Lasting Solutions for Advancement of Women of Color : Academic Medicine

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Invited Commentaries

Lasting Solutions for Advancement of Women of Color

Verduzco-Gutierrez, Monica MD1; Wescott, Siobhan MD, MPH2; Amador, Juan3; Hayes, Andrea A. MD4; Owen, Mary MD5; Chatterjee, Archana MD, PhD6

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doi: 10.1097/ACM.0000000000004785
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Abstract

Although the number of women who matriculate into medicine and work in health care continues to grow, the literature demonstrates gender bias in medicine related to equitable pay, 1,2 promotion, 3,4 speaking opportunities, journal editorial positions, 5 research funding, and leadership positions. This bias becomes more prominent for women with intersectional identities who come from underrepresented groups inclusive of women of color, women with disabilities, and transwomen. 6 It is critical to understand why the pathway to academic leadership and promotion is especially treacherous for women in medicine, especially women of color and women with other intersectional identities.

The barriers on the pathway are clearly multifactorial and especially wide-ranging. When Jeffe and colleagues analyzed variables in promotion and attrition among more than 27,000 faculty members, they found that the 10-year probability of promotion was lower and the probability of attrition was higher for faculty who were women (compared with men) and for faculty from underrepresented groups (compared with Whites); furthermore, pay was lower and financial debt was higher for faculty from underrepresented groups compared with Whites. 7 Since the authors also found that, in general, faculty with greater debt had higher risk for attrition, it is not surprising that women from underrepresenting groups have a higher probability of leaving academic medicine. Furthermore, while the need for inclusion is well recognized, the lack of equity is evident in the selections for prestigious awards and editorial positions and in the work environments that may transmit exclusionary messages with images in halls and labs reinforcing a stereotype of medicine as a male-led profession. Meanwhile, mentorship is an imperative construct in academia, but the lack of women of color who hold leadership roles results in fewer potential mentors. 8 Additionally, historical institutional racism persists, continuing to impede advancement in the health care workforce.

This commentary focuses on promising practices for enriching the pathway to leadership for women of color who are qualified and ready to take the helm. As academic leaders who come from underrepresented groups, we examine ways to make the academic pathway supportive for women of color and include discussions on mentoring and sponsorship, formal leadership programming, upstander initiatives, professional society support, early-career leadership education, and expanded promotion criteria.

Mentoring and Sponsorship

Mentorship plays a well-recognized role in career development and advancement in many fields, including academic medicine. Furthermore, mentorship has been proposed as an important avenue for reducing gender disparities and bias in medicine. Formal mentorship programs are known to be effective and to offer participants a high level of satisfaction. Two recent systematic reviews of mentorship of women in academic medicine, one reviewing 91 studies 9 and one reviewing 20 studies, 10 showed that mentorship was associated with both objective and subjective measures of career success. Another systematic review of mentoring programs for underrepresented physician and trainees reviewed 31 publications that found that the programs showed satisfactory outcomes and participants reported high satisfaction. 11

Individuals who are underrepresented in medicine are less likely to report having mentors both during training 12 and later as faculty. 13 Mentees have also reported a lack of appropriate mentors based on underrepresented status. 14 Mentorship programs specifically designed to address the needs of women faculty with intersectional identities are needed.

Given time restraints and barriers around lack of mentors from underrepresented groups, novel models of mentoring must be implemented that move beyond that traditional dyadic mentorship models that most programs use. 10,11 Technology-delivered interventions and online platforms may provide social support, alleviate barriers, and increase diversity in health care. The Association of American Medical Colleges (AAMC) Group on Women in Medicine and Science has developed toolkits on mentorship, and the AAMC Group on Diversity and Inclusion has provided a national presentation platform that may be beneficial to individuals and institutions interested in improving the mentorship of this group of faculty. 15

Specific attention also needs to be directed to the role of sponsorship in developing women leaders with intersectional identities. Compared with mentorship, the role of sponsorship is less well known and understood, particularly in the development of leaders. 16 While mentors advise their mentees, sponsors advocate for the individuals they are assisting and promoting. While mentorship is generally a private professional relationship, sponsorship involves a public endorsement, placing the sponsor’s reputation on the line for the sake of the protégé. It is imperative that the current academic medicine leaders understand the important role that they can play in sponsoring colleagues from underrepresented groups. Furthermore, women faculty need guidance to understand how to capitalize on the opportunity to be a protégé.

Formal Leadership Programming

There are several long-standing, highly successful, formal leadership development programs for women in medicine. 17 These include 3- to 4-day seminars as well as longitudinal programs developed by professional organizations, including the AAMC, American College of Physicians, and Association of Pediatric Program Directors, and universities, including Drexel University’s Executive Leadership in Academic Medicine program. Investments in leadership programs have many benefits for both women and their institutions and have been shown to improve faculty retention and reduce institutional costs. 18,19

None of these programs, however, are specifically directed toward the leadership development of women who come from underrepresented groups. This gap needs to be filled so that academic medicine may benefit from the talent that these women bring to it. If women of color achieve executive leadership positions in academic medicine, there will be improved outcomes for patients, learners, and organizations. 20 To achieve equity within academic medical institutions, current institutional leadership must take meaningful and effective actions that will permanently end the culture of privilege that has gone unchallenged for decades.

Upstander Initiatives

Upstanders are advocates, allies, and supporters for people who share a different background or identity from their own. We recognize that it is often not easy to be an upstander when gender bias and/or harassment occur. Harassment and bias both contribute to a hostile work environment, perpetuating inequities for women of color in health care. Institutional-level change—inclusive of meaningful communication, fixing a toxic work culture, and increasing ability to communicate—would be effective for reducing these inequities. Individuals do not only need institutions to be upstanders—everyone has the potential to be an upstander. We highlight 2 social justice efforts that demonstrate this point.

The first social justice effort is led by a woman, Julie Silver, MD, who leads the Harvard Medical School Career Advancement and Leadership Skills for Women in Healthcare course. Each year, the course leads a campaign to develop innovation in achieving gender equity in medicine. The 2020 #HerTimeIsNow campaign focused on women with intersectional identities. The 2021 #GiveHerAReasontoStay campaign, supported by the American Medical Women’s Association, offered a summary sheet of the status of women in medicine, including strategies to address barriers to gender equity in medicine. 21

The second social justice effort is led by a man, Francis Collins, MD, PhD. In 2019, using his platform as the Director of the National Institutes of Health, Collins stated, “I want to send a clear message of concern: it is time to end the tradition in science of all-male speaking panels, sometimes wryly referred to as ‘manels.’”22 He further asserted that if conference organizers did not diversify panels, he would decline their invitation to speak. These efforts by Collins provide an example of a social justice campaign in which male leadership pushes to level the playing field. This campaign has also come with use of the hashtags #heforshe and #nomoremanels.

Professional Societies

Professional societies that represent underrepresented minorities can help support underrepresented minorities in academic leadership. For example, the Society of Black Academic Surgeons (SBAS) has contributed to the collective understanding by highlighting the barriers that underrepresented minorities face on the pathway to academic leadership positions. Using data from the AAMC, SBAS has brought attention to the lack of African American female tenured professors. 23 SBAS has also documented the role of race and gender in academic surgery. 24 Having this information supports a call to action for our communities. Without knowing the depth of the problem, we cannot begin to find solutions. In a 2020 review in the Annals of Surgery, Berry and colleagues reported that there were only 9 tenured African American female professors of surgery in the United States and no current female African American chairs of departments of surgery. 23 Since this publication, 2 women surgical chairs have been named who are African American.

Smaller, minority-based medical societies can also provide an intimate environment in which open conversation can occur. These informal conversations often provide the best mentorship and sponsorship opportunities for discussions in a relaxed environment. At minority-based annual society meetings and at subsections of larger meetings, senior leaders are enthusiastic about being available for residents, students, and junior faculty from underrepresented groups. This opportunity for 1-on-1 mentorship and sponsorship is critical to career development in academic medicine. Long-term bonds, professional relationships, and networks can be forged and nurtured in these environments.

Early-Career Education

Another solution to improving the proportion of women of color in leadership positions in medical schools is to address the issue early in their careers. Many assistant professors are hired without having an in-depth conversation with their supervisors about the different options and criteria for academic advancement. Often, young faculty members are unsure of their path and accept the first faculty position offered. For example, an assistant professor might be pleased to be hired into a position at 90% or 100% clinical productivity. However, they may not realize that this contract does not allow for any kind of research or scholarly activity and therefore takes them off of the tenure track while also making advancement on the nontenure track difficult.

When first-time faculty members are hired, all of the options for faculty tracks should be presented to them by at least one other person who is not the chair of the department. This way the individual faculty member can make a more-informed decision about pursuing an academic track based on their desires rather than the pressures of obtaining employment. In many institutions, the office of faculty affairs or faculty development can provide such information about options for faculty tracks. Institutions could also appoint senior faculty members, preferably full professors of diverse backgrounds, to have in-depth conversations with potential new faculty members, so that these new faculty members can begin their academic careers on a clear path to success. Senior faculty members who provide this kind of support could potentially serve as a mentor to the junior faculty members. Junior faculty members need to start on the first or second rung of the academic ladder, not without a ladder at all, and mentorship and sponsorship can help give them that boost to upward mobility.

Journal Editorial Board Representation

The peer-reviewed literature is the primary method for sharing clinical and research findings, thereby creating a lasting record of the practice of medicine and highlighting new discoveries. The individuals who decide what the record of clinical decision making and research findings should be are particularly influential in medicine, and so they deserve special attention. But as we work to achieve equity for women of color in academic medicine, disparities are evident in biomedical editorial boards. As yet, the demographics of journal editorial boards remain skewed toward White males. Salazar and colleagues found that 50.8% of editors at biomedical journals with an impact factor over 10 were male, yet 65% editors-in-chief were male; race was more starkly inequitable: 77.2% of the biomedical editors responding to the survey were of White race. 25 When Givens examined the gender and race distribution of the New England Journal of Medicine and the Journal of the American Medical Association editorial boards, 26 he found more men named David than the combined number of Black and Hispanic editors—a surreal finding indicative of the lack of diversity.

Ellinas and colleagues have described steps toward achieving more equity on editorial boards, including actionable items for the AAMC, for journals and their associated medical societies, and for medical schools and academic medical centers. 27 They note that each of these organizations must address workforce equity and inclusion as a data-driven process. Leaders of journals, medical societies, medical schools, and academic medical centers must understand the literature on workforce equity, and the data must be transparent and reported to stakeholders. Every effort should be made to improve representation on their boards.

Expanded Promotion Criteria

Community-based research and involvement is not as valued for promotion as translational or clinical research, thereby disincentivizing this important work. 28 Faculty from underrepresented groups often do not receive recognition and promotion for community-engaged scholarship, inclusive of diversity, equity, and inclusion (DEI) research. To retain faculty who are interested in community-engaged scholarship and to improve health disparities, medical schools need to recognize and reward community-engaged service, advocacy, and research, and demonstrate commitment to both diverse communities and faculty of color.

Furthermore, the racial justice issues raised during the summer of 2020 have led to an increased focus on DEI initiatives at many medical schools. Often, this work falls on the shoulders of women of color, particularly those with additional intersectional identities. Research in this arena is critical, yet often unfunded and poorly supported. Institutions need to make changes to their promotion and recognition criteria to apportion appropriate value to these efforts, on par with other scholarly activities performed by their faculty members. This “minority tax” must be turned into high-priority subsidies that leads to advancement. Furthermore, research on social determinants of health and health disparities, which disproportionately affect communities of color, needs to be encouraged. Additionally, the shortage of curricula that address population health and culturally appropriate care also needs to be remedied.

All of this research and curriculum develop requires engagement with affected communities and should be conducted as much as possible by representatives of diverse communities. Yet too few faculty are equipped to meet the need of diversifying medical school curricula across the United States. Until there are more faculty of color, schools might fill the gaps in their curricula by asking trusted cultural allies to help in creating suitable content.

Relationships are critical to the development of community-based research and engagement of community members. The COVID-19 pandemic made clear that a significant portion of people from underrepresented communities distrust academia and organized medicine. Faculty of color often have an inherent knowledge of and comfort with diverse populations and are able to develop strong relationships within these communities. Such relationships can enhance community engagement and assist in guiding the development of population-based curricula and community-based research.

Challenges and Future Opportunities for Women of Color

Traditional approaches to achieve equity for women of color have failed to solve the problems that include higher rates of sexual harassment toward women in academic medicine. In fact, the National Science Foundation has reported that women from underrepresented racial/ethnic groups are more likely to be targets of sexual harassment than those who are not from underrepresented racial/ethnic groups. 29 Along this vein, the literature has described racial violence that includes interactions with abusive and discriminatory patients. 30 In these cases, physicians who are from underrepresented racial and/or ethnic groups may be excluded from the care team by a patient’s unacceptable racist demands.

Meanwhile, women of color in medicine continue to perform necessary but uncompensated and unrecognized work. At the same time, these qualified women continue to be overlooked for promotions, raises, and a seat at the leadership table. The COVID-19 pandemic may set back progress for women in medicine at least 25 years. 31 This setback threatens the workforce equity gap—especially at the leadership level—in ways that will impact women physicians and scientists of color throughout their careers.

We are at a historic moment in time. The environment in academic medicine must change for women in medicine with intersectional identities and from underrepresented groups. DEI initiatives must become a financial priority at institutions of higher learning and become integrated into the systems of care. Programming must have solid funding. Journals and medical societies need to examine their commitments and further allocate their pocketbooks to DEI efforts, as well. Furthermore, pay transparency is a major step toward systemic equity and audits should be done in this regard, especially with the known evidence that women of color are paid less. 32 Inclusive cultures should be the norm and not just touted on webpages. Targeted strategies must be developed and implemented at the highest levels of research, board rooms, journal editorial boards, medical societies, and throughout academic medical centers. Additionally, faculty needs assessments must be done. System-wide changes that are quantifiable using a scientific approach with data analysis will help us forge a path toward workforce equity in academic medicine.

The consequences of not having equal representation to influence medicine and research are evident. Beyond the effect on the marginalized individuals in academic medicine, there is direct impact on patient care and outcomes. Women of color continue to depart from the academic pathway, despite anecdotal success stories. Diverse representation in academic medicine remains essential. We must forge along so that the path consistently taken is one where women of color become leaders in academia.

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