Volume 7 no 1
Take Black excellence all the way to the top
Addressing Black underrepresentation in Canadian medical leadership
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Take Black excellence all the way to the top
Addressing Black underrepresentation in Canadian medical leadership
Henry Annan, MD
Since 1867, the Canadian Medical Association has served as the national representative body of the medical profession in Canada. Of the 153 people who have headed the organization, none of them has been Black. The first Canadian medical school was founded in 1824; Canada now boasts 17 medical faculties. Of the scores of individuals who have served as medical faculty dean in Canada, none has been Black. Each year, six Canadian “role models of excellence in health in Canada and the world” are inducted into the Canadian Medical Hall of Fame. Of the 137 people on whom this honour has been bestowed, none of them has been Black.
CITATION: Annan H. Take Black excellence all the way to the top: addressing Black underrepresentation in Canadian medical leadership. Can J Physician Leadersh 2020;7(1):18-23.
The goal here is not to admonish Canada’s most revered medical organizations, but rather to illustrate the historic and longstanding dearth of Black representation in Canadian medical leadership. Over the past few years, calls to address barriers to achieving diversity in the Canadian health workforce have been gaining momentum. Diversity exists along a broad spectrum that includes gender, socioeconomic, linguistic, and racial subsets, to mention a few. Acknowledging that there exist many populations that are also underrepresented in the highest echelons of Canadian medical leadership, this article speaks specifically to the paucity of Black Canadians in formal physician leadership roles while proposing four key recommendations for addressing this diversity gap. Top
Step 1: Recognize the problem. Start the dialogue.
The first step in proposing a solution is to identify and acknowledge the problem. It is unclear whether the Canadian medical community recognizes the extent to which people of Black descent are underrepresented in formal leadership positions in the health care system and academic medicine.
Even when this under-representation is appreciated, it may not necessarily be seen by all as a result of inequitable policies. The lack of knowledge about the impact of systemic racism on determining who is and is not at the proverbial table is at least partly reinforced by a lack of engagement in constructive conversations about racial bias in Canada. Top
Race dialogue is difficult for a variety of reasons. Dr. Derald Wing Sue1 of Columbia University describes three ways in which discussing race conflicts with a variety of societal norms, making race-talk a Herculean task in today’s society. First, discussing race necessitates a violation of the “politeness protocol,” that is, the notion that topics that are potentially offensive or uncomfortable should be avoided, ignored, silenced, or discussed in a superficial manner. Race dialogue inherently provokes discomfort. Second, race dialogue violates the “academic protocol,” which implies that discussions taking place at an intellectual level should be objective and rational, devoid of emotion, and value empiric data over experience. Race dialogue is bound to be emotional and deeply personal. Finally, race dialogue violates the “colour-blind protocol” — the belief that race is irrelevant and all individuals should be judged on agreed-upon internal attributes alone. The fundamentals of race dialogue reject a meritocratic system.
One may argue that the individual impact of race dialogue is most profound and most assured when these discussions occur face-to-face. As such, constructive race dialogue must be a pervasive phenomenon in the Canadian medical community. It must occur in the boardrooms of Canada’s medical institutions, in medical faculty classrooms, and at the highest decision-making tables.
Although it will not always be comfortable, race dialogue should strive to be productive; that is, it must have a defined purpose. Constructive race dialogue can “improve communication and learning, enhance racial harmony, increase racial literacy, and expand critical consciousness of one’s racial/cultural identity.”1 If a larger community of physicians understands the leviathan challenges at hand in addressing the racial diversity gap in medical leadership and commit to doing the required work, the individual workload becomes lighter. It is incumbent on the “enlightened” majority to recognize its responsibility in initiating and sustaining these conversations. This is work that is worth doing by everyone. Top
Step 2: Increase the number of Black medical students in Canadian medical faculties
Increasing the number of Black physician leaders requires a critical number of Black physicians in the physician workforce. Achieving a critical number of Black physicians in the physician workforce requires an increase in the number of Black students in medical schools. Recent evidence suggests that the medical student make-up in Canadian medical schools continues to lag behind in its representation of Black Canadians. In 2002, Dhalla et al.2 estimated that only 1.2% of medical students identified as Black compared with 2.5% of the Canadian population aged 18–24 years. The most recent survey by the Association of Faculties of Medicine of Canada (AFMC) to include racial data was performed in 2015. The 2015 AFMC Graduation Questionnaire National Report3 achieved a 75.8% response rate. Of those who responded, only 0.8% identified as Black (e.g., Black African, Black Caribbean, Black North American, etc.). A more recent cross-sectional study by Khan et al.4 surveyed almost 1400 medical students in 14 English Canadian medical schools. Respondents were less likely to identify as Black (1.7%) compared with the census population (6.4%) suggesting further underrepresentation of Black students in Canadian medical faculties. Suffice it to say, there has been no appreciable improvement in the representation of Black medical students in Canada in almost two decades. Top
There are obvious social accountability reasons why every effort must be made to ensure that medical school classes are reflective of the populations they serve. Medical students from underrepresented minority groups are more likely to practise in underserved populations and receive better satisfaction scores from minority patients.5,6 They are also more likely to provide care that is culturally safe.5 Furthermore, white students who attend a medical faculty with a diverse student body feel better prepared to care for patients from minority populations than those from less diverse programs.7 Racial diversity in medical school may also lead to more underrepresented minority physicians in leadership roles down the road.
In 2010, Page et al.8 sought to identify factors that contributed to medical faculty diversity in the United States. The authors conducted a cross-sectional survey of diversity program leaders in 106 US medical schools. Of the diversity program characteristics studied, high racial medical student diversity ten years prior was most strongly associated with current medical faculty diversity. The authors went on to conclude that, while this association may in part be explained by higher population densities of underrepresented minorities in certain states over others, improving the ethnic and racial minority representation among medical student matriculants may lead to a more diverse medical faculty in the future. Top
Increasing medical school diversity requires deliberate and purposeful effort. Policies that acknowledge historical racial inequities and seek to correct them remain among the most effective strategies in increasing racial diversity in medical schools. The University of California offers an interesting case study on how efforts to make student populations more racially diverse can be futile if race is not considered in application and selection processes. In 1996, the state of California adopted Proposition 209, which banned the use of affirmative action policies by California universities as a means to diversify their student populations. Immediately after its implementation, the number of underrepresented minorities at the University of California dropped significantly, and subsequent efforts to restore the number of racialized students to pre-Proposition 209 levels have fallen flat.9
Affirmative action to increase racial diversity need not be controversial. Similar programs to increase the representation of other underrepresented populations have been enacted with great success. The Northern Ontario School of Medicine (NOSM) was established in 2005 by the Ontario government to meet the health needs of residents of Northern Ontario.10 Today, most NOSM graduates practise in Northern Ontario.11 Simply put, if the goal is to increase the number of medical students from an underrepresented group, affirmative action policies are a tried and true mechanism for achieving this objective. The University of Toronto Faculty of Medicine’s Black Student Application Program was established in 2017 to increase the number of Black medical students at the university. As a result, the number of Black medical students has grown from 1 in the Class of 2020 to 24 in the Class of 2024—the largest cohort of Black medical students in the school’s history.12 Programs such as Toronto’s offer a blueprint that other medical faculties may follow to further diversify their medical programs.
Step 3: Create environments where Black medical learners and physicians can thrive
The experience of Black people in the Canadian medical community is poorly studied in the literature. However, there is evidence to suggest that acts of racism and racial microaggressions directed toward racialized minorities are relatively common. A 2003 survey of third-year Canadian medical students showed that racialized minorities were more likely to feel as if they did not “fit in” at their medical school compared with non-racialized groups.13 In the 2019 AFMC Graduation Questionnaire, approximately 1 in 10 respondents reported being subject to racially or ethnically offensive remarks at least once.14 American data show that medical faculty from minority groups were more likely to experience racial discrimination by their peers or superiors compared with their white counterparts.15 Top
Racism is recognized as a key determinant of health, with victims of racism experiencing worse physical and mental health outcomes than the general population.16 By compromising their well-being, racial discrimination in the workplace prevents Black physicians from effectively discharging their duties as health care providers. Consequently, the types of professional development activities that make the path toward leadership roles in medicine possible cannot occur in learning and working environments that breed racism. In health systems science, the Quadruple Aim framework dictates that the well-being of the care team is essential to achieve optimal health system performance.17 Thus, it is imperative that the unique factors that negatively impact the health of Black medical learners and physicians be identified, mitigated, and eliminated for them to excel as health care providers.
Medical education curricula are likely to perpetuate racial microaggression that has gone unidentified by predominantly white educators. The mental well-being of Black medical students is threatened with each racist encounter. Some examples of racial microaggression in the classroom include reinforcing the notion that certain diseases occur only in certain minority populations, stereotyping racial minority patients in case-based learning, failing to recognize how some disease conditions may present in minority patients, and ignoring racist commentary that arises during group discussions. To preserve the health of Black student physicians, medical education must be culturally safe and race informed. Equipping all medical students and faculty with tools to engage in race dialogue and to recognize their own racial biases further promotes safe learning environments for Black medical students. Medical faculties must also institute policies that encourage reporting of racism faced by Black medical learners and guarantee swift, effective corrective action.
Navigating the medical professional landscape in medicine may be more difficult for Black medical learners and early career physicians because of the lack of Black role models. Mentorship programs within academic medicine are influential in determining career choice and personal development.18 An important study in 201319 identified strategies that succeeded in increasing faculty racial diversity in US medical schools. Mentorship by experienced minority faculty and a “grow your own approach,” where minority learners were mentored with the specific goal of transitioning them into junior faculty members, were cited as exemplary initiatives. Clear commitment from administrative leadership to promoting diversity positively influenced recruitment and retention of minority physician leaders. Mentorship programs designed to develop Black medical students and early career physicians into leaders in their fields may, therefore, be an effective strategy for increasing the diversity of Canada’s physician leadership community. Top
Step 4: Study the issue. Track progress.
In Canada, there is little to no information about the racial diversity of the physician workforce. Until 2016, results of the AFMC’s Graduation Questionnaire contained the most robust data on Canadian medical student demographics including race. Demographic data have since been excluded from the questionnaire. This is in contrast to the American Association of Medical Colleges, which collects race data of American medical students each year. To the author’s knowledge, there is currently no program that tracks racial diversity in medical schools in Canada, making it difficult to refine national policies designed to increase racial diversity in Canadian medical faculties. Top
In addition, although large-scale surveys have looked at the wellness of Canada’s physicians and medical learners, these surveys have not included information about their experiences with racism. The AFMC questionnaire does report on whether students have been subject to racially offensive remarks, have been denied opportunities because of their race, or received lower marks because of race.
In a field where evidence-based practice is championed, the Canadian medical community has been slow to study its own responses, or lack thereof, to anti-Black racism. For effective policies to be proposed and maintained, they need to be evaluated. For them to be evaluated, there must be data. Research into the racial make-up of Canada’s medical community can help inform best practices in increasing racial diversity among Canada’s physician leaders. National medical organizations and governments are well equipped to undertake this work and fund grassroots efforts to establish more Black leaders in Canadian medicine.
Black Canadians are among the most severely underrepresented minority groups in medicine. The low number of Black medical students, residents, and physicians in the context of systemic racism contributes to a near absence of Black Canadian physician leaders. Recognizing this lack of racial diversity as a problem and engaging in constructive racial dialogue are the first steps toward increasing racial diversity in the Canadian medical community. Efforts must also be made to create learning and working environments that promote the emotional and physical well-being of all physicians and medical students, especially those of Black descent. Top
Fortunately, there have been some signs of progress. National Black medical student and physician organizations have recently been established in Canada. Medical faculties have begun proposing specific policies aimed at increasing the number of Black medical students in their classrooms. Dalhousie medical school went a step further from its affirmative action application process and, in 2019, introduced dedicated medical school seats for students from underrepresented populations, including Black students.20 The Cumming School of Medicine in Calgary also recently announced a new process for Black applicants.21 Although the outcome of these actions remains to be seen, they represent a welcome commitment to addressing Black underrepresentation in Canadian medicine.
The journey to achieving racial diversity and equity is an iterative process that requires constant evaluation and redirection if necessary. Although perfect racial diversity may never be achieved, the objective is always to meet the challenge of making the next iteration more diverse than the previous. Perfecting, not perfection, is the ultimate goal. Black Canadians are brimming with talent, perspective, expertise, and excellence. The medical community in Canada suffers when it denies Black Canadians the opportunity to lead it. Top
1. Sue DW. Race talk: the psychology of racial dialogues. Am Psychol 2013;68(8):663-72. https://doi.org/10.1037/a0033681
2. Dhalla IA, Kwong JC, Streiner DL, Baddour RE, Waddell AE, Johnson IL. Characteristics of first-year students in Canadian medical schools. CMAJ 2002;166(8):1029-35.
3. Graduation questionnaire national report 2015. Ottawa: Association of Faculties of Medicine of Canada; 2015. https://tinyurl.com/yyzyk72v
4. Khan R, Apramian T, Kang JH, Gustafson J, Sibbald S. Demographic and socioeconomic characteristics of Canadian medical students: a cross-sectional study. BMC Med Educ 2020;20(1):151. https://doi.org/10.1186/s12909-020-02056-x
5. Cohen JJ, Gabriel BA, Terrell C. The case for diversity in the health care workforce. Health Aff (Millwood) 2002;21(5):90-102. https://doi.org/10.1377/hlthaff.21.5.90
6. LaVeist TA, Nuru-Jeter A. Is doctor-patient race concordance associated with greater satisfaction with care? J Health Soc Behav 2002;43(3):296-306. https://doi.org/10.2307/3090205
7. Saha S, Guiton G, Wimmers PF, Wilkerson L. Student body racial and ethnic composition and diversity-related outcomes in US medical schools. JAMA 2008;300(10):1135-45. https://doi.org/10.1001/jama.300.10.1135
8. Page KR, Castillo-Page L, Wright SM. Faculty diversity programs in U.S. medical schools and characteristics associated with higher faculty diversity. Acad Med 2011;86(10):1221-8. https://doi.org/10.1097/ACM.0b013e31822c066d
9. Santos JL, Cabrera NL, Fosnacht KJ. Is “race-neutral” really race-neutral? Disparate impact towards underrepresented minorities in post-209 UC system admissions. J Higher Educ 2010;81(6): 605-31. https://doi.org/10.1080/00221546.2010.11779074
10. Strasser R, Hogenbirk JC, Minore B, Marsh DC, Berry S, McCready WG, et al. Transforming health professional education through social accountability: Canada’s Northern Ontario School of Medicine. Med Teach 2013;35(6):490-6. https://doi.org/10.3109/0142159X.2013.774334
11. Hogenbirk JC, Timony PE, French MG, Strasser R, Pong RW, Cervin C, et al. Milestones on the social accountability journey: family medicine practice locations of Northern Ontario School of Medicine graduates. Can Fam Physician 2016;62(3):e138-45.
12. Collie M. 24 Black medical students accepted to U of T Medicine — the most in Canadian history. Global News 2020;2 June. https://tinyurl.com/y5ybnfts
13. Beagan BL. “Is this worth getting into a big fuss over?” Everyday racism in medical school. Med Educ 2003;37(10):852-60. https://doi.org/10.1046/j.1365-2923.2003.01622.x
14. Graduation questionnaire national report 2019. Ottawa: Association of Faculties of Medicine of Canada; 2019. https://tinyurl.com/y2tt9t95
15. Peterson NB, Friedman RH, Ash AS, Franco S, Carr PL. Faculty self-reported experience with racial and ethnic discrimination in academic medicine. J Gen Intern Med 2004;19(3):259-65. https://doi.org/10.1111/j.1525-1497.2004.20409.x
16. Paradies Y, Ben J, Denson N, Elias A, Priest N, Pieterse A, et al. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One 2015;10(9):e0138511. https://doi.org/10.1371/journal.pone.0138511
17. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med 2014;12(6):573-6. https://doi.org/10.1370/afm.1713
18. Sambunjak D, Straus SE, Marusić A. Mentoring in academic medicine: a systematic review. JAMA 2006;296(9):1103-15. https://doi.org/10.1001/jama.296.9.1103
19.Peek ME, Kim KE, Johnson JK, Vela MB. “URM candidates are encouraged to apply”: a national study to identify effective strategies to enhance racial and ethnic faculty diversity in academic departments of medicine. Acad Med 2013;88(3):405-12. https://doi.org/10.1097/ACM.0b013e318280d9f9
20.Doucette K. Dalhousie adds medical school seats for black, Indigenous and rural students. Globe and Mail 2019;8 Aug. https://tinyurl.com/y3x7r57v
21.Meddings J. Black applicant admissions process: taking action against systemic racism. Calgary: University of Calgary; 2020. https://tinyurl.com/y4n65lky
Henry Annan, MD, is a third-year pediatrics resident at the IWK Health Centre in Halifax, Nova Scotia. In 2017–2018, he served as the 40th president of the Canadian Federation of Medical Students. He was the first and, to date, is the only Black person to hold that office.
Correspondence to: H.Annan@dal.ca
This article has been peer reviewed.