LAUSR

Bias can be defined as a systematic error introduced into sampling or testing by selecting or encouraging one outcome over others. As surgeons, we strive daily to mitigate the effects of bias on patient care through the routine use of evidence-based practice. As researchers we make special considerations during study design, data collection and analysis to mitigate inherent biases on study outcomes and conclusions. By no means, does this mean we have eliminated bias as a profession, in fact the opposite is true. However, the normalization of discussions around bias as a systematic problem in health care delivery and clinical research, has resulted in significant improvements as we aim to close the health care gap, and improve generalizability and interpretation of clinical trial results. Unfortunately, conversations around mistreatment within the profession of surgery are far less common and are still emotionally fraught. This is because, the act of exacting bias during interpersonal interactions is still largely viewed as an individual or personal problem, generating feelings of anger, emotional distress, and tension when these incidents are recognized. While we have made significant progress in addressing overt or explicit bias, other forms of bias remain rampant within the profession and our surgical societies. However, while some forms of bias are due to conscious, discriminatory personal beliefs (explicit bias), the vast majority occur below our level of consciousness and are reinforced within organizations and societies without intent (unconscious and implicit bias). These beliefs and stereotypes manifest as microassaults, microinsults and microinvalidations; collectively referred to as microaggressions (Table 1). The cumulative effects of bias and microaggressions are evidenced in the lack of diversity and inclusion in surgery and surgical leadership. Over the last three decades, we have seen a steady increase in female representation within surgery with an approximate 3-fold increase in the number for female surgical faculty. Female residents now account for approximately 40% of all general surgery trainees. Still, women account for only 20% of associate professors of surgery, 10% of full professors of surgery and remain significantly under-represented in surgical leadership. Low racial and ethnic diversity in surgery is persistent at all levels of surgical training and practice, with very little progress on the horizon. In 2020, only 5.3% of general surgery residents identified as Black, 8.1% as Hispanic/ Latino, 0.8% American Indian and 0.3% Pacific Islander. While individuals certainly have a personal and professional duty to address bias, organizations and surgical societies must also strive to minimize the effects of bias, by creating an atmosphere of equity, inclusivity, tolerance, and empowerment in order to retain members and attract individuals from diverse backgrounds. Inconsistencies in use of professional titles when introducing colleagues and trainees in the workplace and at professional meetings has long been a subtle but damaging microinvalidation that has been pervasive throughout the medical profession. Professional titles such as ‘‘Doctor’’ or ‘Professor’’ convey personal expertise and authority. Consequently, the exclusion of these salutations may imply professional inferiority. Several studies have evaluated disparities in the use of professional titles by gender, race and ethnicity, as well as academic rank when introducing speakers. Files et al. evaluated the use of professional titles at 124 consecutive internal medicine grand rounds and Society of Surgical Oncology 2021