Moving Beyond Checking the Box

Attention and accountability are the 2 “A’s” that drive change. It’s true in medicine, business, even family. If it is not monitored, it is not regarded as important nor will change be affected. As ob/gyns, we see this in our practice. Those where cesarean delivery, open, and laparoscopic hysterectomy rates (among others) are publically known, ideally alongside others in similar practice, typically adjust if they become an outlier.

Proving the point, several studies have shown that institutional interest in a metric directly affects change. Oshiro and colleagues demonstrated that implementing a policy and institutional awareness to reduce elective early-term deliveries affected an 83% decline in 1 year, from 37.8% to 4.8%.¹ Wilson-Leedy and colleagues demonstrated a reduction in overall cesarean delivery rate and cesarean after induction of labor after implementing a labor management guideline at their institution.²

The key features are that leadership agrees the metric is important, it is tracked, and reported out regularly. Metrics that help guide decisions and ensure accountability are also useful. Without knowledge, we cannot affect change. In his 2015 book “Sapiens: A Brief History of Humankind,” Yuval Noah Harari wrote that knowledge is power.³ The real test of knowledge, he said, is not whether it is true, but whether it empowers us.

I can’t help but ask how we can use these concepts to enhance inclusion. I believe we can all find in our inbox invitations to meetings with expert panels— often with photos of the experts. Interestingly, and often, many experts seem to share similar characteristics. Although it is essential that those participating are considered experts— how do we ensure that we are truly expanding these rosters to represent the best cross-section?

When we developed a roster such as for a meeting, review group, or advisory panel at the National Institutes of Health, it was essential that the panel was diverse. Each roster was submitted with a table that listed the name, gender, race, ethnicity, and geographic location. These were attempts to ensure diversity. In my mind, this exercise is both positive and negative.

On one hand, experts must be at the table, and people are not included simply on the basis of a characteristic. However, this method only ensures diversity and gives the appearance of being inclusive. Without directed thought to truly achieve real diversity, this method is not sufficient. It is critical to measure something meaningful, not just something easily measured.

A difficulty in identifying diversity lies in the knowledge of who is creating the roster, who they know, and who is considered an expert in the topic. To enhance diversity, amplifying experts across gender, race, ethnicity, geography, and any other grouping is essential. A few groups have started this process.

For example, there are lists of women in maternal and fetal health, microbiology, infectious diseases, cardiology, pelvic floor disorders, women’s health policy, and more, just as examples, that should be curated and then used to ensure representation. One such group is the Womxn’s Health Collaborative. At WomxnsHealthCollaborative.org/list-of-women-in-womens-health-research, you will find a working list of women in women’s health research. If you are so inclined, you should add your own name there and your areas of expertise. If you know of others who should be added, please also let them know.

Throughout human existence, the challenge has been putting new knowledge to work meaningfully as it is acquired in scientific research. We must continually assess where we are and where we want to be so that the knowledge we build upon becomes a true representation of the human race. Evolving science requires critical thinking for an effective model that will benefit human health. As physicians and scientists who dedicate our lives to women’s health, we should want that to be our legacy.

References

1. Oshiro BT, Kowalewski L, Sappenfield W, et al. A multistate quality improvement program to decrease elective deliveries before 39 weeks of gestation. Obstet Gynecol. 2013;121(5):1025-1031. doi: 10.1097/AOG.0b013e31828ca096. Erratum in: Obstet Gynecol. 2013 Jul;122(1):160.
2. Wilson-Leedy JG, DiSilvestro AJ, Repke JT, Pauli JM. Reduction in the cesarean delivery rate after obstetric care consensus guideline implementation. Obstet Gynecol. 2016;128(1):145-152. doi: 10.1097/AOG.0000000000001488
3. Harari, YN. Sapiens, A Brief History of Humankind. 2015