Increasing Diversity in Pediatric Hospital Medicine: An Enduring Priority for a Young Subspecialty

As children in America represent an increasingly racially and ethnically diverse population,¹  the field of pediatrics faces the challenge of optimizing their care. One response to promote quality outcomes is to increase diversity in the health care workforce. In patient care, studies have revealed that diverse medical teams give more accurate diagnoses, have higher patient satisfaction, and foster greater patient adherence.²  Overall, a more diverse workforce can enhance cultural humility, improve access to care for underserved populations, and promote cultural competency in research.³  In alignment with the importance of diversity in driving improved outcomes, there is an increased national focus on improving diversity among health care providers.

In this issue of Hospital Pediatrics, the American Academy of Pediatrics Section on Hospital Medicine (SOHM) Diversity and Inclusion (D&I) Task Force, led by Dixon et al,⁴  describes the recent state of diversity within Pediatric Hospital Medicine (PHM) fellowships. A survey was sent to PHM fellowship program directors in 2018 to assess sex, race and ethnicity, sexual identity and orientation, disability status, and socioeconomic disadvantage among PHM fellows, program directors, and faculty. A key finding in this study was the lack of racial and ethnic diversity in PHM fellowships, with no Black and only 2 Hispanic or Latino leaders out of 57 program directors from 35 programs in 2018 (4%). This was reflective of the lack of racial and ethnic diversity among PHM faculty with only 50 Black, American Indian, or Hispanic and/or Latino individuals out of 734 faculty (7%). Most concerning was the lack of diversity in the pipeline, with only 6 total fellows from Black, American Indian, or Hispanic and Latino backgrounds (10%). Meanwhile, it is estimated that 40% of US children were from these underrepresented backgrounds in 2018.⁵  Although in their study, Dixon et al were unable to assess trends over time or provide comparisons of PHM to other subspecialities, they provided novel data on diversity within academic PHM programs.

A commitment to racial and ethnic diversity in health care needs to be an enduring priority in medicine.⁶  Looking upstream in the pipeline, the percentage of underrepresented in medicine (URM) students matriculating into medical schools nationally has remained relatively flat over >3 decades.⁶  In 2018, the year the survey was conducted, <15% of applicants to US medical schools were from URM backgrounds.⁷  Contributing factors for low URM numbers in medical school may include inequities in academic support, lack of exposure to the medical field, and biased admissions practices.⁶  Programs exist to reach URMs in the earliest part of the pipeline from Head Start preschool programs through college.⁶  When considering the URMs who do matriculate into medical school, there are additional barriers to entering a career in academic pediatrics. Previous qualitative work by Dixon et al revealed that educational debt and lack of knowledge about the field were barriers, whereas factors such as mentorship, a desire to serve as a role model to their patients, exposure to URM academic pediatricians, and family support positively influenced students’ pursuit of academic pediatrics.⁸  Although lack of diversity among physicians represents a complex and large scale problem, evidence exists to guide future directions in addressing this challenge. As a young subspeciality, PHM is now in the position to prioritize this issue. One framework to approach diversity includes building a pipeline, seeking out candidates, implementing inclusive (fair and unbiased) recruitment practices, and investing in trainee success.⁹  Rooted in this framework, below we highlight strategies to promote diversity in PHM physicians with a focus on the PHM medical student and resident pipeline, inclusive fellowship recruitment practices, fellow and faculty retention, and future research priorities.

To promote diversity in PHM, the URM pipeline is an important focus. Upstream in the pipeline, there is an opportunity to invest in recruiting talented URM medical students and residents into the field of PHM. Programs such as the National Institutes of Health Promoting Research Opportunities Fully-Prospective Academics Transforming Health (PROF-PATH) and the Academic Pediatric Association New Century Scholars and Research in Academic Pediatrics Initiative on Diversity (RAPID) are examples of professional development opportunities for URM residents in academic pediatrics.⁸  Given the importance of exposure, PHM could also implement initiatives to introduce more medical students and residents to PHM, starting with national PHM conference programming geared to students and residents and increased PHM conference scholarships for URMs. Most critical in developing the pipeline is mentorship. In a qualitative survey of academic faculty, Dixon et al found that early mentorship was a factor that positively influenced URM faculty in medical school.¹⁰  Notably, mentorship did not need to be from faculty who were URM.¹⁰  There are not currently enough URM faculty to take on the full responsibility of mentoring all URM trainees, because URM faculty are often already overloaded with the “diversity tax,” which refers to the burden of extra responsibilities in the name of diversity borne by URM faculty, including mentorship.¹¹  Larger scale mentorship of URM medical students and residents can only be accomplished with the support of the greater academic pediatric community.

Inclusive recruitment practices are also essential to increase diversity in PHM fellowships nationally. In 2019, the Accreditation Council for Graduate Medical Education asked all accredited training programs to ensure policies and procedures were in place to recruit and retain URM trainees, faculty, and staff.¹²  One evidence-based example is an Adult Cardiology fellowship that created a quality improvement (QI) project to ensure adequate matriculation of women and URMs into their fellowship program.¹³  They instituted a D&I taskforce, which reviewed their past recruitment practices to identify signs of implicit bias or racism. The program also surveyed talented women and URMs who were in a position to match but joined other programs. Next, the task force created a strength, weakness, opportunity, and threat analysis focused on increasing diversity and implemented a targeted initiative with a blinded primary application review and a secondary review processes to ensure that no qualified URM applicants were excluded. The recruitment experience also included preinterview events and an emphasis on opportunities for mentorship. This QI project resulted in a significant increase in matriculation of women and URMs without significant changes in the time that fellows across the program took to achieve Accreditation Council for Graduate Medical Education milestone competency levels as a balancing measure. Engaged stakeholders such as the national Council of PHM Fellowship Directors and the SOHM D&I taskforce could consider creating evidence-based, best practice recommendations for an inclusive fellowship recruitment process. Additionally, the annual fellowship council survey of matched and unmatched PHM fellowship applicants could analyze effective URM recruitment strategies. Ultimately, PHM has the infrastructure in place to optimize URM recruitment practices.

PHM also has an opportunity to invest in URM fellow and faculty retention locally and nationally, including leadership development for URMs. By developing the current URM fellows and faculty, PHM may be able to sustain the URM pipeline and the growth of future leaders. A recent systematic review provided strong evidence that faculty development and mentoring programs increase retention, productivity, and promotion of URMs as medical faculty.¹⁴  Similarly, beyond mentorship, PHM may promote sponsorship to make an accelerated impact on developing URM leaders. Sponsorship is the active support by someone who has significant influence on decision-making, processes, or structures in an organization and who is advocating, protecting, and fighting for the career advancement of an individual.¹⁵  In academic pediatrics, sponsorship may include recommendations of talented URMs for leadership positions, nominations for awards, or endorsements for national speaking opportunities.¹⁵  Another tenet to support diversity efforts and URM retention is ensuring that all faculty engaging in this work (including mentorship and sponsorship) are given adequate time and acknowledgment for their diversity efforts in evaluations and promotion.¹¹  Additionally, PHM may consider developing national leadership offerings to engage URMs in faculty development. AAP SOHM has created outstanding national training opportunities such as the Advancing Pediatric Educator Excellence (APEX) program.¹⁶  There would be great value in a similar national program for URM leadership. By investing in retaining and developing URM faculty, the PHM community can actively ensure that this group is not overlooked for national opportunities, promote sponsorship, enhance further diversity strategies, and demonstrate a commitment to diversity to the next generation of pediatric hospitalists.

There is also importance in supporting research efforts in diversity. PHM has established the ability to engage in high-quality research across a variety of areas. Diversity research can traverse multiple domains including medical education,¹⁷  QI,¹³  qualitative,¹⁰  and advocacy research.¹⁸  By continuing to prioritize evidence-based interventions, PHM may be able to more effectively allocate efforts and resources to maximize outcomes. There are large gaps in knowledge and several future directions for diversity research. For example, much of the current diversity literature has focused on sex, race, ethnicity, and socioeconomic background. There is a lack of guidance around best practices for Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual diversity development, engagement, and retention. Additionally, less is known about PHM diversity in community settings and among advanced level practitioners in the field. PHM can drive research diversity initiatives across groups and domains.

As a young subspeciality, committed to quality and innovation, PHM has an opportunity to make diversity an enduring priority. Diversity is key to improving health care outcomes and is complementary to equity and inclusion efforts. As summarized by the Association of American Medical Colleges, diversity is the core of an institution, and it is essential to recognize that diverse people, perspectives, and backgrounds drive excellence.¹⁹