A little white girl is born in suburban Chicago to two physicians. At her house, dinner table talk revolves around clinical encounters and research pursuits. Much is expected from this girl. She is not asked whether she will go to college, but where. After much deliberation, she has decided that she wants to become a doctor. From her parents, she knows exactly which tests to take, which experiences to seek out to make herself a more attractive candidate. She knows that she will have to work hard, but is confident that she will be able to reach her goal.
Consider another girl, this one black, born in inner city Chicago to unmarried parents with just high school diplomas. She is raised by her mother and grandmother and attends a public school where she buys subsidized lunch for 40 cents daily. At this school, on Career Day, she meets a plastic surgeon. To demonstrate her craft, the surgeon incises a raw turkey leg and sutures it closed again. The girl is sold; she now wants to become a doctor. But how does one become a doctor, and a successful one to boot?
Our nation's physician workforce has a distinctly different demographic profile than the population it serves. By and large, medical doctors are more white, more male, more heterosexual and less disabled than America as a whole. This difference is even more marked in academic medicine. The Association of American Medical Colleges notes in its annual report on medical faculty diversity that, although strides have been made in improving the percentage of women in academic medicine, addressing racial, ethnic and other types of under-representation has been more vexing.
Why, other than acceding to a vague sense of fairness, has diversity been embraced by academic medical centers? First, there is evidence that racial concordance is associated with increased patient satisfaction, adherence to care plans and improved outcomes. Second, physicians from under-represented groups are more likely to practice in areas serving patients with disproportionately poor health outcomes. Finally, scientists from diverse backgrounds approach research endeavors from different viewpoints. This may underlie findings that demographically heterogeneous research teams produce work that is more cited than do homogeneous teams.1
Historically, institutions have taken a pipeline approach to increasing diversity in medicine. That is, if more people from a given background are admitted to each stage preceding faculty appointment, diversity must necessarily increase. "Affirmative action" is a widely-used descriptor of programs adopting this model. Affirmative action and other admissions policies accounting for race, gender and other demographic factors have indeed increased the number of trainees at the college, medical school, and resident levels. At the faculty level, however, gains have been much less robust.
Perhaps in recognition of the pipeline strategy's limitations, some organizations interested in healthcare workforce diversity have turned their attention from recruitment towards retention of faculty from underrepresented backgrounds. But why are retention programs needed in the first place? After negotiating the hurdles of undergraduate and graduate medical education, why do some underrepresented physicians struggle upon faculty appointment? I believe that the answer is one of culture.
As with any culture, academic medicine has its own language, customs, and unwritten rules. Promotion depends on understanding and largely abiding by these rules that many of us do not know before we accept our first appointment. And, just like foreign travelers without tour guides, we are bound to have any number of awkward experiences before we get things right. Add to this the burden of stumbling in the presence of people who resemble the stereotypically older, white-haired male physician, and leaving the academy becomes an appealing option.
Women may be at a particular disadvantage when it comes to succeeding in the academy. Setting aside the substantial concerns about integrating motherhood and professional identity, recent evidence suggests that the rule-following tendency that helps women excel in school hamstrings them in the professional world.2 Much like the first girl, above, we proceed through training by achieving the right combination of grades, standardized test scores, and extracurricular activities. After faculty appointment, though, our trusty formulae disappear. Left to our own devices as faculty, it is difficult to know how to apportion our limited time between family, clinical practice, teaching, scholarship, and university service.
Yet another hurdle faced by women and people from racial/ethnic minority groups is the imposter syndrome, the feeling of inadequacy despite being objectively competent.3 The imposter syndrome amounts to an inner monologue detailing all of one's faults and warning of the inevitability of failure. Although people of all backgrounds experience this phenomenon to some degree, physical difference can serve to reinforce a sense of not belonging.
So how did I, the second girl with so many barriers to overcome, achieve some small measure of professional success? I was fortunate enough to have mentors who helped me navigate through the wilderness of higher education and academic appointment. From the high school English teacher who helped me apply to college when my parents could not, to the premedical advisor who encouraged me to apply to Ivy League medical schools when my thesis advisor cautioned against this, my mentors have encouraged me to dream impossibly big dreams and have shown me how to get closer to them.
The pivotal role of mentorship in academic success is a core concept behind the AAMC Minority Faculty Career Development Program,4 the Robert Wood Johnson Foundation's Harold Amos Medical Faculty Development Program,5 and the Executive Leadership in Academic Medicine Program,6 among others. These programs provide a cultural orientation to the academy, making explicit those rules that become stumbling blocks when they go unseen. With the help of mentors, participants are guided through the intricacies of negotiating, grant writing, publication and promotion. These programs boast impressive gains: participants have high rates of retention within academic medicine5 and demonstrate more leadership competencies than non-participants.6 The success of these programs suggests that this model is a promising one.
Of course, mentorship is necessary for everyone in academic medicine, from interns to department chairs and deans. Rather than imply that those from "over-represented" groups do not need guidance, I submit that minority (broadly defined) physicians should be paired with mentors who understand both the academic and cultural barriers to advancement. It is necessary but insufficient to meet "as needed", or to address solely those questions asked by the mentee. Mentees, especially those from under-represented groups, may not know what questions to ask. Merely having a minority faculty program is not enough to achieve the goal of improving diversity in the professoriate. Indeed, in their study of minority faculty development programs, Guevara et al found that only the more intense minority faculty development programs were able to achieve gains in the percentage of faculty from underrepresented backgrounds.7
It is equally important that mentees take an active role in the mentoring relationship. It is okay to not know, but not okay to suffer in silence. If the mentor-mentee relationship is not mutually fulfilling, either party should be able to break away. Academic medical centers can help in this regard, providing concrete expectations for mentoring relationships and facilitating re-pairings as needed.
Ultimately, increasing diversity in the academy is not merely a matter of opening the door. It also requires helping people understand what to do on the other side of the threshold. Only when these expectations are understood by all can we achieve our ideal of a truly representative physician workforce.
ACKNOWLEDGEMENTS
I gratefully acknowledge the support and guidance of my many mentors, sponsors, and champions.
REFERENCES
1. Freeman RB, Huang W. Collaborating With People Like Me: Ethnic co-authorship within the US. National Bureau of Economic Research Working Paper Series. 2014;No. 19905(published as Richard B. Freeman, Wei Huang. "Collaborating With People Like Me: Ethnic Co-authorship within the US," in Sarah Turner and William Kerr, organizers, "High-Skill Immigration" (University of Chicago Press), Journal of Labor Economics (2014)).
2. Johnson W, Mohr T. Women Need to Realize Work Isn't School. HBR Blog Network 2013; http://blogs.hbr.org/2013/01/women-need-to-realize-work-isnt-schol/.
3. O'Brien McElwee R, Yurak TJ. The phenomenology of the impostor phenomenon. Individual Differ. Res. 2010;8(3):184-197.
4. Cora-Bramble D, Zhang K, Castillo-Page L. Minority faculty members' resilience and academic productivity: Are they related? Acad. Med. 2010;85(9):1492-1498.
5. Ardery NL, Krol DM, Wilkes DS. Leveraging diversity in American academic medicine: The harold amos medical faculty development program. Annals of the American Thoracic Society. 2014;11(4):600-602.
6. Dannels SA, Yamagata H, McDade SA, et al. Evaluating a leadership program: A comparative, longitudinal study to assess the impact of the Executive Leadership in Academic Medicine (ELAM) program for women. Acad. Med. 2008;83(5):488-495.
7. Guevara JP, Adanga E, Avakame E, Carthon MB. Minority faculty development programs and underrepresented minority faculty representation at US Medical Schools. JAMA - Journal of the American Medical Association. 2013;310(21):2297-2304.