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A Resident-Led Initiative to Advance Diversity, Equity, Inclusion, and Antiracism in a Pediatrics Residency Program

  • Kayla L. Karvonen
    Correspondence
    Address correspondence to Kayla L. Karvonen, MD, Department of Pediatrics, University of California, San Francisco, 1825 4th St, San Francisco, CA 94143-1660
    Affiliations
    Department of Pediatrics, University of California, San Francisco (KL Karvonen, JS Menjívar-López, D Brissett, D McBride, R Olveda, C Cribb Fabersunne, O Low, M Cronin, and BR Argueza)
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  • Jennifer S. Menjívar-López
    Affiliations
    Department of Pediatrics, University of California, San Francisco (KL Karvonen, JS Menjívar-López, D Brissett, D McBride, R Olveda, C Cribb Fabersunne, O Low, M Cronin, and BR Argueza)

    Department of Pediatrics, San Francisco General Hospital and Trauma Center (JS Menjívar-López and D McBride), San Francisco, Calif
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  • Daniela Brissett
    Affiliations
    Department of Pediatrics, University of California, San Francisco (KL Karvonen, JS Menjívar-López, D Brissett, D McBride, R Olveda, C Cribb Fabersunne, O Low, M Cronin, and BR Argueza)
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  • Dannielle McBride
    Affiliations
    Department of Pediatrics, University of California, San Francisco (KL Karvonen, JS Menjívar-López, D Brissett, D McBride, R Olveda, C Cribb Fabersunne, O Low, M Cronin, and BR Argueza)

    Department of Pediatrics, San Francisco General Hospital and Trauma Center (JS Menjívar-López and D McBride), San Francisco, Calif
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  • Rebecca Olveda
    Affiliations
    Department of Pediatrics, University of California, San Francisco (KL Karvonen, JS Menjívar-López, D Brissett, D McBride, R Olveda, C Cribb Fabersunne, O Low, M Cronin, and BR Argueza)
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  • Camila Cribb Fabersunne
    Affiliations
    Department of Pediatrics, University of California, San Francisco (KL Karvonen, JS Menjívar-López, D Brissett, D McBride, R Olveda, C Cribb Fabersunne, O Low, M Cronin, and BR Argueza)

    San Francisco Department of Public Health (C Cribb Fabersunne), San Francisco, Calif
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  • Olivia Low
    Affiliations
    Department of Pediatrics, University of California, San Francisco (KL Karvonen, JS Menjívar-López, D Brissett, D McBride, R Olveda, C Cribb Fabersunne, O Low, M Cronin, and BR Argueza)
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  • Morgan Cronin
    Affiliations
    Department of Pediatrics, University of California, San Francisco (KL Karvonen, JS Menjívar-López, D Brissett, D McBride, R Olveda, C Cribb Fabersunne, O Low, M Cronin, and BR Argueza)
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  • Bianca R. Argueza
    Affiliations
    Department of Pediatrics, University of California, San Francisco (KL Karvonen, JS Menjívar-López, D Brissett, D McBride, R Olveda, C Cribb Fabersunne, O Low, M Cronin, and BR Argueza)
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Published:October 19, 2021DOI:https://doi.org/10.1016/j.acap.2021.09.020

      Abstract

      A racially and ethnically diverse physician workforce is critical to meeting the needs of the United States’ increasingly diverse patient population. Unfortunately, Black, Latinx, American Indian, and Alaska Native communities remain underrepresented in medicine. The disproportionate impact of the COVID-19 pandemic by race/ethnicity and increased public attention to anti-Black and anti-Asian racism have inspired a growing national discourse on addressing systemic racism. Within academic medicine, there has been a call for the fundamental incorporation of antiracism into medical training and professional competency. From the perspective of a group primarily led by residents who are women of color, we describe our 6 years of experience leading a Diversity Committee that catalyzed sustained and systemic efforts to advance diversity, equity, inclusion (DEI), and antiracism at a large urban pediatrics residency program. We outline the implementation and key outcomes of the Diversity Committee's ongoing initiatives to increase resident diversity, foster an inclusive learning environment, develop a resident curriculum on DEI and antiracism, and center the needs and wisdom of the communities that our institution serves. Finally, we highlight challenges and lessons learned to inform other institutions striving to advance DEI and antiracism in academic medicine.

      Keywords

      What's New
      We describe the work of a Diversity Committee in implementing sustained and systemic efforts to advance diversity, equity, inclusion, and antiracism in a pediatrics residency program. We describe lessons learned and challenges to inform efforts at other institutions.
      Increasing the racial and ethnic diversity of the physician workforce can improve the health care system's ability to meet the needs of diverse patient populations.
      • Cohen JJ
      • Gabriel BA
      • Terrell C.
      The case for diversity in the health care workforce.
      ,
      • Cooper LA
      • Powe NR.
      Disparities in Patient Experiences, Health Care Processes, and Outcomes: The Role of Patient-Provider Racial, Ethnic, and Language Concordance.
      A racially and ethnically diverse physician workforce can improve the provision of quality care for patients from different cultural backgrounds, expand health care access for marginalized communities, increase patient satisfaction, and broaden research and public policy agendas.
      • Cohen JJ
      • Gabriel BA
      • Terrell C.
      The case for diversity in the health care workforce.
      ,
      • Cooper LA
      • Powe NR.
      Disparities in Patient Experiences, Health Care Processes, and Outcomes: The Role of Patient-Provider Racial, Ethnic, and Language Concordance.
      Unfortunately, Black, Latinx, American Indian, and Alaska Native communities remain underrepresented in medical school, graduate medical education, medical school faculty, and the physician workforce.

      United States Census Bureau. Overview of Race and Hispanic Origin: 2010. Available at: https://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf. 2011. Accessed February 20, 2021.

      Association of American Medical Colleges. Figure 8. Percentage of matriculants to U.S. medical schools by race/ethnicity (alone), academic year 2018-2019. Available at: https://www.aamc.org/data-reports/workforce/interactive-data/figure-8-percentage-matriculants-us-medical-schools-race/ethnicity-alone-academic-year-2018-2019. 2019. Accessed February 20, 2021.

      Accreditation Council for Graduate Medical Education. Data resource book, academic year 2018-2019. Available at: https://www.acgme.org/About-Us/Publications-and-Resources/Graduate-Medical-Education-Data-Resource-Book. 2019. Accessed February 20, 2021.

      Association of American Medical Colleges. Figure 15. Percentage of full-time U.S. medical school faculty by race/ethnicity, 2018. Available at: https://www.aamc.org/data-reports/workforce/interactive-data/figure-15-percentage-full-time-us-medical-school-faculty-race/ethnicity-2018. 2018. Accessed February 20, 2021.

      Association of American Medical Colleges. Figure 18. Percentage of all active physicians by race/ethnicity, 2018. Available at: https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018. 2019. Accessed February 20, 2021.

      Physicians who are underrepresented in medicine (UIM) experience structural and interpersonal barriers, including racial microaggressions and bias, social isolation, inequitable career advancement, and limited access to racially and ethnically congruent mentorship.

      Association of American Medical Colleges. Figure 18. Percentage of all active physicians by race/ethnicity, 2018. Available at: https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018. 2019. Accessed February 20, 2021.

      ,

      Association of American Medical Colleges. Underrepresented in medicine definition. Available at: https://www.aamc.org/what-we-do/diversity-inclusion/underrepresented-in-medicine. 2004. Accessed February 25, 2021.

      UIM physicians also experience “minority tax,” frequently carrying extra responsibilities to promote diversity without recognition or compensation. These obstacles and many others contribute to the limited progress in increasing the diversity of the physician workforce and stifle the success and wellbeing of UIM physicians.
      Medical training programs and their accrediting bodies have increasingly recognized the need to diversify the physician workforce. The Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education have issued requirements to implement sustained and systemic efforts to recruit and retain a diverse physician workforce in medical schools (2009), residency programs (2019), and fellowship programs (2020).

      Liaison Committee on Medical Education. Liaison Committee on Medical Education (LCME) Standards on Diversity. Available at: https://health.usf.edu/∼/media/Files/Medicine/MD%20Program/Diversity/LCMEStandardsonDiversity1.ashx?la=en. Accessed February 20, 2021.

      Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements (Residency). Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRResidency2019.pdf. 2018. Accessed February 20, 2021.

      Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements (Fellowship). Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRFellowship2020.pdf. 2020. Accessed February 20, 2021.

      Meanwhile, racial inequities in the impact of the COVID-19 pandemic and increased public attention to anti-Black and anti-Asian racism have catalyzed a growing national discourse on advancing antiracism, including in academic medicine. Antiracism refers to practices and policies that redistribute power and resources to achieve racial equity.
      • Kendi IX.
      How to Be an Antiracist.
      There is an urgent need to ensure that all physicians understand how systemic racism perpetuates health inequities and develop the skills to promote equitable health outcomes in the communities they serve. Incorporating antiracism curricula into medical education and requiring physicians to understand the health effects of structural racism as a professional competency are crucial steps toward these goals.
      • Ahmad NJ
      • Shi M.
      The need for anti-racism training in medical school curricula.
      ,
      • Hardeman RR
      • Medina EM
      • Boyd RW
      Stolen breaths.
      In this article, we, as former leaders of a Diversity Committee at a large urban pediatrics residency program, describe our sustained and systemic efforts to increase resident diversity, foster an inclusive learning environment, implement a resident curriculum on diversity, equity, inclusion (DEI), and antiracism, and center the communities we serve. We discuss the implementation and key outcomes of these initiatives over the past 6 years. From the unique perspective of a group led primarily by residents who are women of color, we highlight challenges and lessons learned to inform efforts at other academic medical institutions.

      Impetus

      In 2015, 3 of the authors led a handful of residents and faculty to revitalize the Diversity Committee at the University of California, San Francisco (UCSF) Pediatrics Residency Program. While the Diversity Committee had existed for years, it had inconsistent participation and primarily focused on recruiting UIM applicants during recruitment season with limited success. That year, only 3 (11%) residents identified as UIM (Table 1). Sustained and systemic efforts were clearly needed to effectively recruit and support UIM physicians.
      Table 1Matriculating Interns at the University of California, San Francisco (UCSF) Pediatrics Residency Program by Self-Reported Race/Ethnicity and Academic Year, 2015 to 2022
      Academic Year2015–20162016–20172017–20182018–20192019–20202020–20212021–2022
      All interns, n28282728292828
      UIM interns, n (%)3 (11)4 (14)4 (15)9 (32)13 (45)10 (36)14 (50)
      UIM (underrepresented in medicine) refers to people who identify as having heritage including Black/African American, Latinx, Native American, Native Alaskan, Native Hawaiian, Other Pacific Islander, and South East Asian (including Hmong and Filipino/a).

      Mission and Goals

      The mission of the revitalized Diversity Committee was to increase the recruitment of UIM physicians, foster a community that allows UIM physicians to thrive, and train physicians to provide quality care for diverse patient populations. To inform this work, we conducted a climate survey assessing residents’ perceptions of the residency program's support of DEI in terms of physician recruitment, the resident curriculum, the program climate, and resident mentorship. We developed 5 goals based on the results:
      • 1.
        Obtain explicit commitment from the residency program and department of pediatrics to support the committee's mission in the form of leadership engagement, funding, and other key resources.
      • 2.
        Implement a robust recruitment, retention, and support strategy for UIM residents, fellows, and faculty, including strengthening UIM mentorship.
      • 3.
        Develop a longitudinal curriculum to teach residents skills to address bias, support colleagues from diverse backgrounds, and care for diverse patient populations
      • 4.
        Foster an inclusive climate and community.
      • 5.
        Monitor progress toward the committee's mission and goals.
      The Diversity Committee has since added a goal to 6) center the needs and collective wisdom of the communities that UCSF serves and strives to apply an antiracist lens in all its initiatives.

      Structure and Responsibilities

      We developed a branched leadership structure to address each goal while distributing tasks to make it easier for busy physicians to engage. The committee includes a leadership core (3 resident leaders and a Director of Diversity faculty member) and 7 subcommittees (recruitment, curriculum, social, community partnership, advocacy, liaison and alliance, and media). Each subcommittee is led by 2 to 3 resident co-chairs and 1 to 2 faculty advisors who engage resident, fellow, and faculty subcommittee members. The Associate Residency Program Director (APD) for DEI and a chief resident DEI Champion also support the Diversity Committee.
      The leadership core oversees the subcommittees and engages residency and departmental leadership to obtain funding and logistical support. The recruitment subcommittee attends regional and national conferences held by UIM medical student organizations and works with the APD for DEI to support the recruitment of UIM residents. The curriculum subcommittee works with the APD for DEI and the Chief Resident DEI Champion to implement a resident curriculum on DEI and antiracism. The social subcommittee organizes community-building events for UIM applicants, residents, fellows, and faculty and allies. The community partnership subcommittee works with local pipeline programs that promote higher education and health careers for youth from underrepresented backgrounds. The advocacy subcommittee works with internal and external organizations that promote DEI and antiracism, from hospital policies to broader legislation that affect child health. The liaison and alliance subcommittee facilitates mutually reinforcing activities with UCSF organizations that are doing similar DEI and antiracism work. The media subcommittee maintains the Diversity Committee's website and promotes our activities on the residency program's recruitment materials and related media.

      Key Outcomes

      Table 2 summarizes key outcomes related to the Diversity Committee's goals from 2015 to 2021.
      Table 2Key Outcomes Related to the Goals of the Diversity Committee at the University of California, San Francisco (UCSF) Pediatrics Residency Program by Academic Year, 2015 to 2021
      GoalsKey Outcomes
      Institutional commitment

      Obtain explicit commitment from the residency program and department of pediatrics to support the committee's mission in the form of leadership engagement, funding, and other key resources
      2016–2017
      • Limited funding for DEI-related convenings was obtained
      • The Chief Resident DEI Champion role was established
      2017–2018
      • A Director of Diversity for the department of pediatrics was appointed
      2018–2019
      • An APD for DEI was appointed
      Recruitment and retention

      Implement a robust recruitment, retention, and support strategy for UIM residents, fellows, and faculty, including strengthening UIM mentorship
      2016–2017
      • Socials for UIM residency applicants were implemented
      • Diversity Committee members were intentionally included in the Ranking Advisory Committee
      2017–2018
      • Antiracist holistic review principles were incorporated into the intern selection rubric
      • Anti-bias training was required for all Ranking Advisory Committee members
      2018–2019
      • “Diversity Days” for UIM residency applicants were implemented
      • “Second Look” opportunities for UIM residency applicants were implemented
      Curriculum

      Develop a longitudinal curriculum to teach residents skills to address bias, support colleagues from diverse backgrounds, and care for diverse patient populations
      2017–2018
      • DEI-focused noon conferences and grand rounds were implemented
      2020–2021
      • A longitudinal resident DEI and antiracism curriculum was launched
      Climate and community

      Foster an inclusive climate and community
      2017–2018
      • “Summer Celebrations” were implemented in the department of pediatrics
      Centering communities

      Center the needs and collective wisdom of the communities that UCSF serves
      2019–2020
      • An educational webinar series for underrepresented high school students was developed in partnership with a local pipeline program
      Tracking progress

      Monitor progress toward the Diversity Committee's mission and goals
      2015–2016
      • An annual climate survey for residents was implemented
      • A consistent definition of UIM was implemented in the residency program
      APD indicates Associate Residency Program Director; DEI, Diversity, equity, and inclusion; and UIM, Underrepresented in medicine.

       Institutional Commitment

      In 2016, the Diversity Committee presented a report informed by the climate survey to the residency program and department of pediatrics leadership including a request for substantive support to achieve its goals. The Diversity Committee advocated to establish 3 key leadership roles: a departmental Director of Diversity (10% full-time equivalent) to support the Diversity Committee and broader departmental initiatives, an APD for DEI (10% full-time equivalent) to support the recruitment of UIM residents and the development of a DEI curriculum, and a Chief Resident DEI Champion to facilitate resident-facing initiatives.

       Recruitment and Retention

      Diversity Committee members are intentionally included in the residency program's Ranking Advisory Committee to support the thoughtful review of UIM applicants. The Diversity Committee also helped incorporate holistic review principles into the intern selection rubric to reduce bias and explicitly value the contributions of UIM applicants.

      Association of American Medical Colleges. Holistic review. Available at: https://www.aamc.org/services/member-capacity-building/holistic-review. Accessed February 24, 2021.

      Notably, the Diversity Committee pushed to eliminate an ill-defined “global ranking score” that was meant to determine overall fit but invited implicit bias as there was no specific criteria and relied solely on the individual reviewer's opinion of the candidate's perceived suitability for the residency program. The Diversity Committee advocated for creating a “DEI” score to reward contributions to DEI. The Diversity Committee also championed mandatory anti-bias training for Ranking Advisory Committee members.
      The Diversity Committee works with the residency program to organize special events for UIM applicants during recruitment season: informal socials hosted by residents, unique interview days called “Diversity Days” that showcase DEI initiatives, and “Second Look” opportunities. The Diversity Committee also sends personalized correspondence to UIM applicants to answer questions and offer support.
      As these recruitment strategies have been implemented, the racial and ethnic diversity of the residency program has significantly increased.
      • Marbin J
      • Rosenbluth G
      • Brim R
      • et al.
      Improving diversity in pediatric residency selection: using an equity framework to implement holistic review.
      The number of matriculating UIM interns increased from 3 (11%) in 2015 to 2016 to 14 (50%) in 2021 to 2022 (Table 1).

       Curriculum

      The Diversity Committee works with the chief residents to implement DEI-focused noon conferences and grand rounds (eg, racial inequities in preterm birth, gender-affirming care, school-to-prison pipeline). The Diversity Committee also helped develop a required longitudinal curriculum on DEI and antiracism for residents. The curriculum includes didactics (eg, cultural humility, structural racism, stereotype threat, leading a diverse team), standardized simulations on interrupting microaggressions, and racial affinity groups. The racial affinity groups are facilitated opportunities to discuss experiences of racism, power, privilege, and allyship within the context of social identity.
      • Hudson KD
      • Mountz SE
      Teaching note—third space caucusing: borderland praxis in the social work classroom.
      Residents can also participate in optional social justice discussion clubs, which use media (eg, books, podcasts, movies) to facilitate conversations on social justice. The curriculum's impact on residents’ sense of inclusion and capacity to address interpersonal biases and structural factors is currently being evaluated.

       Climate and Community

      In addition to hosting regular socials to build community among UIM physicians and allies, the Diversity Committee collaborates with the department of pediatrics to host annual “Summer Celebrations'' to celebrate their accomplishments.

       Centering Communities

      The Diversity Committee partnered with FACES for the Future Coalition, a local organization that supports underrepresented high school students in pursuing higher education and health careers, to create a series of educational webinars, which were attended by over 300 students in California, Colorado, and New Mexico.

      UCSF Medical Education School of Medicine. UCSF pediatrics diversity committee hosts virtual outreach program for high school students. Available at: https://meded.ucsf.edu/news/ucsf-pediatrics-diversity-committee-hosts-virtual-outreach-program-high-school-students. 2020. Accessed February 24, 2021.

      The webinar series included a health care career panel, pediatric case simulations, a COVID-19 informational forum, and a wellness and resilience exercise.

       Tracking Progress

      To monitor the impact of its initiatives, the Diversity Committee implemented an annual climate survey to assess residents’ perception of the residency program's support of DEI. The results are not reported here due to inadequate response rates. The Director of Diversity, which has been elevated to the role of Vice Chair for DEI due in part to advocacy by the Diversity Committee, and APD for DEI are now responsible for monitoring progress toward DEI efforts. This change reflects our success in embedding this responsibility at the institutional level.

      Discussion

      The Diversity Committee has catalyzed sustained and systemic efforts to advance DEI and antiracism in the UCSF pediatrics residency program and department of pediatrics. These initiatives have led to a more diverse residency program, a longitudinal DEI and antiracism curriculum, robust community-building efforts, and community partnerships.

       Next Steps

      Despite the Diversity Committee's progress, many opportunities remain. The Diversity Committee hopes to develop a community advisory board to guide DEI efforts in the residency program and department of pediatrics. Centering in the margins, or “[m]aking the perspectives of socially marginalized groups…the central axis around which discourse on a topic revolves,” is fundamental to antiracism.
      • Ford CL
      • Airhihenbuwa CO
      Critical race theory, race equity, and public health: toward antiracism praxis.
      Diversity Committee members are helping to develop a mentorship program, with a particular focus on supporting UIM residents. Diversity Committee members are also engaged in initiatives to increase the recruitment and retention of UIM fellows and faculty. The Diversity Committee is advocating for strengthening mentorship for UIM fellows and developing support structures for trainees who experience racism and discrimination. The Diversity Committee is also advocating for DEI-focused professional development workshops, diverse search committees for faculty positions, and explicitly valuing DEI work in faculty advancement.

       Challenges

      The Diversity Committee faced several critical challenges. Limited time and funding were significant barriers, and more robust institutional investment (eg, additional paid faculty time, implementation funds, support staff) is needed to achieve the Diversity Committee's goals. As a group primarily led by residents who are women of color, we also experienced minority tax, which must be addressed to create a truly antiracist institution. DEI and antiracism work is emotionally exhausting and takes time away from medical education, other professional interests, and self-care. Additionally, limited participation in the climate surveys made it challenging to comprehensively assess progress, and a more detailed measure will be required moving forward.

       Lessons Learned

      As academic medical institutions implement their own initiatives to advance DEI and antiracism, we highlight several factors that contributed to the Diversity Committee's success. Aligning with institutional leaders and calling for the development of DEI-focused leadership roles was critical. The Director for Diversity facilitated access to departmental funds, while the APD for DEI facilitated reforms in intern recruitment and resident education. Focusing on changing policies and employing a longitudinal, multipronged approach was crucial because systemic racism must be addressed with systemic solutions. For example, the recruitment of a diverse residency program must parallel the development of a mentorship program that can meet the needs of an increasing number of UIM residents. We also learned that a continuous leadership structure is necessary to implement longitudinal initiatives, while periodic changes in leadership (ie, when residents graduate) encourage innovation, as reflected in the Diversity Committee's evolving goals and initiatives. Further, recruiting a large membership of deeply engaged physicians through annual recruitment emails facilitated a more feasible distribution of labor for busy physicians. Finally, faculty advisors played an impactful role in leveraging their positionality to amplify resident voices and advocate for institutional change.

      Conclusion

      There is an urgent need to increase the racial and ethnic diversity of the physician workforce, support the success and wellbeing of UIM physicians, and train antiracist physicians. By implementing sustained and systemic efforts, academic medical institutions can make a meaningful impact in advancing DEI and antiracism.

      Acknowledgments

      Financial statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
      The authors wish to thank the dedicated members of the Diversity Committee who have volunteered their time and efforts for the benefit of their institution and the communities they serve. The authors also wish to thank Drs Alma Martinez and Jyothi Marbin for their thoughtful review of this article and ongoing support for the work described. Finally, the authors wish to thank Drs Carol Miller, Amber Pope, Edward Cruz, and Tim Kelly for their support in revitalizing the Diversity Committee.

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