepresented minorities volunteer on 12 of 18 committees, accounting for 13% of AGA committee participation (Table 3). Among these committees, the Diversity and Government Affairs Committees have the highest underrepresented minority representation. The AGA has been tracking diversity on committees since before the inception of the appointments committee in 2011. To further ensure that all ethnicities are appropriately represented within the leadership structure, in 2016 the Diversity Committee implemented an annual assessment of all committees. Although members may opt out of disclosing race/ethnicity information, data are now available for 75% of committee members (Table 2).Table 3Racial and Ethnic Demographics of AGA Staff and Committee Members, 2010 and 2020AGA StaffAGA Committee MembersRace and ethnicity2010aAs of July 2010.2020bAs of July 2020.2020bAs of July 2020.n%n%n%American- Indian/Alaskan NativecUnderrepresented minorities (first 4rows).000010.5Black/ African-AmericancUnderrepresented minorities (first 4rows).1922.92524.8136.0Hawaiian/Pacific IslandercUnderrepresented minorities (first 4rows).00000HispaniccUnderrepresented minorities (first 4rows).3355.0136.0Asian22.465.95224.1White5971.16564.411452.8Other————2310.6Total reporting83100101100216Total URM2226.53029.72712.5Not Reporting0072Total83101288URM, underrepresented minorities.a As of July 2010.b As of July 2020.c Underrepresented minorities (first 4rows). Open table in a new tab URM, underrepresented minorities. The Diversity Committee (formerly the Underrepresented Minorities Committee) has been in existence since 1993. The committee helps the AGA to address challenges with health care access and use among diverse patient populations inclusive of racial, cultural, religious, sexual orientation, gender, disability, age, and economic diversity. The committee also advocates for the inclusion, advancement and recognition of members from underrepresented groups in all AGA activities. The AGA disbanded this committee and the Women's Committee (which focuses on the promotion and advancement of women members of the AGA and women's health issues) for a 3-year period from 2005 to 2008 until AGA task forces recommended their re-establishment, thus demonstrating that even well-intentioned organizations can contribute to actions that may perpetuate inequity. The Diversity Committee has since created and supported several organizational initiatives to drive its core values of diversity, equity, and inclusion to the forefront. Examples include sponsorship of initiatives involving unconscious and implicit bias, gastroenterological (GI) care for the immigrant population, and increasing the diversity of the GI pipeline for fellowship training and society leadership positions. The current Diversity Committee has 4 main initiatives: (i) improving the collection of demographic data from both AGA members-at-large and committee members; (ii) using AGA communication outlets to educate members about GI health disparities and unconscious/implicit bias; (iii) creating the first of its kind repository of renowned underrepresented minority GI physicians and scientists to be used by the AGA committees when seeking mentors, speakers, and nominations for committees and potential awards; and (iv) increasing the visibility of GI disparities research during the annual Digestive Disease Week (DDW) conference through dedicated e-Poster sessions and poster tours. The Diversity Committee also sponsors an annual symposium at DDW, with past symposia topics including unconscious and implicit bias, diversity in GI research, and GI care for the immigrant population. The national proportion of only 11% underrepresented minority GI physicians reflects a striking contrast with the racial and ethnic diversity of the patient populations we serve. This racial and ethnic disparity among GI physicians also exists for the GI pipeline of medical student and GI trainees.7Carethers J.M. Quezada S.M. Carr R.M. Day L.W. Diversity within US gastroenterology physician practices: the pipeline, cultural competencies, and gastroenterology societies approaches.Gastroenterology. 2019; 156: 829-833Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar,8Day L.W. Gonzalez S. Ladd A.M. Bucobo J.C. Pickett-Blakely O. Tilara A. Christie J. Diversity in gastroenterology in the United States: where are we now? Where should we go?.Gastrointest Endosc. 2016; 83: 679-683Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar In a 2019 DDW Diversity Committee symposium and follow-up article, Carethers et al7Carethers J.M. Quezada S.M. Carr R.M. Day L.W. Diversity within US gastroenterology physician practices: the pipeline, cultural competencies, and gastroenterology societies approaches.Gastroenterology. 2019; 156: 829-833Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar highlighted our current state whereby both the tributaries that produce future gastroenterologists and the systems that support the retention of underrepresented minority gastroenterologists have been unable to increase GI underrepresented minority representation to a level commensurate with population demographics. In fact, GI fellowship applications by underrepresented minority residents have been decreasing over time. Some strategies that may mitigate these trends include programs designed to specifically recruit underrepresented minorities to the field of GI, increasing mentorship opportunities, and integrating cultural humility curricula.7Carethers J.M. Quezada S.M. Carr R.M. Day L.W. Diversity within US gastroenterology physician practices: the pipeline, cultural competencies, and gastroenterology societies approaches.Gastroenterology. 2019; 156: 829-833Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar The AGA has had several programs to help expand the pool of underrepresented minority students, GI trainees, and GI research; to promote the retention of underrepresented minority AGA members; and to create a diverse leadership within the AGA. Examples of these initiatives include the following. (a) The Investing in the Future Program, a now discontinued program owing to cessation of funding focused on exposing underrepresented minority medical students to the field of gastroenterology and engaging them in summer research opportunities. This program is likely to restart via a generous gift from an AGA member. (b) The Future Leaders Program, an organizational leadership development and mentorship program available to all AGA members that also aims to identify and provide opportunities for underrepresented minority members. (c) The Fostering Opportunities Resulting in Workforce And Research Diversity (FORWARD) program, an ongoing National Institutes of Health–funded R25 leadership development program for underrepresented minority AGA members. Investing in the Future Program (I and II) were R25 National Institutes of Health–supported programs that started in 2001 in collaboration with American Society for Gastrointestinal Endoscopy. Underrepresented minority medical students and residents were introduced to gastroenterology through presentations, hands-on endoscopy simulations and 8- to 10-week long summer research opportunities. Through this program, AGA members performed outreach to >2300 students spanning 7 institutions and 19 regional and national conferences. The FORWARD Program is the newest AGA initiative established in 2019 for underrepresented minority AGA members who wish to participate in a structured active mentorship program that helps to develop leadership, research, and management skills, and affords networking opportunities to promote investigational or leadership careers in academic medicine. These programs, although important and worthy of support, are by themselves insufficient to reverse the trends in recruitment and retention of underrepresented minority AGA members. The AGA has proudly supported many research, scholarship, and honorific awards since its inception. The AGA research portfolio has included $12 million of Research Foundation funding from 2016 to 2020. Eleven percent of AGA awards were competitively awarded to underrepresented minority members (excluding abstract and travel awards) amounting to approximately 15% of AGA Research Foundation funding. Currently, there are no underrepresented minority–specific research award mechanisms within the AGA, although such awards did exist in the past. Honorific awards (ie, distinguished recipient awards) were received by 10% of underrepresented minorities over the same time period. Among them are 2 Distinguished Clinician Awards, 2 Distinguished Mentor Awards, and 1 Distinguished Achievement Award in Basic Science. The main venue to showcase the scholarship of AGA members is DDW, the largest GI conference in the world, attracting >14,000 attendees per year. Although 10% of the AGA members are underrepresented minorities, only 5% of DDW speakers are underrepresented minorities. This differential may reflect what has been recently termed the "diversity–innovation paradox in science" in which underrepresented minority groups are less likely to receive academic recognition for their research contributions despite innovating at higher levels than their majority counterparts.9Hofstra B. Kulkarni V.V. Munoz-Najar Galvez S. He B. Jurafsky D. McFarland D.A. The diversity-innovation paradox in science.Proc Natl Acad Sci U S A. 2020; 117: 9284-9291Crossref PubMed Scopus (472) Google Scholar This paradox again highlights a systemic need for alternative and additional approaches to encourage and sustain underrepresented minority engagement and leadership in research and discovery as an integral component of the AGA's mission. The AGA has five journals that it sponsors. During the past 5 years, AGA publications have featured several articles on diversity, equity and inclusion. AGA members have advanced this topic in the flagship journal, Gastroenterology,7Carethers J.M. Quezada S.M. Carr R.M. Day L.W. Diversity within US gastroenterology physician practices: the pipeline, cultural competencies, and gastroenterology societies approaches.Gastroenterology. 2019; 156: 829-833Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar,10Lang L. Racial diversity among medical students may better prepare them for minority patient care.Gastroenterology. 2008; 135: 1439Scopus (4) Google Scholar,11Merchant J.L. Omary M.B. Underrepresentation of underrepresented minorities in academic medicine: the need to enhance the pipeline and the pipe.Gastroenterology. 2010; 138: 19-26 e1–3Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar and in GI and Hepatology News, The New Gastroenterologist,12Quezada S.M. Diversity in GI training: a timely goal. GI and Hepatology News. The New Gastroenterologist, Frontline Medical Communications Inc., Parsippany, NJ2017Google Scholar,13Badurdeen DPA, Malespin M, Oduyebo I, Quezada S, Stephen O. Promoting diversity through the AGA. Parsippany, NJ: GI and Hepatology News: The New Gastroenterologist Frontline Medical Communications Inc.Google Scholar and AGA Perspectives.14Gray D. Diversity in gastroenterology: purpose and progress. AGA Perspectives, 2017Google Scholar,15Munroe C.A. Quezada S.M. Lamousé-Smith E. The AGA Diversity Committee: opening up a conversation about unconscious bias in GI practice. AGA Perspectives, 2019Google Scholar Although this is evidence of a growing commitment to diversity, equity, and inclusion within the AGA, this commitment has not extended to journal editorship. Of the 260 current journal editors and editorial board members among all AGA publications, currently only 6 (2.3%) are underrepresented minorities, compared with 3% in 2010. Correcting this limited underrepresented minority editorial board representation is of paramount importance for the AGA. Racial health disparities exist for a number of GI diseases and the AGA's Diversity Policy calls for their elimination. With minor exception, African Americans are most affected by these disparities in the United States. In fact, based on 2002 data, approximately 84,000 excess deaths could have been prevented if the mortality disparity between Black and Caucasian patients were eliminated.16Satcher D. Fryer Jr., G.E. McCann J. Troutman A. Woolf S.H. Rust G. What if we were equal? A comparison of the black-white mortality gap in 1960 and 2000.Health affairs. 2005; 24: 459-464Crossref PubMed Scopus (231) Google Scholar Using colorectal cancer disparities in African Americans as an example, several strategies have been proposed, including improvement of patient access and provider education.17Kupfer S. Carr R.M. Carethers J.M. Reducing colorectal cancer risk Among African Americans.Gastroenterology. 2015; 149: 1302-1304Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Although most of the AGA's activities on patient access occur through advocacy activities (detailed elsewhere in this Commentary), the AGA previously sponsored the Colon Cancer Roundtable designed to improve colon cancer screening rates in African Americans. Efforts in provider education have included the incorporation of racial/ethnic disparity data in GI clinical guidelines and a DDW session specifically focused on delivering culturally competent care. Attendees were encouraged to complete implicit bias testing as part of that session. The AGA also cosponsors with the American Society of Clinical Oncology, AstraZeneca, and the Society of Surgical Oncology an annual Gastrointestinal Cancers Symposium that focuses on the cancer care continuum that includes racial and ethnic differences in epidemiology, treatment, and survivorship. To date, however, there is no AGA-wide curriculum on health disparities or cultural humility. The numbers of GI researchers engaged in health disparities work has increased over time as evidenced by the number of DDW presentations. In 2017, the DDW Council adopted the Diversity Committee's recommendation to include a "Health Care Delivery, Disparities and Practice Management" track. In 2019, this track was renamed the "Healthcare Delivery, Disparities, and Quality" track, and has had a greater volume of programming in care delivery and quality compared with programming in GI health disparities. Although the Diversity Committee has remained consistent in its commitment to symposium planning for DDW, these symposia have had modest attendance. Despite evidence for continued, systemic underrepresented minority racial and ethnic disparities in GI disease prevalence and outcomes, underrepresented minorities are also underrepresented in clinical research participation. During the Diversity Committee's sponsored symposium at the 2017 DDW "Closing the Data Gaps: Strategies to Recruit and Retain Diverse Patient Populations in Clinical Studies," AGA members initiated a discussion of some of the patient-, provider-, and system-level barriers that contribute to such low inclusion of underrepresented minorities in GI research. Although this conversation was critical, the AGA does not currently have specific mechanisms to improve underrepresented minority enrollment in clinical trials. This national crisis needs to be addressed as a priority.18US Food and Drug AdministrationEnhancing the diversity of clinical trial populations — eligibility criteria, enrollment practices, and trial designs guidance for industry.2019www.fda.gov/regulatory-information/search-fda-guidance-documents/enhancing-diversity-clinical-trial-populations-eligibility-criteria-enrollment-practices-and-trialDate accessed: July 6, 2020Google Scholar The AGA has a long track record of advocacy engagement on behalf of patients and members. The Government Affairs committee works to define the AGA advocacy priorities. Members and staff of this committee and members who participate in the Congressional Advocates and Young Delegates programs facilitate this advocacy work on state and national levels. Although not based on a race- or ethnicity-based platform, the AGA advocacy priorities include ensuring patient access to and coverage of specialty care, ensuring patient access to and coverage of evidence-based preventive screenings without cost sharing, and preventing insurers from discriminating on the basis of preexisting conditions. These fundamental differences in access often underlie racial health disparities. Unique among GI organizations, the AGA also has a nonpartisan Political Action Committee that actively supports candidates who support these advocacy efforts. The AGA has long advocated for access to specialty care for patients. In the 1990s when managed care penetration restricted access to specialists like gastroenterologists, the AGA pushed for a patient bill of rights legislation to ensure patients were able to seek unfettered access to specialists. Since 2010, the AGA has advocated for fixing the screening colonoscopy "surprise billing" practice for Medicare patients wherein a patient is charged the rate of a therapeutic colonoscopy if during a screening colonoscopy a polyp is removed. More recently, the AGA has been advocating for Congress and the Centers for Medicare and Medicaid Services to ease administrative burdens for prior authorization and other use management policies that restrict timely access to care for patients. These policies have a disproportionate impact on minority communities, given the higher rates of uninsured and underinsured patients in these communities and the potential for delayed or unfunded care. In addition to the Colon Cancer Roundtable discussed above in this article that addressed the higher incidence of colorectal cancer and lower screening rates in African Americans, AGA advocates have worked with Representative Donald Payne Jr. (D-NJ), a member of the Congressional Black Caucus whose father died of colorectal cancer and who authored H.R. 1570, the "Removing Barriers to Colorectal Cancer Screening Act" that would fix the screening colonoscopy cost-sharing problem. Together with the Congressional Black Caucus, the AGA has also collaborated on raising awareness of health disparities and the need to increase minority participation in clinical research, especially in areas like liver disease and hepatitis C, which have significant racial and ethnic disparities. This latter collaboration resulted in AGA members meeting with the US Food and Drug Administration (FDA) at the 2016 AGA–FDA Office of Minority Health Meeting. The meeting resulting in the FDA agreeing to (1) share information with the AGA about FDA grants through their Broad Area Announcement process, (2) provide the AGA with more information about existing regulatory science fellowship programs in which the FDA participates, (3) send information about how the AGA could subscribe to the FDA's hepatitis listserve, and (4) share information with the AGA about the FDA Advisory Committee participation and how AGA members could get involved. The AGA, in turn, agreed to (1) actively communicate upcoming guidelines, clinical practice updates, position papers, and white papers to FDA staff and (2) explore opportunities to host educational programs on regulatory science with FDA input. The recent unjustified killings of Breonna Taylor, George Floyd, and many other African Americans have heightened our national awareness of longstanding, systemic racism against African Americans and its related health inequities. Despite many gains made in the last 50-plus years toward increasing equity in health care and digestive diseases, as of today, priorities of the AGA have not adequately kept pace with the rapid and significant demographic changes in the United States. Nor have they kept pace with the diverse, evolving needs in research, education, clinical care, and community engagement. The gap between societal health care needs and delivery in the United States is also reflected globally. On June 2, 2020, leaders of the AGA, American Association for the Study of Liver Diseases, American College of Gastroenterology, and American Society for Gastrointestinal Endoscopy adopted an anti-racism policy that condemns "racism, bigotry and discrimination based on race, religion, gender, country of origin and sexual orientation." The 4 GI societies pledged to "continue to advocate for diversity in our staff and governance, grant awards to research health care disparities, ensure quality care for all and work tirelessly to reduce inequalities in health care delivery and access."4Racism, social injustice and our pledge to lead change. Joint GI society statement from AGA, AASLD, ACG and ASGE.https://gastro.org/news/racism-social-injustice-and-our-pledge-to-lead-changeDate accessed: June 30, 2020Google Scholar Here, we use this platform to delineate specifically how the AGA as an organization plans to engage anti-racism as a mechanism to go beyond its mission of "empowering clinicians and researchers to improve digestive health" toward reducing the effects of structural racism on health inequities and promoting equity for all. Anti-racism is an intentional set of behaviors and policies that work to combat racism, which can be defined as the rules, practices, and customs that permeate societal systems.19Understanding commonly used terms, ideas related to racism, injustice.https://abc30.com/society/understanding-commonly-used-terms-about-racism-inequality/6248593/Date accessed: July 1, 2020Google Scholar Although diversity, equity, and inclusion are necessarily components of successful anti-racism strategies, these 3 terms and anti-racism are not equivalent, because diversity, equity, and inclusion represent outcomes, whereas anti-racism strategies lead to these desired outcomes. We have elected to undertake the following framework to ensure long-term success in incorporating anti-racism as a cross-cutting actionable strategy to bolster diversity, equity, and inclusion within our organization and in much broader terms within the field of gastroenterology. We additionally commit to using this framework to improve the care of the diverse groups of GI patients we serve. Adapting an organizational anti-racism framework established by the National Juvenile Justice Network,20National Juvenile Justice NetworkMoving a racial justice agenda: organizational assessment: are you ready?.http://www.njjn.org/uploads/digital-library/westernstates3.pdf?phpMyAdmin=14730ab3483c51c94ca868bccffa06efDate accessed: June 25, 2020Google Scholar the AGA leadership recognizes that a commitment to anti-racism requires that the AGA: (1) establish organizational readiness through self-assessments of its anti-racism activities and anti-racism institutional culture, including an evaluation of the racial diversity of the membership and leadership; audit of resource allocation for prior anti-racism programming and initiatives; and an analysis of the past and ongoing alliances with racially diverse organizations; (2) develop leaders who receive formal instruction in diversity, equity and inclusion, cultural humility, unconscious bias, and anti-racism; (3) commit to educating and engaging membership and stakeholders in anti-racism efforts; (4) commit to coalition building with other organizations who are working toward incorporating anti-racism as a strategy to improve diversity and reduce disparities; (5) perform a financial and resource audit to identify current resources that can be applied to new initiatives and develop a plan for fundraising for initiatives that cannot be accommodated with current resources; and (6) establish an interval assessment to permit determining how we have done and to assess the need for any calibration of efforts and resource allocation. Informed by the results of this self-assessment and the need to develop concrete and actionable strategies and tactics, the AGA has established the AGA Equity Project, led by the AGA Equity Task Force (https://gastro.org/aga-leadership/initiatives-and-programs/aga-equity-project/). The Task Force was established June 12, 2020, and was charged with developing a vision of equity for the organization overseeing AGA initiatives designed to make this vision a reality. The Task Force proposed a vision to "achieve equity in digestive health and eradicate disparities in digestive disease" focused on the following six domains: (1) justice, equity, and education (2) research and funding, (3) workforce and leadership, (4) recognition, (5) unconscious bias, and (6) engagement of the next generation (Figure 2). The following is a preview of the Task Force's assessment of the current state, and its vision for each domain. Many individuals have assumptions (we believe incorrect) that justice and equity for all have already been achieved in 2020, resulting in general assumptions that racism, discrimination, and bias do not exist on personal or systemic levels, and thus there is no current need for a solution or paradigm change. We envision a just world free of health disparities in digestive diseases and free of inequities in access and effective health care delivery. There is greater emphasis on funding and prominence of research that focuses on GI diseases that primarily affect the majority population, and a relative lack of funding and research that advances the science of health care disparities and scientific understanding of diseases most prevalent in minority populations. We envision state-of-the-art and well-funded research that aligns with the realities of the current multicultural patient population and disease states to achieve health equity for all.

BACKGROUND:Depression is common in patients with inflammatory bowel disease (IBD) and contributes to poor quality of life (QoL). The use of information technology for the remote management of patients with IBD is growing, but little is known about its impact on depressive symptoms (DS) and QoL. We aimed to evaluate the impact of telemedicine on DS and generic QoL in IBD patients.METHODS:We analyzed data from the Telemedicine for Patients with IBD (TELE-IBD) study. During this 12-month clinical trial, patients were randomized to receive text message-based telemedicine weekly (TELE-IBD W), every other week (TELE-IBD EOW), or to standard care. Depressive symptoms and QoL were assessed over time with the Mental Health Inventory 5 (MHI-5) and the Short Form 12 (SF-12), respectively. We compared the change in MHI-5 and SF-12 (with separate physical (PCS) and mental component summary (MCS) scores) between the study arms.RESULTS:A total of 217 participants were included in this analysis. After 1 year, there was no significant difference in the change in MHI-5 (TELE-IBD W +3.0 vs TELE-IBD EOW +0.7 vs standard care +3.4; P = 0.70), MCS (TELE-IBD W +1.4 vs TELE-IBD EOW +1.0 vs standard care +2.5; P = 0.89), and PCS scores (TELE-IBD W +0.4 vs TELE-IBD EOW +0.6 vs standard care +3.7; P = 0.06) between the groups.CONCLUSIONS:Text message-based telemedicine does not improve DS or QoL when compared with standard care in IBD patients treated at tertiary referral centers. Further studies are needed to determine whether telemedicine improves DS or QoL in settings with few resources.