Psychiatry Diversity Leadership in Academic Medicine: Guidelines for Success

Identifying the prevalence and characteristics of diversity, equity, and inclusion leaders in academic emergency medicine

Objectives

Our study aims to better understand and describe the current state of diversity, equity, and inclusion (DEI) leadership in emergency medicine (EM) by identifying the prevalence of department DEI leadership positions, their demographics, and their job duty characteristics.

Methods

We disseminated an electronic survey from April to July 2022 to Society for Academic Emergency Medicine (SAEM) Association of Academic Chairs of Emergency Medicine, Academy for Diversity and Inclusion in Emergency Medicine, and the Equity and Inclusion Committee to identify department DEI leads. From July to August 2022, a 45-question survey was sent to all identified DEI leaders on individual characteristics, DEI experience, and DEI lead job description.

Results

We received a response from 79 out of 120 academic EM departments identified (65.8%). Of the responding institutions, 59 (74.7%) reported a DEI leader. A total of 74.6% of these DEI leaders responded at least partially to our survey and 57.6% responded in full. The most common titles were vice/associate chair of DEI (34.4%), director of DEI (28.1%), and DEI committee chair (18.8%). Most respondents (84.4%) were the inaugural DEI lead in their department and 84.4% of respondents did not have a formal DEI role in their department previously. On average, respondents have had their DEI title for 2 years (range 0-7 years) with an average of 7 years (range 0-30 years) of experience performing DEI work. Many (63.4%) do not receive any funded effort for their DEI roles. Most DEI leads were not tenure track (72.2%) and most commonly at the rank of assistant professor (47.2%) followed by associate professor (33.3%), full professor (16.7%), and instructor (2.8%).

Conclusions

This is the first known study to assess the characteristics of DEI department leaders in EM. EM DEI leadership positions are new, common, and led by diverse personal identities and are often not funded. Future directions could gain qualitative insight into this workforce to guide best practices in EM DEI leadership.

Annual Meeting Content Analysis: Leveraging Annual Meetings to Promote Diversity, Equity, Inclusion, and Belonging in the Academy of Consultation-Liaison Psychiatry

BACKGROUND

There is an increasing need to promote diversity, equity, and inclusion (DEI) in all aspects of academic medicine, including through continuing medical education. Although professional medical organizations' annual meetings play an instrumental role in continuing medical education for physicians, there are no studies describing DEI content in the annual meeting programming of professional medical organizations, including the Academy of Consultation-Liaison Psychiatry (ACLP), the primary professional organization for consultation-liaison psychiatrists.

OBJECTIVE

To examine the ACLP annual meeting titles using Content Analysis.

METHODS

We examined the publicly available ACLP annual meeting content titles on the ACLP website from 2010 to 2021. National DEI leaders from ACLP's DEI subcommittee iteratively generated keywords that covered a broad scope of DEI-related themes. Each annual meeting's content was independently coded by 2 members of the DEI subcommittee with discrepancies adjudicated by 2 additional members. Descriptive statistics were used to characterize the content of the annual meeting.

RESULTS

Of the 2615 annual meeting titles from 2010 to 2021 that were analyzed, 2531 were not coded to have DEI themes. Three percent (n = 84) of titles were coded to have a DEI theme as follows: Culture/diversity (n = 20, 24%), bias/disparities (n = 17, 20%), race/racism (n = 17, 20%), social justice (n = 12, 14%), gender/sexism (n = 10, 12%), and LGBTQ+ (n = 8, 10%). The frequency of DEI titles each year ranged from 1% (2010, 2018) to 17% (2021) with an increase in DEI content in 2021 (n = 24, 17%).

CONCLUSIONS

Although professional medical organizations like the ACLP are poised to leverage their continuing medical education platforms embedded in annual meeting programming to train consultation-liaison psychiatrists on DEI topics, our findings suggest more work is needed to develop and promote DEI-focused educational programming for their annual meetings.

Integrative Health Equity: Definition, Principles, Strategies, and Reflections

In this viewpoint, we define integrative health equity as optimal health for all through a whole-person approach that explicitly recognizes cultural, social, and structural determinants of health. We describe seven guiding principles, along with organizational goals, strategies, and reflections to advance integrative health equity.

Profiles in Wisdom: A Survey of Leading Psychiatrists to Inform the Diversity of the Future Psychiatric Workforce

Long-standing challenges facing the mental health system require more effective strategies to furnish a workforce whose diversity matches an increasingly diverse population. Current and former system leaders can offer expert guidance informed by their experiences and perspectives. Their professional journeys to leadership in this area provide context and unique insight into issues of justice, including workforce diversity, equity, and inclusion in psychiatry. These experts agree that significant policy changes are needed to improve psychiatric workforce diversity and that implementing change will require that disparate groups together to achieve this goal. Financial considerations must be included in policy and advocacy.

Gender Diversity in the Psychiatric Workforce: It's Still a (White) Man's World in Psychiatry

Academic psychiatry has slightly higher rates of women in the upper ranks and leadership positions than academic medicine as a whole but women continue to be seriously underrepresented. Psychiatry departments should take specific steps to address barriers for women in psychiatry including harassment and discrimination, Imposter Syndrome, lack of mentorship and sponsorship, work-life integration issues, and overinvolvement in nonpromotion generating activities. Addressing these barriers within academic psychiatry will improve the environment for all minorities.

Building a Diverse Psychiatric Workforce for the Future and Helping Them Thrive: Recommendations for Psychiatry Training Directors

The COVID-19 pandemic and murder of Mr George Floyd served as catalysts for examining antiracism efforts in psychiatry training programs and health care systems. Our recruitment and retention of Black, Indigenous, and other racial/ethnic minority psychiatry trainees has not met the demand for care and does not represent the communities served. Training directors at a critical juncture in creating systemic changes to recruitment, retention, policies, and curricular competencies to address ongoing inequities and disparities in health care. We describe several strategies and considerations for training directors in supporting a diverse psychiatric workforce.

Structural Racism in Psychiatric Research Careers: Eradicating Barriers to a More Diverse Workforce

Investigators from minoritized backgrounds are underrepresented in psychiatric research. That underrepresentation contributes to disparities in outcomes of access to mental health care. Drawing on lived experience, scholarly qualitative reports, and empirical data, the authors review how the underrepresentation of minoritized researchers arises from interlocking, self-reinforcing effects of structural biases in our research training and funding institutions. Minoritized researchers experience diminished early access to advanced training and opportunities, stereotype threats and microaggressions, isolation due to lack of peers and senior mentors, decreased access to early funding, and unique community and personal financial pressures. These represent structural racism-a system of institutional assumptions and practices that perpetuates race-based disparities, in spite of those institutions' efforts to increase diversity and in contradiction to the values that academic leaders outwardly espouse. The authors further review potential approaches to reversing these structural biases, including undergraduate-focused research experiences, financial support for faculty who lead training/mentoring programs, targeted mentoring through scholarly societies, better use of federal diversity supplement funding, support for scientific reentry, cohort building, diversity efforts targeting senior leadership, and rigorous examination of hiring, compensation, and promotion practices. Several of these approaches have empirically proven best practices and models for dissemination. If implemented alongside outcome measurement, they have the potential to reverse decades of structural bias in psychiatry and psychiatric research.

"Head of the Class": equity discourses related to department head appointments at one Canadian medical school

Purpose

Equitable appointments of departmental leaders in medical schools have lagged behind other Equity, Diversity, and Inclusion (EDI) advancements. The purpose of this research was to 1) analyze how policy documents communicate changing ideas of EDI, employment equity, and departmental leadership; and 2) investigate department heads' (DH) perspectives on EDI policies and practices.

Methods

We conducted a critical discourse analysis to examine underlying assumptions shaping EDI and departmental leadership in one Canadian medical school. We created and analyzed a textual archive of EDI documents (n = 17, 107 pages) and in-depth interviews with past (n = 6) and current (n = 12) DH (830 minutes; 177 pages).

Results

Documents framed EDI as: a legal requirement; an aspiration; and historical reparation. In interviews, participants framed EDI as: affirmative action; relationships; numerical representation; and relinquishing privilege. We noted inconsistent definitions of equity-deserving groups.

Conclusions

Change is slowly happening, with emerging awareness of white privilege, allyship, co-conspiracy, and the minority tax. However, there is more urgent work to be done. This work requires an intersectional lens. Centering the voices, and taking cues from equity-deserving leaders and scholars will help ensure that EDI pathways, such as those used to cultivate department leaders, are more inclusive, effective, and aligned with intentions.

The Current State of Departmental Diversity, Equity, and Inclusion Efforts Within US Academic Radiation Oncology Departments

PURPOSE

Promoting a diverse workforce of health care professionals that delivers equitable patient care is an important goal in oncology, as in all of medicine. Although most medical schools have a diversity office and associated initiatives, little is known about radiation oncology (RO) department-level efforts to promote diversity, equity, and inclusion (DEI). We describe the current state of DEI leadership and initiatives in RO departments in the US to guide future policies and programs.

METHODS AND MATERIALS

A total of 124 US RO departments affiliated with a medical school were contacted to identify departmental DEI leadership. Identified DEI leaders were asked to complete an anonymous survey assessing characteristics of their departmental DEI leadership, committee/organizational structure, activities, and perceived barriers to, and effect of, their work. Descriptive statistics are reported.

RESULTS

Among 85 RO departments that responded (68.5% response rate), 48 (56.5%) reported having a departmental DEI leader. Thirty-four DEI leaders completed the survey (70.8%). Of those who answered each survey question, most DEI leaders were assistant or associate professors (n = 24, 82.8%), women (n = 19, 73.1%), and identified with at least one non-White race or Hispanic ethnicity (n = 15, 53.6%). Nineteen (57.6%) had an associated departmental DEI committee; with 10 of these starting in 2020 or later. Few DEI leaders had administrative support (38.2%), funding (29.4%), protected time (23.5%), or increased compensation for added duties Fifteen (50.0%) believed their DEI-focused efforts were considered for promotion. The most reported initiatives included offering programming/education, supporting students from backgrounds underrepresented in medicine, improving recruitment practices/hiring, and implementing pipeline/pathway projects. The perceived impact of DEI initiatives included an increased culture of respect (89.7%), improved health care disparity awareness (75.9%), and improved systemic/structural racism awareness (79.3%).

CONCLUSIONS

Departmental DEI efforts are increasingly common within RO, however, the structure, resources, and recognition associated with DEI work are variable. Additional dedicated resources and recognition for these efforts will help ensure a culture of inclusive excellence for the RO workforce and patients.

Anti-Black racism in clinical supervision: asynchronous simulated encounters facilitate reflective practice

Background Racist interactions in clinical practice remain a pervasive reality for Black healthcare providers. We sought to develop a framework to inform supervisors' actions when confronting racism in clinical practice and protecting trainees under their oversight. Methods We conducted a qualitative study in which experienced supervisors responded to seven short, videotaped interactions between: 1) Black trainees and a simulated patient (SP) in a racist role; 2) the trainees and their respective supervisors; and 3) the trainees and their supervisors together with the SP. The clinical exchanges exemplified different types of racist (entrenching) or antiracist (uprooting) behaviors by the supervisors. After viewing each clip, participants wrote their reflections confidentially; they later joined a structured debriefing together. We used thematic analysis to identify supervisors' behavioral patterns when confronting racist interactions. Results Based on the input of 52 participants recruited into five two-hour-long sessions, we categorized the behaviors of supervisors facing anti-Black racial injuries involving learners under their oversight. We organized supervisor behaviors into five interlocking domains, each with a range of possible themes: 1) Joining: from conciliatory to confrontational in communicating with the aggressor; 2) Explicitness: from avoiding to naming racism; 3) Ownership: from individual to shared responsibility of the event and the response to it; 4) Involving: from excusing to including the aggrieved party when confronting the aggressor; and 5) Stance: from protective to paternalistic in supporting the learner's autonomy. Conclusions Our qualitative findings can provide a framework for facilitated discussion toward reflective practice among healthcare providers who may have experienced, witnessed, or intervened in anti-Black racist interactions. They can also help medical educators to inform faculty development to fight anti-Black racism in clinical practice. The video materials we developed are available for viewing and download and can be used or adapted as springboards for reflective discussion or faculty development activities.

The representation of authors of color in schizophrenia research articles published in high-impact psychiatric journals

OBJECTIVE

We evaluate how often scholars of color publish papers on schizophrenia in high-impact psychiatric journals, and whether they are more likely than white authors to prioritize race/ethnicity as a primary variable of interest in analyses.

METHODS

Prior work categorized the types of ethnoracial analyses reported in 474 papers about schizophrenia published in high-impact psychiatric journals between 2014 and 2016. In this study, the photographs of the first and last author for each paper were coded as "person of color" (POC) or "white". Additionally, each author was asked to self-report their race and ethnicity. The percentage of papers published by white versus POC authors was calculated. Chi-square analyses tested the hypotheses that (a) white scholars are more likely than POC scholars to conduct any sort of racial analysis; (b) POC scholars are more likely to conduct primary analyses by race/ethnicity; and (c) white scholars are more likely to analyze race/ethnicity as extraneous variables.

RESULTS

Eighteen percent of papers were published by POC first authors, and 17% were published by POC last authors. There were minimal differences in the types of analyses conducted by POC and white authors. Self-reported race/ethnicity showed that Asian scholars were the most highly represented within POC authors (9% of respondents), but only 3% of authors identified as Hispanic/Latinx and none identified as Black or Indigenous American.

CONCLUSIONS

People of color are underrepresented as authors in US-based schizophrenia research published in high-impact journals. Culturally-informed mentorship as well as prioritization of race/ethnicity in funding structures are important to increase representation of POC authors.

Undue burden: Black faculty, COVID-19, and the racial justice movement

A crucial reckoning was initiated when the COVID-19 pandemic began to expose and intensify long-standing racial/ethnic health inequities, all while various sectors of society pursued racial justice reform. As a result, there has been a contextual shift towards broader recognition of systemic racism, and not race, as the shared foundational driver of both societal maladies. This confluence of issues is of particular relevance to Black populations disproportionately affected by the pandemic and racial injustice. In response, institutions have initiated diversity, equity, and inclusion (DEI) efforts as a way forward. This article considers how the dual pandemic climate of COVID-19-related health inequities and the racial justice movement could exacerbate the "time and effort tax" on Black faculty to engage in DEI efforts in academia and biomedicine. We discuss the impact of this "tax" on career advancement and well-being, and introduce an operational framework for considering the interconnected influence of systemic racism, the dual pandemics, and DEI work on the experience of Black faculty. If not meaningfully addressed, the "time and effort tax" could contribute to Black and other underrepresented minority faculty leaving academia and biomedicine - consequently, the very diversity, equity, and inclusion work meant to increase representation could decrease it.

Anti-Black racism in clinical supervision: asynchronous simulated encounters facilitate reflective practice

Background Racist interactions in clinical practice remain a pervasive reality for Black healthcare providers. We sought to develop a framework to inform supervisors’ actions when confronting racism in clinical practice and protecting trainees under their oversight. Methods We conducted a prospective study in which experienced supervisors responded to seven short, videotaped interactions between: 1) Black trainees and a simulated patient (SP) in a racist role; 2) the trainees and their respective supervisors; and 3) the trainees and their supervisors together with the SP. The clinical exchanges exemplified different types of racist (entrenching) or antiracist (uprooting) behaviors by the supervisors. After viewing each clip, participants wrote their reflections confidentially; they later joined a structured debriefing together. We used thematic analysis to identify supervisors’ behavioral patterns when confronting racist interactions. Results Based on the input of 52 participants recruited into five two-hour-long sessions, we categorized the behaviors of supervisors facing anti-Black racial injuries involving learners under their oversight. We organized supervisor behaviors into five interlocking domains, each with a range of possible themes: 1) Joining: from conciliatory to confrontational in communicating with the aggressor; 2) Explicitness: from avoiding to naming racism; 3) Ownership: from individual to shared responsibility of the event and the response to it; 4) Involving: from excusing to including the aggrieved party when confronting the aggressor; and 5) Stance: from protective to paternalistic in supporting the learner’s autonomy. Conclusions Our qualitative findings can provide a framework for facilitated discussion toward reflective practice among healthcare providers who may have experienced, witnessed, or intervened in anti-Black racist interactions. They can also help medical educators to inform faculty development to fight anti-Black racism in clinical practice. The video materials we developed are available for viewing and download and can be used or adapted as springboards for reflective discussion or faculty development activities.

Profiles in Wisdom: A Survey of Leading Psychiatrists to Inform the Diversity of the Future Psychiatric Workforce

Long-standing challenges facing the mental health system require more effective strategies to furnish a workforce whose diversity matches an increasingly diverse population. Current and former system leaders can offer expert guidance informed by their experiences and perspectives. Their professional journeys to leadership in this area provide context and unique insight into issues of justice, including workforce diversity, equity, and inclusion in psychiatry. These experts agree that significant policy changes are needed to improve psychiatric workforce diversity and that implementing change will require that disparate groups together to achieve this goal. Financial considerations must be included in policy and advocacy.

Building a Diverse Psychiatric Workforce for the Future and Helping Them Thrive: Recommendations for Psychiatry Training Directors

The COVID-19 pandemic and murder of Mr George Floyd served as catalysts for examining antiracism efforts in psychiatry training programs and health care systems. Our recruitment and retention of Black, Indigenous, and other racial/ethnic minority psychiatry trainees has not met the demand for care and does not represent the communities served. Training directors at a critical juncture in creating systemic changes to recruitment, retention, policies, and curricular competencies to address ongoing inequities and disparities in health care. We describe several strategies and considerations for training directors in supporting a diverse psychiatric workforce.

Editorial: We Can Do Better: Meta-analysis Demonstrates Inequities in Psychotherapy Efficacy for Black Children

We read with great interest and admiration, "Meta-analysis: Are Psychotherapies Less Effective for Black Youth in Communities With Higher Levels of Anti-Black Racism?" in this issue of JAACAP.² Price et al. conduct a meta-analysis examining the association between anti-Black racism and mental health outcomes across 194 psychotherapy studies based on the racial composition of the study sample Majority-Black vs Majority-White sample. The authors demonstrated that the measured benefits of psychotherapeutic interventions were associated with the measured level of anti-Black racism among Majority-Black samples but not the Majority-White Samples. Higher levels of anti-racism were associated with less measured benefit of psychotherapy interventions among Majority-Black samples but not Majority-White samples. This finding is disturbing to us, but not surprising. We choose to highlight a few of the important findings from this impactful work.

Gender Diversity in the Psychiatric Workforce: It's Still a (White) Man's World in Psychiatry

Academic psychiatry has slightly higher rates of women in the upper ranks and leadership positions than academic medicine as a whole but women continue to be seriously underrepresented. Psychiatry departments should take specific steps to address barriers for women in psychiatry including harassment and discrimination, Imposter Syndrome, lack of mentorship and sponsorship, work-life integration issues, and overinvolvement in nonpromotion generating activities. Addressing these barriers within academic psychiatry will improve the environment for all minorities.

Training the Next Generation of Clinical Psychological Scientists: A Data-Driven Call to Action

The central goal of clinical psychology is to reduce the suffering caused by mental health conditions. Anxiety, mood, psychosis, substance use, personality, and other mental disorders impose an immense burden on global public health and the economy. Tackling this burden will require the development and dissemination of intervention strategies that are more effective, sustainable, and equitable. Clinical psychology is uniquely poised to serve as a transdisciplinary hub for this work. But rising to this challengerequires an honest reckoning with the strengths and weaknesses of current training practices. Building on new data, we identify the most important challenges to training the next generation of clinical scientists. We provide specific recommendations for the full spectrum of stakeholders-from funders, accreditors, and universities to program directors, faculty, and students-with an emphasis on sustainable solutions that promote scientific rigor and discovery and enhance the mental health of clinical scientists and the public alike.

Rising to the Challenge: Strategies to Support Latinas and Other Women of Color in Science and Medicine

Although the number of Hispanic/Latina women earning medical degrees has increased in recent years, the article by Anaya and colleagues in this issue highlights their stark underrepresentation in the U.S. physician workforce. In this Invited Commentary, the authors provide context on proposed drivers of underrepresentation, including bias, discrimination, harassment, and other structural barriers, which are amplified for women with multiple minoritized identities. They summarize the 2020 National Academies of Sciences, Engineering, and Medicine recommendations for supporting women in science, technology, engineering, mathematics, and medicine (STEMM) fields, including committed leadership, dedicated financial and human resources, data-driven accountability, and use of an intersectional approach to address the challenges faced by individuals who encounter multiple forms of bias and discrimination. The authors also provide additional recommendations and highlight innovative new National Institutes of Health funding opportunities to promote diversity in the scientific workforce. They argue that more research is needed to identify and best implement institutional practices that increase representation and retention of Latina women and other women with minoritized identities in STEMM fields.

Addressing Structural Racism in Psychiatry With Steps to Improve Psychophysiologic Research

IMPORTANCE

The American Medical Association has acknowledged the public health threat posed by racism in medicine. While clinicians in psychiatry have echoed the sentiment, the research community has largely been silent. Current understanding of the biological domains that underlie psychiatric disorders was historically established by studying White populations, often leaving widely used treatments ineffective for Asian, Black, Hispanic, Indigenous, and other racial and ethnic minority individuals. This article addresses how undersampling of racial and ethnic minority individuals has led to overgeneralized physiological findings, the implications for development of psychiatric treatments, and steps to improve service to racially diverse communities.

OBSERVATIONS

Three primary observations regarding differences associated with race and ethnicity have been addressed in the existing psychiatric research: misdiagnosis, medication nonadherence, and treatment efficacy and expression of adverse effects. While cultural factors have been discussed as potential factors associated with these differences, a lack of understanding of physiologic systems may be foundational to each of these issues. Recent evidence points to race differences in psychophysiological measures, likely attributed to factors including the lived experience of racism as opposed to inherent biological differences. This mounting evidence supports a reassessment of existing work to examine potential divergent patterns within racial and ethnic groups. The following strategies may improve understanding of the influence of racism on physiology, allowing clinicians to better address psychiatric symptoms and improve existing treatment approaches. Thus, psychiatric researchers need to (1) understand the historic and current terminology for race and ethnicity and use appropriate terms and categories as defined by sociologists, population health experts, and databases while respecting individuals' right to self-identify, (2) refine research questions, and (3) reexamine research data to determine whether patterns observed in largely White populations can extend to other groups. To appropriately implement these steps, researchers must accept the discomfort that accompanies growth, invite scientists from diverse backgrounds to participate, and use resources to increase diversity in recruitment of study participants. This will require a commitment from funding agencies to provide adequate support to recruit and investigate large, diverse samples.

CONCLUSIONS AND RELEVANCE

To create more suitable medical treatments and improve the quality of care received by those with psychiatric conditions, further discussion is needed surrounding the physiologic toll that racism has had on multiple generations of racial and ethnic minority groups and how that may alter responsivity to biobehavioral interventions. To better inform psychiatric research, the resources provided must be expanded, basic physiologic studies should be replicated with more diverse samples and adequate analyses, and psychiatry scientists must reconsider approaches to clinical research.