Improving physician diversity and inclusion benefits physicians and patients

Elizabeth Hillier, BSc, Kiera Keglowitsch, BSc, Marni Panas, CCIP, Blaire Anderson, MD, Sandy Widder, MD, and Debrah Wirtzfeld, MD

 

https//doi.org/10.37964/cr24736

 

Note on language and bias

All authors of this article have taken implicit bias training and have based the points made here on empirical data rather than opinion. Throughout this article, the term “women” is used to refer to those who identify as women regardless of their sex at birth, to be as inclusive as possible within the scope of this project. Any person identifying as a woman can and likely does experience the discrimination outlined in this paper. We also acknowledge that concerns of transgender individuals within the health care system is an important topic in and of itself and should be further explored.

 

A diverse physician workforce in the Canadian health care system would result in more cultural competence, greater patient satisfaction, and improved population health. However, increasing representation and diversity does not automatically resolve issues of inequity, inequality, and discrimination. In this article, we discuss three broad areas of health care — the clinical environment, academic advancement, and leadership — that require intentional, systemic change if we are to make a lasting impact in terms of increasing the diversity and inclusion of underrepresented groups in medicine, and consequently, improve health outcomes. Inclusive and equitable practices to target pay inequity, unconscious bias, opposition to career advancement, and sexual harassment are integral to diverse physician recruitment and retention. Equity strategies and checks to remediate systemic biases in academic advancement through grant funding, academic criteria of merit for promotion, and the acknowledgment of differences of experience can be employed to improve equity in academic medicine. The long-standing culture, policies, and traditions of institutions within the medical establishment must be combated with a collaborative effort to foster equity through the engagement of academics and physicians from underrepresented minority groups, and the implementation of implicit bias training and meaningful accountability for creating a safe, equitable work environment for diverse physicians. Any proposed solution to improve equity and diversity should not be taken as a fixed principle to follow uncritically, but rather as a starting point for understanding and implementing the unique changes required in various local contexts

 

KEY WORDS: diversity, inclusion, equity, leadership, underrepresentation

 

CITATION: Hillier E, Keglowitsch K, Panas M, Anderson B, Widder S, Wirtzfeld D. Improving physician diversity and inclusion benefits physicians and patients. Can J Physician Leadersh 2021; 7(3):108-114. https//doi.org/10.37964/cr24736

 

A global viral pandemic, worldwide anti-racism protests, and a stance against overt sexism - each of these 2020 occurrences on their own should have been enough to give our society pause to reflect on what we value. Taken together, they should motivate us to create the changes we want to see in the world.

 

Within the Canadian health care system, 2020 also brought sobering moments. In September, an Indigenous woman recorded racist slurs being directed at her before she died in a Quebec hospital. Tragically and ironically, this occurred days before the first anniversary of a report outlining systemic racism in the Quebec health care system.1,2 A recent public health report described similar pervasive systemic racism and discrimination in British Columbia’s health care system.3 These problems are not isolated in Quebec and BC; racism in health care is a national crisis so ubiquitous that it not only impacts patient care and health outcomes, but also extends into our health systems’ leadership and academic institutions. The recent events and reports are a wakeup call that there is still work to be done to improve diversity, inclusivity, and equity of patients and workers in the Canadian health care system.3,4

 

Data have shown that a diverse physician workforce results in more cultural competence, greater patient satisfaction, improved population health, and a more inclusive education and research agenda.5-11 It also results in improved health care outcomes.

 

Over the past few decades, individual physicians, academic institutions, health care systems, and national physician groups, including the Canadian Medical Association, have committed to increasing diversity and inclusion. These commitments have been successful in improving some realms of diversity. Currently, over half of medical school graduates are women.5

 

Efforts have been made to increase the number of Indigenous students in Canadian medical schools.6 Although no data are currently collected nationally, many faculties have recommitted to increasing the number of Indigenous students as a result of the calls outlined in the Truth and Reconciliation Commission’s report to more accurately reflect populations being served.6,7 The University of British Columbia has a target of filling 5% of its 300 seats with Indigenous students, and the University of Alberta and McMaster admit all Indigenous students who meet the rigorous standards of their admissions processes.8,9 Similarly, the University of Toronto has been a national leader in implementing the Black Student Application Program, in response to a 2010 Association of Faculties of Medicine of Canada report that called for enhanced admissions processes to achieve desired diversity in the physician workforce.10,11

 

Increasing representation and diversity does not automatically resolve issues of inequity, inequality, and discrimination. Many groups still endure everyday experiences of sexist or racist jokes, sexual harassment, weaker or gendered reference letters for faculty positions, pay disparity, and higher representation in lower-paid fields of practice, despite increased diversity in the field.12 Therefore, even as the management of the COVID-19 crisis takes priority, we must maintain a focus on improving the inclusivity and diversity of the physician workforce without reversion to previous, more familiar, modes of operating.

 

In this article, we discuss three broad areas of health care — the clinical environment, academic advancement, and leadership — that require intentional, systemic change if we are to make a lasting impact in terms of increasing the diversity and inclusion of underrepresented groups in medicine and, consequently, improve health outcomes.

 

Clinical environment

 

Current models of health care delivery result in disproportionate negative health outcomes in marginalized and racialized communities. In Ontario during the first four months of the pandemic, those living in urban, ethnically diverse neighbourhoods had COVID-19 infection rates three times higher than predominantly white neighbourhoods and experienced more severe outcomes, including four times the rate of hospital admissions and twice the death rate.13,14

 

Inclusion of more women and underrepresented racial groups in medicine might help to alleviate this imbalance. Multiple studies have shown that female and racialized physicians bring added value through higher satisfaction rates, fewer emergency room visits, fewer subsequent admissions to hospital, and earlier detection of disease.15-20 Furthermore, physicians from underrepresented minority racial groups are more likely than their peers to work in underserved communities and care for minority, low socioeconomic, or uninsured patients across all specialities and all racial groups.21

 

Despite important positive contributions to the Canadian health care system and patient care, physicians who are women and/or people of colour continue to face systemic inequity. Currently, 54% of Canadian physicians under 40 are women22; with a predicted even split among men and women physicians by 2030.23 Yet, women physicians are five times more likely to experience opposition to career advancement and three times more likely to experience actions perceived to be disrespectful or punitive in the workplace when compared with their male counterparts.15 Female physicians experience greater consequences than men for identical mistakes.24 Furthermore, a mounting body of evidence has shown that physicians from underrepresented minorities face significant challenges in the workplace, such as sexual assault and harassment, unconscious bias, and pay inequity.25

 

The gender pay gap among physicians is not unique to Canada. A recent survey of primary care physicians in Brazil, France, Germany, Mexico, the United Kingdom, and the United States reported than women physicians earned 20–29% less than their male colleagues.26 Remuneration disparities continue to exist after accounting for factors, such as years of practice, participation in clinical trials, number of publications, specialty, region, age, hours worked, and practice characteristics.15 A recent Canadian study of surgeons in Ontario found that women earned 24% less than their male colleagues, when controlling for factors such as hours worked.27

 

The current schedule of benefits, fee-for-service structures, and billing codes supports higher remuneration for the styles of practice traditionally performed by men.20 In addition, traditional referral systems may reinforce gender bias.28-30 Different referral models, designed to increase efficiency, may also improve physician equity. For example, single-entry models create a single queue that will direct each patient to the next available provider based on appropriateness and priority.31 Team-based care allows a group of health care providers to share the responsibility of patient care; the provider who sees the patient for a consultation may not be the one to perform a procedure. Both single-entry and team-based models have been supported by providers and patients.32,33 To be truly inclusive, however, these models must be inclusive of all of the providers’ voices.

 

Academic advancement

 

Equity in academic medicine has been at the centre of public commitments by the federal government, granting agencies, and postsecondary institutions for over a decade.34-37 Many health care bodies and faculties of medicine have set diversity targets as part of strategic plans in an effort to continue to improve diversity and inclusion.9,37-40 The Canadian Institutes of Health Research (CIHR) published an equity strategy with the goal of identifying and remediating systematic biases in their grant system to create an equitably responsible agency for providing research funds to academic researchers.35,41

 

Gaps continue to exist. Not only do women and racial minority researchers receive less grant funding than researchers who are men,42,43 but also, at academic conferences, women are less likely to be keynote presenters. One study found that, overall, only 21% of conference presenters were women, and only 28% of study authors were women.44,45 Research in the United States on academic surgery has demonstrated that these disparities can be remediated through inclusion of more women among faculty and in leadership positions; for example, women who obtained National Institutes of Health research funding were more likely to come from institutions with a high proportion of faculty members or chairs who were women.46

 

Despite a recent increase in the number of women, racially diverse learners, and junior faculty in the positions of assistant or associate professors, this increase has not addressed the large gap that remains in academic leadership. A UNESCO report addresses what has come to be known as the “leaky pipeline” phenomenon.23 That is, there is a progressive increase in gender inequity with each increasing stage of education and academic career advancement. The hierarchies of privilege inherent in the “meritocracy” of academic medicine, with their critical roles in determining promotion and appointments, have been established through histories of sexism, racism, and colonialism. As such, they are likely to reflect a limited perspective on what is considered valuable and to be imbued with implicit biases.47 Therefore, what serves as “merit” in medicine should be re-evaluated to acknowledge more inclusive and diverse assessments and understanding of excellence, as suggested by Razack et al.,47 such as, the participation of diverse individuals in the development and assessment of new excellence criteria; an equity check intrinsic to the process of excellence assessment; and explicit, purposeful discussion of the foundational values and assumptions underlying excellence and merit criteria as they pertain to specific uses.

 

It is also important to address the harmful argument of “colour-blindness” or inability to see racial differences. This perspective is built on the notion that problems of inequality can be solved by seeing everyone as the same. What is problematic and dangerous about this approach, however, is that it fails to understand the role of unconscious bias in shaping perceptions and interactions. Furthermore, colour-blindness creates an impossible situation in which the very racial inequality the perspective is trying to address cannot be discussed or assessed because it would inherently involve “seeing” racial differences. Although race or gender, or any identifying feature, should never be used in assessing academic or professional performance, it is important to acknowledge differences and remain aware of how those differences influence inequities.

 

Leadership

 

Long-standing culture, policies, and traditions that result in inequity in institutions are built into the foundation of the medical establishment. Systemic institutional change is brought about by those who lead the institutions into the future.

 

Crucial in a collaborative effort to foster equity in medicine is engaging and consulting with academics and physicians from underrepresented minority groups, to understand their lived experiences, capacity to aspire, and opportunities to succeed.12 The implementation of implicit bias training and meaningful accountability for creating a safe, equitable work environment for diverse physicians is a strategy that has previously resulted in success.48 Allocating a certain percentage of funding to underrepresented groups is one way to hold academic and health care leadership to account for increasing diversity and inclusivity and move toward equity. For example, the CIHR has taken steps to increase diversity and inclusivity through the allocation of 4.6% of the COVID-19 Rapid Research Funding to Indigenous health research, to align with the Canadian Indigenous population (4.9%).41,49 This example demonstrates how renewed commitments to diversity, equity, and inclusion must be met with new, intentional action.

 

Current leaders must be willing to create countermeasures to mitigate barriers to inclusion.50 Tools for the retention and promotion of underrepresented physicians and faculty have been proposed by Doll et al.50 and encompass a range of strategies:

 

• providing continuing education for faculty development
• becoming allies and advocates for underrepresented faculty through mentorship and leadership programs
• implementing institutional structural support in the form of time, funding, and clear expectations for new faculty
• dedicating local and national funding for underrepresented minorities

 

Conclusion

 

Diversity and inclusion policies and statements of support are ubiquitous today at nearly every organizational level. However, decades after national taskforces and diversity efforts began, there remains a striking lack of women and minority physicians in leadership positions.51-53 The racial and gender inequity that is currently found in Canadian health care is a symptom of the historic design of the clinical, academic, and leadership environments. An equity-by-design model, supporting diverse physicians and their inclusion, will lead to the enhancement of clinical practice and patient outcomes.

 

Any proposed solution to improve equity and diversity should not be taken as a fixed principle to follow uncritically, but rather as a starting point for understanding and implementing the unique changes required in various local contexts. For the health care system to address the issues of inclusion and diversity outlined in this paper, dedicated, informed, and ongoing action must be taken across all levels of organization and leadership. The COVID-19 pandemic should be perceived, not as a barrier, but as an opportunity for positive health care system restructuring.  Top

 

References

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Author

Elizabeth Hillier, BSc, is a medical student in the faculty of medicine and dentistry, University of Alberta, Edmonton, and a PhD candidate in the Department of Medicine, McGill University, Montréal.

 

Kiera Keglowitsch, BSc, is a medical student in the faculty of medicine and dentistry, and a master of arts candidate in the faculty of women’s and gender studies, University of Alberta, Edmonton.

 

Marni Panas, CCIP, is the program manager, Diversity and Inclusion, Alberta Health Services.

 

Blaire Anderson, MD, is an assistant professor in the faculty of medicine and dentistry, University of Alberta, Edmonton.

 

Sandy Widder, MD, MHA, MSc, is an associate professor in the faculty of medicine and dentistry, University of Alberta, Edmonton, and associate zone medical director for integrated quality management with Alberta Health Services.

 

Debrah Wirtzfeld, MD, MSc, MBA, is a professor of surgery in the faculty of medicine and dentistry, University of Alberta, Edmonton, and associate chief medical officer, Diversity and Wellness, with Alberta Health Services.

 

Author attestation: EH, MP, BA, SW, and DW were involved in the design, concept, and initial research for the article. EH, KK, and DW drafted the manuscript. All authors contributed to and edited the article and approved the final version.

 

 

Correspondence to:

Debrah.Wirtzfeld@albertahealthservices.ca

 

 

This article has been peer reviewed.

 

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