Embedding Diversity, Equity, Inclusion, and Justice in Hospital Medicine
Photo credit: Blend Images/Getty Images
The language of equality in America’s founding was never truly embraced, resulting in a painful legacy of slavery, racial injustice, and gender inequality inherited by all generations. However, for as long as America has fallen short of this unfulfilled promise, individuals have dedicated their lives to the tireless work of correcting injustice.
Although the process has been painstakingly slow, our nation has incrementally inched toward the promised vision of equality, and these efforts continue today. With increased attention to social justice movements such as #MeToo and Black Lives Matter, our collective social consciousness may be finally waking up to the systemic injustices embedded into our fundamental institutions.
Medicine is not immune to these injustices. Persistent underrepresentation of women and minorities remains in medical school faculty and the broader physician workforce, and the same inequities exist in hospital medicine.1-6 The report by the Association of American Medical Colleges (AAMC) on diversity in medicine highlights the impact widespread implicit and explicit bias has on creating exclusionary environments, exemplified by research demonstrating lower promotion rates in non-White faculty.7-8 The report calls us, as physicians, to a broader mission: “Focusing solely on increasing compositional diversity along the academic continuum is insufficient. To effectively enact institutional change at academic medical centers ... leaders must focus their efforts on developing inclusive, equity-minded environments.”7
We have a clear moral imperative to correct these shortcomings for our profession and our patients. It is incumbent on our institutions and hospital medicine groups (HMGs) to embark on the necessary process of systemic institutional change to address inequality and justice within our field.
A road map for DEI and justice in hospital medicine
The policies and biases allowing these inequities to persist have existed for decades, and superficial efforts will not bring sufficient change. Our institutions require new building blocks from which the foundation of a wholly inclusive and equal system of practice can be constructed. Encouragingly, some institutions and HMGs have taken steps to modernize their practices. We offer examples and suggestions of concrete practices to begin this journey, organizing these efforts into three broad categories:
1. Recruitment and retention
2. Scholarship, mentorship, and sponsorship
3. Community engagement and partnership.
Recruitment and retention
Improving equity and inclusion begins with recruitment. Search and hiring committees should be assembled intentionally, with gender balance, and ideally with diversity or equity experts invited to join. All members should receive unconscious bias training. For example, the University of Colorado utilizes a toolkit to ensure appropriate steps are followed in the recruitment process, including predetermined candidate selection criteria that are ranked in advance.
Job descriptions should be reviewed by a diversity expert, ensuring unbiased and ungendered language within written text. Advertisements should be wide-reaching, and the committee should consider asking applicants for a diversity statement. Interviews should include a variety of interviewers and interview types (e.g., 1:1, group, etc.). Letters of recommendation deserve special scrutiny; letters for women and minorities may be at risk of being shorter and less record focused, and may be subject to less professional respect, such as use of first names over honorifics or titles.
Once candidates are hired, institutions and HMGs should prioritize developing strategies to improve retention of a diverse workforce. This includes special attention to workplace culture, and thoughtfully striving for cultural intelligence within the group. Some examples may include developing affinity groups, such as underrepresented in medicine (UIM), women in medicine (WIM), or LGBTQ+ groups. Affinity groups provide a safe space for members and allies to support and uplift each other. Institutional and HMG leaders must educate themselves and their members on the importance of language (see table), and the more insidious forms of bias and discrimination that adversely affect workplace culture. Microinsults and microinvalidations, for example, can hurt and result in failure to recruit or turnover.
Conducting exit interviews when any hospitalist leaves is important to learn how to improve, but holding ‘stay’ interviews is mission critical. Stay interviews are an opportunity for HMG leaders to proactively understand why hospitalists stay, and what can be done to create more inclusive and equitable environments to retain them. This process creates psychological safety that brings challenges to the fore to be addressed, and spotlights best practices to be maintained and scaled.
Scholarship, mentorship, and sponsorship
Women and minorities are known to be over-mentored and under-sponsored. Sponsorship is defined by Ayyala et al. as “active support by someone appropriately placed in the organization who has significant influence on decision making processes or structures and who is advocating for the career advancement of an individual and recommends them for leadership roles, awards, or high-profile speaking opportunities.”9 While the goal of mentorship is professional development, sponsorship emphasizes professional advancement. Deliberate steps to both mentor and then sponsor diverse hospitalists and future hospitalists (including trainees) are important to ensure equity.
More inclusive HMGs can be bolstered by prioritizing peer education on the professional imperative that we have a diverse workforce and equitable, just workplaces. Academic institutions may use existing structures such as grand rounds to provide education on these crucial topics, and all HMGs can host journal clubs and professional development sessions on leadership competencies that foster inclusion and equity. Sessions coordinated by women and minorities are also a form of justice, by helping overcome barriers to career advancement. Diverse faculty presenting in educational venues will result in content that is relevant to more audience members and will exemplify that leaders and experts are of all races, ethnicities, genders, ages, and abilities.
Groups should prioritize mentoring trainees and early-career hospitalists on scholarly projects that examine equity in opportunities of care, which signals that this science is valued as much as basic research. When used to demonstrate areas needing improvement, these projects can drive meaningful change. Even projects as straightforward as studying diversity in conference presenters, disparities in adherence to guidelines, or QI projects on how race is portrayed in the medical record can be powerful tools in advancing equity.
A key part of mentoring is training hospitalists and future hospitalists in how to be an upstander, as in how to intervene when a peer or patient is affected by bias, harassment, or discrimination. Receiving such training can prepare hospitalists for these nearly inevitable experiences and receiving training during usual work hours communicates that this is a valuable and necessary professional competency.
Community engagement and partnership
Institutions and HMGs should deliberately work to promote community engagement and partnership within their groups. Beyond promoting health equity, community engagement also fosters inclusivity by allowing community members to share their ideas and give recommendations to the institutions that serve them.
There is a growing body of literature that demonstrates how disadvantages by individual and neighborhood-level socioeconomic status (SES) contribute to disparities in specific disease conditions.10-11 Strategies to narrow the gap in SES disadvantages may help reduce race-related health disparities. Institutions that engage the community and develop programs to promote health equity can do so through bidirectional exchange of knowledge and mutual benefit.
An institution-specific example is Medicine for the Greater Good at Johns Hopkins. The founders of this program wrote, “health is not synonymous with medicine. To truly care for our patients and their communities, health care professionals must understand how to deliver equitable health care that meets the needs of the diverse populations we care for. The mission of Medicine for the Greater Good is to promote health and wellness beyond the confines of the hospital through an interactive and engaging partnership with the community ...” Community engagement also provides an opportunity for growing the cultural intelligence of institutions and HMGs.
Tools for advancing comprehensive change – Repurposing PDSA cycles
Whether institutions and HMGs are at the beginning of their journey or further along in the work of reducing disparities, having a systematic approach for implementing and refining policies and procedures can cultivate more inclusive and equitable environments. Thankfully, hospitalists are already equipped with the fundamental tools needed to advance change across their institutions – QI processes in the form of Plan-Do-Study-Act (PDSA) cycles.
They allow a continuous cycle of successful incremental change based on direct evidence and experience. Any efforts to deconstruct systematic bias within our organizations must also be a continual process. Our female colleagues and colleagues of color need our institutions to engage unceasingly to bring about the equality they deserve. To that end, PDSA cycles are an apt tool to utilize in this work as they can naturally function in a never-ending process of improvement.
With PDSA as a model, we envision a cycle with steps that are intentionally purposed to fit the needs of equitable institutional change: Target-Engage-Assess-Modify. As highlighted (see graphic), these modifications ensure that stakeholders (i.e., those that unequal practices and policies affect the most) are engaged early and remain involved throughout the cycle.
Dr. Delapenha, Dr. Kisuule, Dr. Martin, and Dr. Barrett
As hospitalists, we have significant work ahead to ensure that we develop and maintain a diverse, equitable and inclusive workforce. This work to bring change will not be easy and will require a considerable investment of time and resources. However, with the strategies and tools that we have outlined, our institutions and HMGs can start the change needed in our profession for our patients and the workforce. In doing so, we can all be accomplices in the fight to achieve racial and gender equity, and social justice.
1. Diversity in Medicine: Facts and Figures 2019: Figure 19. Percentage of physicians by sex, 2018. AAMC website.
2. Diversity in Medicine: Facts and Figures 2019. Figure 16. Percentage of full-time U.S. medical school faculty by sex and race/ethnicity, 2018. AAMC website.
3. Diversity in Medicine: Facts and Figures 2019. Figure 15. Percentage of full-time U.S. medical school faculty by race/ethnicity, 2018. AAMC website.
4. Diversity in Medicine: Facts and Figures 2019. Figure 6. Percentage of acceptees to U.S. medical schools by race/ethnicity (alone), academic year 2018-2019. AAMC website.
5. Diversity in Medicine: Facts and Figures 2019 Figure 18. Percentage of all active physicians by race/ethnicity, 2018. AAMC website.
6. Herzke C et al. Gender issues in academic hospital medicine: A national survey of hospitalist leaders. J Gen Intern Med. 2020;35(6):1641-6.
7. Diversity in Medicine: Facts and Figures 2019. Fostering diversity and inclusion. AAMC website.
8. Diversity in Medicine: Facts and Figures 2019. Executive summary. AAMC website.
9. Ayyala MS et al. Mentorship is not enough: Exploring sponsorship and its role in career advancement in academic medicine. Acad Med. 2019;94(1):94-100.
10. Ejike OC et al. Contribution of individual and neighborhood factors to racial disparities in respiratory outcomes. Am J Respir Crit Care Med. 2021 Apr 15;203(8):987-97.
11. Galiatsatos P et al. The effect of community socioeconomic status on sepsis-attributable mortality. J Crit Care. 2018 Aug;46:129-33.