The 2022 Joseph W. St Geme, Jr, Leadership Award Address—Diversity and Social Justice: The Field of Pediatrics Can and Should Lead

In 2020, our country achieved a nation-changing demographic threshold, with half of all children being of color: Black, Hispanic, Asian American, American Indian and Alaska Native, Pacific Islander, and those who are multiracial.²  In addition, 1 in 4 children lived in an immigrant family in which at least 1 parent was born outside of the United States.³  This diversity will continue to grow, so that by 2065, almost two-thirds of the US child population will be from these groups, with Hispanic children nearly equaling non-Hispanic white (NHW) children, and children in immigrant families becoming 1 out of every 3.⁴ 

What does this mean for pediatrics, our clinical care, research, education, and child health policies? I believe we will need to consider diversity issues in all our activities because, without this reflection, we will not achieve excellence in our work.^5,6  It also means that we need to see children of color along with all others as our country’s human capital, that is, the human potential that will advance our nation’s success. Unfortunately, if we examine the past and present economic status of Black, Hispanic, and American Indian and Alaska Native families, there has been a lack of economic resources available for their success. Since the 1960s, when our nation started the “War on Poverty,” Black and Hispanic families have been at the bottom of household incomes, leading to a family wealth gap in which these families have only 10% to 12% of the wealth of NHW families.7,8 The situation is worst for American Indian and Alaska Native families, who have the highest poverty rate at 25.4%.⁹ 

This lack of family wealth has resulted in these communities having more underresourced schools. Consequently, for the past 30 years, the US Department of Education has reported eighth-grade math test scores for Black, Hispanic, and American Indian and Alaska Native students that are consistently one-half standard deviation lower than for NHW students.¹⁰  These educational disparities are not because these students are less capable, but because their families and schools have fewer resources. Unfortunately, these educational disparities have led to lower rates of college entry and graduation.^11,12 

The disparities in household income and lower educational opportunities, in addition to poorer health care and unequal treatment in the criminal justice system, are byproducts of structural racism. The term “structural racism” might make some people feel uncomfortable; nevertheless, these are the issues that communities of color and their children deal with daily. Therefore, our pediatric community needs to acknowledge the existence of structural racism and act to decrease its impact on the lives and futures of children. It must move forward in pursuing the recommendations made in the American Academy of Pediatrics policy statement on the effect of racism on child and adolescent health.¹³ 

Consequently, it is not hard to understand how social injustice has impacted the diversity in our physician workforce, inclusive of our pediatric workforce. At present, Black, Hispanic, and American Indian and Alaska Native are ∼5.2%, ∼7.8%, and ∼0.1% of certified general and subspecialist pediatricians respectively.^14,15  Obviously, diversity in our pediatric workforce can only occur if there is diversity in our medical students. Unfortunately, this has been a persistent problem for decades. For example, when I became an assistant dean of student affairs in 1983, Black, Hispanic, and American Indian and Alaska Native students were 10.4% of medical school graduates.¹⁶  In 2019, almost 40 years later, they were only 11.7%.¹⁷  Comparing the percentages of these groups in 1983 and 2019 to their population percentages at those times (18.6% and 31.4%, respectively) reveals a decrease in population equity in medical school graduates for these communities (percentage of medical school graduates/percentage of US population) from 56% to 37%. These data suggest 2 things: first, that the educational pathways into medicine need to be enhanced to increase recruitment of diverse students and, second, and perhaps more importantly, the retention and advancement into leadership positions of those that do enter medical school is critical. Many academic institutions have developed recruitment programs for Black, Hispanic, and American Indian and Alaska Native medical students, as well as for other students, to add to their school’s diversity. However, in my experience as a dean of diversity over the past 4 decades, fewer programs have been developed for the retention and success of these students and their advancement into academic and/or community leadership roles. A recent analysis of matriculants into US medical schools from 2014 to 2015 and 2015 to 2016 revealed that Black and Hispanic students had twice the attrition rates as NHW students, 5.7% and 5.2% versus 2.3%, respectively.¹⁸  Once adjusted for low-income families and underresourced neighborhoods, the rates fell to 3.5% for both groups compared with 2.5% for NHW students. American Indian and Alaska Native students were most at risk for attrition with an adjusted rate of 7.4%. At the other end of the spectrum, medical school faculty from these groups are also low in number, with Black, Hispanic, and American Indian and Alaska Native faculty comprising 3.6%, 5.5%, and 0.2%, respectively.¹⁹  Moreover, most of these faculty are at the levels of instructors and assistant professors (65% to 70% compared with NHW 54%),²⁰  and they have higher attrition rates than NHW faculty.²¹  Improvements in recruitment and retention will happen quicker if we have diversity in leadership making change happen. Therefore, advancing diverse individuals into leadership positions is vital for our success in diversity.

What is the status of diversity in Pediatrics? In 2015, the Federation of Pediatric Organizations’ (FOPO) Diversity and Inclusion Working Group published the results of a national survey of pediatric department chairs with a 50% response rate and revealed that 76% of departments had a diversity plan.²²  However, only 8% to 12% of residents, fellows, and faculty were underrepresented in medicine (UIM).²³  Nevertheless, 69% of chairs felt that they were doing “good to excellent” in the pursuit of diversity. A more recent study revealed that from 2007 to 2019, the UIM pediatric residents’ proportion did not change, staying at 16%, but the proportion of pediatric fellows who were UIM decreased from 14.2% to 13.5%.²⁴  Is pediatrics, like many of the other fields in medicine, stuck in a status quo when it comes to diversity, or can we change?

Insights of how diversity in our pediatric workforce can be improved may best be accomplished by a case example that starts with the nation’s initial efforts in 1969 and ends with our current efforts. Because I experienced the early beginnings of diversity efforts in medical schools and participated in diversity efforts throughout my career, I will present my experiences over my 50 years, from a high school student to a Stanford professor with reflection on mentorship, sponsorship, leadership, and system change.

I came from a family that one would not expect to have produced a physician, let alone a professor at Stanford. My father, Aurelio Niño Mendoza, was born in Mexico, raised in California, and attended a segregated school for Mexican children until sixth grade. He left school to support his family as a farmworker and eventually became a truck driver. My mother, Velia Sanchez Mendoza, was a US citizen but, at 5 years old, was deported back to Mexico, where she completed high school. Together, my parents nurtured and supported our family of 6 children. Although my family was of low income, we lived in an area in which children went to a well-resourced high school. It was in high school when my counselor, Ms Down, called me in and told me she had heard I wanted to be a doctor. Although I do not think I had ever stated this, I decide to follow her lead. She sent me to a conference for high school students interested in health careers. This is 1 of 2 life-changing moments that transformed my life and brought me here today. Her sponsorship began my path toward medicine. However, it was the events of the 1960s civil rights movement and the assassination of Dr Martin Luther King that facilitated my admission to Stanford Medical School. Those events made Stanford Medical School change its admissions process to improve its diversity. They did this by including a student’s “distance traveled,” or what today we call a holistic review, in their admissions process. In 1969, by using this new process, Stanford Medical School began its affirmative-action program with a quota of 10 UIM students per class. I was in its third class in 1971, and all 10 of us became physicians, with 5 becoming medical school professors. This social justice effort changed Stanford Medical School forever by revealing that potential existed in students from all backgrounds.

While at Stanford as a medical student, I was lucky to have mentors and sponsors. I believe each one saw in me the ability to succeed and my willingness to work hard to do so. Dr William Fowkes mentored and sponsored me in community health activities, Drs Bruce Tune and Phil Sunshine fostered my interest in pediatrics, and Dr Irving Schulman, our pediatric department chair, became my sponsor who kept me as a resident and then brought me back as a fellow and then a faculty member. But I would not have returned to Stanford for a fellowship if it had not been for the mentorship and sponsorship of Dr Robert Haggerty. Indeed, the second conversation that transformed my life was with him in Boston as a student at the Harvard School of Public Health, when I was explaining to him that I wanted to do community pediatrics. He asked if I had ever thought about doing academics. I responded no, and he then told me that I should and that he would help me get back to Stanford for fellowship by talking to Dr Schulman.

This is how I ended up here today, by social justice changing an institution through the bold leadership of its faculty, mentors, and sponsors who saw my potential and the support of family, friends, and colleagues.

To pay back the mentorship and sponsorship I received, in 1983, 2 years after becoming an assistant professor at Stanford, I became an assistant dean of student affairs to support UIM medical students. At that time, most faculty in the country felt that UIM students were being trained to return to their communities, a process that Dr Marc Nivet labels “Diversity Operating System 1 (DOS1),” diversity without inclusion, in this case, becoming faculty.²⁵  However, with my colleagues, Drs Robert Cutler and Ronald Garcia, we envisioned a program that would encourage UIM medical students to become faculty, thereby becoming part of an academic institution, DOS 2: diversity with inclusion. Our program, the Early Matriculation Program, brought UIM medical students as prematriculants and linked them with Stanford research and clinical faculty. This acculturated them to the Stanford Medical School environment and created a student/faculty network for their support. Over the past 37 years, the Early Matriculation Program has exposed Black, Hispanic, and American Indian and Alaska Native medical students to academic careers, as well as others from educationally disadvantaged backgrounds and encouraged them to become faculty. Many of these students are now senior faculty and/or leaders in medicine. This program exemplified how early introduction to faculty and leadership positions as career paths can influence students’ career trajectories.

To change the status quo in diversity, equity, and inclusion (DEI), we need to have bold leaders. Across the country, I have seen leadership for DEI efforts coming from both junior and senior faculty, and not infrequently from those in pediatrics. At Stanford, the leadership of our pediatric chair, Dr Mary Leonard, is an example of how listening to the faculty and supporting their efforts in DEI and health disparities can lead to innovative programs, such as our nationally recognized Leadership Education for Advancing Diversity.²⁶  Likewise, strong leadership from our Dean and the Chief Executive Officers of our hospitals has led to a unique social justice plan for the whole medical center. This plan is now being executed by the school’s leadership and its Diversity Cabinet, representing all members of our medical center. Through these efforts, we have changed the status quo, resulting in >30% of matriculating medical students and pediatric residents being UIM and 48% of medical school department chairs being women.

Although these efforts have worked at Stanford, many other institutions may have different challenges. What is needed are programs across institutions. For example, the Academic Pediatric Association (APA) and the National Institute of Diabetes and Digestive and Kidney Diseases are supporting the Research in Academic Pediatrics Initiative on Diversity (RAPID). I have been privileged to colead this program with its principal investigator, Dr Glenn Flores, and work with its national advisory committee (NAC) of distinguished faculty.²⁷  Since 2012, RAPID has supported the development of 2 UIM senior fellows or junior faculty per year with small grants, mentorship, and sponsorship. It holds an annual meeting with NAC for the RAPID scholars to present their work and to mentor and support additional UIM physicians who are chief residents, fellows, or junior faculty interested in academic medicine.²⁸  The mentorship component of RAPID involves the scholar’s local mentor, their NAC mentor, and the codirectors. The codirectors are involved in bimonthly discussions to address issues commonly faced by UIM faculty, such as academic bias, minority tax, imposter syndrome, leadership development, and other issues arising from the acculturation process into academic medicine. During its first 5 years (2013–2018), its 10 scholars produced 56 articles and obtained 2.5 grants per scholar. In its 10-year history, RAPID has also helped increase the membership diversity of the APA. RAPID’s success has resulted in partnerships with other pediatric programs and societies, including the APA’s New Century Scholars, the American Board of Pediatrics, the Pediatric Infectious Disease Society, and the American Pediatric Society. RAPID has revealed that we can create an academic faculty retention network that is not limited to a specific academic center, but one that can reach across the country and across academic fields through partnerships with other programs and academic societies resulting in a greater collective impact on workforce diversity.

Indeed, if we look throughout pediatrics, we will see efforts addressing DEI and structural racism. Although most efforts focus on recruitment and some on retention, as noted, the advancement of UIM individuals into leadership positions is key for supporting long-term effects on workforce diversity. One of the programs addressing academic leadership is the APA’s New Century Scholars, which, in 2004, began its effort to increase the number of UIM pediatric residents entering academic positions and has resulted in 63% of participants entering academic careers.²⁹  Over time, other programs have been developed by pediatric organizations, and today, FOPO is intensifying its effort to coordinate members’ activities in diversity, such as the Association of Medical School Pediatric Department Chairs’ Pediatric 2025: the Association of Medical School Pediatric Department Chairs Workforce Initiative, and its partnerships with the National Institutes of Health to diversify our pediatric research workforce.³⁰  However, our efforts in DEI need to go beyond pediatrics. Many pediatricians have worked with groups outside of our field that have the same goal for health care workforce diversity. For example, pediatricians are working with the Association of American Medical Colleges Group on Diversity and Inclusion, Health Resources and Services Administration’s Bureau of Health Workforce, and national minority medical groups. Our professional societies and groups need to create DEI goal-oriented partnerships with these and other groups for significant improvements in our nation’s workforce diversity.

Lastly, to improve our workforce’s diversity, pediatricians and their American Academy of Pediatrics chapters should consider partnerships with schools and community colleges to encourage students to pursue health careers. We should encourage all our pediatric colleagues to ask the important question to their patients, “Have you thought about becoming a doctor?” This was one of the recommendations of the FOPO Diversity and Inclusion Working Group: “…encourage minority children and youth to pursue careers in health and science.”

So, I end with a question for you. What can you do to advance diversity and social justice in pediatrics? Can you mentor, sponsor, or lead? Can you advocate for changing the status quo to improve DEI at all levels, or can you partner with others who want all our children to succeed? We, as pediatricians, are optimistic at heart because we work with children. We should not forget that others in our communities are as well, even in the worst of times. I recall President Obama conveying this sense of optimism in his phrase, “Yes, we can!” But I also recall those much less powerful using the same phrase in Spanish in the 1970s to get farmworkers decent job conditions, a phrase developed by Cesar Chavez and Dolores Huerta, “Si, se puede!” I echo this for our efforts in diversity and social justice: “Si, se puede!”

Thank you for the honor of this award.

APA

American Pediatric Association

DEI

diversity, equity, and inclusion

FOPO

Federation of Pediatric Organizations

NAC

national advisory committee

NHW

non-Hispanic white

RAPID

Research in Academic Pediatrics Initiative on Diversity

UIM

underrepresented in medicine