It’s Not You, It’s Us

In this issue of Pediatrics, Montez et al¹  found the trend in proportions of underrepresented in medicine (URiM) trainees was unchanged in pediatric residencies (16%) and decreased for pediatric subspecialty fellows from 2007 through 2019 (14.2% to 13.5%). Importantly, URiM representation among pediatric trainees was far lower than that of the US population.

As a community of pediatricians, we have long asserted the importance of a diverse pediatric workforce and have issued multiple calls to this end.^2–4  The thoughtful analysis of the data compiled by Montez et al¹  compels us to question why we have not achieved our goal. The authors highlight the challenges we face in URiM recruitment and retention across the spectrum of training. These challenges have previously been presented as a “leaky pipeline.” This metaphor has been challenged^5,6  because it can inadvertently place the responsibility for leaving science, technology, engineering, and mathematics fields on the departing individuals. However, we resurrect the metaphor here to draw attention not to the individuals who are “leaking” but rather to the pipeline itself, one that has corroded because of the toxic environment of academic medicine that exists today.

Analyzing the separate steps to establishing a career in medicine is key to understanding attrition for URiM students and trainees. Structural racism affects each of these steps, from primary and secondary school education to the clinical learning environment. Academic medicine is not immune to the impacts of structural racism.⁷  However, our attempts to increase diversity in the pediatric workforce have focused largely on the individual and not the environment. Pediatric mentoring programs like New Century Scholars,⁸  Frontiers in Science,⁹  and Advancing Inclusiveness in Medical Education Scholars¹⁰  have been successful in providing opportunities, mentorship, and additional skills to URiM pediatric trainees; however, we cannot continue to fortify our learners only to immerse them in an environment that does not support them.

URiM students,¹¹  trainees,¹²  and faculty^13–16  have described their experiences in academic medicine extensively. Their stories depict a learning and working environment that is rife with bias, discrimination, microaggressions, misalignment of values, invisibility, and depravation of opportunity. Structural racism in medical education is the driving force responsible for this toxic environment. The misguided belief that URiM students, trainees, and faculty should opt to remain in this environment facilitates our refusal to examine our role in their attrition. If we truly intend to diversify our workforce and ultimately provide care to our patients free from bias and racism, we must work actively to be antiracist.

As a community of pediatricians and pediatric educators, we must begin a thorough process of self-reflection and honest evaluation. We must use tools like the Association of American Medical Colleges Diversity Engagement Survey¹⁷  and the White Coats 4 Black Lives Racial Justice Report Card¹⁸  to critically assess the climate for our URiM learners and educators. We must collect data within our individual departments to assess equity in hiring, pay, promotion, and tenure. We must critically evaluate disparate outcomes for our URiM students, residents, and faculty and link them back to policies that may perpetuate these differences. Those same policies must be challenged and replaced if they result in inequitable grading, assessment, promotions, or retention. We must reimagine equity in pediatric academic medicine using innovative tools like liberatory design,¹⁹  which puts forward that systems affected by racism can be redesigned, that designing for equity requires meaningful participation of those impacted by inequity, and that equity-driven designs require equity-informed processes. We must engage different pedagogical frameworks in graduate medical education and continuing medical education, such as structural competency,²⁰  which emphasizes how societal structures contribute to disparate health outcomes. Critical consciousness²¹  is another important pedagogical framework, which allows the learner to acknowledge the social and political nature of health care, the influences of power and privilege in the delivery of care, and how we as health care providers can combat assumptions that foster oppression. We must train our learners and educators to identify and interrupt microaggressions in the clinical learning environment and we must empower them to report these events to department leadership. Finally, we must evaluate how our departments and hospitals engage with our community of Black and Brown patients and families. We must critically evaluate how we collaborate with community stakeholders, use quality metrics to assess health outcomes for distinct populations, and actively dismantle social determinants of health which negatively impact patients.

To recruit and retain URiM learners into pediatrics, we must offer them opportunities for skill-building and mentorship in an environment free from microaggressions, bias, and discrimination. These forces which communicate a sense of peril to trainees also create a hostile environment for faculty and patients. Improvement in workforce diversity will necessitate a comprehensive, active commitment to antiracism that is long overdue and will ultimately benefit us all.

URiM

underrepresented in medicine