The Priority of Intersectionality in Academic Medicine

Gender and Pathways to Leadership in Academic Anesthesiology: A Qualitative Content Analysis of US Chairpersons' Curricula Vitae

BACKGROUND

Women are underrepresented in medicine and academic anesthesiology, and especially in leadership positions. We sought to characterize career achievement milestones of female versus male academic anesthesiology chairs to understand possible gender-related differences in pathways to leadership.

METHODS

We conducted a retrospective observational cross-sectional analysis. In November 2019, curricula vitae (CVs) were requested from then-current members of the US Association of Academic Anesthesiology Chairs. Data reflecting accomplishments up to the time of chair appointment were systematically extracted from CVs and analyzed using a mixed methods approach with qualitative content analysis supplemented by descriptive statistics and bivariate statistical testing. Missing data were not imputed.

RESULTS

Seventy-two CVs were received from eligible individuals (response rate 67.3%). The respondent sample was 12.5% women (n = 9), 87.5% men (n = 63), and no transgender or nonbinary people; this is similar to the known gender balance in anesthesiology chairs in the United States. No statistically significant differences in objective markers of academic achievement at the time of chair appointment were evident for female versus male chairs, including time elapsed between the first faculty appointment and assumption of the chair role (median 25 vs 18 years, P = .06), number of publications at the time the chair was assumed (101 vs 69, P = .28), or proportion who had ever held a National Institutes of Health (NIH) grant as principal investigator (44.4% vs 25.4%, 0.25). Four phenotypes of career paths were discernible in the data: the clinician-administrator, the educator, the investigator, and the well-rounded scholar; these did not differ by gender.

CONCLUSIONS

Female chairpersons who were members of the Association of Academic Anesthesiology Chairs in the United States demonstrated similar patterns of academic achievement as compared to male chairpersons at the time the position of chair was assumed, suggesting that they were equally qualified for the role as compared to men. Four patterns of career achievements were evident in the chairperson group, suggesting multiple viable pathways to this leadership position.

Exploring poems of intersectionality in the disorientation of interprofessional learning

Exploring students' interprofessional education experiences highlights the occurrence of hierarchy as a barrier to collaborative practice. Individuals are however influenced by the multiple social identities of themselves and others and not just professional hierarchy. Intersectionality offers a useful lens through which to understand the complex influences of students' learning experiences. Using poetic inquiry, this paper explores the influence of intersectionality on health professional students' interprofessional learning experiences on two rural training platforms in South Africa. Sixteen individual interviews with final-year undergraduate students from five different healthcare professions were conducted in 2022. An inductive narrative analysis of the data was undertaken and represented using 'found poems'. Reflexive analysis of the data presented in poems was conducted with student participants, co-authors, and an independent qualitative researcher. Themes related to the intersection of language and ethnicity, religion and profession, culture and profession as well as professional discipline and being a student were extracted from the data. Participants demonstrated disorienting learning experiences in both the clinical and social context. Using intersectionality as a lens, we have gained insight into the sometimes-disorienting influence of students' intersecting social identities during interprofessional learning on two rural training platforms. A nuanced understanding of how multiple social identities intersect to influence experiences could help educators mitigate student and educator biases and understand structural power dynamics in training environments. Transformative learning may be a way to introduce intersectionality into both interprofessional education and health professions education in general.

Gender and race in radiology: An intersectional analysis of the American Association of Medical Colleges (AAMC) database from 1966 to 2021

PURPOSE

To describe trends in gender and racial representation within academic radiology in the United States over a 55-year period from 1966 to 2021.

METHODS

A retrospective analysis of the American Association of Medical Colleges database of radiology faculty members from 1966 to 2021 was conducted. Trends in academic rank and tenure status for five different ethnoracial groups (White, Asian, Black, Hispanic, and Native American) each subdivided into two gender identities (men and women) were analyzed. The proportional change over time of each demographic group per outcome was analyzed with linear regression models.

RESULTS

Between 1966 and 2021, White men comprised the largest demographic in academic radiology each year. A significant decrease in both White individuals (-0.51 % per year) and men (-0.30 % per year) were observed over the study period. Additionally, the only demographic groups with meaningful changes in representation were White women (+0.20 % per year) and Asian men (+0.23 % per year), followed by Asian women in later years. Underrepresented minority groups (Black, Hispanic and Native American) collectively comprised less than 5 % of all academic radiologists. Finally, within each demographic group, the representation of women consistently lagged behind men. Despite these relative increases, in 2021, the majority of US academic radiologists were White (59.1 %) and male (70.1 %).

CONCLUSION

Historically underrepresented minorities, especially women within these groups, continue to face discrimination and are consistently the least represented in radiology. Initiatives that incorporate the intersectionality framework are imperative to break this cycle.

A critical awareness approach to cluster hiring for academic inclusion

Minoritized groups experience interpersonal, structural, and systemic marginalization that is also perpetuated within academic institutions. This marginalization produces barriers that exclude racial/ethnic minoritized groups within academic medicine from career opportunities and advancement. Racial/ethnic minoritized faculty are often expected to take on additional labor to serve the diversity needs of the program and/or institution that are often unrecognized or undervalued in the tenure or promotion process or detract from additional responsibilities. The unique needs resulting from multiple intersecting identities must be considered when planning initiatives to support minoritized groups in academia. This is detrimental to medicine as it limits innovation, perpetuates health disparities, and prevents the recruitment of scholars/physicians that are representative of the diversity within the U.S. population. Cluster hiring is a newer initiative adopted by many institutions; recently supported by funding from the National Institutes of Health (NIH) to improve diversity and inclusion of racial/ethnic minoritized groups. Here we discuss the elements of the cluster hire process and how they might be particularly relevant to intersectional inclusion and structural change of academic institutions, while also highlighting potential limitations to broad adoption. We conclude with recommendations for the potential need for integration of more culturally informed cluster hiring practices that can be made at the departmental, institutional and national level to positively impact the hiring, retention and advancement of faculty from marginalized populations.

Gender Bias in Patient Care Learning Experiences: Reflective Writings of Third-Year Medical Students

Introduction

Medical students' accounts of gender bias in their patient care learning experiences remain limited. This study examines students' responses to gender bias and their consideration for how to prepare for gender bias in their futures.

Methods

We analyzed reflective writings of third-year clinical students. Within a phenomenology framework, conventional content analysis was used to inductively analyze all essays, using HyperResearch software. We coded in teams and reconciled disagreements, then combined codes in categories to identify themes.

Results

Sixty-seven students (39 females; 28 males) wrote about gender bias in patient encounters. We identified five themes: bias, context, students' responses to patients' bias, patient-centered approach, and preparation for future encounters. Observations of bias addressed gender and structural bias, sexism, and racism. Students reflected on how context framed their experiences. Students aimed for patient-centered care, while simultaneously feeling ambivalence regarding patients' expressed bias. Students described their need to prepare for future experiences of gender bias and their plans to use specific strategies to cope with this bias.

Discussion

Our study offers the voices of medical students regarding gender bias in their clinical learning, presenting an important perspective, given an often-hierarchical system of medical education. This examination, which includes recommendations for curricula and policies, informs education leaders of the need to incorporate preparation for dealing with gender bias and to help students personally as they face challenging encounters with patients and medical teams. Enlightened by critical theories, these findings should also motivate resident and faculty development and promote critical inquiry for institutional changes.

Sense of Belonging Among Medical Students, Residents, and Fellows: Associations With Burnout, Recruitment Retention, and Learning Environment

PURPOSE

This study examines sense of belonging (belongingness) in a large population of medical students, residents, and fellows and associations with learner burnout, organizational recruitment retention indicators, and potentially modifiable learning environment factors.

METHOD

All medical students, residents, and fellows at Mayo Clinic sites were surveyed between October and November 2020 with items measuring sense of belonging in 3 contexts (school or program, organization, surrounding community), burnout (2 Maslach Burnout Inventory items), recruitment retention indicators (likelihood of recommending the organization and accepting a job offer), potentially modifiable learning environment factors, and demographics (age, gender, race and ethnicity, LGBTQ+ identification, disability, socioeconomic background).

RESULTS

Of 2,257 learners surveyed, 1,261 (56%) responded. The percentage of learners reporting a somewhat or very strong sense of belonging was highest in the school or program (994 of 1,227 [81%]) followed by the organization (957 of 1,222 [78%]) and surrounding community (728 of 1,203 [61%]). In adjusted analyses, learners with very strong organization belongingness had lower odds of burnout (odds ratio [OR], 0.05; 95% CI, 0.02-0.12) and higher odds of being likely to recommend the organization (OR, 505.23; 95% CI, 121.54-2,100.18) and accept a job offer (OR, 38.68; 95% CI, 15.72-95.15; all P < .001). School or program and community belongingness also correlated strongly with these outcomes. In multivariable analyses, social support remained associated with higher odds of belongingness in all 3 contexts; favorable ratings of faculty relationships and leadership representation remained associated with higher odds of belongingness in 2 contexts (school or program and organization); and favorable ratings of diversity, equity, and inclusion learning climate remained associated with belongingness in 1 context (community).

CONCLUSIONS

Sense of belonging among medical students, residents, and fellows varies across contexts, correlates strongly with burnout and organizational recruitment retention indicators, and is associated with multiple potentially modifiable learning environment factors.

The need for critical and intersectional approaches to equity efforts in postgraduate medical education: A critical narrative review

BACKGROUND

Racialised trainees in Canada and the USA continue to disproportionately experience discrimination and harassment in learning environments despite equity, diversity, and inclusion (EDI) reform efforts. Using critical approaches to understand what problems have been conceptualised and operationalised as EDI issues within postgraduate medical education (PGME) is important to inform ongoing learning environment reform in resident training.

METHODS

We conducted a critical narrative review of EDI literature from 2009-2022 using critical race theory (CRT) and the concept of intersectionality to analyse how issues of discrimination in PGME have been studied. Our search yielded 2244 articles that were narrowed down to 349 articles for relevance to Canadian and American PGME contexts. We attended to reflexivity and our positionality in analysing the database and identifying themes related to EDI reform.

RESULTS

Interest convergence was noted in how EDI reform was rationalised primarily by increased productivity. Problems of learner representation, gender inequities and curricular problems were conceptualised as EDI issues. The role that racism played in EDI-related problems was largely invisible, as were explicit conceptualisations of race and gender as social constructs. Overall, there was a lack of critical or intersectional approaches in the literature reviewed. Misalignment was noted where studies would frame a problem through a critical lens, but then study the problem without attention to power.

DISCUSSION

Interest convergence and epistemic injustice can account for the absence of critical approaches due to the alignment of existing EDI work with institutional interests and priorities. Interest convergence conceptually limits existing EDI reform efforts in PGME. CRT and intersectionality connect racialised learner experiences to systemic phenomena like racism and other forms of discrimination to challenge dominant assumptions. Because they attend to power, critical approaches are key to understanding why inequities have persisted to advance equity in learning environments for racialised and intersectionally marginalised learners.

Examining fundamental nursing textbooks for inclusivity and exclusivity content: A directed qualitative content analysis

BACKGROUND

Growing awareness of social inequities and injustices in education highlights the urgent need to address harmful mechanisms, policies, and norms within health education curricula and systems.

PURPOSE

This study examines inclusivity and exclusivity content in four fundamental nursing textbooks and contributes to the broader discourse on fostering equitable health education.

METHODS

A Directed Qualitative Content Analysis on 32 chapters from four fundamental nursing textbooks was systematically conducted. Seven codes within inclusivity and exclusivity themes were deductively developed from the literature. Inclusivity codes included equity language and contextualized race-based prevalence. Exclusivity codes included normalizing Whiteness in assessment, stigmatizing and negative descriptors, race-based prevalence without context, cisgenderism, and othering. Two trained analysts independently reviewed the chapters, assigning texts to these codes. Discrepancies were resolved by team consensus.

RESULTS

A total of 118 inclusivity instances: equity language (n = 109) and race-based prevalence with context (n = 9). Exclusivity codes were more prevalent (n = 642), including normalizing Whiteness (n = 398), stigmatizing descriptors (n = 106), cisgenderism (n = 59), and othering (n = 32).

CONCLUSION

The study highlights inclusive language in fundamental nursing textbooks but reveals significant exclusive language perpetuating negative generalizations, including marginalized identities and race prevalence without context. This content undermines person-centered care and hinders understanding the complex interplay between intersectionality, social justice, and social determinants of health.

Redefining professionalism to improve health equity in competency based medical education (CBME): A qualitative study

Purpose

There is a pressing need to address all forms of anti-oppression in medicine, given systemic harm and inequities in care and outcomes for patients and health care professionals from equity-deserving groups. Revising definitions of professionalism used in competency-based education can incorporate new professional competencies for physicians to identify and eliminate the root causes of these inequities. This study redefined the CanMEDS Professionalism definition to centre perspectives of equity-deserving groups.

Methods

In this qualitative study there were two phases. The authors conducted individual semi-structured interviews with participants representing equity-deserving population groups to understand their perspectives on and iteratively build a definition of medical professionalism. Then, the authors undertook a consensus-building process, a modified nominal group technique, using focus groups with community members from equity-deserving groups and healthcare providers to verify findings and arrive at an updated definition of medical professionalism.

Results

Four main themes were identified: 1) healthcare at the margins; 2) equity-oriented domains of professionalism; 3) structural professionalism; and 4) supporting improved professionalism. These themes were incorporated into a consensus-based definition of medical professionalism, with a focus on anti-oppression, anti-racism, accountability, safety, and equity.

Conclusions

The authors propose a new definition of medical professionalism that embeds anti-oppression, including anti-racism, as critical competencies in clinical practice and education.

Barriers and Facilitators to the Success of Black Academic Physicians

Despite efforts to recruit and retain Black physicians, Black individuals continue to be underrepresented in medicine in the USA. Although numerous studies have investigated the experiences of academic physicians from racial/ethnic backgrounds underrepresented in medicine, the experience of Black academic physicians, who may face additional unique challenges, remains underinvestigated. Using a qualitative research design, we investigate barriers to and facilitators of success and well-being of Black faculty at one academic medical center through interviews of 30 Black faculty members. Overall, ten themes emerged as barriers or facilitators to faculty success and well-being. Significant barriers include continued lack of representation; devaluing of research in community health and health disparities, as well as other diversity-related activities; and both overt and implicit discrimination, which contribute to feelings of isolation and disrespect. Facilitators include having a community to maintain sense of belonging, financial support for health disparities and diversity-related contributions, and collaboration with peers. Good mentorship and sponsorship as well as an institutional culture that supports inclusion can play significant roles as facilitators, whereas the lack of these factors can present substantial barriers. Institutional policies and external socio-political factors have a major influence on both the barriers and facilitators to the success and well-being of Black faculty. Our study has put a clearer focus on barriers that are unique to or more pronounced among Black faculty and the facilitators that may serve to mitigate these barriers. These findings can inform the design of interventions to recruit and retain Black faculty in medicine.

Exploring the implicit meanings of 'cultural diversity': a critical conceptual analysis of commonly used approaches in medical education

Existing approaches to cultural diversity in medical education may be implicitly based on different conceptualisations of culture. Research has demonstrated that such interpretations matter to practices and people concerned. We therefore sought to identify the different conceptualisations espoused by these approaches and investigated their implications for education. We critically reviewed 52 articles from eight top medical education journals and subjected these to a conceptual analysis. Via open coding, we looked for references to approaches, their objectives, implicit notions of culture, and to implementation practices. We iteratively developed themes from the collected findings. We identified several approaches to cultural diversity teaching that used four different ways to conceptualise cultural diversity: culture as 'fixed patient characteristic', as 'multiple fixed characteristics', as 'dynamic outcome impacting social interactions', and as 'power dynamics'. We discussed the assumptions underlying these different notions, and reflected upon limitations and implications for educational practice. The notion of 'cultural diversity' challenges learners' communication skills, touches upon inherent inequalities and impacts how the field constructs knowledge. This study adds insights into how inherent inequalities in biomedical knowledge construction are rooted in methodological, ontological, and epistemological principles. Although these insights carry laborious implications for educational implementation, educators can learn from first initiatives, such as: standardly include information on patients' multiple identities and lived experiences in case descriptions, stimulate more reflection on teachers' and students' own values and hierarchical position, acknowledge Western epistemological hegemony, explicitly include literature from diverse sources, and monitor diversity-integrated topics in the curriculum.

Graduates' Reflections on Professionalism and Identity: Intersections of Race, Gender, and Activism

Phenomenon: Professionalism as a construct is weaponized to police and punish those who do not fit the norm of what a medical professional should look like or behave, more so when medical professionals in training engage in protests for social justice. In addition, professionalism silences trainees, forcing them not to question anything that looks or feels wrong in their eyes. Socialization in medicine, in both the undergraduate and postgraduate training spaces, poses challenges for contemporary medical professionals who are expected to fit the shape of the 'right kind of doctor.' Intersectionality seems to impact how medical trainees experience professionalism, be it intersections of gender, race, how they dress or adorn themselves, how they carry themselves and who they identify as. Although there is literature on the challenges pertaining to professionalism, not much has been written about the weaponization of professionalism in medical training, particularly in the South African context. There is also a paucity of data on experiences of professionalism during or after social upheaval. Approach: This is part of a study that explored the experiences of professionalism of five medical trainees during protests and after protests, extending into their postgraduate training. The main study had 13 participants, eight students and five graduates, who were all interviewed in 2020, five years after the #FeesMustFall protests. For the five postgraduate participants, we looked at how gender, race, hairstyles, adornment, and protests played out in the experiences of professionalism as medical trainees at a South African university. We employed a qualitative phenomenological approach. An intersectional analytical lens was used in analyzing the transcripts of the five graduate participants. Each transcript was translated as the story of that participant. These stories were compared, looking for commonalities and differences in terms of their experiences. Findings: The participants, four males (three Black and one white) and one Black female, were victimized or judged based on their activism for social justice, gender, and race. They were made to feel that having African hairstyles or piercings was not professional. Insights: Society and the medical profession has a narrow view of what a doctor should look like and behave - it should not be someone who wears their hair in locks, has body piercing, or is an activist, least of all if she is a woman, as professionalism is used as a weapon against all these characteristics. Inclusivity should be the norm in medical education.

Who drive the health policy agenda in India? Actors in National Health Committees since Independence

Introduction

Health policies reflect the ideas and interests of the actors involved. The Indian Government constituted many health committees for policy recommendations on myriad issues concerning public health, ranging from tribal health to drug regulation. However, little is known about their composition and backgrounds. We reviewed these committees to map the actors and institutions.

Methods

We elicited information on all relevant health committees available in the public domain. All were constituted post-independence, except two, with recommendations that remain pertinent to date. Data for chairpersons and members - their professions, gender, institutions, and location were extracted and analysed. Reliable online sources were used to collate the information.

Results

We identified 23 national health committees from 1943 to 2020 with available reports. There were 25 chairpersons and 316 members. All except three chairpersons were men. Among members, only 11% were women. The majority (51%) had experience working in health systems; however, most were medical doctors, with negligible representation of other cadres. We noted the centralization of location, with 44% of members based in the national capital of Delhi. Government administrators were maximally represented (55%), followed by medical academia (19%). Post-2000, we have observed slightly improved diversity across some parameters like gender (15% women vs 9% earlier) and affiliation. However, the centralization of the location to the national capital had increased (55% post-2000 vs. 39% pre-2000).

Conclusion

Indian health committees lack diversity in representation from multiple perspectives. Henceforth, health policymakers should prioritize including diverse social, geographical, and health systems actors to ensure equitable policymaking.

Promoting Equity, Diversity, and Inclusion in Medicine: A Comprehensive Toolkit for Change in Radiology

This toolkit presents a comprehensive framework for a toolkit intended to increase equity, diversity, and inclusion (EDI) within the medical field and recommendations. We advocate for clear, comprehensive definitions and interpretations of fundamental EDI terms, laying the groundwork necessary for initiating and maintaining EDI initiatives. Furthermore, we offer a systematic approach to establishing EDI committees within medical departments, accentuating the pivotal role these committees play as they drive and steer EDI strategies. This toolkit also explores strategies tailored for the recruitment of a diverse workforce. This includes integral aspects such as developing inclusive job advertisements, implementing balanced search methods for candidates, conducting unbiased appraisals of applications, and structuring diverse hiring committees. The emphasis on these strategies not only augments the diversity within medical institutions but also sets the stage for a more holistic approach to healthcare delivery. Therefore, by adopting the recommended strategies and guidelines outlined in this framework, medical institutions and specifically radiology departments can foster an environment that embodies inclusivity and equity, thereby enhancing the quality of patient care and overall health outcomes.

Challenges and Opportunities for Implementing Diversity Competence in a Medical Education Curriculum: A Qualitative Study of Perceptions Among Students and Teachers

OBJECTIVES

Medical education is under continuous pressure to introduce new curriculum content to ensure that physicians possess the competences that the population needs. Diversity competence (DC) is a relatively new area within medicine, challenging the existing curriculum. Frameworks and guidelines have been developed to provide support and assistance to educators in integrating DC into medical programs. However, integrating DC into curriculum has proven difficult and is therefore still not included in many European medical programs. The purpose of the study is therefore to identify the challenges and opportunities for implementing DC including a focus on migrant and ethnic minorities in a medical education program.

METHODS

From November 2-20, 2020, focus group discussions with medical students, junior physicians and course leaders were conducted. The participants were recruited via Facebook, newsletters, and emails. Two interview guides were developed and used as guidance for topics to be discussed. The focus group discussions were conducted partly physically and partly digitally. The interviews were transcribed and were analyzed using thematic analysis.

RESULTS

Three main challenges and opportunities were identified across the focus groups. Challenges: (i) a disparaging discourse about humanistic and social disciplines within the curriculum, (ii) limited levels of DC among teachers, and (iii) need for institutional support. Opportunities: (i) a clear interest in strengthening teachers' DC levels, (ii) incentives for improving the image of humanistic and social medicine, and (iii) relevant courses for implementing DC.

CONCLUSION

Our results showed that action in this area is needed. The themes identified indicated that there are within the curriculum many opportunities to implement DC, but they also illuminated the challenges. The results suggested both a need for focusing on individual competences for medical teachers and students, and also for organizational change and support in favor of DC training.

The Intersection of Race and Sex: A New Perspective Into Diversity Trends in Orthopaedic Surgery

INTRODUCTION

Studies on diversity in orthopaedic surgery have exclusively examined challenges from a race or sex perspective. This study examines trends in the diversity of entering orthopaedic surgery residents from the intersection of race and sex.

METHODS

The American Association of Medical Colleges was queried for individuals entering orthopaedic surgery residencies in the United States from 2001 to 2020. Deidentified data on self-reported sex and race were collected. Proportions by the intersection of sex and race were calculated for 5-year intervals.

RESULTS

From 2001 to 2020, most of the new female residents identified as White (mean, 71.0%). The average proportion of White female residents was lower in 2016 to 2020 than in 2001 to 2005 (71.0% vs. 73.2%) but higher than that in 2011 to 2015 (66.8%). The 2016 to 2020 average was lower than that of 2001 to 2005 for those who identified as Asian (11.7% vs. 14.9%), Black (4.1% vs. 4.8%), Hispanic (3.0% vs. 4.4%), and American Indian/Alaska Native (0.0% vs. 1.5%). Most of the new male orthopaedic surgery residents from 2001 to 2020 identified as White (mean, 74.1%), but the average decreased across every 5-year interval from 2001 to 2005 (76.1%) to 2016 to 2020 (71.1%). The 2016 to 2020 average was lower than that of 2001 to 2005 for those who identified as Asian (12.2% vs. 13.6%), Black (3.5% vs. 4.2%), Hispanic (3.0% vs. 3.4%), American Indian/Alaska Native (0.0% vs. 0.6%), and Native Hawaiian/Other Pacific Islander (0.1% vs. 0.3%). In 2020, White male residents made up to 54.2% of new residents. White female residents were the second highest group represented (12.1%).

CONCLUSION

Increases in representation were observed for some subgroups of new orthopaedic surgery residents from 2001 to 2020. Although the proportion of both White female and male residents decreased by 11.5% during the 20-year study period, these individuals still made up most of the trainees in 2020. These results underscore the need for conversations and recruitment practices to take into consideration the intersectionality of identities.

Intersectionality in Medical Education: A Meta-Narrative Review

Introduction

Despite increasing attention to improving equity, diversity, and inclusion in academic medicine, a theoretically informed perspective to advancing equity is often missing. Intersectionality is a theoretical framework that refers to the study of the dynamic nature of social categories with which an individual identifies and their unique localization within power structures. Intersectionality can be a useful lens to understand and address inequity, however, there is limited literature on intersectionality in the context of medical education. Thus, we explored how intersectionality has been conceptualized and applied in medical education.

Methods

We employed a meta-narrative review, analyzing existing literature on intersectionality theory and frameworks in medical education. Three electronic databases were searched using key terms yielding 32 articles. After, title, abstract and full-text screening 14articles were included. Analysis of articles sought a meaningful synthesis on application of intersectionality theory to medical education.

Results

Existing literature on intersectionality discussesthe role of identity categorization and the relationship between identity, power, and social change. There are contrasting narratives on the practical application of intersectionality to medical education, producing tensions between how intersectionality is understood as theory and how it is translated in practice.

Discussion

A paucity in literature on intersectionality in medical education suggests that there is a risk intersectionality may be understood in a superficial manner and considered a synonym for diversity. Drawing explicit attention to its core tenets of reflexivity, transformational identity, and analysis of power is important to maintain fidelity to how intersectionality is understood in broader critical social science literature.

A Qualitative Study of Underrepresented Minority (URM) Student Pharmacists' Intersectionality and Professional Identity Formation

OBJECTIVE

To determine how underrepresented minority (URM) student pharmacists' intersectionality affects professional identity formation early in their academic career.

METHODS

A qualitative study was undertaken. All students from Classes 2022 through 2025 at Texas A&M University School of Pharmacy were required to engage in reflection on a personal statement of philosophy of practice early in their first year of pharmacy as part of the structured longitudinal co-curricular course requirement. Statements of the URM students who referenced their intersecting identities were selected for deductive analysis per Bingham and Witkowsky and inductive analysis using Lincoln and Guba's approach to content analysis.

RESULTS

Of the 221 URM student pharmacists within the 4 cohorts who submitted a statement, 38 statements (92% Hispanic students) met the inclusion criteria. Student hometowns and the identity domains of the individual, relational, and collective were selected a priori for the deductive analysis. Students most often referenced individual identity characteristics that fit under the Principles I, IV, V, and VII of the Code of Ethics for Pharmacists. Three themes emerged from the inductive analysis: (1) defining experiences and resulting realizations, (2) motivating forces, and (3) aspirations as a pharmacist. A working hypothesis was developed.

CONCLUSION

The URM students' intersecting identities (race, ethnicity, socioeconomic class, and belonging to an underserved community) influenced their early professional identity formation. The desire to bring about racial uplift was observed among the Hispanic students as early in their P1 year through the School's required co-curricular reflection. Such reflective practice serves as an effective vehicle for the students to recognize their intersecting identities that impact their professional identity.

Time for a Gut Check: A Qualitative Study of Proposed Interventions to Address Gender Inequality in Gastroenterology

Background

Gender inequalities persist in medicine, particularly in some speciality fields where fewer women are employed. Although previous research has suggested potential interventions to broadly address gender inequality in medicine, no research has focused on interventions in the field of gastroenterology. The purpose of this research was to engage women in the field of gastroenterology in Canada, to identify interventions with potential to be effective in addressing gender inequality.

Methods

A World Café was hosted in 2019 to discuss gender inequality and interventions in gastroenterology. Twelve women employed in the field of gastroenterology (i.e. physicians, nurses, research staff, and trainees) were purposively recruited and participated in the event. The discussion rounds were audio-recorded, transcribed, and thematic analyses was conducted using Braun and Clarke's principles.

Results

Three key themes identifying potential interventions to address gender inequality in gastroenterology were generated: (1) Education; (2) Addressing institutional structures and polices; and 3) Role modelling and mentorship. Participants indicated that interventions should target various stakeholders, including both women and men in gastroenterology, young girls, patients, and administrators.

Conclusion

Many of the interventions identified by participants correspond with existing research on interventions in general medicine, suggesting that institutional changes can be made for maximum effectiveness. Some novel interventions were also identified, including publicizing instances of gender parity and supporting interventions across the educational and professional lifecourse. Moving forward, institutions must assess their readiness for change and evaluate existing policies, programs, and practices for areas of improvement.

Diversity competence training for health professionals in Europe: a modified delphi study investigating relevant content for short or online courses

BACKGROUND

Diversity is a reality in our societies, requiring health professionals to adapt to the unique needs of all patients, including migrants and ethnic minorities. In order to enable health professionals to meet related challenges and reduce health disparities, long and demanding training courses have been developed. But due to busy schedules of professionals and often scarce resources, a need for shorter training courses exists. This study aims to investigate which topics and methods should be prioritised in designing basic diversity training courses that provide health professionals the opportunity to foster this competence.

METHODS

The study provided an expert panel of 31 academic and clinical migrant health experts with the content and methods of an existing diversity training course. The panel was asked to prioritise training topics and teaching methods in a two-stage process, using an adapted Delphi method. In the first stage, experts rated 96 predefined items, commented on those items, provided answers to eight open-ended questions and suggested additional content for a short course. In the second stage, they commented on the ratings from Round 1, and rated new suggested content. Consensus for training topics was set to 80% and for teaching methods 70%.

RESULTS

The entire panel deemed 'health effects of migration (pre-, during- and post-migration risk factors)' to be important or very important to include in a short/online, basic diversity training (100% consensus). Other high-scoring items and therefore topics to be included in trainings were 'social determinants of health' (97%) and 'discrimination within the healthcare sector' (also 97%). A general trend was to focus on reflective practice since almost all items regarding reflection reached consensus. 'Reflection on own stereotypes and prejudices' (97%) was the highest-rated reflection item. 'Opportunities and best practices in working with interpreters' was the highest-scoring skills item, both on consensus (96%) and mean value (5.77).

CONCLUSIONS

Experts' prioritizations of teaching content and methods for diversity training can help the design of short (online) trainings for health professionals and reduce unnecessary course content, thereby fostering professional development and enabling diversity competence trainings to be implemented also when time and/or financial resources are limited.

Integrating LGBTQIA + Community Member Perspectives into Medical Education

ProblemLGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexual and gender minorities) people have unique health care needs related to their sexual orientation, gender identity and expression, and sex development. However, medical education has historically excluded LGBTQIA + health-related content in formal curricula. It is common for medical students to interact with diverse patient populations through clinical rotations; however, access to and knowledge about LGBTQIA + patients is inconsistently prioritized in medical schools. This is especially true for LGBTQIA + patients with intersecting historically marginalized identities, such as people of color and people with disabilities. Learning from and listening to medically underserved community members can help both medical students and educators better understand the unique health needs of these communities, and address implicit biases to improve health care and outcomes for their patients. Intervention: To address the lack of LGBTQIA + health-related content in medical education and improve access to and knowledge about LGBTQIA + patients, LGBTQIA + community members' perspectives and lived experiences were integrated into undergraduate medical education via four primary methods: Community Advisory Groups, community panel events, standardized patients, and community member interviews. Context: LGBTQIA + community members' perspectives and lived experiences were integrated into medical education at Harvard Medical School (HMS) as part of the HMS Sexual and Gender Minority Health Equity Initiative. Impact: LGBTQIA + community members' perspectives and lived experiences were successfully integrated into multiple aspects of medical education at HMS. During this process, we navigated challenges in the following areas that can inform similar efforts at other institutions: representation of diverse identities and experiences, meeting and scheduling logistics, structural barriers in institutional processes, and implementation of community member recommendations. Lessons Learned: Based on our experiences, we offer recommendations for integrating LGBTQIA + community members' perspectives into medical education. Engaging community members and integrating their perspectives into medical education will better enable medical educators at all institutions to teach students about the health care needs of LGBTQIA + communities, and better prepare medical students to provide affirming and effective care to their future patients, particularly those who are LGBTQIA+.

Review of current 2SLGBTQIA+ inequities in the Canadian health care system

Gender identity and sexual orientation are determinants of health that can contribute to health inequities. In the 2SLGBTQIA+ community, belonging to a sexual and/or gender minority group leads to a higher risk of negative health outcomes such as depression, anxiety, and cancer, as well as maladaptive behaviors leading to poorer health outcomes such as substance abuse and risky sexual behavior. Empirical evidence suggests that inequities in terms of accessibility to health care, quality of care, inclusivity, and satisfaction of care, are pervasive and entrenched in the health care system. A better understanding of the current Canadian health care context for individuals of the 2SLGBTQIA+ community is imperative to inform public policy and develop sensitive public health interventions to make meaningful headway in reducing inequity. Our search strategy was Canadian-centric and aimed at highlighting the current state of 2SLGBTQIA+ health inequities in Canada. Discrimination, patient care and access to care, education and training of health care professionals, and crucial changes at the systemic and infrastructure levels have been identified as main themes in the literature. Furthermore, we describe health care-related disparities in the 2SLGBTQIA+ community, and present available resources and guidelines that can guide healthcare providers in narrowing the gap in inequities. Herein, the lack of training for both clinical and non-clinical staff has been identified as the most critical issue influencing health care systems. Researchers, educators, and practitioners should invest in health care professional training and future research should evaluate the effectiveness of interventions on staff attitudinal changes toward the 2SLGBTQIA+ community and the impact on patient outcomes.

Anti-oppressive pedagogy in medical education: A qualitative study of trainees and faculty

PURPOSE

Despite the proliferation of interest in health equity and justice in medical education, there is limited research into the practical implementation of pedagogical approaches that align with anti-oppressive practices. This study sought to explore how to integrate anti-oppressive pedagogy into medical education.

METHODS

Using constructivist grounded theory, the authors conducted 19 semi-structured interviews with a continuum of medical education stakeholders including learners and faculty in a Canadian context between June and August 2021. Transcripts were iteratively analysed using constant comparative analysis.

RESULTS

Findings suggest that existing approaches to anti-oppressive pedagogy in medical education are misaligned with the perceived values, priorities, pace, biomedical focus and hierarchical nature of medical education, and medical practice. Although some learners are motivated to advance anti-oppressive teaching, their motivations are often related to their personal experiences of oppression. Participants suggested that transformative and structural changes are required to effectively integrate anti-oppressive pedagogy into medical education. Suggestions included a shift to community-based learning while ensuring adequate compensation for educators and addressing resistance at individual and institutional levels.

CONCLUSION

Anti-oppressive pedagogy does not presently align with existing medical education practices. Effectively integrating anti-oppressive approaches will require individual and institutional reflection on the values and assumptions that underpin the field before progress can be made in a meaningful and sustainable way.

Sponsorship in Otolaryngology-Head and Neck Surgery: A Pathway to Equity, Diversity, and Inclusion

Importance

Sponsorship, distinct from mentorship or coaching, involves advancing the careers of individuals by nominating them for roles, increasing the visibility of their work, or facilitating opportunities. Sponsorship can open doors and enhance diversity; however, achieving desirable outcomes requires equitable approaches to cultivating potential in sponsees and promoting their success. The evidence on equitable sponsorship practices has not been critically examined, and this special communication reviews the literature, highlighting best practices.

Observations

Sponsorship addresses an unmet need for supporting individuals who have historically been afforded fewer, less visible, or less effective opportunities for upward career mobility. Barriers to equitable sponsorship include the paucity of sponsors of underrepresented identity; smaller and underdeveloped networks among these sponsors; lack of transparent, intentional sponsorship processes; and structural inequities that are associated with recruitment, retention, and advancement of diverse individuals. Strategies to enhance equitable sponsorship are cross-functional, building on foundational principles of equity, diversity, and inclusion; patient safety and quality improvement; and insights from education and business. Equity, diversity, and inclusion principles inform training on implicit bias, cross-cultural communication, and intersectional mentoring. Practices inspired by patient safety and quality improvement emphasize continuously improving outreach to diverse candidates. Education and business insights emphasize minimizing cognitive errors, appreciating the bidirectional character of interactions, and ensuring that individuals are prepared for and supported in new roles. Collectively, these principles provide a framework for sponsorship. Persistent knowledge gaps are associated with timing, resources, and systems for sponsorship.

Conclusions and Relevance

The nascent literature on sponsorship is limited but draws on best practices from various disciplines and has potential to promote diversity within the profession. Strategies include developing systematic approaches, providing effective training, and supporting a culture of sponsorship. Future research is needed to define best practices for identifying sponsees, cultivating sponsors, tracking outcomes, and fostering longitudinal practices that are sustainable at local, regional, and national levels.

Lesbian Gay Bisexual Transgender and Queer Health-Care Experiences in a Military Population

ABTRACTThis study aimed to understand the experiences of lesbian, gay, bisexual, transgender, and queer of former military service members. Data for this analysis was collected from the two open-ended survey questions as part of a larger online survey. The analysis was performed using the web-based data analysis application Dedoose. Eighty-eight qualitative responses were used. Analysis of the responses revealed five main themes: (1) identity, (2) negative experiences, (3) impact of experiences, (4) policy, and (5) positive experiences. These findings can influence future military research by focusing on the effects of the Don't Ask Don't Tell policy, negative and positive experiences, and the impact of those experiences.

Health occupations salary outcomes: intersections of student race, gender, and first-generation status

Greater diversity in the healthcare workforce has been identified as a critical need in serving an increasingly diverse population. Higher education institutions have been tasked with increasing the number of underrepresented students in the health occupations pipeline to better align with the demographics of the general population and meet the need for a diverse health occupations workforce. This study used the National Science Foundation's National Survey of College Graduates dataset to capture data across time, examining the intersectionality of race, gender, and first-generation status on the salary outcomes of students who earn degrees related to health occupations. Results indicate that the intersecting identities of students who earn a bachelor's degree or higher in the health professions impact salary outcomes. Results of this study have implications for higher education policies that can impact increased diversity in the health occupations workforce pipeline.

Diversity, Equity, and Inclusion within Pediatric Adherence Science

Given the long-standing history of systemic racism in psychological science, diversity, equity, and inclusion (DEI) efforts are increasingly vital to the advancement and improvement of the field. This commentary extends the seminal work of the article Upending Racism in Psychological Science: Strategies to Change How Our Science is Conducted, Reported, Reviewed, and Disseminated (Buchanan et al., Am Psychol, https://doi.org/10.31234/osf.io/6nk4x , 2020) by providing tangible applications and recommendations to improve DEI integration into pediatric adherence science. Real-world adherence examples are discussed regarding the challenges faced in systematically integrating DEI principles, potential solutions to overcoming barriers, and the implications of these efforts on scientific advancement in an effort to address and dismantle research practices that perpetuate inequity and White supremacy. Specifically, we provide discourse and practical guidance related to the conduct, reporting, reviewing, and dissemination of pediatric adherence science to promote dialog and produce actionable change toward the promotion of health equity and social justice.

Gender Discrimination and Sexual Harassment in a Department of Pediatrics

The last substantial description of gender discrimination and harassment described in the journal Pediatrics was in 2019. It is unclear whether the field has made progress toward its goal of equity. We aimed to describe: (1) the recent gender-equity climate according to women and men faculty in the department of pediatrics at a single, large academic center, and (2) institutional efforts to address persistent gender discrimination and harassment. In late 2020, we distributed an anonymous survey to all department faculty that included demographic data, a modified version of the Overt Gender Discrimination at Work Scale, questions about experiences/witnessed discriminatory treatment and sexual harassment, and if those experiences negatively affected career advancement. Of 524 pediatrics faculty, 290 (55%) responded. Compared with men, women more commonly reported gender discrimination (50% vs. 4%, P < .01) and that their gender negatively affected their career advancement (50% vs 9%, P < .01). More than 50% of women reported discriminatory treatment at least annually and 38% recognized specific sexist statements; only 4% and 17% of men reported the same (P < .01 for both). We concluded that a disproportionately low number of male faculty recognized the harassment female faculty experienced. In the 18 months since, our department and university have made efforts to improve salary equity and parity in leadership representation, created an anonymous bias-reporting portal, mandated bias training, and implemented new benchmarks of "professionalism" that focus on diversity. Although we acknowledge that culture change will take time, we hope our lessons learned help promote gender equity in pediatrics more broadly.

Healthcare Utilization for Medicaid-Insured Children with Medical Complexity: Differences by Sociodemographic Characteristics

OBJECTIVE

To compare differences in healthcare utilization and costs for Medicaid-insured children with medical complexity (CMC) by race/ethnicity and rurality.

METHODS

Retrospective cohort of North Carolina (NC) Medicaid claims for children 3-20 years old with 3 years continuous Medicaid coverage (10/1/2015-9/30/2018). Exposures were medical complexity, race/ethnicity, and rurality. Three medical complexity levels were: without chronic disease, non-complex chronic disease, and complex chronic disease; the latter were defined as CMC. Race/ethnicity was self-reported in claims; we defined rurality by home residence ZIP codes. Utilization and costs were summarized for 1 year (10/1/2018-9/30/2019) by complexity level classification and categorized as acute care (hospitalization, emergency [ED]), outpatient care (primary, specialty, allied health), and pharmacy. Per-complexity group utilization rates (per 1000 person-years) by race/ethnicity and rurality were compared using adjusted rate ratios (ARR).

RESULTS

Among 859,166 Medicaid-insured children, 118,210 (13.8%) were CMC. Among CMC, 36% were categorized as Black non-Hispanic, 42.7% White non-Hispanic, 14.3% Hispanic, and 35% rural. Compared to White non-Hispanic CMC, Black non-Hispanic CMC had higher hospitalization (ARR = 1.12; confidence interval, CI 1.08-1.17) and ED visit (ARR = 1.17; CI 1.16-1.19) rates; Hispanic CMC had lower ED visit (ARR = 0.77; CI 0.75-0.78) and hospitalization rates (ARR = 0.79; CI 0.73-0.84). Black non-Hispanic and Hispanic CMC had lower outpatient visit rates than White non-Hispanic CMC. Rural CMC had higher ED (ARR = 1.13; CI 1.11-1.15) and lower primary care utilization rates (ARR = 0.87; CI 0.86-0.88) than urban CMC.

DISCUSSION

Healthcare utilization varied by race/ethnicity and rurality for Medicaid-insured CMC. Further studies should investigate mechanisms for these variations and expand higher value, equitable care delivery for CMC.

Knowledge Retention and Clinical Skills Acquisition in Sexual and Gender Minority Health Curricula: A Systematic Review

PURPOSE

To identify exemplary medical education curricula, operationalized as curricula evaluating knowledge retention and/or clinical skills acquisition, for health care for sexual and gender minoritized (SGM) individuals and individuals born with a difference in sex development (DSD).

METHOD

The authors conducted a systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were performed in PubMed/MEDLINE, The Cochrane Library, Web of Science, ERIC, Embase, PsycINFO, and the gray literature to identify studies that (1) pertained to undergraduate and/or graduate medical education, (2) addressed education on health care of SGM/DSD individuals, and (3) assessed knowledge retention and/or clinical skills acquisition in medical trainees. The final searches were run in March 2019 and rerun before final analyses in June and October 2020.

RESULTS

Of 670 full-text articles reviewed, 7 met the inclusion criteria. Five of the 7 studies assessed trainee knowledge retention alone, 1 evaluated clinical skills acquisition alone, and 1 evaluated both outcomes. Studies covered education relevant to transgender health, endocrinology for patients born with DSDs, and HIV primary care. Only 1 study fully mapped to the Association of American Medical Colleges (AAMC) SGM/DSD competency recommendations. Six studies reported institutional funding and development support. No studies described teaching SGM/DSD health care for individuals with multiply minoritized identities or engaging the broader SGM/DSD community in medical education curriculum development and implementation.

CONCLUSIONS

Curriculum development in SGM/DSD health care should target knowledge retention and clinical skills acquisition in line with AAMC competency recommendations. Knowledge and skill sets for responsible and equitable care are those that account for structures of power and oppression and cocreate curricula with people who are SGM and/or born with DSDs.

LGBTQ+ Worker Protections: Implications for Academic Medicine Today and in the Future

The Supreme Court's 2020 ruling prohibiting workplace discrimination based on sexual orientation or gender identity ( Bostock v Clayton County ) offers new legal protections for LGBTQ+ employees and allies and new opportunities for academic medicine to advance LGBTQ+ inclusion at their institutions. In this perspective piece, the authors examine the history of LGBTQ+ community recognition, tolerance, protections, and ongoing inclusion and the advocacy efforts led by LGBTQ+ patients, community activists, and medical colleagues. They also examine the current limitations of the court's ruling and recommend future actions to advance workplace and health equity. While recent advancements in equality have not erased chronic barriers to inclusion and advancement, they can pave the way for leaders in research, education, and clinical care to shape national health guidelines and policies that impact the health of all Americans.

For us by us: Instituting mentorship models that credit minoritized medical faculty expertise and lived experience

The woefully low proportion of scientists and clinicians underrepresented in medicine (UIM), including members of African-American/Black, Hispanic/Latinx, American Indian/Alaska Native or Native Hawaiian/Pacific Islander communities, is well characterized and documented. Diversity in medicine is not only just, but it improves quality and outcomes. Yet, diversity in academic medicine remains stagnant, despite national recognition and urgent calls to improve diversity, equity, and inclusion across health sciences. One strategy that has shown to improve diversity in many sectors is high quality mentoring. While many institutions have adopted mentoring programs, there remains a lack of mentorship that is equitable, individualized, and sets a clear timeline for academic milestones that will position UIM mentees at the optimal trajectory for promotion and retention. A barrier to assembling these programs is the small number of UIM among the senior faculty ranks who are able to serve in this role, given the disproportionate burden to serve on a multitude of academic committees, task forces, and workgroups to fulfill institutional mandates to diversify representation. These time-consuming services, documented in the literature as the "minority tax," are generally uncompensated and unaccounted for in terms of consideration for promotion, leadership positions, and other measures of career advancement. The Justice, Equity, Diversity, and Inclusion Academic Mentors (JAM) Council represents a novel, culturally responsive, and anti-racist approach to achieve a more equitable and inclusive institutional environment. This approach strategically leverages the intergenerational wisdom and experience of senior UIM faculty via time-protected effort with the overall goals of improving rates of promotion, retention, and career satisfaction of early career UIM colleagues. This community case study describes the rationale, resources needed, processes, and proposed workflow required to launch the JAM Council, as well as the major roles and responsibilities for JAM mentors and mentees, which may be considered by academic medical centers focused on improving diversity among the faculty ranks.

Curricula, Teaching Methods, and Success Metrics of Clinician-Scientist Training Programs: A Scoping Review

PURPOSE

To describe the literature on clinician-scientist training programs to inform the development of contemporary and inclusive training models.

METHOD

The authors conducted a scoping review, searching the PubMed/MEDLINE, CINAHL, and Embase databases from database inception until May 25, 2020. Studies presenting primary research that described and evaluated clinician-scientist training programs were identified for data abstraction. On the basis of deductive and inductive methods, information about program characteristics, curricula, teaching strategies, and success metrics was extracted. The extracted variables were analyzed using descriptive statistics.

RESULTS

From the initial 7,544 citations retrieved and 4,974 unique abstracts screened, 81 studies were included. Of the 81 included studies, 65 (80.2%) were published between 2011 and 2020, 54 (66.7%) were conducted in the United States, and 64 (79.0%) described programs that provided broad clinician-scientist training. Few programs provided funding or protected research time or specifically addressed needs of trainees from underrepresented minority groups. Curricula emphasized research methods and knowledge dissemination, whereas patient-oriented research competencies were not described. Most programs incorporated aspects of mentorship and used multiple teaching strategies, such as direct and interactive instruction. Extrinsic metrics of success (e.g., research output) were dominant in reported program outcomes compared with markers of intrinsic success (e.g., career fulfillment).

CONCLUSIONS

Although programs are providing clinician-scientists with practical skills training, opportunities exist for curricular and pedagogic optimization that may better support this complex career path. Training programs for clinician-scientists can address contemporary issues of wellness and equity by reconsidering metrics of program success and evolving the core tenets of their education models to include equity, diversity, and inclusion principles and patient-oriented research competencies.

Equity, diversity and inclusion of pediatric clinician-scientists in Canada: a thematic analysis

BACKGROUND

Underrepresented voices and perspectives are missing from academic and clinical health sciences. We aimed to define the unique opportunities and challenges of pediatric clinician-scientists related to equity, diversity and inclusion; and to identify key components of training needed to support people from equity-seeking groups as emerging and early-career pediatric clinician-scientists to generate diverse health research leaders in knowledge generation, implementation and translation.

METHODS

Using a qualitative descriptive approach, we examined the experiences of clinician stakeholders. Semistructured interviews were conducted with pediatric clinician-scientist stakeholders. Thematic analysis was performed.

RESULTS

We interviewed a total of 39 individuals. Our analysis resulted in 4 interrelated themes: the pervasiveness and invisibility of sexism; the invisibility and visibility of racism; proposed individual-level solutions to the sexism and racism; and proposed institutional and system-level changes to address the porous and leaky pipeline. These themes acknowledged that, ultimately, system change is required for addressing equity, diversity and inclusion in clinical and academic training environments.

INTERPRETATION

These findings highlight the importance of addressing systemic biases that limit the inclusion of women and racialized individuals in pediatric clinician-scientist careers. Further research is needed to explore the problem of exclusion, which will, in turn, inform education of pediatric clinician-scientists and inform better ways to promote equity, diversity and inclusivity; these steps are needed to foster systemic change in the cultures that perpetuate exclusivity in both academic and clinical communities.

Intersectionality: a means for centering power and oppression in research

Intersectionality theory examines how matrices of power and interlocking structures of oppression shape and influence people's multiple identities. It reminds us that people's lives cannot be explained by taking into account single categories, such as gender, race, sexuality, or socio-economic status. Rather, human lives are multi-dimensional and complex, and people's lived realities are shaped by different factors and social dynamics operating together. Therefore, when someone occupies multiple marginalized intersections, their individual-level experiences reflect social and structural systems of power, privilege, and inequality. And yet, knowing that people occupy different social locations that afford them unique experiences is not the same as knowing how to analyze data in an intersectional way. Intersectional analyses are rigorous, and require the use of theory at multiple levels to see theoretical connections that are often only implicit.In this paper, we ask "How does one actually do intersectional research and what role does theory play in this process?" In an effort to make intersectionality theory more accessible to health professions education research, this article describes the simpler version of intersectional analyses followed by the more complex version representing how it was originally intended to be used; a means to fight for social justice. Using pilot data collected on first-generation medical students' professional identity experiences, we demonstrate the thinking and engagement with theory that would be needed to do an intersectional analysis. Along the way, we describe some of the challenges researchers may find in using intersectionality in their own work. By re-situating the theory within its original roots of Black feminist thought, we hope other health professions education (HPE) researchers consider using intersectionality in their own analyses.

Chief Residency Selection in Internal Medicine: Who Is Left Out?

Little progress has been made in improving racial, gender, or intersectional diversity within academic internal medicine (IM). Chief Residency fulfills a unique opportunity to target diversity efforts; Chief Residents (CR) are integral in creating an inclusive environment and support system for IM trainees, and the position serves as a steppingstone for future leadership positions within academia. However, the CR selection process often lacks transparency and includes steps that are fraught with bias, thereby disadvantaging underrepresented minority groups from gaining important experience needed to climb the academic ladder. We describe a more standardized selection process that will improve recruitment and selection of more diverse CRs and ultimately improve the recruitment, retention, and promotion of more diverse faculty within academic internal medicine. Key recommendations include an open call for applications, the use of standardized and structured interviews, and the formation of a diverse selection committee to conduct a transparent selection process based on explicitly defined criteria.

Mentoring Underrepresented Minority Physician-Scientists to Success

As the nation seeks to recruit and retain physician-scientists, gaps remain in understanding and addressing mitigatable challenges to the success of faculty from underrepresented minority (URM) backgrounds. The Doris Duke Charitable Foundation Fund to Retain Clinical Scientists program, implemented in 2015 at 10 academic medical centers in the United States, seeks to retain physician-scientists at risk of leaving science because of periods of extraordinary family caregiving needs, hardships that URM faculty-especially those who identify as female-are more likely to experience. At the annual Fund to Retain Clinical Scientists program directors conference in 2018, program directors-21% of whom identify as URM individuals and 13% as male-addressed issues that affect URM physician-scientists in particular. Key issues that threaten the retention of URM physician-scientists were identified through focused literature reviews; institutional environmental scans; and structured small- and large-group discussions with program directors, staff, and participants. These issues include bias and discrimination, personal wealth differential, the minority tax (i.e., service burdens placed on URM faculty who represent URM perspectives on committees and at conferences), lack of mentorship training, intersectionality and isolation, concerns about confirming stereotypes, and institutional-level factors. The authors present recommendations for how to create an environment in which URM physician-scientists can expect equitable opportunities to thrive, as institutions demonstrate proactive allyship and remove structural barriers to success. Recommendations include providing universal training to reduce interpersonal bias and discrimination, addressing the consequences of the personal wealth gap through financial counseling and benefits, measuring the service faculty members provide to the institution as advocates for URM faculty issues and compensating them appropriately, supporting URM faculty who wish to engage in national leadership programs, and sustaining institutional policies that address structural and interpersonal barriers to inclusive excellence.

Marginalized identities, mistreatment, discrimination, and burnout among US medical students: cross sectional survey and retrospective cohort study

OBJECTIVE

To describe the association between mistreatment, burnout, and having multiple marginalized identities during undergraduate medical education.

DESIGN

Cross sectional survey and retrospective cohort study.

SETTING

140 US medical schools accredited by the Association of American Medical Colleges.

PARTICIPANTS

30 651 graduating medical students in 2016 and 2017.

MAIN OUTCOME MEASURES

Self-reported sex, race or ethnicity, and sexual orientation groups were considered, based on the unique combinations of historically marginalized identities held by students. Multivariable linear regression was used to determine the association between unique identity groups and burnout along two dimensions (exhaustion and disengagement) as measured by the Oldenburg Burnout Inventory for Medical Students while accounting for mistreatment and discrimination.

RESULTS

Students with three marginalized identities (female; non-white; lesbian, gay, or bisexual (LGB)) had the largest proportion reporting recurrent experiences of multiple types of mistreatment (88/299, P<0.001) and discrimination (92/299, P<0.001). Students with a higher number of marginalized identities also had higher average scores for exhaustion. Female, non-white, and LGB students had the largest difference in average exhaustion score compared with male, white, and heterosexual students (adjusted mean difference 1.96, 95% confidence interval 1.47 to 2.44). Mistreatment and discrimination mediated exhaustion scores for all identity groups but did not fully explain the association between unique identity group and burnout. Non-white and LGB students had higher average disengagement scores than their white and heterosexual counterparts (0.28, 0.19 to 0.37; and 0.73, 0.52 to 0.94; respectively). Female students, in contrast, had lower average disengagement scores irrespective of the other identities they held. After adjusting for mistreatment and discrimination among female students, the effect among female students became larger, indicating a negative confounding association.

CONCLUSION

In this study population of US medical students, those with multiple marginalized identities reported more mistreatment and discrimination during medical school, which appeared to be associated with burnout.

Intersectionality in cancer care: A systematic review of current research and future directions

OBJECTIVES

The objective of the current review was to synthesize the literature on intersectionality relative to disparities across the cancer care continuum. A model to support future intersectional cancer research was proposed.

METHODS

Web-based discovery services and discipline-specific databases were queried for both peer-reviewed and gray literature. Study screening and data extraction were facilitated through the Covidence software platform.

RESULTS

Among 497 screened studies, 28 met study inclusion criteria. Most articles were peer-reviewed empirical studies (n = 22) that focused on pre-diagnosis/screening (n = 19) and included marginalized racial/ethnic (n = 22) identities. Pre-cancer diagnosis, sexual orientation and race influenced women's screening and vaccine behaviors. Sexual minority women, particularly individuals of color, were less likely to engage in cancer prevention behaviors prior to diagnosis. Race and socioeconomic status (SES) were important factors in patient care/survivorship with worse outcomes among non-white women of low SES. Emergent themes in qualitative results emphasized the importance of patient intersectional identities, as well as feelings of marginalization, fears of discrimination, and general discomfort with providers as barriers to seeking cancer care.

CONCLUSIONS

Patients with intersectional identities often experience barriers to cancer care that adversely impact screening, diagnosis, treatment, as well as survivorship. The use of an "intersectional lens" as a future clinical and research framework will facilitate a more multidimensional and holistic approach to the care of cancer patients.

Achieving Greater Health Equity: An Opportunity for Anesthesiology

Anesthesiology and anesthesiologists have a tremendous opportunity and responsibility to eliminate health disparities and to achieve health equity. We thus examine health disparity and health equity through the lens of anesthesiology and the perspective of anesthesiologists. In this paper, we define health disparity and health care disparities and provide tangible, representative examples of the latter in the practice of anesthesiology. We define health equity, primarily as the desired antithesis of health disparity. Finally, we propose a framework for anesthesiologists, working toward mitigating health disparity and health care disparities, advancing health equity, and documenting improvements in health care access and health outcomes. This multilevel and interdependent framework includes the perspectives of the patient, clinician, group or department, health care system, and professional societies, including medical journals. We specifically focus on the interrelated roles of social identity and social determinants of health in health outcomes. We explore the foundational role that clinical informatics and valid data collection on race and ethnicity have in achieving health equity. Our ability to ensure patient safety by considering these additional patient-specific factors that affect clinical outcomes throughout the perioperative period could substantially reduce health disparities. Finally, we explore the role of medical journals and their editorial boards in ameliorating health disparities and advancing health equity.

The Effect of Implicit Bias and Role Misidentification in the Learning Environment

BACKGROUND

Little is known about the impact of implicit bias our trainees experience in the form of role misidentification in the clinical learning environment.

ACTIVITY

We surveyed 540 residents and clinical medical students to determine the frequency and impact of role misidentification.

RESULTS AND DISCUSSION

Most respondents (85%, n = 162) experienced role misidentification, directly resulting in heightened emotions that led to guarded behavior. An additional indirect impact for trainees is transmitted through frequent non-promotional role misidentification and personalizing the incidents. Women and trainees with marginalized identities had significant impacts. These findings present an opportunity to improve our understanding of the trainee experience.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-021-01475-9.

Perception of Racial and Intersectional Discrimination in the Workplace Is High Among Black Orthopaedic Surgeons: Results of a Survey of 274 Black Orthopaedic Surgeons in Practice

INTRODUCTION

There are approximately 573 practicing Black orthopaedic surgeons in the United States, which represents 1.9% overall. The purpose of this study was to describe this underrepresented cohort within the field of orthopaedic surgery and to report their perception of occupational opportunity and workplace discrimination.

METHODS

An anonymous survey was administered to 455 practicing orthopaedic surgeons who self-identify as Black. The 38-question electronic survey requested demographic and practice information and solicited perspectives on race and racial discrimination in current orthopaedic practices and general views regarding occupational opportunity and discrimination.

RESULTS

The survey was completed by 274 Black orthopaedic surgeons (60%). Over 97% of respondents believe that Black orthopaedic surgeons in the United States face workplace discrimination. Most Black orthopaedic surgeons (94%) agreed that racial discrimination in the workplace is a problem but less than 20% agreed that the leaders of national orthopaedic organizations are trying sincerely to end it. Black female orthopaedic surgeons reported lower occupational opportunity and higher discrimination than Black male orthopaedic surgeons across all survey items.

DISCUSSION

This study is the first to report on the workplace environment and the extent of discrimination experienced by Black surgeons, specifically Black orthopaedic surgeons in the United States. Most respondents, particularly female respondents, agreed that racial discrimination and diminished occupational opportunity are pervasive in the workplace and reported experiencing various racial microaggressions in practice.

Professional identity formation for underrepresented in medicine learners

Professional identity formation (PIF) is a dynamic developmental process by which individuals merge the knowledge and skills of clinical practice with the values and behaviors of their personal identity. For an individual physician, this process is a continuum which begins with their nascent interest in the field of medicine and extends through the end stages of a medical career. The impact of PIF has become a growing focus of medical education research in the last decade, and in that time, little attention has been paid to the influence underrepresented in medicine (UIM) identities may have on this fundamental process. Importantly, in discussions of how medical educators can support and encourage successful PIF, there is little discussion on the distinct challenges and different needs UIM learners may have. The purpose of this paper is to address the current literature around PIF for UIM trainees. This review explores various threats to identity formation, including identity fusion, stereotype threat, minority tax, implicit bias, and lack of mentorship. Evidence-based strategies to mitigate these challenges is also presented, including furthering institutional support for PIF, building the community of practice, supporting an inclusive environment, and developing PIF assessment tools. Through exploring these challenges and solutions, we are better able to address the needs of UIM trainees and physicians as they proceed in their PIF during their lifelong journey in medicine.

Understanding and finding opportunities for inclusive mentorship and sponsorships in vascular surgery

Deliberate efforts are needed to address the lack of diversity in the vascular surgery workforce and to correct the current scarcity of diversity in vascular surgery leadership. Effective mentorship and sponsorship are crucial for success in academic surgery. In the present report, we have explained the importance of mentorship and sponsorship relationships for surgeons historically underrepresented in medicine, discussed the unique challenges faced by them in academic surgery, and provided a practical framework for fostering intentional and thoughtful mentor and sponsor relationships to nurture their careers.

First year medical student experiences with a clinical skills seminar emphasizing sexual and gender minority population complexity

PURPOSE

Patients identifying as sexual and gender minorities (SGMs) face healthcare barriers. This problem is partly due to medical training.¹ We evaluated first year medical student experiences during a novel four-hour seminar, in which students answered discussion questions, participated in peer role-plays, and interviewed two standardized patients.

METHOD

A constructivist qualitative design employed audio-recorded and transcribed student focus groups. Using generic content analysis, transcripts were iteratively coded, emergent categories identified, sensitizing concepts applied, and a thematic framework created.

RESULTS

Thirty-five students (71% female) participated in five focus groups. Two themes were developed: SGM bias (faculty, standardized patients [SPs], students, curriculum), and Adaptive Expertise in Clinical Skills (case complexity, learner support, skill development). SPs identifying as SGM brought authenticity and lived experience to their roles. Preceptor variability impacted student learning. Students were concerned when a lack of faculty SGM knowledge accompanied negative biases. Complex SP cases promoted cognitive integration and preparation for clinical work.

CONCLUSIONS

These students placed importance on the lived experiences of SGM community members. Persistent prejudices amongst faculty negatively influenced student learning. Complex SP cases can promote student adaptive expertise, but risk unproductive learning failures. The lessons learned have implications for clinical skills teaching, learning about minority populations, and medical and health professions education in general.