More than good seed: Cultivating investigators from underrepresented minority backgrounds in physiatric research

INTRODUCTION

Numerous events of brutality against Black people in 2020, peaking with the senseless murder of George Floyd in May 2020, have brought renewed vigor to the fight against social injustice in America. Social injustice, in the middle of a global pandemic disproportionally affecting communities of color, has placed increased attention on health inequities as well. The medical and health communities are engaged more than ever in using their powerful voices and perspectives in creating more equitable communities and learning environments.

Fewer areas spotlight current health inequities as starkly as academic medicine and biomedical research. Health care inequities experienced by patients can often be traced back to inequities experienced by minority clinicians and researchers, who were underrepresented in the workforce. A lack of representation has been shown to result in negative health outcomes for minority patients.^1,2 We must not only use our voices but also be intentional in our action to improve diversity and representation in physiatry research.

The authors Skelton (F.S.) and Sholas (M.S.) target this manuscript to underrepresented minority (URM) investigators³ and their allies as an acknowledgement of challenges but, more important, as a call to action. Unique challenges in physiatric research will be highlighted, and specific strategies to support URM physiatric investigators will be described.

(M.S.) My maternal grandfather taught agriculture and ran a small farm. We were clear on the importance of picking good seed, planting at the appropriate time, and tending to the plants and animals to help them mature and produce. I am a novice urban gardener to this day. Growing things is my way to relax and create a beautiful and rich environment.

(F.S.) My paternal grandfather was a gardener and landscaper. He created beautiful lawns for people all over Houston, and some of my fondest childhood memories are of exploring the greenhouse he built and kept in his own backyard. My father worked under him growing up, and he too has a green thumb; our family lawn won countless “Yard of the Year” awards, and I send him my sick plants to be nurtured back to life. It is very clear, unfortunately, that I did not inherit the family trait of plant whispering, but I did learn a few things from these two men. Picking the right seed to plant is very important, but not everything. The time of the year, the soil, the amount of sunlight available, planting in the ground vs in a pot—the size of the pot—all determine whether your efforts will be fruitful.

This analogy can be extended to describe the lack of representation of racial and ethnic minority groups (URM, defined for the purposes of this manuscript as persons from Black or African American, American Indian or Alaska Native, Latinx or Hispanic, Native Hawaiian or other Pacific Islander backgrounds)³ in academic medicine and in research. URM physicians comprise about 9% of the U.S. physician workforce and about 7% of MDs or MD-PhDs with National Institutes of Health (NIH) research grants.³

There is good seed available—bright, capable, ambitious physician scientists ready to use their unique perspectives to advance science and improve population health—but it is in short supply. In 2019, the (NIH) noted that Black and Hispanic investigators comprised less than 10% of mentored career development or K awards. Less than 5% of R01 (the major funding category of NIH independent investigator-initiated research) applications came from these two groups, and they represented only 3% of awardees.⁴

Even if more seed were available, however, the current landscape of many academic departments is not conducive to supporting URM early investigators such that their careers will flourish. It has been well documented that the proportion of URM academic faculty is well below representation in the general population, and the disparity becomes exponentially starker the higher in academic rank.⁵

More specifically, the process of becoming a physiatrist as well as a researcher has intrinsic mores and steps that are not always inclusive. In the next section, we discuss initiatives that have been implemented to promote equity in the biomedical research workforce as a foundation for discussing strategies specific to physiatry.

Previous initiatives to promote health equity in biomedical research

The benefits of a diverse biomedical workforce have been highlighted extensively in the literature. Specifically, for biomedical research, advantages of diverse teams include they are more likely to focus on facts, thus their products are more accurate and objective; they process information more carefully, and thus are more likely to reach more conclusive decisions; they are more likely to reject the “status quo” and innovate, which leads to richer research questions and thus scientific advancement, not to mention improving minority participation in clinical research.⁶ The Oakland Barber Shop study showed how profoundly important having Black physicians was to positive health outcomes for Black patients,² a finding also echoed in a neonatal intensive care unit study of infant mortality,¹ highlighting the direct link of how racial diversity in the clinical researcher workforce affects health and wellness outcomes.

Given the positive impact of a diverse workforce on health outcomes, successful programs have been developed to diversify the biomedical investigator workforce. Title VII of the Public Health Service Act supports building a diverse health care workforce through providing funding for health equity Centers of Excellence and Health Careers Opportunity Programs for students interested in matriculating into health science schools and scholarships for students from disadvantaged backgrounds, thus forming pipeline initiatives. The NIH Maximizing Access to Research Careers Undergraduate Student Training in Academic Research (MARC U-STAR) T34 program has supported 9000 students between 1985–2013. An analysis of program alumni between 2001–2005 showed that 46% of alumni went on to successfully obtain a PhD, MD/DO, or MD/PhD, well higher than the overall rates of URMs not involved with the program.⁷ The Minority Biomedical Research Support (MBRS) Programs has three components. The Research Initiative for Scientific Enhancement (RISE) and Initiative for Minority Student Development (IMSD) R25 programs are like the MARC U-STAR in that they target URM undergraduates to promote into PhD programs. The third component, Support of Competitive Research (SCORE), then offers separate funding opportunities of individual investigator-initiated research awards.⁸

The current need for pipeline programs is based in historical events. Historically Black colleges and universities (HBCUs) have had great success in driving high school students, especially Black men, into medicine. Standouts include Xavier University of Louisiana, which was recently recognized nationally as sending more Black students to medical school who then successfully earn their MD/DO degree than any other university in the country,⁹ and the partnership between Tennessee State University and Meharry Medical College. Despite this success—good seed being placed in good soil to flourish—HBCUs are susceptible to withering due to racially biased practices. One of the more egregious practices came in the form of the Flexner report, a scoping review of the 155 medical schools in existence in the early 20th century.^10,11 Largely credited for the standardization of medical school education, it also led to the closure of 89 of the reviewed schools, including 5 of the 7 schools devoted to educating Black physicians in an era where most medical schools were not offering admission to Black students. Althogh the report has largely been recalled for its racial, gender, and economic biases, the shortage of Black physicians it propagated persists.

Unique challenges in physiatric research

Although resources and models of successful workforce capacity-building programs are available, building a diverse physiatry workforce unfortunately poses additional challenges. Many medical students learn about physiatry, still considered a relatively “hidden gem,” late in their medical school career. Currently, 86% of osteopathic and 46% of allopathic medical schools do not have a physical medicine and rehabilitation (PM&R) training program at their home institution.¹² A recent study highlights the glaring paucity of racial diversity among trainees in PM&R programs, which inherently propagates into academic leadership: only 4% of PM&R program directors identify as Hispanic and 2% identify as Black.¹²

Physiatry is also catching up to other specialties in many ways in the breadth and depth of all physician scientists, let alone those from URM backgrounds. Leading physiatry physician scientists recognized the need to formally develop young investigators and developed the Association of Academic Physiatrists’ (AAP) Rehabilitation Medicine Scientist Training Program (RMSTP) in 1995 to address this need.¹³ Although the overall success of the program is laudable, diversity, equity, and inclusion have not been priority areas in the past and remain an area of immense potential for future efforts.

Finally, by nature of physiatric clinical practice, physiatric research requires a knowledge of diverse methodologies to address research questions of interest to physicians and patients. Physiatric research is lacking in both workforce and methodological diversity, which in some cases are linked. URM investigators often have interest in community engaged, applied, qualitative, and other forms of research that tend to involve mixed methods and an emphasis on lived experience. However, academic training programs do not nurture or provide mentorship for these types of research and academic faculty positions and often see this work as “service” as opposed to more traditional ways of knowing (basic science or clinical trial research). This is unfortunate, as both forms of underrepresentation, in URM physician-scientists and in research methodology, combine to severely limit the questions physiatric research can ask and answer.

Beyond good seed: necessary components to growing successful physician scientists in physiatry

Figure 1 provides a visual representation of the “more than good seed” analogy and will be described in detail as we review specific strategies to support URM physiatric investigators.

FIGURE 1.

A visual representation of the “more than good seed” analogy. Graphics credit: Anisa Kenyatta Parks, Maurice Sholas, and Felicia Skelton

Develop physiatry physician-scientist pipelines

Academic physiatry departments must be more intentional in their desire to promote equity in biomedical research. This could include trainee and faculty recruitment from HBCUs, as well as developing research collaborations with these institutions. The Department of Veterans Affairs (VA), which is a large component of the clinical training of many physiatry departments, has an entire career development award mechanism across its four research and development domains aimed at supporting URMs in research. The goal of this program is to develop long-term research collaborations between VAs and HBCUs. In addition, there are several well-established national programs promoting equitable biomedical research workforces where physiatry clinician scientists are currently underrepresented. The NIH/National Medical Association, the oldest historically Black physician association in the country, holds an annual Careers in Academic Medicine Workshop for residents, fellows, postdoctoral students, and junior faculty. The Association of American Medical Colleges also has several successful programs, including the Diversity 3.0 learning series and Minority Faculty workshops. Leaders in academic physiatry thus have opportunities to support talented URM applicants in their pursuits with minimal time and other departmental resources, but they must educate themselves on available resources and connect URMs to these resources.

Intentional diversity in succession planning for academic and research leadership

We charge clinical and academic leadership associations such as the American Board of PM&R, the American Academy of Physical Medicine and Rehabilitation, AAP, and their associated journal editorial boards to be more deliberate in promoting diversity among their leadership. Many of these organizations already have existing leadership development programs; it is simply a matter of operationalizing diversity and equity in them. This same focus should be extended to academic department leadership (residency/fellowship program directors, deans of research, chairs, etc). One way to achieve this would be for universities to provide financial support to departments to recruit and retain URM junior faculty, grooming them for leadership positions.

Although formal programs certainly provide opportunities, in the absence of these types of programs, those in leadership positions can educate themselves on different ways to support URMs through both mentorship (someone of advanced rank and expertise who guides, teaches, and develops a more novice person on mutual interests) and sponsorship (promoting junior faculty by putting them forward for opportunities they might not otherwise have access to) (Figure 2).

FIGURE 2.

Types of academic mentorship required to successfully develop a physiatric clinician–scientist. Graphics credit: Anisa Kenyatta Parks, Maurice Sholas, and Felicia Skelton

Diversity, equity, and inclusion as a quality metric

We are firm believers that you cannot change what you cannot measure, and you cannot measure what you cannot define. Under the Merit-Based Incentive Payment System (MIPS) clinicians have some choice of activities they can participate in to meet the requirements, of which “Achieving Health Equity” is one.¹⁴ We argue, however, that this could stand to be elaborated upon and better operationalized. Objectives and outcomes can be developed using methods similar to those used by the National Quality Forum, outlining the numerator and denominator of the metric. Then, departments must develop a rigorous and reliable method of tracking the information related to the metric. Once concrete definitions are made and put into action, we must then measure failure or success. We propose developing a health equity report card for academic physiatry departments, so that internal and external leadership can measure progress, as well as deliberately recognize successful departments.

Additionally, academic physiatry departments should specifically explore ways to recruit diverse voices into quality improvement, patient safety, and policy research. Physiatrists have the potential to be natural leaders in these spaces, leveraging our skills in communication and interdisciplinary/interspecialty cooperativeness.

Focus on retaining minority faculty

In addition to actively recruiting physiatry scientists from underrepresented backgrounds, institutions must be deliberate in creating environments where they can flourish. Doing this helps everyone in the department. Many minority faculty in academic medicine are only now developing the language to describe the negative experiences and microaggressions they face daily: “walking around in a size 9.5 shoe, but you have a size 10 foot” or “death by a 1000 cuts.” Academic leadership must recognize and listen to these often-subtle cries for help or risk losing talented URM academicians to industry or other endeavors.¹⁵

Additionally, leadership should educate themselves and be aware of the “minority tax.” Often, minority faculty are asked to pay the “minority tax”—taking on mentoring and leadership roles to promote diversity and equity within the institution that are often uncompensated and not readily recognized toward tenure and promotion.¹⁶ This includes diversity/inclusion/equity committees, mentorship, speaking engagements, panels, and social media initiatives. If these initiatives are truly valued by institutions, clear pathways to promotion and tenure involving these activities must be delineated. As described previously, physiatry departments must support diverse research interests, including equity research, as a faculty retention strategy.

Lastly, but equally important, academic departments must be mindful of the environment they are cultivating, through words and action. Overland et al. previously discussed how the prohibition on certain language involving race contributed to less than welcoming, if not overtly hostile, environments for URMs. We argue because of this historical censure, it is even more important to have these discussions now in a constructive way. They also describe the concept of being antiracist—actively engaging in activities that promote racial tolerance– in the literature.¹⁷

CONCLUSION

“The grass is greener where it is watered.” And has good sun, fertilizer, and irrigation. This may seem like a simple colloquialism, but as we hope we have illuminated, is a powerful mantra toward meaningful change in diversity in physiatric research. Supporting URMs in physiatric research careers will benefit all in academic medicine, as well as the health of our communities.