Justice Equity Diversity Inclusion Toolbox

Strategic Recommendations to Promote Justice, Equity, Diversity, and Inclusion Principles in the Pediatric Scientific Workforce

Domain: Support and Allyship 

Focus: Social Isolation and Acculturation 

Special Challenges for Underrepresented Minorities and International Medical Graduates in Academic Medicine 

Authors: Bindiya Bagga, MD and Shilpa Vyas-Read, MD  

Editor: Jamie L Lohr, MD 

On behalf of the Justice Equity Diversity and Inclusion Committee, Society for Pediatric Research 

Background:

Within academic environments, only 17-19% of underrepresented minorities (URM) and 20 – 26% of women are full professors or in senior leadership positions^1,2,3.  Biases and discrepancies between mission statements and their implementation in academia may contribute to a culture that constrains the advancement of URM and women to higher-ranks among faculty⁴. The resultant lack of a “critical mass” of URM in the workforce can impede the natural formation of social networks that engage faculty and create employment and advancement opportunities within institutions^5. Nationally, this can lead to a paucity of high-ranking URM and female faculty that can be professionally isolating.

Social isolation, which is defined as a measure of social network size and frequency of social interactions, has been associated with psychological distress and is often cited as contributory to poor retention and professional satisfaction in scientific communities^2,6. Difficulties with cross-cultural communication coupled with small minority numbers in faculty can also contribute to feelings of being “invisible” and socially isolated⁷.  URM and women in academic settings experience exhaustion from serving as representatives on diversity and minority committees, and from being pulled from smaller pools of faculty willing to serve as mentors for trainees. A lack of social network may weaken the opportunities for professional growth and serve to perpetuate the stereotype that minorities are unable to progress in the academic environment^5,8.  Further, the scarcity of role models and mentors with whom URM and women can identify may cloud the path to promotion in the academic environment⁹.

Based on survey data, departmental culture affects both the quality of research and the mental health of URM and women within institutions^7,10. URM and women are more likely contribute to “invisible work,” including formal and informal mentoring and committee work, that is outside traditional pathways to promotion but contributes to workload and feelings of burnout. Social isolation may additionally contribute to increased feelings of burnout as social support networks have been shown to attenuate feelings of exhaustion and cynicism among healthcare professionals¹⁰. As women and URM who experience discrimination have higher rates of burnout, factors affecting social isolation within academic institutions should be formally addressed^11,12.

International medical graduates (IMGs) are another group whose members are an important part of the physician work force and may face obstacles to a research career or career advancement^13,14. IMGs are a heterogenous group of physicians who have received their medical degree outside the United States (US) and Canada¹⁵. This group includes US citizens who went abroad for their medical degree before pursuing post-graduate training in the US.  IMG’s account for 23.2% of all general pediatricians and pediatric subspecialists. There are many challenges that non-US born IMGs face which might dissuade them from pursuing a career as a physician scientist in an academic setting or may limit or delay success when they do^13,14.

Challenges for women and URM in academic medicine include: 

1. Fewer mentors and role models for women and URM faculty
2. Fewer networking opportunities due to lack of “critical mass” of women and URM faculty in positions of power at individual institutions
3. Slower career advancement and potentiation of stereotypes due to lack of infrastructure to support women, URM and IMGs.
4. Women and URM spend more time serving communities, providing mentorship to women and URM mentees, serving on diversity committees, and doing “invisible work” that is not recognized in salary consideration or on the promotion pathway.
5. Social isolation may accentuate burnout by decreasing social support systems.

Unique challenges for IMGs in academic medicine include:

1. Acculturation
2. Lack of mentoring
3. Changing Immigration requirements
4. Fewer NIH funding opportunities
5. Overt and covert forms of bias and discrimination.
6. Transparency regarding conditions of employment (unspoken limitations)

What Can National Organizations Do?

1. Empower physicians by advocating for women, URM and IMGs on a system-level across national institutions
2. Benchmark adherence to diversity goals and publicly acknowledge institutions that perform well through awards and publications in national journals
3. Create survey and funding opportunities to investigate the determinants of diversification in the workplace
4. Create large scale databases to evaluate patient-level outcomes based on the diversity of the faculty within an institution
5. Create sub-sections within national organizations for women, URM and IMGs to allow networking opportunities across institutions
6. Create a list serve of female, URM and IMG faculty willing to mentor and support trainees, junior and mid-career faculty
7. Collaborate with other national organizations to empower pediatric residency program leaders with tools to help with effective and timely acculturation.
8. Create a resource of all available funding opportunities for IMGs on VISA in all pediatric subspecialities and make this easily available to pediatric residency and fellowship program directors through national organizations like APPD (Association of Pediatric Program Directors).

What Can Institutions Do?

Current Recommendations:

1. Create a leadership structure that provides equal access to opportunities and resources
2. Standardize and conduct regular bias and diversity training for members of recruitment and promotion committees
3. Regularly examine the diversity of faculty, and promote retention and recruitment of female, IMG and URM faculty
4. Foster pathways to promotion and leadership for URM. IMGs and women to create a critical mass of senior faculty
5. Promote and reward research on community-based care and health disparities
6. Foster the development of peer affinity networks within and across institutions
7. Consider non-traditional pathways to promotion and recognition for “invisible work”
8. Consider alternative work schedules to promote flexibility and well-being within faculty

Specific Recommendations for IMGs:

1. Institutions should provide an acculturation tool kit to help with the transition to a new work climate¹⁵. Given that IMGs are a heterogeneous group with diverse cultural and ethnic backgrounds, the initiatives must be individualized.
2. More formal and directed mentoring at institutional and national level ¹⁶ 
   1. faculty development on cultural humility and implicit bias training
   2. Networking – outside mentors
3. Increase in funding opportunities
4. Support institutional transparency during hiring
5. Policies to address systemic discrimination
6. Transparent, effective, and easily accessible microaggression reporting system

Aspirational Recommendations for Institutions:

1. Increase the recruitment, promotion and retention of female, IMG and URM faculty by utilizing quality-based approaches^17,18
2. Create diversity training curriculums for pediatric trainees (medical students, residents, and fellows) and faculty, to promote awareness of how bias and discrimination may affect childhood health outcomes¹⁹
3. Fund the generation of alternative networks for scientific publications, grant sponsorship, and promotion of diversity-focused literature^20,21
4. Increase “visibility” of women, URM and IMG to enhance mentorship opportunities for trainees and to broaden workforce diversity²²
5. Define short- and long-term goals for increases in women, IMG and URM faculty nationally and conduct regular internal institutional and national assessments potentially utilizing strategies such as the “Holistic Review Framework”²³
6. Enforce “zero tolerance” policies to discrimination and bias in the workplace
7. Sponsor events that increase community and opportunities for advancement of women, URM and IMG by sponsoring social events, networking opportunities, and affinity groups²⁴

What Can Individuals Do?

1. Faculty should be trained in the recognition of implicit bias in themselves and others
2. Leadership should make conscious efforts to be inclusive when allocating opportunities and resources for research and promotion
3. Leaders and faculty should make introductions and extend networking opportunities to women, IMGs and URM both within the institution and at professional conferences²⁵
4. Faculty may introduce female, URM and IMG faculty to potential mentors both within the institution and nationally
5. Divisions may construct teams that value diversity and recognize barriers to the recruitment and retention of female, URM, and IMG faculty²⁶
   1. Women, URM, and IMGs may be offered positions on faculty, trainee, and staff recruitment committees
   2. Individuals and divisions may create affinity groups to provide social support systems for women, URM and IMGs
   3. Men and non-URM faculty may be allies by participating in diversity initiatives and health equities research

References Cited

1. Westring AF, Speck RM, Dupuis Sammel M, et al. Culture matters: the pivotal role of culture for women’s careers in academic medicine. Acad Med. 2014;89(4):658-663.
2. Albert MA. #Me_Who Anatomy of Scholastic, Leadership, and Social Isolation of Underrepresented Minority Women in Academic Medicine. Circulation. 2018;138(5):451-454. doi:10.1161/CIRCULATIONAHA.118.035057
3. Silver JK, Poorman JA, Reilly JM, Spector ND, Goldstein R, Zafonte RD. Assessment of Women Physicians Among Authors of Perspective-Type Articles Published in High-Impact Pediatric Journals. JAMA Netw Open. 2018;1(3). e180802. doi:10.1001/jamanetworkopen.2018.0802
4. Sotto-Santiago S, Sharp S, Mac J, et al. Reclaiming the mission of academic medicine: An examination of institutional responses to (anti)racism. AEM Educ Train. 2021;5(Suppl 1):S33-S43. doi:10.1002/aet2.10668
5. Bowden AK, Buie CR. Anti-Black racism in academia and what you can do about it. Nat Rev Mater. August 2021:1-2. doi:10.1038/s41578-021-00361-5
6. Das A, Padala KP, Crawford CG, et al. A systematic review of loneliness and social isolation scales used in epidemics and pandemics. Psychiatry Res. 2021;306:114217. doi:10.1016/j.psychres.2021.114217
7. Pololi L, Cooper LA, Carr P. Race, disadvantage and faculty experiences in academic medicine. J Gen Intern Med. 2010;25(12):1363-1369. doi:10.1007/s11606-010-1478-7
8. Kaplan SE, Gunn CM, Kulukulualani AK, Raj A, Freund KM, Carr PL. Challenges in Recruiting, Retaining and Promoting Racially and Ethnically Diverse Faculty. J Natl Med Assoc. 2018;110(1):58-64. doi:10.1016/j.jnma.2017.02.001
9. Price EG, Gozu A, Kern DE, et al. The role of cultural diversity climate in recruitment, promotion, and retention of faculty in academic medicine. J Gen Intern Med. 2005;20(7):565-571. doi:10.1111/j.1525-1497.2005.0127.x
10. Westring AF, Speck RM, Sammel MD, et al. A culture conducive to women’s academic success: development of a measure. Acad Med. 2012;87(11):1622-1631. doi:10.1097/ACM.0b013e31826dbfd1
11. Silver JK, Bean AC, Slocum C, et al. Physician Workforce Disparities and Patient Care: A NarrativeReview. Health Equity. 2019;3(1):360-377. doi:10.1089/heq.2019.0040
12. Ramas M-E, Webber S, Braden AL, Goelz E, Linzer M, Farley H. Innovative Wellness Models to Support Advancement and Retention Among Women Physicians. Pediatrics. 2021;148(Suppl 2). doi:10.1542/peds.2021-051440H
13. Chen PG-C, Curry LA, Bernheim SM, Berg D, Gozu A, Nunez-Smith M. Professional challenges of non-U.S.-born international medical graduates and recommendations for support during residency training. Acad Med. 2011;86(11):1383-1388. doi:10.1097/ACM.0b013e31823035e1
14. Chakraborty R, Rathore MH, Dreyer BP, Stein F. The Pivotal Role of the International Medical Graduate. Pediatrics. 2019;143(2). doi:10.1542/peds.2018-1189
15. Duvivier RJ, Gusic ME, Boulet JR. International Medical Graduates in the Pediatric Workforce in the United States. Pediatrics. 2020;146(6):e2020003301

15. Katz C, Barnes M, Osta A, Walker-Descartes I. The Acculturation Toolkit: An Orientation for Pediatric International Medical Graduates Transitioning to the United States Medical System. MedEdPORTAL. 2020 Jul 16;16:10922. doi: 10.15766/mep_2374-8265.10922. PMID: 32704536; PMCID: PMC7373352
16. Joseph MM, Ahasic AM, Clark J, Templeton K. State of Women in Medicine: History, Challenges, athe Benefits of a Diverse Workforce. Pediatrics. 2021;148(Suppl 2). doi:10.1542/peds.2021-051440C.
17. Unaka NI, Winn A, Spinks-Franklin A, et al. An Entrustable Professional Activity Addressing Racism and Pediatric Health Inequities. Pediatrics. January 2022. doi:10.1542/peds.2021-054604.
18. McPeek-Hinz E, Boazak M, Sexton JB, et al. Clinician Burnout Associated With Sex, Clinician Type, Work Culture, and Use of Electronic Health Records. JAMA Netw Open. 2021;4(4):e215686. doi:10.1001/jamanetworkopen.2021.5686.
19. Spector ND, Asante PA, Marcelin JR, et al. Women in Pediatrics: Progress, Barriers, and Opportunitiesfor Equity, Diversity, and Inclusion. Pediatrics. 2019;144(5). doi:10.1542/peds.2019-2149.
20. Ofili EO, Sarpong D, Yanagihara R, et al. The Research Centers in Minority Institutions (RCMI) Consortium: A Blueprint for Inclusive Excellence. Int J Environ Res Public Health. 2021;18(13). doi:10.3390/ijerph18136848.
21. Vinci RJ, Degnon L, Devaskar SU. Pediatrics 2025: The AMSPDC Workforce Initiative. J Pediatr. 2021;237:5–8.e1. doi:10.1016/j.jpeds.2021.02.004
22. Harris TB, Jacobs NN, Fuqua CF, et al. Advancing Equity in Academic Medicine Through Holistic Review for Faculty Recruitment and Retention. Acad Med. December 2021. doi:10.1097/ACM.0000000000004568
23. Flores G, Mendoza F, Brimacombe MB, Frazier W3. Program Evaluation of the Research in Academic Pediatrics Initiative on Diversity (RAPID): Impact on Career Development and Professional Society Diversity. Acad Med. 2021;96(4):549-556. doi:10.1097/ACM.0000000000003531
24. Davis T, Goldstein H, Hall D, et al. Women and children first? Gender equity in paediatric medicine. Arch Dis Child. 2021;106(2):201-203. doi:10.1136/archdischild-2018-316586
25. Dixon G, Kind T, Wright J, Stewart N, Sims A, Barber A. Factors That Influence the Choice of Academic Pediatrics by Underrepresented Minorities. Pediatrics. 2019;144(2). doi:10.1542/peds.2018-2759.

Additional References not cited:

Rao N.R., Kotapati V.P. (2020) Pathways for Success in Academic Medicine for an International Medical Graduate: Challenges and Opportunities. In: Roberts L. (eds) Roberts Academic Medicine Handbook. Springer, Cham. https://doi.org/10.1007/978-3-030-31957-1_18

Link to Comprehensive References on Social Isolation