Recent events highlight societal unrest surrounding inequities experienced by marginalized and underrepresented communities in the United States. As highlighted by recent articles published in this journal, academic medicine continues to be engaged in the ongoing process of creating inclusive educational and patient care environments for diverse stakeholders. A variety of approaches have been developed over time: understanding health disparities, emphasizing the importance of cultural competence and cultural competency training,1 and designing focused interventions for specific populations.2 More recently, multidimensional models of diversity and inclusion that also address community engagement and cultural responsiveness have been developed.3 While these methods share the common goals of achieving health equity and creating opportunities for diverse participants in academic medicine, numerous challenges remain. There is value in focusing on singular populations and creating macroscopic frameworks to guide diversity and inclusion initiatives; however, these approaches may not always elucidate the complexities that arise at the intersection between multiple identities and life experiences. This Commentary will describe strategies that can be used to integrate intersectional approaches into academic medicine to encompass multidimensionality.
Intersectionality and Academic Medicine
The term “intersectionality” was originally coined in 1989 to describe how the exclusion of women of color from prominence in both feminist movements and civil rights movements rendered their dual identities as women and people of color invisible.4 Although the term has evolved to include experiences of multiple “intersecting” identities, including race, socioeconomic class, gender, sexual orientation, and more, three central tenets exist: (1) cultural patterns of discrimination, and subsequent inequities, are interlocking and cannot be separated on the basis of only one aspect of identity or experience5; (2) interrelationships between identities must be understood in the context of social institutions and their inherent power dynamics6; and (3) despite originally being created to analyze and address health disparities, use of an intersectional lens can also reveal unique strengths and resiliency in different communities which, when properly understood and appreciated, may be employed to enhance public health outcomes.
These tenets build on concepts already addressed in academic medicine. The Association of American Medical Colleges’ (AAMC) Diversity 3.0 framework emphasizes that all aspects of human difference represent diversity, and calls for institutional culture and climate to demonstrate “inclusiveness, mutual respect, and multiple perspectives.”3 This framework considers pervasive power dynamics in health care with respect to the hidden curriculum in medical education and patient–provider interactions.7 Recent research on intersectionality has the potential to further inform both medical education and practice. In academic medicine, the experience of black male medical students is instructive: Although the number of black medical school matriculants has remained stagnant for the past three decades, the number of black male matriculants has declined while the number of black female matriculants has increased.8 Health care disparity research has greatly benefited from incorporating nuanced intersectional viewpoints. For example, black gay and bisexual men are less likely to drink heavily compared with heterosexual white and black men, whereas Latino gay and bisexual men are more likely to drink heavily than their heterosexual counterparts.9 These insights emphasize the importance of using an intersectional perspective to better understand how multiple identity experiences impact different populations. However, significant work remains in integrating and evaluating intersectional approaches across academic medicine and clinical practice.
Recommendations for Advancing Intersectional Approaches in Academic Medicine
Many well-recognized frameworks in academic medicine point to the importance of an intersectional perspective in medical research, medical education, patient care, and health economics (see Table 1). These frameworks are widely used and provide a cornerstone on which modern diversity and inclusion initiatives can be built. Therefore, rather than advocating for development of a new intersectional framework, we provide recommendations for advancing intersectionality in academic medicine based on existing foundational principles.
Embrace personal and collective loci of responsibility
The first and most critical component in advancing intersectionality in academic medicine is aligning awareness of historical abuses of power and ongoing discriminatory practices with one’s professional responsibilities as a member of the academic medical community. Throughout history, medicine has permitted abuses of power such as the Tuskegee Syphilis Experiment and forced sterilization of individuals based on differences in race, intellectual ability, and sexual orientation.10 The emphasis on underrepresented communities in health care and academic medicine has shifted from exploitive unethical practices to the importance of understanding pervasive structural barriers and unconscious biases that contribute to differential access to and receipt of culturally responsive health care. Embracing locus of responsibility entails recognizing one’s own role and that of the greater medical community in perpetuating cycles of discriminatory practice, believing that both individuals and institutions can take meaningful actions to remediate inequities. By setting an expectation that all physician trainees will be able to demonstrate these abilities by the time they graduate from medical school, as outlined by Eckstrand and colleagues,2 we can begin to create a workforce that has the capacity to develop novel solutions to improve health care outcomes by using a multidimensional lens.
Examine and rectify unbalanced power dynamics
Intersectionality requires thinking beyond individuals and identities to the systems that perpetuate inequality. Even if personal or collective loci of responsibility are embraced, institutional policies and practices can stifle the efforts of individuals and groups engaged in meaningful change if these efforts do not align with institutional priorities. Historically, health care professionals who are most engaged in serving communities affected by institutionalized discrimination are often those who are least celebrated. As described by Powers and colleagues,11 this reality places a dual pressure on minority health care professionals: to strive for academic recognition and advancement via traditionally valued rewards systems while working simultaneously to enhance the health and well-being of underserved communities. To realize opportunities for intersectional innovation, we must examine the ways in which existing institutional infrastructure segregates the individuals and programs engaged in remedying persistent inequality from decision making and ensure that we obtain input from diverse stakeholders.
Celebrate visibility and intersectional innovation
The shift from health equality to health equity in academic medicine resulted from a realization that rather than a “one-size-fits-all” approach, different strategies must be applied on the basis of an individual patient’s unique and overlapping cultural and demographic characteristics to achieve and maintain health. This realization also catalyzed the development of important innovations such as improved community-oriented research and training programs12 inclusive of individuals with overlapping identities and experiences. At the same time, it also created challenges, as fears of inadvertently excluding key voices and/or causing offense to some community constituents can serve as deterrents to proceeding with multifaceted, diversity-oriented initiatives. Failing to respond to these reactions invalidates the long-overdue recognition of the multidimensional biases and institutionalized discrimination that affect marginalized individuals and communities. Embracing the fact that conflict and challenges exist because significant work remains to be done and setting an explicit intention to establish a systematic process where all participants can safely express ideas and perceptions are necessary ingredients for meaningful change.
Engage all stakeholders in the process of change
Ultimately, everyone in the academic medical community is responsible for promoting a conducive educational environment in which scientific inquiry can flourish and inclusive perspectives are heard. All institutional stakeholders must have confidence that they are empowered to challenge and counteract tacit and uncontested assumptions that communicate unconscious bias. Training programs, like the AAMC Unconscious Bias Training for the Health Professions, can be implemented to support the development of these skills.13 Engaging all stakeholders also means involving all members of the academic medical community (i.e., students, staff, residents, faculty, program administrators, and policy makers) as active participants in the change process. It is also crucial to involve patients and other constituents of the diverse communities we serve, as exemplified by inclusion of persons with disabilities in developing and delivering the longitudinal disabilities curriculum described by Sarmiento and colleagues.14 External stakeholders can also ensure that fresh ideas are continually brought to the fore and help to mitigate entrenched institutional power dynamics and assumptions.
Select and analyze meaningful metrics
Multiple theoretical models referencing intersectionality themes have been proposed (see Table 1), each of which offers opportunities for research, medical education, and clinical care applications given the appropriate resources and infrastructure. Apropos research to date has presented novel strategies to evaluate diversity and inclusion outcomes. For example, Martin and colleagues15 examined every slide presented to medical students at their institution to evaluate diversity in human pictures, finding a striking predominance of white, male photos on their presentations; Zazove and colleagues16 reviewed documents from MD-granting and DO-granting medical schools to determine compliance with the Americans with Disabilities Act, finding that most medical schools do not have reasonable accommodations for students based on ability. Future interventions should go a step further by combining similar innovative assessment strategies with additional, nuanced analyses that are intersectionally meaningful. The process of selecting specific metrics, determining the most systematic analytic approach, interpreting results, and planning subsequent action steps should be conducted following principles of community-based participatory research,12 maintaining open communication and transparency, and involving diverse stakeholders in all aspects of continuous quality improvement.
Sustain the commitment to achieving multidimensional participation and health equity
Successful change processes require a considerable investment of time and sustained personal and institutional commitment. There is always potential for regression toward old practices if leadership support decreases, institutional priorities shift, or the sense of novelty wanes. This may help to explain why new mentoring interventions for underrepresented minorities demonstrated short-term benefits that did not appear to be maintained during longer-term follow-up in a study published by Lewis and colleagues.17 It is therefore crucial to establish sustainable quality improvement processes that support the implementation and assessment of intersectionally oriented health equity initiatives over time.
Applying intersectionality in academic medicine can provide invaluable guidance in developing innovative educational and patient care environments inclusive of the identities, dimensions, and unique perspectives of patients, trainees, and providers. Intersectional approaches can remediate structural barriers for underserved populations and reduce the reliance on overly simplistic structural diversity metrics that can devalue multiple identities and stifle the creative contributions of key stakeholders. Current policies and practices often rely on focused or integrated frameworks (Table 1) that address singular populations or topical areas in a vacuum without considering how historical, structural, and cultural factors may influence the effectiveness of proposed interventions. The foundational intersectional principles outlined here can accelerate the development and implementation of strategies informed by multidimensional aspects of diversity and inclusion. An intersectional framework provides the cornerstone for actualizing a truly inclusive and equitable health care environment that welcomes and formally recognizes contributions from all members of the academic medical community and reduces health disparities experienced by underserved populations.
1. Association of American Medical Colleges. Assessing Change: Evaluating Cultural Competence Education and Training. 2015.Washington, DC: Association of American Medical Colleges.
2. Eckstrand KL, Potter J, Bayer CR, Englander R. Giving context to the physician competency reference set: Adapting to the needs of diverse populations. Acad Med. 2016;91:930935.
3. Nivet MA, Castillo-Page L, Conrad SS. A diversity and inclusion framework for medical education. Acad Med. 2016;91:1031.
4. Crenshaw K. Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. Univ Chic Legal Forum. 1989;1989:139167.
5. Collins PH. Black Feminist Thought: Knowledge, Consciousness, and the Politics of Empowerment. 2002.New York, NY: Routledge.
6. Levine-Rasky C. Intersectionality theory applied to whiteness and middle-classness. Soc Identities. 2011;17:239253.
7. Hafferty FW. Beyond curriculum reform: Confronting medicine’s hidden curriculum. Acad Med. 1998;73:403407.
8. Association of American Medical Colleges. Altering the Course: Black Males in Medicine. 2015.Washington, DC: Association of American Medical Colleges.
9. Gilbert PA, Daniel-Ulloa J, Conron KJ. Does comparing alcohol use along a single dimension obscure within-group differences? Investigating men’s hazardous drinking by sexual orientation and race/ethnicity. Drug Alcohol Depend. 2015;151:101109.
10. Washington HA. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present. 2006.New York, NY: Doubleday Books.
11. Powers BW, White AA, Oriol NE, Jain SH. Race-conscious professionalism and African American representation in academic medicine. Acad Med. 2016;91:913915.
12. Wallerstein N, Duran B. Community-based participatory research contributions to intervention research: The intersection of science and practice to improve health equity. Am J Public Health. 2010;100(suppl 1):S40S46.
13. Association of American Medical Colleges. Unconscious Bias Training for the Health Professions. 2016. https://www.aamc.org/initiatives/diversity/322996/lablearningonunconsciousbias.html
. Accessed March 25, 2016.
14. Sarmiento C, Miller SR, Chang E, Zazove P, Kumagai AK. From impairment to empowerment: A longitudinal medical school curriculum on disabilities. Acad Med. 2016;91:954957.
15. Martin GC, Kirgis J, Sid E, Sabin JA. Equitable imagery in the preclinical medical school curriculum: Findings from one medical school. Acad Med. 2016;91:10021006.
16. Zazove P, Case B, Moreland C, et al. U.S. medical schools’ compliance with the Americans with Disabilities Act: Findings from a national study. Acad Med. 2016;91:979986.
17. Lewis V, Martina CA, McDermott MP, et al. A randomized controlled trial of mentoring interventions for underrepresented minorities. Acad Med. 2016;91:9941001.
References cited only in Table 1
18. Eckstrand KL, Leibowitz S, Potter J, Dreger A. Hollenbach AD, Eckstrand KL, Dreger A. Professional competencies to improve health care for people who are or may be LGBT, gender nonconforming, and/or born with DSD. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born With DSD. 2014.Washington, DC: Association of American Medical Colleges.
19. Tervalon M, Murray-García J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9:117125.
20. Nivet MA. Commentary: Diversity 3.0: A necessary systems upgrade. Acad Med. 2011;86:14871489.
21. Blanch A. Changing Communities, Changing Lives: Report Prepared for the Substance Abuse and Mental Health Services Administration’s National Center for Trauma-Informed Care. 2012.Alexandria, Va: National Association of State Mental Health Program Directors.