Building Inclusive Work Environments

In 2017, diversity in United States medical schools was promising as more women enrolled than men.¹  On closer inspection however, women in medicine appear to be struggling with gender bias and sexual harassment, are paid less than their male colleagues, lack mentorship, and often lag in career advancement.^2–8  The vast gender equity chasm and accompanying disparities are magnified for women who are Black, Indigenous, and/or people of color, women with disabilities, and women who identify as lesbian, gay, bisexual, transgender, or queer.⁹  Although an improvement in the number of women in medicine indicates progress, a collective sense of belonging in an equitable environment milieu is the key indicator of inclusivity.

There are myriad benefits to cultivating an inclusive environment. In a qualitative analysis within health care organizations, researchers found a negative correlation between lack of inclusive culture and wellness and job performance.¹⁰  One tool to measure diversity and inclusion in academic medicine, the Diversity Engagement Survey, considers diversity an institutional driver of operational excellence. This tool defines inclusion as “a set of social processes that influence an individual’s access to information, sense of belonging and job security, as well as social support received from others.”¹¹  Furthermore, an organization that fosters diversity, equity, and inclusion will enhance retention of a diverse workforce with limitless talent, and ultimately optimize patient care and satisfaction.¹⁰ 

As opposed to focusing solely on individuals, it is imperative to build inclusive environments with evidence-based processes that focus on systems and environments. This process must include advocacy and adoption of a trauma-informed lens, analyses of what drives oppressive policies, and movement from abstract guidance to concrete, specific guidelines which include indicators of success. Carefully reviewing the factors that lead to women either not choosing a career in medicine or leaving after medical training (eg, workplace hostility, motherhood penalty, harassment) is imperative.⁹  To build and sustain inclusive environments, attention must be focused on leadership, policy, and accountability.

Equity-focused leadership is built on intention, action, and accountability. Such leadership operates with a sense of urgency, recognizing that people are dying or are being harmed because our systems and decisions do not value nor affirm all aspects of humanity equally.¹²  Yet this work is difficult, and leadership in equity work is a particularly challenging task. There are no easy answers, no easy methods to convey to someone who has not had the experience of being marginalized of the urgency of this work. The status quo is deeply inequitable but has been normalized by dominant narratives and accepted by many as the way society has to be.¹³ 

It is important to first acknowledge that diversity and inclusion, by themselves, are not enough. Diversity and inclusion without power does not lead us to equity. Power to enact change acknowledges that (1) leadership is thoughtful about decisions that advance equity and include the voices of those most impacted by marginalization, (2) leaders are ready to fully resource the work to ensure that it is done without continuing to overburden those who are already having to do this work, and (3) leaders are equipped with meaningful and equitable processes and opportunities to transform dominant institutional culture.

True leadership requires intention and a commitment to building an institutional culture that recognizes that we all have the capacity to lead; the capacity for leadership is not concentrated in only the higher echelons of an organization. Equity-focused leadership requires action and not just words, and the deliberate intention to achieve outcomes that at first may seem improbable: large-scale improvements in health outcomes, elimination of inequities, and systems that create no further harm.

Accountability is essential to doing this work. As a leader, one must clearly be accountable to their organization but also to themselves, finding ways and space to reflect, grow, and listen with humility. For some, this is a courageous act. But not everyone comes to this space through courage. For some, this is not so much about courage but obligation: an obligation built on the work of other Black, Indigenous, and/or people of color individuals who came before: shoulders that we stand on today, people who broke down barriers, opened doors, were enslaved, were disposed of their land, were even killed for their activism. For some, this is a lived obligation to keep that work going and honor the past, and also work for the sake of new generations.

In his groundbreaking book, “How to Be an Antiracist,” Ibram X. Kendi outlines a framework for eliminating racial inequity in organizations. He starts with “Admit racial inequity is a problem of bad policy, not bad people.” Kendi’s construct further underscores the need to recognize which racist policies are causing racial inequity, and then generate antiracist policies that will eliminate these inequities using systems of power that can help institute policies.¹⁴  This very paradigm can be applied to generating policies of inclusion, by recognizing that exclusion is more a product of systems and policies as opposed to individual people, and by dismantling policies of exclusion.

As an example of exclusionary policies, an unintended consequence of certain family leave policies is exclusion of diverse families. One respondent in a qualitative analysis around inclusive work environments in health care organizations stated, “Adoptive parents are not offered any kind of paid parental leave. This makes nontraditional families like mine feel devalued and excluded.”¹⁰  Recognizing that such a family leave policy is exclusionary, followed by an intentional review and rewriting of the policy through a collaborative task force of stakeholders, would undoubtedly help create a revised, inclusive policy and thus an environment of inclusion.

Women are underrepresented in leadership in academic medicine. Most medical school deans and department chairs are men.^15,16  Men serve as deans for 9 years compared with women, who serve for 6 years, on average. Among department chairs who served for 12 years or more, 7% were women and <10% were not Asian American or white.¹⁷  One way to address this may involve including term limits in academic medicine. Additionally, it is critical to ensure the search process in selecting leaders is not biased.¹⁷  Revision of policies around how individuals are selected for these esteemed positions and how long they serve can help bridge the gender equity gap. In fact, search committee training is a policy at several institutions.¹⁸  A collaborative approach that includes these programs will be helpful in instituting inclusive policies.

Women lag behind their male colleagues in promotion and tenure, particularly in advancement from associate professor to professor.²  Although gender bias and lack of mentorship are factors, pregnancy and maternity leave as well as elder or family care can derail a woman faculty member’s career. Policies such as a “stop-the-clock” option, allowing faculty to take a temporary pause from their tenure track under such circumstances, will keep women faculty from having to make the difficult choice between their families and their careers. In addition, paid care leave policies will keep more women, who more often bear the burden of sick child and elder care, in the workforce and on the promotion track. Clear communication of these policies to internal and external reviewers for promotion and tenure is imperative.¹⁹  Furthermore, instituting opt-out procedures for such benefits, meaning they are automatically applied unless faculty choose not to use them, can help minimize associated stigma.^20,21  Under Duke University’s “Professional and Personal Balance Policies” page, a statement reads “We tolerate no stigma for taking advantage of [the policies]; and our data show that both sexes do [take advantage of them].”²² 

Kendi adds that antiracist policies must be monitored closely to ensure they are reducing and eliminating racial inequity. He explained that if policies fail, do not blame the people; simply start over and generate new and more effective policies until they are successful. The same holds true for the process of implementing inclusive policies in general. It is vital to recognize the policies and systems of power at play that promote a culture of exclusion, and to remain focused and steadfast in the shared vision of inclusion and belonging.

Diversity, equity, and inclusion have become fashionable words in recent years, initiating trends that serve as a catalyst for many organizations to divert funding to support and enhance diversity and inclusion efforts. Despite these inroads, progress in these areas remains slow, even within the professional medical community.

According to a report published in 2019 by the management consulting firm Oliver Wyman, women account for only 13% of hospital CEOs and 16% of all medical school deans and medical department chairs in the United States.²³  Indicative of this report, the American Medical Association, founded in 1847, just recently promoted its first African American woman president in 2019: Patrice Harris, MD. The current President and CEO of Meharry Medical College (Nashville, TN) James E.K. Hildreth, MD, PhD, became the first African American to earn full professorship with a tenure in basic science at the Johns Hopkins School of Medicine in Baltimore in 2002: a full 109 years after Johns Hopkins School of Medicine opened its doors. Patricia Wilkerson-Uddyback, MD, Vice President of Detroit Medical Center's Academic and Community Affairs, became the first woman emergency department chief at Harper University hospital in 2010, 147 years after its founding. These are just a few examples that illustrate the need for systemic change; of how long it has taken to make progress, and what still needs to be done.

Diverse professional ethnic participation contributes to improved decision-making, increased productivity, and competitive advantage. According to a 2017 article in Forbes magazine detailing research performed by Cloverpop CEO, Erik Larson, inclusive teams made better business decisions 87% of the time; teams that followed an inclusive process made decisions twice as fast, and diverse teams conveyed 60% better results.²⁴ 

In seeking to close the leadership gaps in health care management, medical organizations should urgently advance diversity and inclusion, making this a priority with both ethical and business implications. A study performed in 2018 by Boston Consulting Group revealed that diverse management teams generated 19% increased business revenue because of innovation.²⁵  Diversity within the leadership team leads to a wider range of ideas which generates innovative approaches that yield more comprehensive, well-informed, and well-balanced solutions.

Twenty-first century leaders in health care organizations should value, support, and readily promote diversity and inclusion initiatives because they contribute to an improved workforce and improved services delivered to health care consumers. In a 2017 study published in JAMA, researchers concluded that “elderly hospitalized patients treated by female internists had lower mortality and readmissions rates compared with those cared for by male internists. These findings suggest that the differences in practice patterns between male and female physicians have important clinical implications for patient outcomes.”²⁶ 

In various aspects of patient care, from colonoscopies to surgeries to diabetes management, studies reveal that the patients of women doctors tend to experience better outcomes.²⁶  Women physician leaders with compelling outcomes are in an ideal position to influence members of the medical team to adopt better practices and optimize health care for their patients.

The need for a more diverse and inclusive medical environment is immediate, but unfortunately, advancement continues to lag. This lack of engagement sets the stage for introducing and advancing “consequential accountability.” Many medical organizations have created diverse and inclusive policies, but without substantial accountability, the policies do not carry the authority to foster meaningful engagement and inclusion. Medical organizations should not only develop robust, trauma-informed, and inclusive policies, but they should also:

1. track metrics related to diversity, equity, and inclusion;

2. perform regular assessments regarding employee satisfaction, employee engagement, and employee experiences in the environment related to the policies;

3. collect robust employee data on race, ethnicity, and other key characteristics and segment key assessment data;

4. routinely re-evaluate their organizational metrics; and most importantly,

5. link the achievement of the metrics to tangible consequences for those in leadership.

Implementing the above recommended policies should be inextricably tied to recruitment, performance evaluations, bonuses, promotions, academic appointments, leadership advancement, and commitments to funding. These strategies along with training strategies for leadership, board members and other key decision-makers can assist in increasing and sustaining diversity, equity, and inclusion practices in health care management, aligning diversity, equity, and inclusion with mission, vision and values of the organizations as well as making contributions to administrative efficiencies and more profitable bottom lines (Table 1).

“I am valued, and I truly belong” is the aspirational mantra of any member of an inclusive organization. Building a diverse, equitable, and inclusive work environment requires acknowledgment of the culture, policies, and procedures which are exclusionary and result in inequities. A deep commitment to dismantling racist and biased policies and procedures on behalf of all members of the organization, beginning with the leadership, coupled with organizational accountability through regular assessments and tracking of relevant metrics, are essential to building and sustaining an inclusive work environment. Women are finally joining the medical profession at the same rate as their male colleagues. It is imperative we sustain the momentum of this vital and talented part of the workforce for the benefit of our medical community, our patients, and society.