Fairness will always be a fundamental argument at the heart of diversity work. This moral imperative has been well articulated in the academic medicine literature, framing diversity in health care as a means to increase access to care for underserved populations, reduce health disparities, shape a more inclusive biomedical research agenda, and enhance the cultural competence of providers.1 At the root of this social justice rationale are two important societal realities: our collective history of inequities on the basis of gender, race, and ethnicity, and the rapid demographic changes taking place nationally. The moral imperative recognizes that unequal educational opportunities and other forms of exclusion and discrimination persist and must be addressed by medical schools and teaching hospitals as part of their societal obligation to care for the health of the public. The collection of articles on diversity and inclusion in this issue of Academic Medicine, however, demonstrates that another imperative is emerging alongside the moral imperative in shaping diversity work: institutional excellence.
One way to define excellence is the degree to which a medical school or teaching hospital achieves its stated mission and goals divided by the amount of resources expended to reach these goals. With the U.S. health care system gearing up for a tumultuous cycle of reform, a tightening of research dollars from the federal government, and overall uncertainty in the broader economic environment, all institutional efforts face a new level of scrutiny, seeking optimal effectiveness. With regard to diversity work, the excellence imperative suggests three priorities:
* To measure progress toward and attain accountability on diversity efforts;
* To make apparent the overlap between diversity and excellence in patient care, research, and medical education; and, in a similar vein,
* Not to lose sight of the social justice rationale at the heart of these efforts, but to further support investment in diversity and inclusion with evidence of their value to organizational performance.
This collection contributes to the laudable trend toward focusing efforts on strategies that have proven effective and employing barometers of success that extend beyond measures of compositional diversity or representational ratios. Articles in the collection describe emerging metrics for success, such as the degree of integration of cultural competence across the medical education curriculum,2 the level of financial commitment to diversity and inclusion at an institution,3 and the amount of cross-cultural interaction on campus and its relationship to preparedness to serve underrepresented populations.4
These new metrics derive from an evolution of thinking around what defines successful diversity initiatives, much of which is echoed in this special collection. The contributions of Young and colleagues,5 Smith,6 and Johnson and Bozeman,7 for instance, profile the ways in which diversity has come to be more broadly defined and present new models for evaluating effectiveness. This moment in time requires a greater appreciation for the additional dimensions of diversity and a willingness to be open about what has worked and what has not.
Driving this leap forward in the evidence-based approach to diversity has been a growing consensus on the inadequacy of data collection efforts and how this has stalled progress. According to a recent survey of deans of health professions schools,8
nearly all [surveyed institutions] have diversity efforts underway, but fewer institutions have mechanisms to track institutional progress or report on outcomes to leaders. Within health professions’ strategic plans, diversity and cultural competence is often a “core value,” but is not always accompanied by specific goals and objectives, responsible agents, or metrics.
The collection in this issue adds needed substance to the assertion that it is not enough to merely catalogue diversity efforts across the health professions landscape but that, rather, the time has come to better distinguish a successful intervention from a marginal one.
A Shared Framework for Success
This issue’s collection of diversity and inclusion articles is quite comprehensive and speaks to a range of audiences, from those who consider themselves experts on diversity and inclusion to the casual and interested reader. This robust collection will afford diversity practitioners, institutional leaders, and policy influencers greater insight into what defines an effective diversity strategy. Each of these groups has differing concepts of what constitutes evidence and where to find sources of information, and varying amounts of time to mull over the subject. However, each group would agree that better evidence leads to better decisions and ultimately better outcomes. We cannot derive top value from diversity efforts until practitioners, deans, CEOs, and policy makers begin operating with a shared framework for success. The excellence imperative calls for improved precision in decision making and resource deployment to drive sustainable outcomes, which in turn requires a strong degree of alignment among all involved parties. To accelerate this effort, it is important to take stock of the perspectives and responsibilities of each.
Diversity practitioners are often on-the-ground operatives who seek specific programmatic guidance in published research. For this group, diversity research reveals what has worked at peer institutions and provides insight into what types of initiatives can best fit with institution-specific goals, challenges, and resources. This collection includes a host of resources relevant to practitioners, from benchmarks on the size and focus of medical school faculty support programs,9 to a case study of a diversity strategic planning process10 and peer-tested cultural competence curricular materials.2 Practitioners can afford to dive deeply into the nuance of what makes for an effective diversity intervention for their community.
Leaders, whether deans of medical schools or CEOs of teaching hospitals, rely on diversity research to inform resource allocation and strategy development at the institutional level. As opposed to the deep-dive and longitudinal information needs of practitioners, leaders require real-time, high-level data, which they use to balance investments and determine return across a range of institutional priorities. Leaders also value data that allow for comparison with peer institutions; helpful measures allow them to understand effectiveness in both absolute and relative terms and guide decision making. By further demonstrating the overlap between diversity and the excellence that leaders seek in patient care, education, and research, this collection of articles provides additional justification for calculating the contribution of diversity efforts to these domains of the overall mission.
Policy influencers are the set of actors, from foundation funders to government officials, who set the broader context for diversity and inclusion in academic medicine. This group shares a desire for effectiveness of interventions with practitioners and leaders, but with a degree of scale that allows for transferability. For policy influencers, it is not enough to know what works in one institution or community; they need to understand what elements of the intervention can be spread through policies that reinforce or support promising practices. Influencers require contextualized, multi-institution data on which programs have the greatest potential of success across locations.
Charting a Road Map for Alignment
This parsing is not a suggestion to silo diversity research on the basis of audience; it is the beginning of a road map for alignment. Real progress on the diversity agenda requires that all three groups be committed to the same barometers for success, using evidence to drive change. In the future, the volume of diversity efforts should not be the only measure that matters; rather, the quality of the outcomes should also be considered. As I have traveled the country visiting medical schools and teaching hospitals, I have seen prolific evidence of a commitment to diversifying student and faculty populations, but far less evidence of its effectiveness. The social justice underpinning is important and must continue to undergird diversity and inclusion efforts. Moral arguments alone, however, will not suffice in this environment of pinched resources. The diversity and inclusion movement must apply rigorous empirical methods to understanding the most effective and efficient interventions for meeting goals and sustaining outcomes.
Acknowledgments: The author wishes to thank Anne Berlin for her editorial support.
Other disclosures: None.
Ethical approval: Not applicable.
1. Cohen JJ, Gabriel BA, Terrell C. The case for diversity in the health care workforce. Health Aff (Millwood).. 2002;21:90–102
2. Thew D, Smith SR, Chang C, Starr M. The Deaf Strong Hospital program: A model of diversity and inclusion training for first-year medical students. Acad Med. 2012;87:1496–1500
3. Myers SL, Fealing KH. Changes in the representation of women and minorities in biomedical careers. Acad Med. 2012;87:1525–1529
4. Niu NN, Syed ZA, Krupat E, Krutcher BN, Pelletier SR, Shields HM. The impact of cross-cultural interactions on medical students’ preparedness to care for diverse patients. Acad Med. 2012;87:1530–1534
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6. Smith DG. Building institutional capacity for diversity and inclusion in academic medicine. Acad Med. 2012;87:1511–1515
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8. Association of Public and Land-Grant Universities.Urban Universities: Developing a Workforce That Meets Community Needs.. 2012 Washington, DC Association of Public and Land-Grant Universities
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10. Deas D, Pisano ED, Mainous AG, et al. Improving diversity through strategic planning: A 10-year (2002–2012) experience at the Medical University of South Carolina. Acad Med. 2012;87:1548–1555