Diversity and inclusion are core leadership competencies: A primer for busy leaders

I truly believe that medicine attracts good people—doctors, nurses and administrators—who are among the most intelligent and empathic people in the world.

Those of us who work with the sick and injured know that it is heart-wrenching and soul-searing. We arrive early, stay late, and often have trouble leaving it behind when we go home. We carry the heavy responsibility of aiming for perfect care and then may internalize feelings of deep regret when we are unable to achieve it.

So, why does research clearly show that in the physician workforce, female doctors are not equitably valued, respected or compensated when compared to male peers? It is well documented that women physicians receive less pay for similar work.1 We lag in promotions and make up a small minority of high level leaders.2 We often lack support and sponsorship. My own research with colleagues has demonstrated that although medical specialty societies have attracted physician members from all walks of life (good diversity), many of them have zero women (no inclusion) among recipients of some recognition awards.3 Is it any wonder that women physicians may become demoralized and experience more symptoms of burnout than male colleagues?

The proportion of women working as physicians and physicians-in-training far outweighs the proportion of women in most other STEM fields such as mathematics and engineering. However, despite an abundance of talented women, medicine is not leading the way in gender equity and we are making far too little progress.4 While the reasons for this are multifactorial, I believe that together we can educate and advocate our way out of evidence-based gender workforce disparities and truly become a role model for all STEM fields. How?

1. Recognize that it is every leader’s responsibility to develop core competencies in diversity and inclusion. This is like leaders developing competencies in strategy, budgets, organizational change management, etc. Sure, some tasks can be delegated, but leaders are still competent experts even if the day to day responsibilities are assigned to someone else.
2. Learn the language of diversity and inclusion and understand how it impacts your work and the work of the people you lead. Education is linguistic based, and it is imperative for leaders to learn the language of diversity and inclusion. (Box)
3. Know the pitfalls of diversity structures and beware the absence of metrics. Diversity committees, task forces, or other structures may counterintuitively make disparities worse because well-intentioned leaders believe that “something is being done” even when proof of efficacy is lacking. Like tackling quality and safety issues in a hospital setting, diversity and inclusion efforts should be ongoing and metrics driven. Be wary of making decisions without data, and recognize that when you get input from other sources, that opinions, observations and recommendations may vary depending on whether people are drawing from the actual data (evidence) or not (assumptions).
4. Recognize the benefits and unintended consequences of mentoring. Consider how the same words spoken to women at different stages of their careers may or may not be helpful. For example, to a woman who is early in her career the comment, “You may benefit from more mentoring, and I will mentor you” may seem very supportive. However, to a highly skilled female physician in mid-career who knows that the historical promotion data from her workplace demonstrates that she has a poor odds ratio of promotion, the same comment may sound disrespectful because it suggests that the woman continues to need “fixing,” while unacknowledged organizational barriers and bias continue on relatively unchecked. By mid-career, women physicians have faced many obstacles already, and they know that the gates to promotion are not equitably open. In these cases, the woman is being mentored against a “closed gate” and with the odds of promotion being consistently far less than for a man, it is likely the organizational promotional system that needs improvement, not the woman candidate. In these cases, an offer to help open doors to advancement (sponsorship) may be better received.
5. Understand the power of sponsorship and learn to use it effectively and efficiently. Every leader has power to quickly open doors for others. Sponsorship at its best is opening a door to something that is tangible—something that can be included on a CV and/or that will help with the next promotion, project or application for funding/compensation. Counterintuitively, sponsorship may entail less time than mentorship--a more effective and efficient tool in your leadership toolbox.
6. Ask yourself who is responsible for fixing a problem before saying to a woman, “You should_____.” Too often, people who identify a problem are told that they should also fix it. For example, after publishing the first of its kind studies in the medical literature demonstrating that women were regularly underrepresented by medical specialty societies among recognition award recipients, both men and women readers suggested that women physicians should nominate more women for recognition awards.5 While this seems logical, consider that many nominations come from institutional leaders, such as chairs of departments, who are overwhelmingly men. Moreover, women may be nominated and still not receive awards (awards committees may have implicit bias issues so lack of nominations is not necessarily the problem). To avoid what I often refer to as “yet another gender tax” on women physicians’ time and limited resources, I would encourage leaders, regardless of gender, to acknowledge disparities (in awards, compensation, promotions, and leadership to name a few) and to put their considerable resources toward remedies rather than suggesting that those who have been underrepresented or even discriminated against fix the problem.
7. Remind yourself to question stereotypes. Stereotypes are learned, and we must actively educate ourselves away from them. Unfortunately, medical school training and workplace initiatives do not do enough to address them. For example, many would easily accept that women physicians, especially those with intersectionality (simultaneous membership in multiple underrepresented groups), experience more burnout symptoms and would benefit from learning resilience skills. However, I would suggest that women physicians, especially women of color and other intersectionality, are among the most resilient people in the entire modern workforce. Consider what it must take for a woman of color or a woman with a disability to become a physician. Even if discouraged and demoralized currently, would it not make more sense to invest in opening doors for her and compensating her equitably than take up her valuable time teaching her how to be even more resilient?

During a recent conversation with the CEO of a healthcare organization, I was asked, “Where do we begin?” We begin with dialogue and education about diversity and inclusion using the robust evidence-base and best practices developed to date. It is not enough to prove that women are represented within the workforce (or any other group); we must also demonstrate that they are equitably included within that group. We do that by defining metrics, transparently reporting the data and making informed decisions. We sponsor and compensate all physicians (and others) equitably. We recognize the tendency for implicit bias and stereotypes to seep into our decision making, and we actively work toward using both common sense and hard data to drive decision making. In medicine, we have the opportunity and the obligation to become progressive leaders and to be a role model in workforce gender equity for all STEM fields. To accomplish that, every leader needs to develop diversity and inclusion competencies.

Important Terms Used in Discussions about Diversity and Inclusion*

Diversity—a diverse group or organization is one that has variety, but this doesn’t mean that it is inclusive (e.g. academic medical centers may have a diverse staff but top leaders are mostly men)
Inclusion—an individual or group that is included and is valued, respected and supported; an organization that has equitable diversity at every level is inclusive
Implicit bias—unconscious attitudes or stereotypes that affect and impact actions and decisions
Explicit bias—conscious attitudes or beliefs about a group of people that are usually based on a perceived threat
Microinequities—subtle ways in which individuals are either singled out, overlooked, ignored, or otherwise discounted based on one or more characteristics that they cannot change (e.g., race, gender or disability)
Microaggressions—commonplace verbal, environmental or behavioral indignities such as snubs, slights or insults, conscious or unconscious, that are disrespectful, derogatory or otherwise not supportive of an individual
Intersectionality—the presence of overlapping social categorizations such as race, gender, and sexuality that may promote an enhanced level of bias or discrimination (e.g., a woman of color)
Stereotype threat--a situation, often involving tokenism, in which a person is or feels at risk of conforming to stereotypes about their perceived group (e.g., when a woman leader chooses not to voice her opinion in a leadership meeting because she does not want to be perceived as bossy or aggressive)
Tokenism—a symbolic effort to appear inclusive in order to give the appearance of equality (e.g., inviting one woman to become a member of a board of directors or to give a plenary lecture)
Diversity structures—formal structures such as departments, committees, task forces, or policies that are formed with the intent to advance diversity and inclusion agendas
Stereotypes—learned beliefs about a group of people that may be widely held but are overly simplified or factually false and tend to promote bias, discrimination and other problems
Mentorship—general career guidance and support provided by a more experienced and knowledgeable person
Coaching—goal-oriented career guidance and support provided by someone experienced and knowledgeable about coaching techniques
Sponsorship—specific, usually tangible, support provided by someone in a leadership position or someone who can offer financial backing to advance someone’s career

*This is not intended to be a complete list. Definitions may vary depending on sources and interpretation. Readers should refer to the literature for more information.

1. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016;176(9):1294-1304.
2. Schor NF. The Decanal Divide: Women in Decanal Roles at U.S. Medical Schools. Acad Med. 2017.
3. Silver JK, Slocum CS, Bank AM, et al. Where are the women? The underrepresentation of women physicians among recognition award recipients from medical specialty societies. PM R. 2017.
4. Helitzer DL, Newbill SL, Cardinali G, Morahan PS, Chang S, Magrane D. Changing the Culture of Academic Medicine: Critical Mass or Critical Actors? J Womens Health (Larchmt). 2017;26(5):540-548.
5. Silver JK. Why are women excluded from medical society awards? STAT. Available at: https://www.statnews.com/2017/07/19/women-excluded-medical-society-awards/. Published 2017. Accessed September 22, 2017.

Julie K. Silver, MD
Associate Professor and Associate Chair, Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Network. Staff physician at Massachusetts General and Brigham and Women’s Hospitals.
Twitter: @JulieSilverMD

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