Persistent Bias: A Threat to Diversity among Health Care Leaders

What Is the New Insight?

Racial/ethnic disparities in primary and nephrology specialty care contribute to marked disparities in CKD in the United States. Eliminating these disparities and thereby improving United States health and its delivery requires ongoing, sustained efforts from leadership of the broad spectrum of health care organizations, including academic centers and those whose primary focus is clinical care delivery. Racial/ethnic diversity among health care leaders galvanizes leadership toward eliminating these disparities, but the current level of diversity in leadership falls short of that necessary critical mass. This lack of diversity persists despite decades of efforts to correct it and obliges the health care community to consider remaining challenges hindering the necessary attainment of this goal. A seldom-acknowledged challenge is the persistence of bias in the United States health care system, including in its organizations (1).

What Is the Challenge?

Although gains in medical school matriculates and graduates for underrepresented minorities, particularly African Americans, on whom this discussion will focus, have fallen short of goals, the lack of racial/ethnic diversity in the United States physician workforce and medical school faculties is even starker. African Americans comprise 13% of the United States population, yet comprise 6% of medical school matriculates and graduates, 4% of physicians, and 4% of medical school faculties (2). Leadership of United States academic medical institutions also reflect these low proportions. African Americans hold 3% of department chairs of academic institutions, including 5% of chairs of internal medicine (3), and comprise <3% of nephrology division chiefs (T. Ibrahim, American Society of Nephrology, unpublished observations). These data show that efforts to increase the proportion of African Americans in health care leadership exclusively through augmenting their proportion of medical school graduates will not succeed in the foreseeable future. Successful efforts to increase this leadership diversity will involve developing and promoting individuals into leadership from the current physician workforce.

Compounding the challenge of increasing the proportion of African Americans in health care leadership are the experiences of those already in such positions. African American physician leaders at academic medical centers report experiencing isolation, disrespect, overt and covert bias, differential expectations on the basis of their ethnicity, devaluing of research regarding community health and health care disparities, and the extra responsibility of leading diversity efforts for which they receive little or no credit toward advancement (4). These bias-based experiences impede African American leaders in their efforts to achieve excellence according to standard leadership expectations. Disturbingly, many of these leaders feel that articulating their concerns will at best, limit their advancement, and at worst, lead to termination (4). Accordingly, the current environment of health care organizations consciously and/or unconsciously discourages African Americans from pursuing leadership.

Much of the bias experienced by African Americans in United States health care organizations goes beyond the interpersonal, with which most are familiar, to include that which is structural (1), i.e., interconnected institutions whose linkages to racialized policies and practices are historically rooted and continue to be culturally and/or politically reinforced. One example is the development of candidate pools from which to choose organizational leaders exclusively through use of referrals from existing physician employees and/or existing organizational leaders. In not too distant United States history, African Americans were specifically excluded from health care organizations and, if hired, were excluded from leadership. This very recent history has limited the exposure of African Americans to settings in which their leadership potential can be recognized. Consequently, focusing the leadership search process on referrals from within the organization inadvertently puts African American candidates at a distinct disadvantage and perpetuates a narrative that reinforces the status quo.

Why Should We Act?

An important consideration for the United States health care community when embarking on efforts to increase the diversity of its leadership is the reason(s) for doing so. There is certainly a moral argument to have the physician workforce and its leadership reflect the demographic composition of the population we serve. This argument is particularly pertinent to the nephrology community given the overrepresentation of ethnic minorities among those with CKD, and includes the fact that federal resources contributed by all demographic groups substantially support physician education. Nevertheless, the more compelling argument for increasing diversity in United States health care leadership relates to how success in these efforts enhances the effectiveness of our health care system to accomplish its mission of improving health (5), just as a diverse leadership enhances effectiveness of nonhealth care organizations (6). A diverse physician workforce and the leadership thereof enhances care, education of trainees, and drives research and innovation toward improving our understanding of health and how best to maximize it (5). Eliminating health care disparities should be a primary focus of United States health care (7) and, given the marked CKD disparities, the nephrology community has the opportunity to take the lead in these efforts. Increasing health care leadership diversity is an effective strategy by which to eliminate these disparities (5), and so should be among the primary motivations for our leadership diversity efforts.

What to Do?

When health care organizations embark on strategies to increase diversity of their leadership, they must begin by recognizing the challenges they face, among them the inherit bias in United States health care and its organizations. This includes assuming that such bias exists in their own organizations. Consequently, the strategies and tactics used must be designed in an effort to overcome assumed bias, recognizing that conducting “business as usual” allows structural bias to covertly but effectively continue to not only thwart efforts to increase diversity among health care leaders, but also to limit the development and preparation of underrepresented minorities in the leadership pipeline. Some strategies that have been recommended or shown to be effective in organizations within and outside of health care include:

• Have all search committees undergo implicit bias training, especially those hiring leaders. We all have biases and although we are often unaware of them, they surreptitiously influence our thoughts and actions, to the detriment of those individuals or population groups against whom we have a bias. These biases held by leaders in particular can have dramatic untoward consequences to individuals, groups, and organizations. When we are made aware of our biases, we have the opportunity to act in a less discriminatory fashion (8).

• Focus on intervention, not just bias reduction. Once having recognized bias, leaders must not assume that what they witnessed is a one-time or limited event. Bias is often “woven into the fabric” of environments and so leaders must act to rid the environment of the consequences. Some organizations routinely provide training to their members to intervene when they see bias or harassment unfolding, in addition to training on how to talk to others about organizational diversity (7). These approaches could be effective in the health care setting, where group dynamics often dictate responses to bias or harassment. Implicit bias training should be routinely conducted and not only in response to an episode of bias. In the case of the latter, members may sense the issue was limited and now resolved, which can undermine recognition of the pervasiveness of bias. Additionally, negative consequences applied by leaders to persons perpetrating bias can change the culture and minimize consequences to targeted individuals.

• Hold leaders accountable for diversity efforts in their units and sponsorship of junior faculty/physicians (i.e., by making it a part of their performance review). Such efforts provide incentives for individual leaders to achieve leadership diversity in their units, and making these expectations public attaches value to diversity and fosters a culture of inclusiveness (5).

• Offer leadership internships targeting underrepresented minorities. As mentioned, African Americans and other underrepresented minorities historically have been excluded from leadership positions and so recent generations often have not had the experience of leadership, nor have they had other underrepresented minorities as role models. Such leadership training not only provides practical tools but also encourages participants to consider pursuing leadership when they previously might not have considered it (9).

• Collaborate with regional and national networks promoting professional success. Increasing diversity in health care leadership is a daunting task. Collaboration(s) with other organizations pursuing the same efforts facilitates sharing of best practices and synergism that allows each organization to achieve more success than if they continued to act in silos (10).

• Develop a more robust national database of health care leadership diversity. In preparing this article, we recognized the need for better data about health care leadership diversity, particularly for organizations focused primarily on clinical care delivery. Ongoing maintenance of such a database would facilitate the tracking of progress and increase awareness of attaining this goal.

Conclusions

Successfully attaining ethnic diversity of health care leadership accrues many benefits to United States health and health care, important among them being helping to eliminate health disparities and driving research and innovation. In embarking on these important efforts, health care organizations must recognize the challenges to achieving this goal, among them being persistent bias in the United States health care system and its organizations. Courageously addressing these challenges with specific interventions and collaborating with others doing the same will take us far in achieving this goal.

Disclosures

D.C.C. reports no conflicts. D.E.W. receives support for his salary as a consultant for Tricida, Inc., paid through his employing institution.