Step Up by Stepping Back to Promote Equity in Academic Medicine

This is a call to action for leaders in academia to step up and take individual responsibility for making room for advancement for historically minoritized individuals in our profession. Thanks to the overdue social reckoning with Black Lives Matter, #MeToo, and other movements, we are now well aware of inequities in academia related to race, ethnicity, religion, immigration status, sexual orientation, gender, and gender identity. These inequities exist in who we welcome into our profession and their experiences when they arrive at our institutions in pay, promotion, experiences of harassment, micro- and macro-aggressions, opportunity, and leadership positions.

The push to create Diversity, Equity, and Inclusion (DEI) positions, such as Chief Diversity Officers or Deans of DEI, is important but is only a first step. Promoting DEI cannot be the responsibility of one office or person. Nor should it be the duty of the individuals and groups who have been systematically disadvantaged to promote DEI in our profession. Simply creating an office or naming a leader could allow other leaders to consider DEI “taken care of,” without each of us taking personal responsibility.

As physician leaders with different identities (White female Vice President for Research, White male Division Chief, and Black female Vice Chair of Faculty Development) whose work entails faculty leadership and career development, we are aware that to make progress, all leaders must take individual responsibility and action as well. There are many actions academic leaders can take:

First, we can advocate for robust resourcing of Diversity, Equity, and Inclusion Offices and that they are integral to Dean’s Offices and C-suites. When organizations invest in creating a more diverse, equitable, and inclusive workplace and place the leadership within the highest levels of an organization, they communicate that they are serious about change and create momentum for change. These new DEI positions are a good start, but sometimes lack the institutional, historical, resources, and sphere of influence of legacy positions like Director, Chief, Chair, or Dean. DEI efforts and positions also must have the cultural influence and resources needed to effect change. We need to be vocal, active partners in this work and advocates for needed resources and seats at the right tables.

Second, we need to develop and act on data and self-awareness. Leaders who come from historically privileged groups need to consider how they, as individuals, might be hampering the promotion of diversity and an inclusive environment. This includes acknowledging how whiteness privileges leaders and acting on this knowledge by making way for others who have not traditionally been in leadership positions.

This includes White women recognizing their privilege, even in settings where women are also underrepresented. There are many studies documenting how affirmative action policies have benefited White women more than Black, Indigenous, and People of Color, men and women, exacerbating disparities in opportunities and wages.¹ This is not to argue that White women have not also been systematically disadvantaged in academia. We are arguing that we need to be more thoughtful as we advance equity, considering intersectionality—the interconnected nature of social categorizations such as race, class, gender, and other axes that can be present in a given individual or group and create overlapping and interdependent systems of discrimination or disadvantage—and consider how policies may create unintended consequences.

Third, we should use the privilege we have to be agents of change. We should ask those we lead to participate in efforts to work on diversity, equity, and inclusion, prioritize it in our spheres of leadership, and be open to feedback as to how it is going and how we can do better. White men, who make up 30% of the US population, are overrepresented in leadership positions. White men who are serious about promoting DEI need to become comfortable leading colleagues in change.

Fourth, we need to step back and make way. Long-tenured leadership incumbency impedes change. Underrepresented minorities account for 12% of US Medical School Deans.² Women, who have outnumbered men at medical school entry since 1992, are not estimated to achieve parity in Department Chairmanships or Medical School Deanships until 2070.³ For those of us in leadership positions who value equity in leadership, we have to recognize, in some respects, we are in the way. We can make way for others by:

• Expanding our professional circles so that we meet and come to know more potential leaders and successors. We need to join professional organizations and committees that are focused on DEI, social justice, health equity, and women in medicine so that when opportunities come up, we know more diverse individuals to invite to apply or recommend.

• Re-framing the job itself. Many leadership positions were designed or, more likely, unconsciously developed to be occupied by a man who does not have childcare or other family responsibilities. Some leadership positions come with the expectation that the leader would be “on call” at all times. Such positions limit who can occupy them. For individuals and organizations who value diversity and work-life balance, rethinking the positions themselves may be in order.

• Implement term limits. Academic medicine has people hold leadership positions much longer than other institutions. In business, the average tenure of a senior executive is about 5 years.⁴ About academic medical leadership, it has been said “with rare exceptions, the appropriate maximum term for an academic leader/administrator is 10 years, plus or minus 3 years.”⁵ After about a decade, leaders may lack fresh ideas and energy and, through inertia, may lack the will or ability to fix errors or move in new directions. In addition, long incumbency may impede the growth of people in an organization and the organization itself through a lack of morale and a feeling of stagnation. Of course, the costs of position turnover may be high. One suggestion might be to set term limits of 5 years with the opportunities for extensions. At a minimum, organizations and individuals should take a hard look at leaders who have been in their positions for more than 10 years.

• Succession plan with diversity and inclusion in mind. We need to be preparing people, giving opportunities to, and sponsoring individuals for leadership positions. Concrete steps might include providing leadership training to candidates and creating interim or “vice” leadership positions as a recognized stepping-stone to a historical leadership position.

Fifth, we need to empower others. Many of us do not think we are qualified or deserving of leadership roles. Increasing Diversity, Equity, and Inclusion requires us to reflect-back to our mentees and colleagues their excellence, deservingness, and qualifications for leadership opportunities; giving them opportunities to practice speaking about how good they are at what they do; and encouraging and sponsoring their application for opportunities. We also need to create pathways to leadership by identifying, nurturing, and developing, and those with leadership potential early.

Promoting DEI requires individual leaders to take the counterintuitive action of stepping up by stepping back to make way for leaders who have been underrepresented in leadership positions due to systematic bias in who we develop as leaders and promote to fill those positions. By doing so, we can individually and collectively create and promote equity and advancement for those historically underrepresented in our profession.