Faculty Perspectives on Diversity, Equity, and Inclusion: Building a Foundation for Pediatrics Free

Pediatric departments and children’s hospitals (hereafter pediatric academic settings) increasingly prioritize diversity, equity, and inclusion (DEI) as transformational principles to address structural racism and ameliorate health inequities.^1–7  The impetus to focus on DEI has been supported by several trends.^8–10  First, epidemiologic data demonstrate the demographic landscape of the United States is increasingly racially and ethnically diverse, whereas medical workforce diversity fails to mirror population trends.^10–12  The US population is undergoing racial and ethnic shifts, led by rises in Hispanic or Latino and multiracial populations. Children are at the forefront of such changes, with only half of the population under age 18 years identified as non-Hispanic white in 2020.¹³  The increasing diversity of US children is contrasted by stagnation in the physician workforce. Evidence demonstrates that diversity in medicine improves clinical decision making, increases patient satisfaction, enhances learner satisfaction, and fosters diverse research questions.¹⁴ 

Despite this evidence, little progress has been made in diversifying the medical workforce for individuals underrepresented in medicine (URiM), defined by the Association of American Medical Colleges as “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.” Historically this definition has comprised those who self-identify as African American, Black, Hispanic or Latino, American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander.¹⁵  According to the Association of American Medical Colleges, 3.6% and 3.2% of medical school faculty identify as African American or Black and Hispanic or Latino, respectively.¹⁶  These proportions fall well below the representation of African American and Black (12.6%) and Hispanic and Latino (18.9%) individuals in the general US population.¹⁵  One study demonstrated that trends in pediatric URiM proportions were unchanged in residents and decreased for fellows between 2007 and 2019.¹⁷  Another study showed that although trends in the proportion of URiM pediatric faculty representation have improved at all academic ranks between 2000 and 2020, those gains were not observed for all subgroups.¹⁵  Decreases were observed for Black males and American Indian or Alaska Native males. The lack of diversity in the pediatric workforce has several potential root causes, including educational disparities during childhood, antiaffirmative action policies, racism in learning and clinical environments, educational debt as a factor in specialty choice, lack of pediatric mentors, and inadequate recruitment and retention.^17–19 

In addition to pediatric workforce diversity, limited progress has been made in ameliorating child health inequities.^20–23  Driven by multiple social and environmental factors, disparities persist along a spectrum of disease burden, access to care, and health care.^23,24  Additionally, structural racism has increasingly been acknowledged as a contributing factor throughout society^20,22  and specifically health care.^10,25–36  Consequently, professional organizations have advocated for increased engagement in DEI activities.^20,37  Concurrently, calls for DEI have been amplified by media attention to police brutality, immigration policies, and hate crimes. All these forces have contributed to an urgency to codify DEI in pediatric academic settings.

Although DEI has recently been promoted to influence policies and programs in health care organizations, such efforts have existed for decades. They were largely fragmented and executed by small groups of minoritized faculty and trainees with little recognition or resource allocation from departments in pediatric academic settings.¹⁹  The foci of efforts have varied but often included pipeline programs, recruitment and retention, and mentorship. As DEI has become more of a visible aspiration in pediatric academic settings, attention has been directed toward the creation of DEI leadership roles and activities.¹⁹  However, DEI activities in pediatric academic settings can have a wide spectrum of definitions and manifestations with variability in scope, authority, resources, and staffing. Guidance is gradually emerging from medical accreditation organizations, pediatric professional societies, and the American Board of Pediatrics.¹⁹ 

As pediatric academic settings implement DEI initiatives, knowledge gaps and uncertainty exist in key areas. First, there is a paucity of quantitative data on the types of DEI activities in which faculty participate (eg, committees, recruitment) and the time spent on them. Second, little is known regarding which faculty typically do this work and how it may be valued. Some have raised the concern that there may be a disproportionate responsibility for such efforts placed on URiM individuals. For many faculty, DEI represents a means toward long-term impact.³⁸  However, participation may not align with historical metrics of academic productivity.³⁹  Participation in DEI may result in the minority tax, defined as the burden of extra responsibility placed on URiM faculty to achieve DEI.^38,40–43  Although several published works have characterized the existence of the minority tax,^40,41  there has been minimal data to quantify its presence in academic pediatrics.

Given the increasing focus on DEI in pediatric academic pediatric settings and knowledge gaps regarding its current state, we sought to develop and pilot test an assessment tool to characterize faculty perspectives and activities regarding DEI, specifically those directed toward increasing URiM representation in the pediatric workforce. The objectives of this exploration among individuals who self-report participating in DEI were to (1) quantify the DEI activitiesof academic pediatric faculty, (2) describe faculty perspectives on how they value participating in DEI activities, and (3) determine perceived institutional (hospital, academic department, and medical school) support for faculty DEI activities. Such knowledge could provide meaningful data on the lived experiences of those doing this work and inform large-scale initiatives in pediatric academic settings.

In collaboration with the Association of Medical School Pediatric Department Chairs (AMSPDC), we conducted a cross-sectional assessment of a national sample of pediatric faculty to describe the current state of DEI participation in pediatric academic settings. Collaboration with AMSPDC ensured access to a large pool of potential subjects and diversity with respect to children’s hospital type, hospital size, racial and ethnic groups, subspecialty representation, and geography. Informed by a literature review, the research team developed a 21-item survey utilizing REDCap (Research Electronic Data Capture) to quantify faculty DEI activities, perceptions of participating in DEI activities, and perceived institutional (hospital, academic department or medical school) support for faculty DEI activities (see Appendix in Supplemental Information). All DEI activities assessed focused on those directed toward increasing the URiM pediatric workforce. After an iterative survey developmental process that included input by members of the AMSPDC DEI Committee and pilot testing for face validity, the survey was distributed via e-mail to all 123 active AMPSDC members (United States and Canada) in January 2021. The Department Chairs in turn were asked to distribute a survey cover letter and survey link to pediatric medical faculty at their individual institutions. To maximize participation, Chairs were sent 2 reminder emails to resend the survey, each 2 weeks apart for a total of 3 communications. The survey was closed March 3, 2021.

Participation was voluntary, and respondents had the ability to skip questions and/or discontinue the survey at any time. Respondents were first asked if they participated in any DEI activities. Those who responded “no” were opted out of completing the remaining 20 questions of the survey. To maintain anonymity, respondents were not asked to identify their institution.

To quantify DEI activities, respondents were asked at which institutional level they participated (division, department, hospital, medical school- checking all that apply) and how many hours per month they spent on specific DEI activities (eg, DEI committee, recruitment, pipeline programs). Questions assessing how respondents value their own participation in DEI activities focused on perceived importance, commitment, aspirations for a career in DEI, potential opportunity costs of participation, and feeling typecast (ie, colleagues do not appreciate other professional skills because DEI is all they see) or stigmatized (ie, devalued or negatively judged) by coworkers. Survey items also assessed perceived departmental support for DEI activities (eg, recognition, academic credit, assigned effort, specific compensation) and inclusion of DEI activities in annual evaluations. Faculty-level variables consisted of race and ethnicity, gender, age, years in practice, and academic rank. Although race and ethnicity are social constructs, these variables were used to examine differences in perspectives and activities related to DEI.

Demographic data were summarized overall using univariate analyses. DEI engagement responses from surveys were summarized overall and grouped by race and ethnicity using counts and percent for all categorical variables. Unadjusted differences in response across race and ethnicity were evaluated using the Pearson’s χ² test. The categorical measures of engagement, ≥1 hr per month and >10 hr per month, of academic faculty DEI involvement were summarized using counts and compared across race and ethnicity using the Pearson’s χ² test. Logistic regression analysis was used to quantify racial and ethnic differences in the likelihood of DEI involvement measures after controlling for academic rank, years of practice, and demographic variables. Binary outcomes in the logistic regression model included whether DEI involvement (1) was perceived to limit opportunities to excel in other endeavors (eg, scholarly work), (2) led to the perception of being stigmatized by colleagues, and (3) led to the perception of being typecast by colleagues. Assessment of goodness of fit of the models to data were done using Hosmer-Lemeshow test. Odds ratios (OR) and 95% confidence interval (CI) were used to establish association between selected survey responses outcomes and race and ethnicity. A 2-side α level of 5% was selected to access statistical significance. R statistical software version 4.1.2 was used for all statistical analyses (Vienna, Austria). The study was approved by the Institutional Review Board of Baylor College of Medicine.

A total of 2045 pediatric faculty responded to the survey, of which 81% (N = 1649) responded that they participated in DEI activities. As the focus of the assessment was the experiences of those who participate in DEI, only those affirming engagement in DEI activities were invited to complete the entire survey and were the focus of these analyses.

Respondent characteristics are shown in Table 1. The majority of respondents were women (62%) and under 55 years of age (68%). Most identified as non-Hispanic white (73%). White faculty had the highest percentage of individuals at the professor rank, whereas Black faculty had the highest percentage of individuals at the assistant professor rank. Only 4% of respondents had ≥11% of their faculty effort assigned to DEI activities.

Faculty reported greater participation at the Division (67%), Department (69%), and Medical School (53%) levels compared with Hospital (36%). Tables 2 and 3 demonstrate participation, (≥1 hr per month) and (≥10 hr per month), in DEI activities according to race and ethnicity. Among all respondents, there was greatest participation (≥1 hr per month) for faculty mentoring (72%) and faculty recruitment (56%) and lower participation for pipeline programs (18%) and premed counseling (13%). Relative to all other racial and ethnic groups, Black respondents had substantially higher proportions of participation for DEI committees, DEI representation, and pipeline programs.

Among all respondents, fewer than 5% spent ≥10 hr per month on all DEI activities except mentoring. Black respondents, compared with other racial and ethnic groups, had a markedly higher proportion of participation (≥ 10 hr per month) in DEI committees (13% vs 2% white respondents, 2% Hispanic respondents, 2% Asian respondents, 0% other respondents) and acting as a DEI representative (7% vs <1% white respondents, 2% Hispanic respondents, 1% Asian respondents, 2% other respondents).

A large majority of respondents reported that participation in DEI activities was very important or somewhat important (96%) and that they were very committed or somewhat committed to DEI activities (97%). When asked what percent of their professional effort they want to commit to DEI in 10 years, 29% of respondents reported >10% effort with some differences by race and ethnicity (white 24%, Black 56%, Hispanic 48%, Asian 40%). Among all respondents, 9% reported that they aspired to a leadership role in DEI with differences seen by race and ethnicity (white 4%, Black 28%, Hispanic 24%, Asian 20%).

When asked if DEI activities limited opportunities to excel in other endeavors (eg, scholarly work), 19% of respondents reported sometimes, usually, or always (versus rarely or never). A higher proportion of Black respondents (56%) reported sometimes, usually, or always compared with 14% for white respondents. A small percentage of faculty (15%) felt typecast (sometimes, usually, or always versus never or rarely) by colleagues for their DEI activities. Differences were observed according to race and ethnicity (9% for white respondents versus 59% for Black respondents versus 25% for Hispanic respondents versus 25% for Asian respondents). A similarly small percentage of respondents (11%) felt stigmatized (sometimes, usually, or always versus never or rarely) by colleagues for their DEI activities. Differences were notable according to race and ethnicity (8% for white respondents versus 31% for Black respondents versus 11% for Hispanic respondents versus 17% for Asian respondents).

A quarter of respondents (25%) reported that their institutions provided recognition, academic credit, assigned effort, or specific compensation for DEI activities. Approximately 45% reported their supervisors sometimes, usually, or always (versus never or rarely) include their DEI activities as part of their annual evaluation. A smaller proportion (16%) said DEI activities are a standard part of their department’s annual evaluation for faculty.

Analyses revealed significant racial and ethnic differences in faculty perspectives of DEI activities (Table 4). After adjusting for respondents’ demographic data, academic rank, and years of practice, compared with white faculty, Black faculty (OR 7.75; 95% CI 5.09–11.9), and Hispanic faculty (OR 2.67; 95% CI 1.59–4.39) respondents had higher odds of reporting DEI activities limited their opportunities to excel in other endeavors. Similarly, compared with their white counterparts, the odds of feeling typecast by colleagues for their DEI activities was highest for Black respondents (OR 15.9; 95% CI 10.2–25.0). Black respondents also had the highest odds (OR 4.9; 95% CI 3.0–7.7) of feeling stigmatized by colleagues for their DEI activities.

Among our most important findings is the variability of participation in DEI activities. Greater participation was shown for mentoring, recruitment, and career counseling with much fewer faculty engaging in efforts toward pipeline programs or premed counseling. These findings indicate that current attempts to advance workforce diversity center on those who have already entered medicine. However, efforts are needed proximally as recruitment at the faculty or fellow level is essentially a 0 sum game among academic institutions.⁴⁴  Because the number of potential URiM recruits is both small and historically constant in size, the gains made by 1 institution are at the expense of others. The only way to actually increase the proportion of URiM faculty in academic pediatrics is to increase the absolute number of URiM individuals in the pipeline. As such, pipeline programs are a critical component of efforts to expand the pool of individuals going into the biomedical sciences.^45–47  Participation in premed counseling can assist URiM individuals who may experience discriminatory practices in existing premed programs.⁴⁸  More efforts are needed by all faculty to help develop the pipeline and promote careers in medicine.

In addition to the types of DEI activities in which faculty participated, variability was also noted according to race and ethnicity with pronounced differences for those spending ≥10 hr per month for different DEI activities. Although only a very small proportion of any faculty group contributed ≥10 hr per month, URiM faculty showed the highest percentage of engagement in all categories. More specifically, Black faculty were outliers in many DEI activities. These findings highlight the existence of disparately large effort among a small subset of URiM faculty that has been postulated in numerous publications.^40,41  As URiM faculty may feel obliged to support future generations of communities they represent,^38,49  they may allocate more time to diversity initiatives relative to their peers.³⁹  Because of their intersectionality (ie, interacting nature of social categorizations that lead to disadvantage by multiple sources), URiM women in academic pediatrics may also endure a “minority woman tax,” given the expectation for participation in both URiM and gender-related efforts.^42,50  A study on citizenship tasks and female physicians in academic medicine found that URiM women felt that race played a role in their perceived obligation to participate in uncompensated citizenship tasks.⁴³ 

Although our assessment quantifies a disparity in diversity efforts, it should be noted that the concept of a minority tax has also included disparities in professional isolation (eg, perceived exclusion, invisibility, poor fit), racism, mentorship, clinical effort, and promotion.³⁸  Scholars have also described a gratitude tax, a feeling of indebtedness that URiM faculty have toward their institution for the opportunity to be a physician.⁴¹  This tax may lead URiM faculty to feel obligated to stay at their institution, forego other opportunities, and commit to more clinical effort.^10,49  Further study is needed to characterize the aggregate impact of all these taxes on URiM faculty.

These data provide a meaningful look at where faculty engage in DEI work. Faculty mostly concentrated their efforts at their Division, Department, and Medical School with little engagement at an affiliated hospital. These findings highlight potentially missed opportunities to influence hospital practices that may directly impact inequities in health care quality, patient experience, and workforce and leadership diversity.⁵  Specific missed opportunities could be dialogue around best practices for DEI, issues of concern for the entire enterprise, and identified gaps in training or performance. Lack of engagement with a hospital may disincentivize executive accountability for DEI and limit interprofessional collaborations toward improvement.

Our findings demonstrate some insights into how faculty perceive their participation in DEI activities. Of significant importance is that URiM faculty, specifically Black faculty, have higher odds of feeling typecast and stigmatized by colleagues for their DEI activities. We also found that URiM faculty were more likely to believe that their DEI activities limited their ability to excel in other endeavors. Prior studies have demonstrated that relative to white faculty, Black faculty have a higher odds of reporting that administrative work and student counseling reduce their time for research and teaching.^10,38  The confluence of our findings and prior literature highlight factors that may limit career advancement, potentiate feelings of isolation, engender job dissatisfaction, and lead to attrition.¹⁰  These outcomes may erode what is already a tenuous state of workforce diversity in academic pediatrics.^8,10,39 

Although academic departments, hospital systems, and medical schools are increasingly publicly promoting DEI, our assessment demonstrates a continued gap in institutional support of faculty DEI efforts. Only a quarter of respondents reported that their institutions provided recognition, academic credit, assigned effort, or specific compensation for DEI activities. Less than half of faculty reported that DEI activities were discussed at annual evaluations or were part of standard evaluations. These findings demonstrate a discordance between what departments espouse and alignment of strategies that reward and incentivize participation.¹⁹  This supports previous studies where URiM faculty report a disconnect between stated institutional goals and activities.³⁹ 

Although this assessment provides novel data on the lived experiences of those doing DEI work, it highlights many methodologic challenges in trying to obtain and interpret such data. As in any survey-based assessment, we were limited by potential sampling and response bias. By leveraging department chairs as a conduit to access faculty and trying to limit the burden on chairs and faculty, we accepted certain limitations. Because of our process of survey distribution being reliant on department chairs sending invitations to their faculty, our survey may not have reached all intended faculty. It is also possible that chairs who do not value DEI deliberately did not distribute the survey. Our survey distribution process also precluded us from calculating a response rate as that would have required more data requests from chairs. To ensure privacy to respondents, we did not collect identifying data on pediatric departments or specialty. As there are small numbers of URiM faculty in many pediatric academic settings, particularly in subspecialties, collecting such data could have created barriers to survey participation because of underlying concerns about being identifiable. Therefore, we could not compare data according to department characteristics and specialties that may impact the degree to which faculty are motivated to engage in DEI activities. We also could not account for clustering by department. In reflecting on the assessment done, its findings and limitations, we highlight the following as next steps.

Whereas our exploratory work provides some preliminary data on DEI activities among pediatric faculty, gaps remain. Future studies should assess what constitutes a DEI activity, investigate what faculty value about engaging in DEI, determine how faculty decide which activities to pursue, delineate how non-DEI activities are valued relative to DEI activities, quantify community-based, regional, or national DEI activities, and measure aspects of the minority tax beyond DEI activities. As DEI encompasses more than the experiences of racial and ethnic minority groups, future explorations should be appropriately broad in scope. Qualitative studies may provide rich detail on the experiences of those who do and do not engage in DEI activities that can in turn inform development of a comprehensive and rigorously tested survey. Lastly, further study is warranted among institutions that have invested in multiple DEI-related initiatives (eg, organizational health equity assessments, DEI as part of promotion criteria).

As our assessment focused on faculty, further study of department chairs, hospital executives, and medical school deans is warranted to better characterize how institutions value and align commitment of resources to DEI and work collaboratively across spheres of academic and hospital missions. In a 2015 study of pediatric department chairs, 69% of chairs reported being successful in diversity efforts and three-fourths of respondents reported that their department used their school of medicine’s diversity plan or a departmental diversity plan.³  Future studies should focus on aspects of DEI beyond diversity. This data may be captured in qualitative studies and surveys.

As more scholarship is generated to evaluate the range of DEI practices, operationalization of DEI programming, and metrics for success, leadership will be paramount in establishing culture change, rigor, intentionality, and investment in DEI.¹⁰  Department leaders can take a number of actions to elevate DEI in their institutions. First, department chairs must take organizational responsibility to determine best strategies to support URiM faculty who disproportionately engage in DEI activities.⁴¹  Potential interventions include incorporation of DEI into mission, values, and outcomes, alignment between stated missions and departmental investments, providing adequate protected effort to those who assume DEI leadership roles, making DEI part of standard evaluations, and creating promotional value to DEI. Chairs must also be sensitive to the small proportion of URiM faculty who are repeatedly asked to lead or partake in DEI activities so as not to increase their diversity burden by reasoning that they are now compensated.

Secondly, departments must expand the pool of faculty engaging in DEI with more involvement by non-URiM faculty. Although such shared responsibility has great potential, it comes with risks for both non-URiM and URiM faculty. For non-URiM individuals, participation in DEI activities may create anxiety of overstepping their roles if not adequately prepared. For URiM individuals, the alleviation of disparities in DEI-focused efforts may be offset by new tensions if they perceive loss of their perspectives, representation, or leadership opportunities. Departmental leaders must help faculty navigate these issues by modeling shared DEI engagement and facilitating coalition building. Lastly, pediatric department leaders must determine best methods on how to more closely align with hospitals on DEI efforts.⁵  Such collaborations amplify initiatives, leverage complementary resources, and provide a unified experience to faculty, staff, and patients.

If we aspire to being a field where DEI efforts are embraced across academic mission areas, we need to know how the effort is distributed among faculty and correspondingly valued by leadership. Considering the findings of this assessment, there is urgent need in pediatric academic settings to define strategic goals for DEI and align them with actions and appropriate resources. Additionally, as we rectify current inequities in health and health care, we must ensure that DEI efforts are shared among faculty. Understanding the current state can help design a comprehensive, coordinated DEI strategy to be more successful and inclusive than the fragmented, poorly resourced, and inadequately supported initiatives that have defined past efforts.

DEI

diversity, equity, and inclusion

URiM

underrepresented in medicine