Mahoney, Megan R. MD; Wilson, Elisabeth MD, MPH; Odom, Kara L. MD, MPH; Flowers, Loma MD; Adler, Shelley R. PhD
As racial and ethnic diversity in the general population of the United States increases, research continues to show that diversity in the physician workforce improves health care quality and access to care for ethnic minorities.1–3 In 2004, three ethnic minority groups, African Americans, Latino Americans, and American Indians, represented more than 25% of the U.S. population but only 6% of the nation’s physicians.4 Several reports, including those of the Institute of Medicine and the Sullivan Commission, have called for measures to increase the diversity of the medical workforce.1,4,5 Recruitment and retention of racial and ethnic minority faculty at medical schools have been identified as key factors in increasing the pipeline of minority medical students. Minority faculty provide support for minority students in the form of role models, educators, and mentors.6,7 Unfortunately, minority faculty continue to be alarmingly underrepresented, comprising only 4.2% of medical school faculty nationwide in 2005.8 In that same year, approximately 20% of minority faculty were located at three historically black medical schools and three Puerto Rican medical schools accredited by the Liaison Committee on Medical Education.9 Minority academic medicine faculty are less likely to hold senior rank, are promoted at lower rates,10–12 and report more discrimination than white faculty.13 In addition, high rates of discrimination and harassment during medical education and training14,15 might explain differences in the level of physicians’ professional satisfaction according to race and ethnicity.16 A recent study of physicians of African descent found that race-related experiences can create “racial fatigue” and result in personal and professional costs for physicians.17
Diversity in the student body at medical schools has been shown to enhance the educational experience for all students.18 In addition to addressing health disparities in academic medicine and improving the education and training of all medical students, increasing the number of minority faculty may improve care by increasing the numbers of physicians working with underserved populations19 and by multiplying options for minority patients who prefer racially concordant physicians.20–22
The far-reaching effects of anti-affirmative-action policies, such as Proposition 209 in California, have negatively affected minority student enrollment and recruitment. Proposition 209, a constitutional measure passed in 1996, outlawed race- and gender-based admissions and hiring policies at California public institutions. As of 2008, the University of California–San Francisco (UCSF) School of Medicine faculty includes 2.1% African American and 2.6% Latino faculty. UCSF is working on a variety of strategies to increase diversity through initiatives such as the Underrepresented in Medicine Mentorship Program, the School of Medicine Task Force on Underrepresented Minorities, the Chancellor’s Advisory Committee on Diversity, and a new position for a director of academic diversity.
In our study, we bring the voice of minority faculty to current diversity efforts by examining the effects of anti-affirmative-action policies on the diversity climate and by making specific recommendations for academic institutions seeking to increase diversity. Previous studies have focused on junior faculty or students,23,24 whereas our study explores both the junior and senior faculty experience. To explore the diversity climate at UCSF, we designed a qualitative study to examine the perceptions of minority faculty with regard to diversity and discrimination on campus. Our objectives were to (1) elicit and explore the perspectives of minority faculty regarding racial and ethnic diversity in academic medicine, and (2) generate collective recommendations on ways to increase diversity in academic medicine at our institution and nationwide.
In 2005, we conducted one-hour interviews with UCSF minority faculty members, using an interview guide that contained a list of open-ended questions (see List 1). We chose one-on-one interviews instead of focus groups to encourage participants to share their experiences, as well as their interpretations of events, in a confidential environment. Interviewers (M.M., E.W., K.O.) were physicians and were trained in the use of qualitative interviewing techniques.25–27
Qualitative methods are particularly useful for studying and describing complex phenomena and providing understanding and description of people’s personal experiences and interpretations of phenomena (i.e., the “emic” or insider’s viewpoint). The purpose of qualitative research is to study human experience to reveal the processes by which people construct meaning about their worlds and to report what those meanings are. Qualitative researchers are interested in understanding the world from participants’ frames of reference.
By exploring the individuals’ “insider” views, we were able to assess the diversity climate in terms of the experiences and understanding of the ethnic minority faculty themselves. Interviewers explored participants’ experiences as minorities, perspectives on diversity and discrimination in academic medicine, and recommendations for improvement.
We recruited participants through a database maintained by the Underrepresented in Medicine Mentorship Program, which lists self-identified racial and ethnic minority faculty at UCSF. We excluded physicians in training and those who were not faculty in the school of medicine. We initially sent 67 faculty members recruitment e-mail letters. Through snowball sampling,28 we sent five additional faculty members recruitment e-mail letters. Forty-seven faculty responded, and 36 of the respondents were enrolled. Eleven interviews could not be completed because of scheduling conflicts. Study participants were not paid for their participation. The UCSF Human Research Protection Program approved the study protocol. This work was supported by a stipend from the Office of the Executive Vice Chancellor at UCSF and a Linking Education, Action, and Research Networks grant.
Digital recordings of interviews and interviewer field notes were transcribed verbatim, and the resulting transcripts were checked by each interviewer for accuracy. Two research team members (E.W., M.M.) independently analyzed each transcript using standard qualitative content-analysis methods. Transcripts were read several times to identify recurring concepts, which, in turn, were developed into discrete codes. Codes were used to label comments in the transcripts that represented discrete thoughts or themes. We (1) compiled a list of codes (the codebook) that corresponded to the themes observed in the transcripts, (2) independently coded transcripts before meeting to conduct between-coder comparisons and to revise the codebook, and (3) after finalizing the codebook, judged a predetermined segment of text for whether a specific code was present. We reviewed codes frequently to achieve high interrater reliability. A third investigator then reviewed codes agreed on by the primary reviewers (S.A.). Codes were subsequently grouped into domains with thematic labels, and these domains underwent independent secondary review for relevancy and consistency by a fourth investigator (K.O.). Finally, domains were used to develop overarching themes. NVivo 2 software (QSR International, Ltd., Cambridge, Mass) was used to facilitate data management and online analysis.
We conducted 36 interviews (with 15 assistant professors, 11 associate professors, and 10 full professors) before achieving theme saturation. We defined assistant professors as junior faculty; associate and full professors were considered senior faculty. Seventeen individuals were African American, 16 were Latino, and 3 were Asian American. Twenty participants were women. Faculty affiliations were distributed across departments, including both primary and specialty care. Gender, race/ethnicity, and academic rank of the interviewed participants are shown in Table 1.
We identified four broad themes: (1) choosing to participate in diversity-related activities, driven by personal commitment and institutional pressure, (2) the gap between intention and implementation of institutional efforts to increase diversity, (3) detecting and reacting to discrimination, and (4) a need for a multifaceted approach to mentorship, given few available minority mentors. We have included representative quotes under each theme subheading.
Diversity-related activities: Personal commitment and institutional pressure
Minority faculty members reported striving to integrate their cultural backgrounds into the context of their work. Their career choices and their involvement in outreach and mentoring reflected a sense of obligation towards their community.
I made the disparities topic or the minority health topic my central research theme. And so, in some ways, I was studying myself or our population, you know, Latinos … and so that made my legitimacy or credibility in talking about these issues; it enhanced it. [Latino man, senior rank]
It is part of being African American, certainly, and probably many other minority groups, that you are expected—that if you have made success, achieved a level that is not common for people of your race—you are responsible for helping out, being a role model, trying to make a change. [African American man, senior rank]
In addition to a personal commitment to promoting diversity, minority faculty members mentioned experiencing institutional pressure to participate in diversity efforts. Participation becomes extremely difficult to decline, and these activities often result in overextension. The decision to participate can be fueled by the experience that if they are not present, the ethnic minority perspective will not be represented.
There are not many. I am the senior ethnic minority faculty in the department, so I do feel that responsibility. I take it on gladly actually. I do enjoy mentoring. I feel I do make a difference…. I know I make a difference, so that’s … it’s not a … I am probably overextended in that area. [Asian American man, senior rank]
There was, I think, a sense of, early on, that you had to speak up for underrepresented or for minorities in general, because no one else would. [Latino man, senior rank]
The interplay between one’s own commitment to diversity and external expectations to participate is particularly heightened when faculty are asked to serve on diversity committees.
Some of the opportunities, particularly early in my faculty career, that I was given were probably to enhance either the gender or ethnic representation on the committees. So when, I mean, I’ve had that because once you get to the table, then you have an equal voice and the opportunity to open your mouth and share, so my feeling is whatever it takes to get you there, that’s fine with me. [Latina woman, senior rank]
Participation on committees might feel neither voluntary nor in the interest one’s own professional career.
I could show you the letter from the chancellor, which said, “You’ve been appointed to the UCSF Diversity Committee.” There was at the same time the dean’s letter from the URM task force. There was no, there’s no question in there. It was more of, “This is when you’re going to start meeting.” And I’m sure I could have done something about it, but, you know, you pick your battles. [Latino male, senior rank]
Minority faculty get called into the committee work so much that they don’t have time because they have to do all their responsibilities, clinical, etc., to do the research thing, which is really what they emphasize when you go to promotion. They don’t emphasize the service on the committees. [Latino male, junior rank]
Increasing diversity as an institutional priority: Intention and implementation
Although minority faculty reported being aware of and actively participating in diversity-related initiatives, study participants observed a gap between intention and implementation of these efforts at the administrative level. This gap is attributable to institutional as well as external barriers, yet it creates the perception that diversity is not an institutional priority.
The system can easily or readily determine the outcome for individuals in the system, and so to me, it’s not just a question of getting people to the stage of interviewing, or getting them to the stage of initial appointment. It is, you have to see that their success is absolutely crucial to the future of the institution, and then you bring the appropriate resources to bear, to bring that to reality! And it can be done. [African American man, senior rank]
I belong to organizations filled with qualified candidates. So it’s just not a priority. And once again, it’s not that the institution is actively working against the recruitment, they’re just not … it’s not a priority. [African American man, senior rank]
Minority faculty called for enhanced leadership, accountability, and adequate funding to increase outreach and improve retention. It was observed that institutional committees make recommendations, but the next step of implementation is challenged by lack of resources, undercommitment, and competing priorities.
We can have committee after committee study the problem. Unless you have some meat behind the issue, nothing’s going to happen. [Latino man, senior rank]
Someone has to be willing to fund the initiatives that are not rocket science. That would make this environment that minorities would find attractive. [African American man, senior rank]
The idea of a centralized focus on minority recruitment and retention was strongly endorsed.
It’s important to have an office of minority affairs where there is a visible place that is going to solve problems…. When we are recruiting students and faculty, there is a place where people can go and get information about what else is out there…. Nobody is coordinating across all the departments…. Having an office, you can have an internal change agent that can really keeps their eye on the ball. [African American woman, senior rank]
If you want to increase diversity, you have got to say it somewhere, and then you have to, you know, so it has to be written down somewhere, and then after it’s written down, it has to say how you’re gonna do it. And then someone has to be responsible for doing that—more than one person has to be—like a group of people, so you know, where’s the office of minority affairs? That’s where there was an explicit group that you knew to go to. They do not exist anymore. [African American woman, junior rank]
Discrimination: Detection and reaction
Many faculty members have difficulty navigating the system of promotion and tenure.29 However, minority faculty members reported feeling pressure to conform to the social conventions of the ethnic majority academic culture, which is generally more familiar to and therefore differentially supports nonminority faculty.
In my experience, they … I call it … there’s a “paradigm person.” So if you fit this kind of paradigm, then you tend to excel. And I hate to say, I think it’s here and everywhere else in the United States, that if you’re a white male … it is unspoken, but there’s clearly … you see who is rewarded. [African American woman, junior rank]
There’s definitely … the “old boys network,” they hang together and that kind of thing and … I don’t hang with them, you know what I mean? [Latina woman, senior rank]
Though often subtle, racial discrimination is perceived to occur in and have serious consequences for career path, research success, and retention in faculty roles. Minority faculty have developed different coping skills in reaction to discrimination, ranging from confrontation to avoidance. Participants indicated that potential loss of peer credibility and respect, as well as personal time and energy, has to be weighed during each encounter with discrimination.
There’s been both the subtle thing that we deal with most of the time, and I think there’s been some overt racism. I have, as I say, made a conscious decision about how much energy I was going to put into confronting those experiences, and have elected not to pursue them as much as probably somebody else would have. [African American woman, senior rank]
I’ve been fairly vocal in expressing my opinions about some of those issues and those things are not always well received. And I try to do them in a politically correct way, but they’re not always well received. So I think that probably the biggest challenges are just sort of you know, within my own department and having people understand how I am making a contribution to the university and have them really appreciate and value those contributions. [African American woman, senior rank]
Mentorship: Significant needs and limited choices
All participants viewed mentorship as a crucial element for achieving success in academic medicine, even though the topic of mentorship was not an explicit part of our interview guide. Receiving mentorship typically correlated with career satisfaction. In addition to career guidance, it was observed that minority mentors provide cultural and emotional support and a sense of belonging to a community. All mentors can help minority faculty members navigate the university structure and institutional conventions.
Being a minority faculty member creates a psychological stress for a divergence of viewpoints that is quite similar to the psychological stress experienced by women who are trying to balance work life and family life, in that there is always a somewhat uneasiness within the social relations in a dominant culture. At least that is how I experience it. I think that psychological stress can be relieved through appropriate mentoring, but that appropriate mentoring requires a great deal of time. [Latina woman, senior rank]
This complex need for mentorship is met with a lack of critical mass of potential mentors. When few senior minority faculty members are available, mentorship becomes fragmented into multiple disparate areas. Although many participants spoke of the benefits of multiple mentors, it was generally out of necessity rather than strategic choice.
While I think that many people have a hard time getting appropriate mentoring at UCSF, I think that, from a certain perspective, minority researchers have a harder time. [Latina woman, senior rank]
This is the kind of thing that unless you have good mentors that are willing to stand up for what seems to be a just cause, I would have been swept under the carpet. I’ve never had a single mentor. I’ve always had a variety of mentors. I’ve used that to my advantage. [Latino man, senior rank]
In this study, we sought input from both senior and junior minority faculty to explore the diversity climate at UCSF, as well as recommendations for improvement at that institution and more generally. We found that minority faculty members face a complex series of tensions in everyday academic life, which requires them to balance professional success with the minority experience at their institution. Tensions exist within each of the four themes: (1) choosing to participate in diversity-related activities, driven by personal commitment and institutional pressure, (2) the gap between intention and implementation of institutional efforts to increase diversity, (3) detecting and reacting to discrimination, and (4) a need for a multifaceted approach to mentorship, given few available minority mentors. We identified consistent themes across academic rank; this implies that each tension, which might be expected to diminish over time, is in fact persistent for minority faculty.
“Comparative isolation within the academic community” has been presented as an impediment to the academic advancement of underrepresented minority faculty in schools of medicine by Jordan Cohen30 in his 1998 editorial, “Time to shatter the glass ceiling for minority faculty.” In that editorial, Cohen explores possible explanations for the differential attainment of senior faculty rank seen between racial and ethnic majority and minority faculty. One explanation is that minority faculty feel disproportionately obliged to work on several time-consuming, diversity-related activities. Time spent on diversity-related activities could be taking them away from activities that traditionally lead to academic advancement. This tension is illustrated in our study by the finding that those faculty who chose to “give back” at a personal level felt overcommitted or overextended.
Another tension is demonstrated by the finding that many study participants doubted the effectiveness of time spent by themselves and others on diversity efforts. There was a perceived failure of the institution to implement these efforts with appropriated funding and other resources. Participants’ recommendations for improving the implementation of diversity efforts included the creation of an office of minority affairs. An office of minority affairs was seen as an expression of the institution’s commitment to diversity and as a community-building force that could hold the institution accountable for achieving stated goals related to diversity.
Minority faculty recognized the potential impact that discrimination might have on achieving career advancement and professional satisfaction. Subtle discrimination and social conventions at the workplace are difficult to discern, whereas the mere acknowledgement places the burden on the minority faculty member to respond personally, by developing appropriate coping skills, and/or professionally. Historically, this burden has been referred to as the “black tax” or, more recently, as “racial fatigue.”17 When confronting discrimination, minority faculty balance the tension between professional risk and their desire to take action against the injustice.
Our findings that effective mentorship and career satisfaction are closely linked are consistent with several previous studies of mentoring in academic medicine.31–33 Although never asked directly about mentorship, all faculty members we interviewed remarked on this association, and many described the unique mentoring needs of minority faculty that persist throughout academic ranks. The various benefits of mentorship were emphasized by most study participants as contributors to their career satisfaction at UCSF. Study participants noted the importance of minority mentors for providing cultural and emotional support and navigating social conventions. A tension exists between minority faculty’s need for racially concordant mentoring and the lack of available mentors. Studies of women faculty have found a similar unmet need for senior women faculty mentors.34 To date, that we know of, there has not been a study of the effect of racially concordant mentoring on career satisfaction among minority faculty. Women and minority faculty likely benefit from mentors of similar gender and racial background who can provide advice and encouragement in issues related to personal development, in addition to traditional mentors who provide guidance in career issues. The need for senior minority mentors is a strong argument for enhancing recruitment and retention of minority faculty.
One of the strengths of our study is the use of qualitative methodology, which allowed us to identify a broad range of faculty-oriented support strategies as well as institutional barriers. Individual interviews allowed for in-depth exploration of experiences and views often not attainable in focus groups. Previous studies of minority faculty have conducted focus groups and compared minority focus groups with nonminority and mixed focus groups, as well as focus groups in community settings. By collecting and presenting individual-interview qualitative data, we include the words of participants themselves and render their voices more widely heard.
Our study has some limitations. Our findings may have limited generalizability, given that our sampling was based on one institution. In addition, selection bias may pertain in that only certain individuals replied to our e-mail who may have been more interested in issues of diversity on campus.
Our study findings suggest both short- and long-term solutions to increasing diversity in academic medicine. Short-term solutions include a more thoughtful approach to faculty duties and responsibilities. Minority faculty are socially committed and interested, but their sense of personal obligation should not be exploited. Responsibilities should be fairly allocated, recognized in academic advancement, and valued by the institution. In addition, soliciting faculty input resulted in several direct recommendations for the institution: (1) create an institutionalized center dedicated to campus diversity, (2) establish a permanent institutional commitment to minority faculty mentoring, (3) increase the funding for interventions in minority recruitment and retention, (4) prioritize diversity in institutional leadership and policy, and (5) close the gap between intention and implementation by acting promptly on recommendations from committees, task forces, and research. In the context of increasing limitations of affirmative action policies, the findings from this study have direct application to future policies in recruitment and retention of underrepresented minority faculty as institutional policies change nationwide.
This work was supported by a stipend from the Office of the Executive Vice Chancellor at UCSF and a Linking Education, Action, and Research Networks grant.
1 Smedley B, Butler AS, Bristow L. In the Nation’s Compelling Interest: Ensuring Diversity in the Health Care Workforce. Washington, DC: Institute of Medicine, National Academies Press; 2004.
2 Cooper LA, Powe NR. Disparities in Patient Experiences, Healthcare Processes, and Outcomes: The Role of Patient–Provider Racial, Ethnic and Language Concordance. New York, NY: The Commonwealth Fund; 2004. Pub. no. 753.
3 Powe NR, Cooper LA. Diversifying the racial and ethnic composition of the physician workforce. Ann Intern Med. 2004;141:223–224.
4 Missing Persons: Minorities in the Health Professions: A Report of the Sullivan Commission on Diversity in the Healthcare Workforce. Washington, DC: Sullivan Commission; 2004.
5 Betancourt JR. Eliminating racial and ethnic disparities in health care: What is the role of academic medicine? Acad Med. 2006;81:788–792.
6 Abernethy AD. A mentoring program for underrepresented-minority students at the University of Rochester School of Medicine. Acad Med. 1999;74:356–359.
7 Wright SM, Carrese JA. Serving as a physician role model for a diverse population of medical learners. Acad Med. 2003;78:623–628.
8 Minorities in Medical Education: Facts and Figures 2005. Washington, DC: Association of American Medical Colleges; 2005.
10 Palepu A, Carr PL, Friedman RH, Amos H, Ash AS, Moskowitz MA. Minority faculty and academic rank in medicine. JAMA. 1998;280:767–771.
11 Fang D, Moy E, Colburn L, Hurley J. Racial and ethnic disparities in faculty promotion in academic medicine. JAMA. 2000;284:1085–1092.
12 Marbella AM, Holloway RL, Sherwood R, Layde PM. Academic ranks and medical schools of underrepresented minority faculty in family medicine departments. Acad Med. 2002;77:173–176.
13 Peterson NB, Friedman RH, Ash AS, Franco S, Carr PL. Faculty self-reported experience with racial and ethnic discrimination in academic medicine. J Gen Intern Med. 2004;19:259–265.
14 Corbie-Smith G, Frank E, Nickens HW, Elon L. Prevalences and correlates of ethnic harassment in the U.S. Women Physicians’ Health Study. Acad Med. 1999;74:695–701.
15 Mangus RS, Hawkins CE, Miller MJ. Prevalence of harassment and discrimination among 1996 medical school graduates: A survey of eight U.S. schools. JAMA. 1998;280:851–853.
16 Glymour MM, Saha S, Bigby J. Physician race and ethnicity, professional satisfaction, and work-related stress: Results from the Physician Worklife Study. J Natl Med Assoc. 2004;96:1283–1289, 1294.
17 Nunez-Smith M, Curry LA, Bigby J, Berg D, Krumholz HM, Bradley EH. Impact of race on the professional lives of physicians of African descent. Ann Intern Med. 2007;146:45–51.
18 Whitla DK, Orfield G, Silen W, Teperow C, Howard C, Reede J. Educational benefits of diversity in medical school: A survey of students. Acad Med. 2003;78:460–466.
19 Komaromy 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;334:1305–1310.
20 Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139:907–915.
21 Saha S, Taggart SH, Komaromy M, Bindman AB. Do patients choose physicians of their own race? Health Aff (Millwood). 2000;19:76–83.
22 Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient–physician racial concordance and the perceived quality and use of health care. Arch Intern Med. 1999;159:997–1004.
23 Price EG, Gozu A, Kern DE, et al. The role of cultural diversity climate in recruitment, promotion, and retention of faculty in academic medicine. J Gen Intern Med. 2005;20:565–571.
24 Odom KL, Roberts LM, Johnson RL, Cooper LA. Exploring obstacles to and opportunities for professional success among ethnic minority medical students. Acad Med. 2007;82:146–153.
25 Denzin N, Lincoln YS. The Sage Handbook of Qualitative Research. 3rd ed. Thousand Oaks, Calif: Sage; 2005.
26 Ryan G, Bernard H. Techniques to identify themes. Field Methods. 2003;15:85–109.
27 MacQueen K, McLellan E, Kay K, Milstein B. Codebook development for team based qualitative analysis. Cult Anthropol Methods. 1998;10:31–36.
28 Marshall MN. Sampling for qualitative research. Fam Pract. 1996;13:522–525.
29 Beasley BW, Wright SM, Cofrancesco J Jr, et al. Promotion criteria for clinician–educators in the United States and Canada. A survey of promotion committee chairpersons. JAMA. 1997;278:723–728.
30 Cohen JJ. Time to shatter the glass ceiling for minority faculty. JAMA. 1998;280:821–822.
31 Palepu A, Friedman RH, Barnett RC, et al. Junior faculty members’ mentoring relationships and their professional development in U.S. medical schools. Acad Med. 1998;73:318–323.
32 Sciscione AC, Colmorgen GH, D’Alton ME. Factors affecting fellowship satisfaction, thesis completion, and career direction among maternal–fetal medicine fellows. Obstet Gynecol. 1998;91:1023–1026.
33 Lewellen-Williams C, Johnson VA, Deloney LA, Thomas BR, Goyol A, Henry-Tillman R. The POD: A new model for mentoring underrepresented minority faculty. Acad Med. 2006;81:275–279.
34 Levinson W, Kaufman K, Clark B, Tolle SW. Mentors and role models for women in academic medicine. West J Med. 1991;154:423–426.