Inside the Struggle to Improve Diversity, Equity, and Inclusion in Academic Medicine

Leaders in diversity, equity, and inclusion (DEI) at academic health centers reported several core challenges in their roles that have led to burnout and isolation, according to a qualitative study.

Key themes that emerged from interviews with 32 DEI leaders included variability in roles, responsibilities, and access to resources; a mismatch between institutional investments and directives; and a lack of evidence-based practices or standards to guide the work, reported Michelle Ko, MD, PhD, of the University of California Davis, and co-authors.

“Relegating the work to a handful of siloed individuals can set DEI leaders up for burnout and perceived failures,” they wrote in JAMA Network Open.

As calls for racial justice after the death of George Floyd made their way into medical education, schools introduced programs and appointed leadership focused on DEI. Yet, despite outwardly supportive positions, DEI leaders said, academic medicine has yet to provide them the tools to deliver real results or measure them.

“We saw the progress was really in people being able to have conversations, to be more open about discussing the problems, but we didn’t see institutional change that needs to happen after that,” Ko told MedPage Today.

In an invited commentary, Kathie-Ann Joseph, MD, MPH, and Renee Williams, MD, MHPE, both of NYU Grossman School of Medicine in New York City, noted that it’s common for DEI roles to be filled by those who are underrepresented in medicine.

This constitutes a “minority tax” of sorts, they wrote, where minority faculty are assigned the added responsibility of helping their colleagues achieve and understand diversity and equity, on top of regular academic workloads.

What’s more, “work focused on DEI initiatives has not been afforded academic credit for promotion,” they added. “Lack of academic credit may contribute negatively to the emotional labor associated with these roles.”

“What is not highlighted in this article is the significance of support and commitment from the top academic leadership,” they said, suggesting the incorporation of DEI into academic strategic plans.

In this study, one dean with a budget of $1 million had 20% time allocation to chair the anti-racism task force and oversee medical school metrics, training, and policies. Another had 30% time allocation to oversee undergraduate medical school curriculum, and recruitment and retention of trainees, faculty, and department chairs, with no budget. Others described a loose structure with “informal on-demand requests, such as providing emotional support following incidents of discrimination and crafting rapid institutional response statements,” the authors wrote.

“Diversity work has always been relatively undervalued [and] under-invested [in]; otherwise we wouldn’t have a problem,” Ko said.

Often, participants reported being positioned separately from units like medical education or faculty development, rather than being integrated into them, making it difficult to advance accountability across an organization. They wondered whether they had “superficial, rather than substantive, roles,” Ko and colleagues noted.

For example, when it came to improving diversity in hiring, one participant said, “I wish I worked within a larger department, with the division chiefs, because they’re the ones who are really calling the shots with the hires.” Ko said department-level DEI leaders who connect with a main DEI office could begin to address this.

Consistent with past studies, a lack of standardized expectations and frameworks also hampered leaders’ efforts at substantive change. They wished for more scholarships and expertise on DEI practices in academic medicine to build an evidence base for measuring success. Accreditation bodies like the Liaison Committee on Medical Education and the Accreditation Council on Graduate Medical Education have instituted some diversity-related standards, but not for DEI leaders specifically, the authors wrote.

Many leaders reported a sense of deep commitment to their work because of personal experiences of discrimination or tokenization, but also a deep sense of professional isolation and burnout in trying to repair systems in academic medicine that continued to marginalize them. As one participant said, “My job is to have hope, to absorb for everybody else, figure out what I can do after every kaboom to help the community heal … But [I] don’t have time to heal or process [myself].”

Study Details

Ko and colleagues included participants who had or recently held formal leadership roles in a DEI office at 27 U.S. medical schools and academic medical centers.

Ko herself was in a health equity interest group at AcademyHealth, a health services research and health policy organization, and is on the DEI academic senate committee at her own institution. She and co-authors, who have held similar positions, built relationships with others in the field after working on a previous study on DEI challenges in admissions.

The researchers used their own professional networks, contacts from the past study, and the UC Davis Center for a Diverse Healthcare Workforce to recruit via email. Snowball sampling was used to capture participants from different geographic areas and types of institutions.

Interviews were conducted via Zoom from December 2020 to September 2021 using a standardized interview guide, and transcripts were reviewed using a phenomenographic approach to identify themes.

Of the participants, 56% were cisgender female, 50% were Black, 25% were white, 19% were Latino, and 9% were Asian or Asian American. Most (63%) identified as underrepresented in medicine. More than half (53%) held dean positions, with an average of 14 years of experience in medical education.

The researchers acknowledged that their study came at a time when more resources were being devoted to DEI, but investment may now be declining. As there was no national directory of DEI offices and roles, selection bias may have occurred. Only participants with formal roles were interviewed, and of these, only seven participants had department-level roles (as opposed to a dean position, for example).

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