The Importance of Diversity and Inclusion in the Healthcare Workforce

Abstract

Diversity and inclusion are terms that have been used widely in a variety of contexts, but these concepts have only been intertwined into the discussion in healthcare in the recent past. It is important to have a healthcare workforce which represents the tapestry of our communities as it relates to race/ethnicity, gender, sexual orientation, immigration status, physical disability status, and socioeconomic level to render the best possible care to our diverse patient populations. We explore efforts by the Liaison Committee on Medical Education (LCME), the Institute of Medicine (IOM), and other medical organizations to improve diversity and inclusion in medicine. Finally, we report on best practices, frameworks, and strategies which have been utilized to improve diversity and inclusion in healthcare.

In order to explain diversity and inclusion in healthcare and beyond, the popular colloquialism has been dispersed on social media outlets originally coined by diversity advocate, Verna Myers, “Diversity is being invited to the party; Inclusion is being asked to dance.” While many believe this to be a gross oversimplification of these issues, it does provide context regarding how we can began to understand and address these issues in healthcare. Throughout all facets of healthcare, race/ethnicity, gender, sexual orientation, immigration status, physical disability status, socioeconomic level plays a role in representation, acceptance, and progress both within and outside of the healthcare setting. We will evaluate the current status of diversity and inclusion in healthcare and note strategies to achieve success in this domain.

The Liaison Committee on Medical Education (LCME) is the US Department of Education body which accredits programs leading to the M.D. degree in the U.S. and Canada, and it is jointly sponsored by the Association of American Medical Colleges (AAMC) and the American Medical Association (AMA).¹ In 2009, they developed 2 diversity accreditation standards which mandated that allopathic medical schools engage in systematic efforts to attract and retain students from diverse backgrounds and develop programs to broaden diversity amongst qualified applicants.² In a recent publication to evaluate the impact of these LCME diversity standards, Boatwright and colleagues conducted an observational study to examine the change in US medical school matriculant sex, race, and ethnicity after their implementation.³ After implementation of the LCME diversity accreditation standards (2012–2017), there was an increase in female, black, and Hispanic matriculants in medical schools in the US. In 2017, 50.4% of matriculants identified as female, 7.3% as black, 8.9% as Hispanic, 24.6% as Asian, and 58.9% as white.³ While there is some progress, the current number of medical school matriculants does not mirror the population of black and Hispanic persons in the US which is 14.1%⁴ and 17%⁵, respectively.

Within medical specialties, problems with diversity training emerge. Let’s explore nuances regarding diversity in physician trainees from underrepresented minorities in medicine and the patients that they serve in several key specialties and subspecialties: internal medicine, pediatrics, and critical care. Cardinal and colleagues evaluated training of internal medicine residents with regard to the care of patients with limited English proficiency. They found that an effective training curriculum is necessary, but such a curriculum is not uniformly present.⁶ In an evaluation on standards in pediatrics, Mendoza and colleagues distributed an 8-question survey to 131 US pediatric chairs to assess plans for diversity, targeted groups, departmental diversity, diversity measures, perceived success in diversity, and presence and type of cultural competency training. Approximately 50% of the chairs responded and approximately 75% reported having a plan for diversity, which targeted racial, ethnic, gender, lesbian, gay, bisexual, and transgender, disabled, and social class groups. Despite these assertions, racial and ethnic diversity was limited among trainees, faculty, and leaders; there was limited information about promotion success for minority groups; and information was even more sparse for lesbian, gay, bisexual, and transgender trainees and faculty.⁷ Along similar lines, Lane-Fall and colleagues determined that the current critical care workforce in medicine has a low number of women and racial and ethnic minorities which has persisted for many years. They conclude that further research is needed to elucidate the reasons underlying persistent underrepresentation of racial and ethnic minorities in critical care fellowship programs.⁸

There is often malalignment with the perceptions and experiences of persons from racial and ethnic minority groups in academic medicine compared to majority groups with regard to their health system and its performance surrounding cultural competency. Aysola and colleagues surveyed ~3500 healthcare professionals to ascertain demographic characteristics, length of employment, position, and place of work and their reported perceptions of institutional culture. They found that minorities and women were less likely to rank their organization as culturally competent, and they concluded that organizational efforts to achieve cultural competency would benefit from measuring this factor to target their efforts.⁹

Just as medicine has sought to evaluate diversity, nursing has tackled the issue also. The Institute of Medicine released its landmark report, The Future of Nursing: Leading Change, Advancing Health, which called for more racial, ethnic, and gender diversity among nurses in order to improve quality of care and reduce health disparities.¹⁰ In 2015, Villaruel and colleagues evaluated the impact of the 2010 report and determined that there is progress, but there are also challenges that remain.¹¹ There has been an increase in racial and ethnic groups in nursing to 20%, but this is still short of the 37% of the US population that are considered to be racial and ethnic minorities. Unfortunately, there continues to be barriers to diversity in nursing education.

So, what are systematic strategies that have been developed to address diversity and inclusion in academic medicine? What is the dialogue surrounding creating change in diversity and inclusion in medicine? Smith noted that we must build institutional capacity for diversity and inclusion in academic medicine to achieve sustained change by including a “deeper engagement of mission, one that considers diversity as core to excellence” which aligns to key institutional elements and identifies diverse talent for leadership at all levels.¹² Since diversity and inclusion are such large tasks to evaluate comprehensively, there have been different strategies proposed to address disparities in different groups. Gillespie and colleagues developed 10 best practices to achieve gender parity in global health organizations which include the following: (1) make diversity and inclusion (D&I) an essential element of global strategy, (2) tailor global D&I to fit local needs, (3) embed D&I throughout organizations, (4) multiply D&I impact via external partnerships, (5) maximize the role of employee resource groups, (6) maximize the role of diversity councils, (7) leverage D&I for innovation, (8) leverage D&I for business development, (9) engage CEO, and (10) make sharing of D&I best practices a meta best practice.¹³ As we evaluate the lesbian, gay, bisexual, and transgender community in medicine, Eckstrand and colleagues developed a framework with elements and processes for successful lesbian, gay, bisexual, and transgender organizational change. Their key elements for success are: organizational champions, organizational priority, depth of mission, commitment to continuous learning, commitment to diversity and inclusion, and organizational resources, and their key processes for success are: change management, information exchange, action research, relationship building, values in action, and leveraging resources.¹⁴ Regardless of which framework or strategy is utilized to improve diversity and inclusion in healthcare, Gill and colleagues note: “there is a growing understanding of the relationship between the providers’ work environments, patient outcomes, and organizational performance”.¹⁵

Much of healthcare has jumped on the “diversity and inclusion bandwagon”, but is the change actually making a difference in the experience of health care workers and the increasingly diverse patient population to whom we render care? Many would argue that much needs to be done. It is not enough for organizations to just add a person to oversee diversity efforts- the organization as a whole must value diversity and inclusion as central to their mission and consistently assess these diverse groups of their perception of progress. Perhaps, Dr. Martin Luther King, Jr. said it best when he stated: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” We have much to do to truly ensure that diversity and inclusion in healthcare is the norm and not the exception.

Here are some tangible strategies to ensure diversity and inclusion in your organization: 1) Ensure that diversity and inclusion is ingrained within the culture by making it integral to the mission and outputs within the organization, 2) Integrate stakeholders from all levels of the organization and ensure that all groups are included in discussions to enact and maintain diversity and inclusion efforts, 3) Share successes and failures with similar organizations as it is this discourse that will allow the organization to reflect on strengths and weaknesses in previous diversity and inclusion strategies, and 4) Start young- engage with local communities and schools to ensure that persons from underrepresented groups get early exposure to fields in medicine. While these are only a few steps, any step forward is a step in the right direction to improve diversity and inclusion in medicine.