Identifying the prevalence and characteristics of diversity, equity, and inclusion leaders in academic emergency medicine

Abstract

Objectives

Our study aims to better understand and describe the current state of diversity, equity, and inclusion (DEI) leadership in emergency medicine (EM) by identifying the prevalence of department DEI leadership positions, their demographics, and their job duty characteristics.

Methods

We disseminated an electronic survey from April to July 2022 to Society for Academic Emergency Medicine (SAEM) Association of Academic Chairs of Emergency Medicine, Academy for Diversity and Inclusion in Emergency Medicine, and the Equity and Inclusion Committee to identify department DEI leads. From July to August 2022, a 45‐question survey was sent to all identified DEI leaders on individual characteristics, DEI experience, and DEI lead job description.

Results

We received a response from 79 out of 120 academic EM departments identified (65.8%). Of the responding institutions, 59 (74.7%) reported a DEI leader. A total of 74.6% of these DEI leaders responded at least partially to our survey and 57.6% responded in full. The most common titles were vice/associate chair of DEI (34.4%), director of DEI (28.1%), and DEI committee chair (18.8%). Most respondents (84.4%) were the inaugural DEI lead in their department and 84.4% of respondents did not have a formal DEI role in their department previously. On average, respondents have had their DEI title for 2 years (range 0–7 years) with an average of 7 years (range 0–30 years) of experience performing DEI work. Many (63.4%) do not receive any funded effort for their DEI roles. Most DEI leads were not tenure track (72.2%) and most commonly at the rank of assistant professor (47.2%) followed by associate professor (33.3%), full professor (16.7%), and instructor (2.8%).

Conclusions

This is the first known study to assess the characteristics of DEI department leaders in EM. EM DEI leadership positions are new, common, and led by diverse personal identities and are often not funded. Future directions could gain qualitative insight into this workforce to guide best practices in EM DEI leadership.

INTRODUCTION

The American Medical Association, Association of American Medical Colleges (AAMC), and the Accreditation Council for Graduate Medical Education have called on academic medical centers to reflect the diversity of the population they serve; create safe and inclusive environments; and address existing inequities, disparities, and injustices. ¹ , ² , ³ These calls to action and subsequent best practices have led to the creation of institutional positions to lead diversity initiatives such as chief diversity officers and deans of diversity, equity, and inclusion (DEI). ⁴ More recently, institutions have begun developing new DEI leadership positions at the departmental level.

Recent increased focus on disparities and systemic racism in the United States has accelerated the rate of DEI leadership roles in academic departments to help provide equitable care for diverse populations, promote diversity and inclusion among the workforce, and address bias and discrimination. However, there are currently no guidelines for the roles and responsibilities of DEI departmental leaders in emergency medicine (EM).

Few studies have investigated the DEI leadership role in departments outside of EM. An evaluation of DEI officers across academic neurology departments determined five key objectives for a DEI leader: (1) understand and utilize data‐driven processes, (2) be an advocate for those impacted by discrimination, (3) coordinate DEI initiatives, (4) promote health equity, and (5) create inclusive departmental culture. ⁵ Another study, in departments of psychiatry, notes that DEI leaders serve as guides, helping departments and institutions develop structural changes addressing issues surrounding DEI. ⁶ Collectively, these studies note that the DEI leader should play a support role, encouraging members to pursue DEI‐related work and establishing opportunities for recruitment, research, and mentoring activities.

Recently, at an SAEM consensus conference on addressing racism, participants identified current research gaps and called for investigators to study the current EM DEI landscape, identify DEI initiatives and metrics, and improve standards in DEI leadership promotion and professional development. ⁷ Notably, similar challenges have been described for EM roles such as the vice chair for education. ⁸ Historically DEI leadership positions may be selectively assigned and exact a minority tax. ⁹ , ¹⁰ Therefore, developing rigorous and generalizable guidelines for the role may ensure that departmental DEI leaders are appropriately acknowledged for their contributions, supported by best practices, and maximally efficacious. ¹¹ , ¹² , ¹³

The characteristics and responsibilities of these DEI leaders for EM departments have not yet been studied. In this workforce study, we use data from a national survey to identify the prevalence of academic EM DEI leaders and characterize variation among leaders and their roles. We aim to inform academic EM departments on the characteristics of this role and areas of opportunity that align with institutional priorities.

METHODS

Study setting and population

A list of academic EM programs in the United States was curated from the membership of an institution's department chair in the Association of Academic Chairs of Emergency Medicine (AACEM) and by participants in the Vice‐Chair Interest Group, Academy for Diversity and Inclusion in Emergency Medicine (ADIEM), and Equity and Inclusion Committee community listservs within the Society for Academic Emergency Medicine (SAEM). A total of 120 academic EM departments were identified, which is concordant with other academic EM survey studies. ¹⁴ Between April 2022 and July 2022, a Qualtrics survey was sent to members on the AACEM listserv, inquiring about the absence or presence of a departmental DEI leader and, if present, the DEI leader's contact information. Up to three reminder emails were sent to nonresponders to increase the number of participants. The members of the Vice‐Chair Interest Group, ADIEM, and Equity and Inclusion Committee community listservs were then contacted to identify additional DEI leaders. Any discrepancy in responses or ambiguous situations were discussed with the entire group of co‐authors at research study meetings until consensus was achieved.

Study design and survey administration

This observational study utilized an electronic survey from July 5, 2022, to August 31, 2022, to collect data from current EM DEI leaders at academic medical institutions in the United States. Participants were sent an email with a 45‐question electronic survey using Qualtrics software. Individual survey links were provided to each DEI leader to track response rates, provide targeted reminder emails to nonresponders, and avoid repeated responses from a single individual. Survey responses were kept confidential and no incentives were provided for survey completion. All questions were optional. Electronic consent was obtained on the first page of the survey. The study was reviewed by the University of Wisconsin Health Sciences Institutional Review Board (IRB) and deemed exempt (IRB# 2022‐0114). For this observational survey study, we adhered to the CROSS reporting guidelines. ¹⁵

Survey content

The survey was drafted by study investigators and finalized using feedback from department chairs, external researchers, and experts in survey design (Data Supplement S1). The survey was tested at one of the author's institutions across all academic departments. Refinements to the survey included the incorporation of published survey items that were described in the EM Vice Chair of Education workforce study. ⁸ Finally, technical survey review services and consultation for this project were provided by the University of Wisconsin Survey Center. ¹⁶ The questions were designed to understand DEI leaders’ demographics, training, current job descriptions, job duties, and compensation. The survey concluded with open‐ended questions to better understand their role in their department.

Outcomes

The main outcome of the first survey was the prevalence of DEI leaders in academic EM departments. Given the desire to describe the characteristics of the EM DEI leadership workforce, secondary outcomes include DEI leaders' responses to quantitative and qualitative survey questions about their individual demographics and job duties.

Data analysis

Data were coded for consistency across questions and analyzed using R version 3.6.3. ¹⁷ , ¹⁸ , ¹⁹ Descriptive statistics for quantitative variables were calculated and reported using medians due to the nonnormal distribution of underlying data. Where applicable, Kruskal–Wallis and chi‐square tests of independence were used to identify statistically significant differences. Descriptive statistics were calculated at the question level, so partial survey responses were included as much as possible.

RESULTS

Survey response rates and demographics

A total of 120 academic EM departments were identified. Of these, 79 (65.8%) institutions responded to our initial survey aimed at identifying DEI departmental leaders (Figure 1). Of the 79 institutions, 59 (74.7%) institutions identified a DEI leader. The remaining 20 (25.3%) institutions reported that they do not have a DEI leader.

FIGURE 1.

Flow diagram. Out of 120 academic emergency departments, 79 department leaders indicated if they had a DEI leader. Of the 59 DEI leaders identified, 44 responded at least partially, and 34 responded in full. DEI, Diversity, Equity, and Inclusion.

Of the 59 identified DEI leaders, a total of 44 (74.6%) responded at least partially to our survey and 34 (57.6%) responded to our survey in full. The demographic information for the respondents' gender, race, and sexual orientation; those who identify as transgender; and practicing geographic region are listed in Table 1. A total of 24 unique states or U.S. territories were represented. All respondents worked at a location where EM is its own academic department.

TABLE 1.

Demographics: self‐reported demographic information of academic EM DEI leaders.

	n	p	95% CI a
Gender
Woman	25	73.50%	(56.88%–85.40%)
Man	9	26.50%	(14.60%–43.12%)
Nonbinary or other	0	0.00%	(0.00%–10.15%)
Race
Black, African American, or African	12	35.30%	(21.49%–52.09%)
White	8	23.50%	(12.44%–40.00%)
Asian	5	14.70%	(6.45%–30.13%)
Multiple selected	5	14.70%	(6.45%–30.13%)
Hispanic, Latino, or Spanish	4	11.80%	(4.67%–26.62%)
Native Hawaiian or Pacific Islander	0	0.00%	(0.00%–10.15%)
Middle Eastern or North African	0	0.00%	(0.00%–10.15%)
American Indian or Alaska Native	0	0.00%	(0.00%–10.15%)
Region
South	14	34.10%	(21.56%–49.45%)
Midwest	11	26.80%	(15.69%–41.93%)
Northeast	9	22.00%	(12.00%–36.71%)
West	7	17.10%	(8.53%–31.26%)
Sexual orientation
Straight	26	76.50%	(60.00%–87.56%)
Gay	3	8.80%	(3.05%–22.96%)
Queer	2	5.90%	(1.63%–19.09%)
Bisexual, pansexual, or fluid	1	2.90%	(0.15%–14.92%)
Lesbian	1	2.90%	(0.15%–14.92%)
Same gender loving	1	2.90%	(0.15%–14.92%)
Asexual or on the ace spectrum	0	0.00%	(0.00%–10.15%)
Two spirit	0	0.00%	(0.00%–10.15%)
Transgender identity
No	33	97.10%	(85.08%–99.85%)
It is complicated	1	2.90%	(0.15%–14.92%)
Yes	0	0.00%	(0.00%–10.15%)

Abbreviations: DEI, diversity, equity, and inclusion; n, number of responses; p, proportion of responses.

^a Using Wilson method for CIs.

DEI title

Out of 44 responses, 12 (27.3%) did not have a formal title for the DEI leadership. Of the 32 with a title, the most common were Vice/Associate Chair of DEI (34.4%), Director of DEI (28.1%), and DEI Committee Chair (18.8%). Included in these are similar titles such as those that include the word “justice.” The remaining 18.8% of DEI titles included nouns such as officer, liaison, and champion. The full list of titles can be seen in Table 2. Of those with a title, 84.4% of respondents were the inaugural recipient of their departmental DEI title. While some were promoted from a previous DEI title such as from committee chair to vice chair of DEI, most respondents did not have any previous DEI title (84.4%).

TABLE 2.

DEI leaders self‐reported titles.

DEI title	N
No formal title	12
Vice/Associate Chair of DEI	11
Director of DEI	8
DEI Committee Chair	5
Co‐Director DEI of Steering Committee and Emergency Medicine Service Line DEI Committee	1
Co‐Chair of JEDI (Justice, Equity, Diversity, and Inclusion)	1
DEI Lead	1
Director of Diversity, Equity, Inclusion and Justice	1
Diversity Champion	1
Liaison of DEI	1
Officer of DEI	1
Vice Chair of Faculty Affairs	1

Abbreviations: DEI, diversity, equity, and inclusion; JEDI, justice, equity, diversity, and inclusion.

Experience and funded support

On average, respondents had their DEI title for 2 years (range 0–7 years) and had 7 years (range 0–30 years) of experience performing DEI work. When sorting respondents into “vice‐chair title,” “other title,” and “no title,” there was a trend toward more years of experience for vice chairs (medians 8.0 years vs. 4.5 years vs. 3.0 years, respectively; Kruskal–Wallis ANOVA p = 0.298).

Financial support was measured by those receiving funded full‐time effort (FTE) or administrative differentials (additional salary support). Most DEI leaders (56.8%) do not receive any financial support for their DEI roles. Most support came in the form of FTE (range 5%–30%), while others received administrative differentials (13.6%). The various combinations of support are shown in Table 3.

TABLE 3.

Support for DEI leadership positions.

Effort support	n (%)
Percentage FTE only	13 (29.50%)
Administrative differential only	4 (9.10%)
Both percentage FTE and administrative differential	2 (4.50%)
No effort support	25 (56.80%)

Abbreviation: FTE, full‐time equivalent.

Respondents reported spending a median of 10% of their time (IQR 5%–15%; n = 37) on activities specific to their DEI leadership role. Those with funding support spent a median of 15% (IQR 8%–20%; n = 17) of their time performing DEI activities, compared to a median of 10% (IQR 5%–10%; n = 20) for those without any funding support.

In addition to the DEI department leadership position, 95% of respondents had other leadership roles at either the institutional or the departmental level. The most common leadership role was in education (44%). Other leadership roles included administration or operations (17%), other institutional roles (32%), research (24%), other departmental leadership roles (22%), and other leadership not otherwise specified (15%).

Most (81%) did not receive any formal leadership training for their role. Those who did participated in a variety of formal training programs including the SAEM's Chair Development Program, the AAMC's Healthcare Executive Diversity and Inclusion Certificate Program, and a Health Equity Fellowship. Most DEI leaders were not tenure track (72.2%) and were most commonly at the level of assistant professor (47.2%) followed by associate professor (33.3%), full professor (16.7%), and instructor (2.8%).

Leadership positioning

DEI leaders most commonly (78.0%) reported to the chair. Other reporting structures included to a vice chair or residency program director. DEI leaders are commonly expected to chair their department DEI committee meetings and frequently attend an institution‐wide meeting for department DEI leaders. There were no direct reports to the DEI leader aside from DEI committee members. Many (52.6%) DEI leaders were part of the department's executive committee. Few (19.4%) DEI leaders reported having defined metrics of success.

Many DEI leaders were involved in recruitment and hiring practices. A majority were involved in faculty (61.0%) and house officer recruitment (58.5%). Some (43.9%) were involved in medical student recruitment. Smaller proportions were involved in the recruitment of advanced practice providers (9.8%), clinical staff (7.3%), and nonclinical staff (12.2%).

DEI leaders’ 5‐year plan

DEI leaders had diverse plans for the next 5 years. Out of 41 respondents, 51.2% planned to remain in their current title and role and 34.1% planned to be promoted to a higher DEI title within their department including through the creation of new titles (e.g., Vice Chair of DEI, if one did not exist). Leaders also aspire to obtain a role in medical school leadership (14.6%), hospital administration (17.1%), or become department chair (17.1%). A total of 31.7% of respondents said they plan to retire, reduce hours, leave academia but remain clinically active, or leave medicine.

Open‐ended responses

DEI leaders were asked several open‐ended questions about how they support the department's DEI mission and their goals and priorities and to provide advice to other DEI leaders and department chairs. A summary of key findings are provided in Table 4.

TABLE 4.

Open‐ended responses from DEI leaders about setting priorities, lessons learned, and advice for department chairs and future DEI leaders.

Describe how you support the DEI mission in your department.

Mentoring and supporting diverse trainees Education material including residency curriculum, journal club, and book club Consultative services for various divisions and domains in the department Assist and advise with recruitment and retention efforts Identify and track metrics for success Advise and advocate for equitable practices and policies Address DEI concerns/complaints Engage with other departments and the community

As department lead for DEI, what are your top 3 priorities for the department?

Recruit a diverse workforce Foster an inclusive and respective environment Participate in community engagement initiatives Increase retention and promotion of those URiM Provide education about DEI topics including health disparities, health equity, biases, and systemic racism Develop a nominating committee for DEI awards Identify and address disparities in care Conduct DEI needs assessment Improve transparency in hiring, salary, and promotion Empower everyone to take an active role in DEI efforts Create DEI departmental leadership positions

As department lead for DEI, what are your top three goals for yourself while in this position?

Get proper support: leadership, financial, and administrative Educate and bring awareness about DEI Perform and support scholarly research on DEI Provide opportunities for and support those who identify as URiM Evaluate and improve departmental climate Leadership development Political advocacy for vulnerable patient populations Decrease health care disparities Create and support pathway programming Not burn out Handoff position to someone else Support medical student/undergraduate medical education and residency/graduate medical education programming

What advice would you offer your chair to ensure the success of the role of DEI department lead in your department?

Provide funding for initiatives Provide protected time to do the work Garner buy‐in by entire department Provide dedicated administrative support Set priorities and clear metrics to evaluate success of interventions· Facilitate transparent DEI considerations across the department including promotions, hiring, and education Ensure consistent messaging and participation across department leaders Provide DEI leaders mentorship and leadership development Establish systems for accountability for all faculty and staff (e.g., tie incentives to DEI metrics) Titled leadership position, e.g., vice chair position Provide public condemnation of acts of bias, microaggressions, misconduct, and racism Support DEI research Implement recommendations from DEI leaders

What advice or lessons learned would you provide prospective candidates for a position as DEI department lead to ensure early success?

Ensure position has time, title, funding, and administrative support that has parity with non‐DEI roles Ensure chair and department buy‐in is present Set goals and clear metrics Build collaborative relationships within and across departments Ensure self‐care and set boundaries Have a passion for the work Slow and steady progress is still progress, be patient Advocate for a platform to promote DEI priorities such as at faculty meetings, townhalls, and grand rounds Track your productivity and department impact Be inclusive across dimensions of diversity Advocate for importance of DEI work Engage in professional development opportunities Get a coach Expect that the work will be more than the funded effort provided

Abbreviations: DEI, diversity, equity, and inclusion; URiM, underrepresented in medicine.

DISCUSSION

This study is the first, to our knowledge, to highlight the emergence of DEI leaders in academic EM and further characterize their leadership positions. We found that most responding academic emergency departments (EDs) have an identified DEI leader. The emergence of leaders in DEI who are charged with elevating the DEI mission of their department is partly a response to the call by the AAMC to diversify the workforce to meet the changing demographics of the U.S. population. ² This also reflects the call from SAEM and other EM specialty–specific leadership societies in their collective pledge to promote diversity, condemn racism, and strive for equitable care. ²⁰ In a recent study interviewing patients in the ED, patients viewed DEI work positively. ²¹ As academic EM DEI leaders emerge, we sought to understand the characteristics of these leaders—how they got to their position, what are their qualifications, what training they received, and what resources are in place to support their position and their DEI missions.

Our study found that most EM DEI leaders identify as non‐White, women, and/or a sexual minority. This supports the authors’ anecdotal observation that DEI leaders came to their position at least partially based on lived experience as historically marginalized individuals, personal interest, and/or passion to serve and care for vulnerable populations. DEI leaders have been engaged in this work for many years; however, many do not have a titled position and most do not have protected or funded effort. The nascency of their position likely contributed to the fact that the majority have no job description. We found that few DEI leaders received formal training for their positions and are of junior academic rank at the level of assistant professor. We believe that these findings suggest that the majority of DEI work continues to be done by minoritized individuals without the necessary training, support, or compensation, which can perpetuate the minority tax. In line with previously published perspectives, we believe these positions must be adequately supported by both the institution and the department. ²²

In academic pediatric medicine, similar challenges with the minority tax were quantified by Raphael et al. ²³ in an exploratory assessment among faculty where they demonstrated that much of the DEI work in pediatric academic settings is done by a small number of individuals, predominantly Black faculty and with limited institutional support or recognition. They recommended that future efforts should focus on expanding participation among all groups to rectify these inequities and increase the institutional alignment to accelerate the impact of initiatives. Our findings showed similar challenges and opportunities for the specialty of EM.

The academic rank of assistant professor for most EM DEI leaders may reflect potential barriers to promotion. Historically, merits for promotion to associate and full professor were focused on research funding and publications. Newer promotion pathways have recently been introduced with a broadened interpretation of scholarly productivity. Considering our findings, we support including DEI and health equity initiatives such as underrepresented in medicine coaching and mentoring, DEI curriculum development, pathway programming, health equity quality improvement initiatives, and department DEI leadership positions as meaningful contributions to promotion packages.

Within EM, prior research on education leadership positions revealed both similarities and differences to our study on DEI leadership positions. Papanagnou et al. ⁸ performed a workforce assessment during the development of the vice chair of education role. Similar to our study, they found that the role was not well defined, and leaders had multiple administrative departmental and institutional duties that created competing priorities. Notably, the vice chairs of education were mostly male (74.4%), White (89.3%), or associate or full professor (93.6%) and had protected time (77.8%). This starkly contrasts our study in which DEI leaders were mostly female, non‐White, assistant professors, and often did not have protected time—potentially exacting a minority tax and creating a unique challenge for DEI leaders and their academic success. Relative to the active EM workforce, EM DEI leaders are disproportionately from Asian, Black or African American, Hispanic, and multiple racial and ethnic backgrounds. ²⁴ Our finding follows a similar trend that has been reported for DEI leadership positions in radiation oncology departments. ²⁵

While our study is the first to attempt to characterize the role of DEI leaders in EM, guidelines for DEI leadership roles in academic departments such as neurology and psychiatry have been previously published. These studies highlight the importance of identifying a title for the DEI leader, ensuring that the DEI leader collaborates closely with departmental leadership, the department providing financial and administrative support, and promoting DEI leaders’ career development. ⁵ , ⁶ Our study revealed that it was rare for these best practices to be implemented in academic EM departments.

Experience from institutional level DEI leadership positions and support from the AAMC can provide insights and opportunities for DEI leadership positions in academic departments. The AAMC has published guidelines for the role of the chief diversity officer in academic medicine, which reflect many similar needs. According to the AAMC, chief diversity officers require clear job descriptions, adequate resources, institutional alignment, and appropriate positioning within the organizational leadership. ⁴ Like all effective academic leaders, EM DEI leaders should have institutional perspective and departmental knowledge to secure resources from their departments. EM DEI leaders need to be able to leverage their positions, work closely with influential leaders, and inspire others to meet the needs of their programming. Because we found that most DEI leaders in EM are at the rank of assistant professor, without funded effort and without formal DEI leadership training, we recommend that EM departments invest in mentoring and developing these leadership skills, which can be done through individualized mentorship or external training programs. One such program, the AAMC Healthcare Executive and Diversity Inclusion Certificate Program (HEDIC), was established in 2013 to develop the next generation of chief diversity officers. ²⁶ HEDIC facilitates networking among peers, guides the development of metrics for success, and teaches the fundamentals of strategic planning. Certificate training programs, in conjunction with close department mentorship, can help ensure the success of DEI leaders.

LIMITATIONS

Although we were able to identify many leaders in academic EM, our response rate may limit the general applicability of the results. Intrinsic to surveys are selection bias and self‐reported outcomes. Our study only surveyed DEI leaders and did not survey other key members within the department leadership infrastructure including department chairs. Our questions were largely quantitative and observational, limiting our ability to understand the root cause of the differences identified. Not all potentially marginalized identities and dimensions of diversity were queried such as religion and disability status.

CONCLUSIONS

Diversity, equity, and inclusion leadership roles in academic emergency medicine are becoming common and have a key role in advancing the department's and institution's diversity, equity, and inclusion efforts. Diversity, equity, and inclusion leaders should be involved their department's strategic planning. ²⁷ , ²⁸ There is variation in title and support for diversity, equity, and inclusion leaders, and clear job descriptions and training are lacking. We recommend that the role should be expanded and developed to attract the participation of all groups to truly demonstrate diversity, equity, and inclusion and alleviate the minority tax on those already minoritized in medicine and society. Our study is the first to describe emergency medicine diversity, equity, and inclusion leaders and reinforces the need to position them appropriately to effectively impact department practices and policies.

AUTHOR CONTRIBUTIONS

Ryan E. Tsuchida and Marcia A. Perry contributed to study concept and design, acquisition of data, analysis and interpretation of the data, drafting of the manuscript, critical revision of the manuscript for important intellectual content, and statistical expertise. Neema Mbele and Zoey Chopra contributed to acquisition of data and critical revision of the manuscript for important intellectual content. Joel Moll, John C. Burkhardt, and Daniel J. Hekman contributed to analysis and interpretation of the data and critical revision of the manuscript for important intellectual content.

FUNDING INFORMATION

ZC was supported in part by an NIA training grant to the Population Studies Center at the University of Michigan (T32AG000221).

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Data S1:

Tsuchida RE, Mbele N, Chopra Z, et al. Identifying the prevalence and characteristics of diversity, equity, and inclusion leaders in academic emergency medicine. AEM Educ Train. 2024;8:e10965. doi: 10.1002/aet2.10965