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 Table of Contents  
EDITORIAL
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 73-78

What's new in academic international medicine? Highlighting the importance of diversity, inclusion, and equity


1 Department of Medicine, St. Luke's University Health Network, Bethlehem, PA, USA
2 Department of Oncology, Division of Hematology and Oncology, St. Luke's Cancer Center, Bethlehem, PA, USA
3 Department of Pediatrics, St. Luke's University Health Network, Bethlehem, PA, USA
4 Department of Human Resources, St. Luke's University Health Network, Bethlehem, PA, USA
5 Department of Family Medicine Residency, St. Luke's University Health Network, Bethlehem, PA, USA
6 Division of Hematology/Medical Oncology, Temple Medical School, St. Luke's University Health Network, Bethlehem, PA, USA

Date of Submission15-Jun-2021
Date of Acceptance21-Jun-2021
Date of Web Publication29-Jun-2021

Correspondence Address:
Dr. Elisabeth Paul
Department of Medicine, St. Luke's University Health Network, Bethlehem, PA
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijam.ijam_81_21

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How to cite this article:
Paul E, Wilson M, Erickson-Parsons L, Desai S, Carneiro R, Belman ND. What's new in academic international medicine? Highlighting the importance of diversity, inclusion, and equity. Int J Acad Med 2021;7:73-8

How to cite this URL:
Paul E, Wilson M, Erickson-Parsons L, Desai S, Carneiro R, Belman ND. What's new in academic international medicine? Highlighting the importance of diversity, inclusion, and equity. Int J Acad Med [serial online] 2021 [cited 2021 Jul 24];7:73-8. Available from: https://www.ijam-web.org/text.asp?2021/7/2/73/319804



The coronavirus disease 2019 (COVID-19) pandemic exposed important stress points in both our personal and professional/organizational lives.[1],[2],[3],[4],[5] Among the most affected areas and in itself, an emerging crisis is the deleterious effect of the pandemic on existing diversity, equity, and inclusion (DEI) initiatives.[3],[6],[7] Women and underrepresented minorities in medicine (URMM) have traditionally experienced formidable systemic barriers when it comes to institutional leadership and tenured positions in academic medicine.[8] Empirical evidence strongly supports this point of view, with only 21% of full professors and 15% of department chairs being women.[9] Moreover, there has only been a 1% increase in URMM faculty over the past 20 years – a figure which now stands at approximately 8%.[10] With the COVID-19 pandemic, this representation has the potential of being further threatened, with indirect evidence demonstrating a significant decline in female first-authored scholarly manuscript submissions (20% in April 2020) compared to 36% in December 2019.[7] Here, we will explore some of the most important aspects of DEI as they relate to the current state of medical academia.


  Lack of Mentorship and Sponsorship Top


Institutional leadership advocating for career advancement and identifying opportunities for junior candidates is critical in promoting DEI.[9] Various systemic biases, often difficult to perceive and deeply ingrained within the institutional culture, play a major role in women and URMM not having the opportunity to join the highest ranks in academic medicine (and other scientific fields).[11],[12],[13],[14] This, in turn, leads to fewer women and URMM available to provide mentorship and sponsorship, resulting in a deleterious cycle that is difficult to break.[13],[15],[16],[17]


  Lack of Understanding of the Difference Between Equality and EquitY Top


Equality results in everyone having the same resources.[18],[19] When diversity is considered, all faculty have a mentor who is a Caucasian male would be considered to represent equality. Equity, on the other hand, refers to everyone having the resources needed to achieve an equal outcome.[20] For example, a female faculty member collaborating with a female mentor and a URMM faculty member having access to a URMM mentor could be considered as basic representations of equity. Of course, this is not to imply that any mentor–mentee combination could not be achievable or feasible; rather, each individual should have access to the highest quality, most optimal resources required to succeed.[3],[21],[22]


  Focus on Diversity, Equity, and Inclusion in the Workplace Top


It is critical that the issues of DEI are addressed effectively in order to create a more equitable workplace for all who participate in academic medicine.[23] While addressing health disparities is the goal of many US health-care institutions, that goal will not be attainable until equity is addressed from within the medical community and across our academic institutions.[23] In addition, it is argued that the lack of diversity in health care and the health-care workforce is a reflection of similar characteristics in health inequity.[24],[25] Consequently, we propose a call to action for change as more diverse representation in academic medicine leadership positions benefits all.


  Scrutinizing Academic Medicine Top


Addressing gender in academic medicine is crucial for health promotion across all populations, and in order to do this, the issue of equity must first be analyzed. It has been estimated that between 47% and 70% of female medicine faculty have reported experiencing gender-based discrimination at work,[26] and a staggering 66% of female physicians who are mothers have reported being discriminated at work based on their gender.[27] Discrimination in this realm is displayed not only by harassment but also by lack of career advancement. Women in academic medicine may also face different barriers than men such as work-life integration and likely associated symptoms of burnout.[28] It naturally follows that teachers, mentors, and supervisors who are female and may be aware of and more attuned to such barriers would propagate more equity for female trainees in academic medicine.


  Clinical Trials and Research Top


Along those same lines, increasing female presence in academic medicine could have a positive impact on research topics, as well as the proportion of female patients enrolled in clinical trials. In the past, women patients have consistently not been included in clinical trials. Then, in 2016, the National Institutes of Health announced that women participants had to be appropriately included in all research trials, acknowledging that men and women do respond differently to treatment.[29] For instance, women typically experience worse outcomes than men after the occurrence of a heart attack. This may be attributed to a predominantly male medical field having previously included few women in research samples to study how different genders are affected by the same condition.[30],[31],[32] Similar considerations apply to underrepresented groups.[33],[34],[35],[36]


  The Minority/Cultural Tax Top


The current lack of URMM representation in academic medicine is likely exacerbating and perpetuating disparities throughout our health-care systems, producing further barriers to success for URMM health-care providers, as well as disadvantages to affected groups within the patient population.[37],[38] Many URMM providers report that they have experienced racism, microaggressions, feel excluded and isolated, miss out on critical career opportunities such as mentorship and promotions, and feel obligated to spend their time assisting the communities they represent instead of pursuing other clinical and academic roles.[39],[40] The latter is known as the “minority tax” or “cultural tax,”[10] often associated with assuming greater comparative workload than non-URMM counterparts.[41]


  Toward Greater Female Leadership Participation in Academic Medicine Top


There is no doubt of the existence of the underrepresentation of female faculty in leadership positions within medical academia – both in clinical and research realms. Despite approximately 50% of medical school enrollees being female, <25% of females are in the divisional chair and chief roles.[42] In research, more than 50% of Ph.D. students are female, yet only 21% of full professors are female and only 15% of department chairs are women.[9] In addition, women in graduate medical education experience on average, less career advancement opportunities than their male counterparts, which is a facet of institutional gender discrimination.[3],[43] In 2014, women were underrepresented in academic medicine, representing 34% of academic professors including only 21% of full professors of internal medicine.[44] Moreover, approximately 48% of women physicians have reported symptoms of burnout, while only 38% of their male counterparts have reported such symptoms.[45]

This is a recognized challenge in medicine and there have been attempts to help retain young faculty, research faculty, in the field and to build on their research and academic potential, to counteract issues facing females in this field that ultimately lead to unacceptable attrition and loss of talent. The existence of “glass ceilings” extends beyond the above considerations, permeating aspects such as unequal funding levels of NIH-sponsored grants. For example, in one study, female awardees received on average approximately $80,000 less in grant funding than male awardees.[43] In another study, the mean income of women physicians was approximately $22,000 less than income of their male counterparts.[46]

The disproportionately low percentage of females in leadership positions and within the general governing structure across our academic institutions has wide-ranging consequences. Training of rising female clinicians and scientists is impacted, with decreased number of role models and mentors. These effects can be appreciated in various secondary mechanisms of recognition and scholarly activity in female physicians. In a study evaluating female authorship in the field of oncology, results demonstrate that, while female authorship has increased over time, it has not kept up with the overall increase of female physicians in oncology.[47] Moreover, in medical oncology publications, females were less likely to be authors on clinical trials in first, second, or last position than corresponding positions on observational studies, a trend that was not seen in the fields of radiation and surgical oncology.[47] This perceived lack of productivity could then affect future employment for trainees and junior faculty, where successful, meaningful publication is valued highly, thus setting up a magnifying effect in ongoing academic pursuits. Ultimately, long-term academic positions can be affected. One study demonstrated that the highest predictor of becoming a dean at U. S. medical schools was being an Associate Dean or Departmental Chair.[48]


  Toward Greater Urmm Leadership Participation in Academic Medicine Top


Despite the growing calls by many leading medical organizations for DEI in academic medicine, the proportion of URMM faculty and students in medical schools has increased minimally.[49] URMM is also underrepresented within the US physician workforce as a whole. As an example, in 2019 minorities in the US comprised one-third of the population, contrasted with URMM making up only 10% of emergency medicine (EM) physicians in 2013 and 13% in 2017, suggesting a substantial discrepancy.[50] Yet compared to EM, URMM representation among orthopedic surgeons is much lower, with 1.7% Hispanic/Latino and 1.5% African-American faculty,[51] whereas Hispanic/Latino faculty make up 18.1% and African Americans make up 13.4% of the US population.[52],[53] In a study to identify causative factors underlying these observations, faculty were interviewed regarding their perceptions of existing barriers to diversity. Of importance, the most frequent answer, at nearly 70% was, “…(we do not have) sufficient minority faculty, which may deter applicants.[53]

Studies also show that URMM residents often report experiencing microaggression, slights, and insults based on racial prejudices,[54],[55] which in turn leads to burnout,[56] and subsequently fewer URMM participants in academic medicine over time. The minority tax also plays an important role in explaining why there may be fewer URMM represented in leadership and mentorship position in academic medicine,[57] which has an increasing negative impact on racial equity for trainees. The achievement gap, referring to a difference in academic achievement and standardized test taking between URMM and non-URMM students, is another factor contributing to racial inequity in medical education.[58] Unfortunately, this gap starts as early as preschool and has been noted to increase as a student progresses through the educational system.[59]

Several interventions have been proposed to create greater equity in academic medicine. Many of these do challenge the concept of equality and equal opportunity. In order for a minority patient population to experience equity when compared to other groups, more URMM trainees would have to be admitted into residencies, particularly in areas and disciplines with large racial disparities. In order to promote a level playing field for URMM candidates for residencies, there would need to be an increase in URMM mentors and faculty associated with those residencies. Following this train of thought, it would seem that there may be a role for quotas and a holistic approach for admission/hiring in all levels of academic medicine, ranging from medical school admission to leadership positions in academic medicine. Medical schools have used a holistic approach with regard to admission of URMM, for decades, although not without controversy. At several points in time, non-minority candidates have challenged affirmative action in medical school, with high profile supreme court cases in 1978, 2003, and most recently in 2014,[60] claiming racial considerations during admission processes to be unconstitutional and ultimately not promoting equal opportunity for all.[61] Each time the race-conscious admission policies applied at the accused institutions have been upheld by the Supreme Court, citing that the diversity of the nation should better be reflected in our physician population. Furthermore, the need for universities to maintain meritocratic standards in enrollment is often pitted against affirmative action.[62] However, there is evidence to demonstrate no increase in drop-out rates in affirmative action students and their normative peers.[62] Based on this, one could make an argument supporting similar measures to be applied when appointing program directors, faculty, and admitting candidates into particular residency programs, thus promoting equity for URMM candidates. This could be difficult to apply in practice as faculty and program director positions are far fewer in quantity and have less frequent openings than student spots, as such appointments tend to last for decades. If appointment durations for professors, deans, program directors, and faculty had preset limitations (e.g., term or duration limits), this could serve as a portal for more URMM to have opportunities to fill such positions, and the frequent changes and updates in the racial and gender makeup of faculty and leadership may better reflect the rapidly growing diversity across the nation. The challenge also lies in how equity would be ensured, and it will be important for any implementations to enhance DEI without abruptly creating or promoting new asymmetric inequities.


  The Synthesis: Toward Initiatives to Reduce Loss of Talent and Faculty Attrition Via Diversity, Equity, and Inclusion Top


Attrition of female faculty in medicine is a complex issue that has overarching ramifications and is an area of active investigation in order to address this growing problem. More female mentors, faculty, and program directors may serve as role models for younger trainees and promote more longevity for female physician's professional lives. Unfortunately, it would appear that many of the challenges that female physicians face stem for inequity related to work-life integration.[63],[64] The Doris Duke Funds to Retain Clinical Scientists (FRCS) is a program to help with this issue disproportionately facing female physicians and researchers today.[65] Moreover, the Doris Duke FRCS benefits all clinical scientists, male and female alike, to support their career and research development while facing external caregiver pressures. This is similar to the inequity created by the achievement gap with regard to URMM candidates, and similar foundations and funds may be needed to fill the gap for URMM physicians and physicians in training. Institutions may also need to decrease the number of URMM faculty on committees if there is an overrepresentation of URMM faculty on committees in order to combat the “minority tax.”[57] It may be appropriate to call for a drastic makeover of academic medicine including end of tenures, limited time spans for program directors, faculty appointments, and quotas demanding that a certain percentage of faculty, program directors, deans during a given time span are female, and/or URMM. The hope then would be that what is lost in continuity and experience would be surpassed through greater DEI.



 
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