Despite national efforts to increase diversity in U.S. medical schools, faculty remain predominantly white (64%) and male (59%). This trend is amplified in senior academic ranks and in leadership positions. Prior research suggests that when underrepresented in medicine (URiM) faculty are recruited to academic institutions, they are less likely to achieve senior promotion, remain in rank longer, report lower levels of job satisfaction, and more likely to leave academia. Barriers to success for URiM faculty include less mentoring than peers, overt and covert bias and racism, and a disproportionate share of non-career advancing activities.
Despite this concerning lack of progress, increased diversity remains the ideal and can be expected to have a significant positive impact. Diversity is associated with expanding market share and profit margin, attracting high caliber recruits, and improving innovation and decision making.1,2 In academic medicine, it has been associated with an improved learning environment. In clinical care, studies have linked race, language, and gender patient-provider concordance to improved patient satisfaction, adherence, trust, along with decreased post MI mortality and infant mortality.3-5 While increasing the diversity at all faculty levels would address these concerns, increasing the number of URiM leaders may lead to unique approaches that further drive change.
I share my own leadership journey as a Black woman in leadership as one example. My career has largely been at Emory which, like most institutions, has fewer women and URiM faculty in senior ranks and leadership positions. My clinical practice is based at Grady hospital, an urban safety-net hospital set apart from Emory’s main campus with approximately 700 faculty who are committed to caring for the underserved and are more diverse than Emory overall. Historically, Grady-based faculty have had high clinical demands. In addition to the physical separation from the Emory campus, faculty often feel their work is less visible to departmental and school of medicine leadership. In my role as chief of the Grady section and now as assistant dean, this paucity of diverse senior leader models and separation represent institutional barriers to the success of the diverse faculty I lead. I established the following innovations in several domains to address these barriers.
One of my most memorable experiences as a new chief was seeing, for the first time, the salaries of the faculty directly reporting to me. I was surprised by the realization that salaries were inexplicably different for people who seemed to be doing the same job. Some faculty who had been at Emory for a shorter time and were at lower academic rank were making more than others—including me. I assumed no malicious intent, however, given the lack of clear trends around the inequities, but I concluded that some had advocated for themselves and received higher salaries while others (like me) did not. While I remain unclear about the source of this discrepancy, I was certain of the impact. As a woman and person of color, I was acutely aware of the impact on culture and trust when pay inequity is suspected and certainly when it is realized.
In collaboration with other stakeholders, we proposed, developed, and implemented a compensation plan where academic promotion is the major currency for salary increases. Since 2013, we have used AAMC benchmark guides and set our salaries based on a simple metric of academic rank and years of service. Faculty at the same level can be assured they are making the same salary. This aligns salary with our broader mission of academic advancement. It also mitigates the impact of historic social norms that may influence women and minorities who, like me, may be less likely to ask for salary increases. Finally, this has made my job easier—there are no salary negotiations for new hires or intermittent discussions about worth for current faculty. Instead, there is a clear message for recruits and current faculty about our values—transparency, equity, and academic advancement. This issue was important not only for individual faculty members but also for the organization as a whole. In 2017, I was elected by my peers to serve on our school of medicine-wide compensation committee where, anchored in principles of transparency and equity, we review salaries across each unit to ensure there is no pattern suggesting gender or racial differences.
Transparent Leadership Development
This experience made me even more aware of my own biases and the potential impact of social norms that often limit self-advocacy among women and minorities. As a result, I have worked to standardize evaluation and selection processes. For example, our division has open announcements about all leadership opportunities. In addition to addressing bias by not hand-picking candidates for roles, this process addresses perceptions of exclusion often felt when faculty are unaware of opportunities and cannot express interest or be considered. The interview and selection process has allowed me to better recognize previously unknown interests and talent among a broader candidate pool. Further, the interview and selection process itself has propelled the eventual recruit toward better preparation and a rapid start.
Transparent Annual Review
In another example, I established clear and transparent criteria for annual review. I developed a standard rubric with input from the faculty which clarifies, for example, specifics about the number of publications, grants, and external research presentations required for commendable, accomplished, or exemplary ratings in the research domain. This process provides a common and transparent language that defines success and areas that need improvement. Importantly, it minimizes the impact of my own biases as I evaluate faculty with whom I have had long-term mentoring and even personal relationships.
Proactive Coaching for Promotion
For my final example, I will share a program about which I have tremendous pride. I developed and initially chaired the Faculty Review Committee which provides proactive, standardized, and transparent review and development for the Grady section of general internal medicine and geriatrics. The inaugural committee members had themselves been promoted within the prior two years and were familiar with the promotion process and willing to pay it forward. This section-wide program regularly reviews faculty profiles and identifies opportunities for 1) faculty development, 2) participation in unique service, leadership, and teaching roles, and 3) recognition and reward within the division, department and beyond. We created an extensive database that included general medicine grant opportunities, career development and training programs, and awards. Each faculty member review is done on a rotating basis a minimum of two years prior to the next potential promotion date. The review is followed by an individualized faculty report that suggests a promotion pathway, provides a list of recommended activities, and recommends a timeline for promotion. Our process also includes administrative support for promotion packet preparation and assistance with award nominations and applications, if applicable, to bolster success.
This program began in 2013 and has a track record of successful academic promotion of women and URiM faculty that is unparalleled across academia. We have one of the most diverse divisions in the department and school of medicine (26% URiM, 66% women). Through 2020, 46% of our URiM and 55% of women faculty have achieved a senior academic rank.
My background and experiences have informed my leadership values, driving me to stand up programs that proactively maintain transparent and consistent methods to compensate, reward and support faculty. These intentional, standardized, collaborative, and systematic processes demonstrate that diverse faculty are more than capable of academic advancement when provided with early and clear guidelines and support. Our innovative programs that promote leadership and equitably and proactively map out individualized plans for career advancement have been pivotal to faculty success. Diverse leadership matters.
- Cohen JJ. The consequences of premature abandonment of affirmative action in medical school admissions. JAMA. 2003 Mar;289(9):1143-1149. DOI: 10.1001/jama.289.9.1143.
- Hunt V, Layton D, Prince S. Why diversity matters. McKinsey & Co. https://www.mckinsey.com/business-functions/organization/our-insights/why-diversity-matters. Published January 2015. Accessed March 15, 2021.
- Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282(6):583–589. doi:10.1001/jama.282.6.583.
- Greenwood BN, Carnahan S, Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci U S A. 2018 Aug 21;115(34):8569-8574. doi: 10.1073/pnas.1800097115. Epub 2018 Aug 6. PMID: 30082406; PMCID: PMC6112736.
- Greenwood BN, Hardeman RR, Huang L, et al. Physician–patient racial concordance and disparities in birthing mortality for newborns. Proc Natl Acad Sci U S A. 2020 Sep;117(35):21194-21200. doi:10.1073/pnas.1913405117.
Health Equity, Leadership, Administration, & Career Planning, Medical Education, Sex and Gender-Informed Medicine, SGIM, Social Determinants of Health, Women's Health
Dr. Bussey-Jones (firstname.lastname@example.org) is professor of medicine and vice chair of diversity, equity and inclusion at the Department of Medicine at Emory University School of Medicine. She is also assistant dean of professional development at Emory at Grady and chief at Grady Section of General Medicine and Geriatrics.
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