Preventing the Demise of Diversity, Equity, and Inclusion (2024)

Has the increased presence of leaders in diversity, equity, and inclusion (DEI) since the murder of George Floyd led to a demonstrable change in academic medical institutions? Elsewhere in JAMA Network Open, Esparza and colleagues¹ surveyed 32 DEI leaders across the United States to learn more about their experiences. Their findings confirm what many people who work in this area also know: their work, while challenging and gratifying, comes with challenges their counterparts in other leadership roles do not encounter. These leaders, charged with promoting DEI at their institutions, vary considerably in their roles, responsibilities, budgets, staffing, and authority.¹ Of the 32 leaders who agreed to participate in this survey, two-thirds identified as underrepresented in medicine (URIM), and one-third were first generation to college.¹ While many stated they had a high level of independence, they were missing a structure and clear directives from their leadership. This begs the question of whether the surge in DEI leadership in academic medical centers, particularly after 2020, was reactionary in nature or part of a sea change to make substantial efforts to create a medical workforce prepared to treat a more diverse population and advance inclusion excellence.

The authors identified 4 themes from their interviews with the DEI leaders. These included wide variability in scope, expectation, and resources; a mismatch between institutional directives and investments that engenders distrust; challenges in use of evidence-based frameworks, theories of change, or standards of expertise; and DEI work that both drives and exhausts.¹ It is worth noting that these roles are filled by people who are overwhelmingly URIM themselves (66%), and several hold more than 1 DEI role. Other studies examine the unrewarded, uncompensated work that often does not count toward academic scholarship.² While metrics for promotion are somewhat variable based on institution, historically, work focused on DEI initiatives has not been afforded academic credit for promotion. Lack of academic credit may contribute negatively to the emotional labor associated with these roles. DEI work, while rewarding in a system that is committed to change, can be equally exhausting. A recent mixed-methods study³ found that leaders utilize significant energy to maintain a neutral stance while suppressing positive and negative emotions. The consequence of this emotional labor was burnout, manifested as emotional exhaustion, diminished personal accomplishment, and depersonalization.³ The minority tax that tasks URIMs with the job of tackling diversity in academic institutions can be time-consuming, often leads to feelings of isolation and increased discrimination, and is a significant source of inequity in academic medicine.⁴

While staffing and resources are important for DEI leaders to succeed, what is not highlighted in this article is the significance of support and commitment from the top academic leadership. Scholars have noted that DEI should be actively supported by the dean and should be part of the school’s academic strategic plan. By incorporating DEI in the strategic plan, it becomes woven into all facets of the school’s mission.⁵ URIM physicians make up approximately 12% of the physician workforce and do not adequately reflect the general population.⁶ Health equity is a public health crisis; however, we cannot achieve health equity until there is a workforce that adequately reflects the population at large. DEI and health equity are closely intertwined; one cannot exist without the other. The ultimate goal of improving patient outcomes in marginalized populations underscores the importance of DEI integration into the departmental goals and strategic plan. For the past 2 years, at our institution, faculty who pursue scholarly work in DEI can include these efforts as a criterion for academic promotion and tenure, thereby reducing the minority tax and burnout experienced by those who choose to integrate DEI into their academic pursuits through research, teaching, or education.

Evidence-based medicine is anchored in scholarship to support practice paradigms. Scholarship focused on DEI would contribute to building a national, shared dialogue on evidence-based practices. Publishing is the standard by which we communicate evidence in academia, and it would enable DEI leaders to combine their service with scholarship, thereby providing a metric for promotion. Publications enable not only scholarship but also give value and visibility to this important topic. Educational scholarship centered on this DEI programming is an area that should be explored to mitigate the impact of burnout from the significant emotional labor required to sustain DEI. Scholarship in this field may include DEI curricula, seminars, or interactive workshops focused on, but not limited to, unconscious bias or holistic review and turning the minority tax into academic credit.

The absence of a practice standard grounded in DEI and the variability of resources are reflected in the results of this study¹ and are noted in 2 of the identified themes. Specifically, there is wide variability in scope, expectations, and resources (theme 1) and lack of evidence-based frameworks, theories of change, or standards of expertise (theme 3).¹ Successful and impactful DEI programs require a shared framework with crucial components. Frameworks such as the target, establish, acquire, and measure (TEAM) roadmap described in gastroenterology are generalizable across most specialties and academic medical centers.⁷ There should be intentionality in targeting DEI metrics at institutional, departmental, and divisional levels. Metrics include but are not limited to departmental or divisional demographics, recruitment, retention, and promotion statistics.⁸ This work should be prioritized at the highest level of leadership and resourced appropriately. Tangible and intangible resources acquired should be robust, sustainable, and standardized across departments. It is imperative that leadership truly invest in DEI with the necessary programmatic and financial support. Lastly, similar to any process involving quality improvement and/or assurance, progress should be measured and programs adjusted accordingly.⁷ These objectives are not attainable without true allyship with institutional and local leadership.

In conclusion, this article¹ highlights the significant challenges faced by DEI leaders nationally. To facilitate this work, a shared framework, evidence-based practices, financial and administrative support, and significant investment by senior leadership and key stakeholders are needed to advance the academic work of DEI and its alignment with institutional goals.

Published: June 13, 2024. doi:10.1001/jamanetworkopen.2024.15379

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Joseph KA et al. JAMA Network Open.

Corresponding Author: Renee Williams, MD, MHPE, Department of Medicine, Division of Gastroenterology and Hepatology, NYU Grossman School of Medicine, Bellevue Hospital Center, 462 First Ave, Room CD603, New York, NY 10016 (renee.williams@nyulangone.org).

Conflict of Interest Disclosures: None reported.