Where We Stand
Section: Workforce Issues
Policy: Equity Task Force Recommendations
Appendix M

Equity Task Force Recommendations

 

EQUITY TASK FORCE REPORT: EQUITY IN THE MEDICAL PROFESSION

 

The OMA supports the following principles related to equity and inclusion in the medical profession:

1. The OMA is committed to improving diversity, equity, and inclusion within the medical community and to being an antiracist organization.
2. Patient care benefits when the medical workforce at all levels and in all specialties reflects the diversity of our communities.
3. The OMA affirms the importance of ongoing collection of data and measurements of inequities for impacted groups to create transparency and accountability. We must respect the sensitivity of information collected but must understand the barriers to improved workforce diversity in order to overcome them.
4. The OMA will work to further an inclusive and supportive environment within medicine. Recognizing the burdens to be overcome by individuals facing barriers, the OMA will offer mentorship opportunities and promote policies resulting in active recruitment and support of a more diverse workforce.
5. The OMA recognizes alternate and nontraditional career pathways and supports them as to ensure the growth of and sustain diversity within the workforce and medical community.
   1. Those caring for children, elder family members, or others with increased needs carry burdens and assume responsibilities that should be highly valued in the profession. Taking on this responsibility demonstrates traits congruent with the calling to a life of service in medicine, and retention of these members of our professional community must be a priority. Traditional cultures and systems within the profession must change to allow all members of our professional community to continue to contribute, even when other life burdens make this challenging.
   1. A shift in medical traditions must allow alternate career pathways to include recognition and rewards for work done to further the goals of a diverse workforce.
   2. A shift in culture must also improve the retention, and hence equity, of the medical workforce by recognizing that overcoming barriers is a task to be shouldered by the whole community.
6. The OMA will increase representation of diverse members of the medical community within the organization and its own leadership.
7. The OMA encourages institutions that intersect any part of the pathway in medicine to actively work to increase recruitment to and retention within the medical professions of diverse members.
8. The OMA affirms that physicians and physician assistants deserve equal compensation for the same work as their peers, without regard to gender, race, ethnicity, religion, sexual orientation, and gender identity; or other factors that have placed people at risk of discrimination. This will require further evaluation of salary inequities by race, gender, and other minority status, as well as development of transparent compensation strategies and advancement metrics.
9. The OMA recognizes that improvements in equity in the medical profession will increase the wellbeing, safety, productivity, work satisfaction, and opportunities for medical professionals, as well as positively impact health outcomes for communities, patient access to care, and satisfaction with care.
10. Equity issues in the profession and our society will always be a work in progress. Task Force members recognize that not all facets of equity are thoroughly addressed in this document, and the OMA commits to continuing to advance equity work with attention to additional areas, including but not limited to systemic racism, disability communities, international medical graduates, and religion.

 

Task Force Background

As disparate communities around the world are brought closer together with advances in technology and transportation, the rich population diversity of the United States has the potential to be a catalyst for innovation and cooperation between people of various cultures and backgrounds. This dynamic and diverse population helps promote creativity and advancements by sharing ideas, products, and services across all disciplines. Although diversity in the United States is a great strength and example of freedom, there are certain challenges diversity introduces to the work environment that have not been fully explored and resolved. These challenges have led to persistent inequities in pay, advancement, and inclusion, and to issues with harassment within the workplace, despite legislation intended to provide protections and aspirations for better. The medical profession is no exception.

To help address concerns of equity in the medical profession, the Oregon Medical Association (OMA) launched its Equity Task Force in October of 2019. Physicians, physician assistants (PAs), and medical and PA students were selected as members from around the state, representing a range of perspectives and backgrounds. The Task Force was charged with providing recommendations to guide the state’s medical community and the OMA’s advocacy work on equity issues related to gender, race, ethnicity, sexual orientation, and gender identity. The work was completed by five workgroups:

●     Pathways into medicine

●     Workplace culture

●     Caregiving responsibilities

●     Patient relationships

●     Pay

The OMA hopes that this work may increase diversity in the healthcare workforce, improve retention of diverse members within the workforce, and ultimately lead to better care of the state’s diverse communities. We believe this can be achieved by increasing the currently available paths into the profession, advancing equitable pay and promotions, improving workplace culture, reducing caregiver stress among clinicians, and supporting the importance of clinician-patient relationships.

The Equity Task Force researched the evidence base regarding the impact of identity characteristics (including gender; ethnic and race groups underrepresented in medicine; and lesbian, gay, bisexual, transgender, queer) on careers in medicine. Members of underrepresented racial and ethnic groups face many barriers when undertaking careers in medicine. Women and members of the LGBTQ+ community also face unique challenges in the clinical, research, and academic settings. Although the Task Force did not specifically focus on the challenges of immigrants, religious minorities, and people with disabilities, improving sensitivity and access related to other equity issues may benefit these populations as well. Additionally, the Task Force recognizes the nuance of intersectional characteristics that together can magnify an individual’s level of privilege and exposure to opportunity or risk of bias and setbacks.

Pathways into Medicine

The traditional pathway into the medical profession includes successful completion of grades K-12, a bachelor's degree, pre-medical school requirements, and admission into a professional school. Historically, racial and ethnic minorities, women, and LGBTQ+ individuals have faced barriers throughout this pathway to medicine, which has contributed to the lack of diversity seen in medicine today. Those who exist at the intersection of these nontraditional identities can be even more strongly impeded. The longstanding effort to keep the medical professional homogeneous suggests that a similar conscientious effort, with interventions at various stages in the pathway, will be required to achieve true diversity.

The Task Force Recommends:

1. Opportunities for early exposure to medicine and specialty fields and early contact with mentors from diverse backgrounds in medical professions;
2. Institutionally and state funded financial support for students interested in healthcare careers who have a demonstrated financial need to help with preparation for medical school, including support for living expenses and medical school application expenses;
3. Community programs that aim to create a diverse conduit of students to enter health professions, such as underrepresented minority-directed pre-med immersive programs, youth outreach to inspire early interest by medical students and clinicians, and paid opportunities for high school students to work in medical practices with clinicians;
4. Enhanced funding for quality early childhood through high school education and for parental educational and employment opportunities and benefit programs; these are foundational for economic and housing stability and food security for all at-risk families;
5. Holistic admission criteria for medical schools, removing standardized testing as a requirement and prioritizing recruitment from underserved regions;
6. Inclusion of sexual orientation and gender identity as standard demographic variables collected on medical school (AMCAS), residency (ERAS), fellowship, and other employment applications, as well as on licensing applications, academic appointment applications, and professional society surveys to understand whether current recruitment practices effectively achieve diversity goals;
7. Routine evaluation of what demographic variables are collected on medical school, residency, fellowship, and other employment applications, as well as on licensing applications, academic appointment applications, and professional society surveys to consider additional expansion of this list over time as needed to help understand whether current recruitment practices effectively achieve diversity goals;
8. Opportunities for interaction and longitudinal mentorship with faculty and clinicians in the community, including mentors whose own knowledge or experiences may help mentees navigate issues related to characteristics of diversity during medical school and training 
9. Accreditation standards of training programs that require programs to promote inclusion by requiring demonstrated actions taken to improve diversity;
10. Training for clinicians and healthcare administrators on critical race theory to improve awareness of potential for bias;
11. Decreased weight of Step 1 board examinations and moving toward holistic evaluation in the residency application process;
12. Universal and equal acceptance of COMLEX exams by all US residency programs to decrease the added financial and testing burden placed on underrepresented DO students when they are implicitly expected to take the USMLE series in addition to the COMLEX series;
13. Robust test preparation resources that are integrated into a medical school’s curricula to minimize inequality of access to high-quality board prep materials;
14. Change to criteria for honors societies, awards, and opportunities for public speaking and elimination of their use from consideration on applications for training positions, hiring, promotions, and tenure if honors have not been scrutinized for issues of equity; and
15. Increased research in key areas in which the literature related to equity in medicine is lacking. This includes, but is not limited to: impacts of sexual gender minority status on experience of training, access to career advancement, and improvement in clinical care delivered; impacts of improved gender, racial, sexual orientation/gender identity diversity on the quality of care and costs, effective interventions that achieve improved representation, and retention of diversity in the practice of medicine; and reasons for clinicians for reducing work hours and ways to improve full engagement and retention in the profession.

Workforce Culture

 A healthy workforce culture is a key enabler in retention of healthcare clinicians, particularly for women clinicians and clinicians from underrepresented minority groups. Workforce culture is multi-faceted, including the existence of discrimination, exposure to violence of many types, clinician burnout, and the abilities for advancement. Significant issues in workforce culture include workplace harassment and violence towards women, the inclusion of LGBTQ+ people, and the inclusion of people of color. Additionally, these groups often experience barriers to equitable advancement opportunities. Efforts are required to remediate existing dysfunction in workforce culture, in addition to the work required to build healthier future foundations of culture.  

The Task Force Recommends:

1. Training for leaders at all levels of organizational structure to be change agents for the development of a positive, inclusive, and respectful workforce culture for all members of a diverse healthcare team, with the goal of moving beyond a focus on reducing legal risk and focus on actively altering culture and climate; 
2. Funding for research on medical institutional climates to better understand the problems and needs of medical professionals and academic medical centers in Oregon;
3. Requirements for tracking and reporting progress in equity through measurable data on representation by race, ethnicity, gender, sexual orientation, etc., monitoring retention in the profession and institution; and exploring the experiences people have with discrimination and/or violence at regular intervals;
4. Medical school accreditation tied to evidence of active and meaningful leadership to improve representation of women, racial/ethnic minorities, and LGBTQ+ people in all arenas;
5. Resources to reduce isolation within the profession and to develop systems to elevate voices and concerns of disadvantaged groups to institutional attention, with an eye toward improving culture;
6. Integrated and centralized diversity within the mission of an organization and within the organization's leadership ranks;
7. Transformation by medical institutions of their internal culture through enhancing the visibility of diverse populations in leadership positions and diversifying leadership positions at every institutional level, including, but not limited to, board of directors membership, executive-level organizational leadership, management positions, medical directorships, and tenured faculty roles; 
8. Publicly reported data on board of directors and C-suite diversity (including trends in diversity over time) from medical institutions within the state;
9. Promotion and tenure policies to be better adapted to reflect and value the career trajectories and contributions of women and underrepresented groups within academic medicine and other medical organizations;
10. Effective mentorship opportunities, either locally or through national organizations, targeting the specific population/demographic group’s experience of barriers and challenges;
11. Strong, meaningful representation of diversity on panels involved in recruitment and promotion reviews within a medical institution, as well as ensuring diversity among candidates for hire before closing the search to fill a position;
12. Recognition that racism is a system that assigns value based on how one looks and internal examination of an organization’s own policies, practices, norms, and values and how they influence decision-making in order to determine how racism is operating within the institution;
13. Access to educational materials and resources to guide the construction of antiracist interventions within medical institutions, including but not limited to identifying who is missing from the decision-making table and what is “on” versus “missing from” the agenda;
14. Close examination of the historical role of sexism/gender bias and racism in an institution or organization to identify how past decision-making and practice may be influencing current policy and climate; the OMA will start by modeling this work internally;
15. Stricter anti-discrimination policies and protections that actively remove barriers to women clinicians and develop an antiracist culture;
16. Adoption of the 2018 NASEM report recommendations for individual, institutional, and legislative changes to reduce workplace discrimination and violence, which include targeted efforts to improve safe and respectful work environments and organizational culture, addressing the most common forms of sexual and gender harassment;
17. Institutional, local, state, and federal legislation that upholds and strengthens the rights and privacy of survivors of sexual harassment and violence and is survivor-centered, including but not limited to changes made to Titles VII or IX;
18. Use and funding of confidential advocates within institutions to support students and professionals who experience harassment and/or violence, with the role of confidential advocates expanded, and appropriately funded, to also address microaggressions and inequities experienced within the organization, with a goal of shifting institutional culture and mitigating current inequities;
19. Zero-tolerance policies for workplace harassment based on race, ethnicity, gender identity, sexual orientation, religion, parenting or caregiving status, disability, or other unique identity held by individuals in the medical workplace;
20. Routine surveying by educational institutions of medical trainees about gender-based violence;
21. Recognition of the value that unique contributions from women clinicians and underrepresented faculty or clinicians offer by modifying promotions processes to positively weight contributions, including but not limited to, underserved patient care advocacy, community service, and research with underserved and minority patients. increased time and commitment to mentoring of women and underrepresented clinicians and students; and time and commitment to diversity work within the organization;
22. Education for academic faculty and organizational leaders about existing literature-documented challenges that women and underrepresented clinicians face and methods to overcome those challenges;
23. Implementation of best practices for collecting data on representation of LGBTQ+ clinicians in the workforce and on the pathway to the workforce, including applicants to medical school, residency, and fellowship training;
24. Efforts and initiatives directed at more broadly Implementing early-career debt relief;
25. Performance evaluation criteria and advancement criteria that are explicit and transparent, including the standards for advancement when a clinician works part-time or has a leave of absence for caregiving responsibilities; to be reviewed annually with employees to identify areas of difficulty and ensure success;
26. Targets for hiring, retention, and advancement of women and underrepresented members of clinical and academic teams and that leadership team reviews, and program accreditation be tied to success in these arenas;
27. Opportunities for leadership training and mentoring in medical organizations, academic institutions, and practices, with a focus on women and other underrepresented clinicians;
28. Family-friendly policies and adjustments to the promotion cycle within organizations that allow for career customization and individualized career plans which span a faculty member’s career, with options to flex up or down in research, patient care, administration, and teaching; 
29. Increased availability of pilot funds from academic and governmental institutions to lower barriers for research and systematically monitor startup packages for research and academic work to ensure resources are equitably distributed, regardless of demographic differences; and
30. Training for decision-makers of hiring, promotions, and leadership to recognize their own biases and on the organizational imperatives around improving diversity.

Caregiving

Family care responsibilities, both for children and for elders or those with healthcare needs, fall disproportionately on women. Cultural and socioeconomic differences and diverse family structures result in differing impacts on some racial and ethnic groups and LGBTQ+ individuals. These responsibilities can impact pay, advancement opportunities and lead to increased experiences of stress and burnout. Issues relating to balancing family and work must be addressed to achieve a more equitable and diverse workforce.

The Task Force Recommends:

1. Flexible course schedules within medical schools that allow for caregiving for family members, with efforts made to ensure timely graduation and progress;
2. Residency application process and cycles that increase options for trainees who seek to care for family members, such as a second application cycle to minimize unused time off;
3. Family leave policies that are opt-out, as opposed to opt-in, with reasonable wage replacement rates;
4. Gender-neutral parental and family leave that would ensure protection for LGBTQ+ families that otherwise face unequal social and economic treatment;
5. High quality publicly and institutionally supported childcare, including backup care for sick children;
6. Accessible lactation resources in workplace and academic settings and standardized policies regarding scheduling accommodations to support breastfeeding;
7. Opportunities for flexible work schedules;
8. Resources to ensure the provision of childcare in emergency and on-call situations;
9. Increased resources for in-home care for the elderly and reduced-cost high quality options for institutional care; and
10. Increased research on care for older adults by “sandwiched” families.

 

Patient Relations

Patient bias toward clinicians and clinician bias toward patients can have impacts on the quality of care and the clinicians’ wellbeing. Mismatch in identities can also create problems within the relationship. Negative bias toward a clinician can lead to mistreatment or affect how the quality of care is perceived by the patient. A clinician’s characteristics play a role in which patients will select them for care, leading to panels that are inequitable with regard to workload and revenue generation.

The Task Force Recommends:

1. Increased research on how to improve identity-conscious care;
2. Improved education for trainees and continuing education for practicing clinicians that addresses not just issues of cultural difference, but systemic racism, sexism, homophobia, and transphobia, and provides tools to examine these issues;
3. Self-assessment of institutional bias by healthcare organizations while creating a robust support system for clinicians and other healthcare members;
4. Nuanced approaches to reimbursement to account for differences in patient utilization and care needs;
5. Discrimination reporting systems for both clinicians and patients within healthcare organizations;
6. Funding to increase access to healthcare resources and clinician training in rural settings.
7. Resources for clinicians to adequately assess their appropriate amount of workload in their patient panels and support these findings with appropriate panel assignment;
8. Policies within healthcare organizations that explicitly address patient bias, with a clear mechanism for reporting incidents of patient bias and procedures to inform decisions about future care of the patient and support of the medical staff; and
9. Standardized responses by medical groups and healthcare institutions to be directed to patients who demand different clinicians due to patient bias against clinicians.

 

Pay

Pay inequity remains a challenge for many populations of healthcare workers, with particular impact on women, ethnic and racial minorities, and the LGBTQ+ population. This impact is felt downstream by our patients in lower worker satisfaction, lower workforce retention, and diminished understanding of community health challenges. The inequities are multifactorial, systemic, and persistent throughout the careers of impacted populations. Factors such as bias in hiring and promotions and payment system type are some of the contributors.  Clinician groups must be made aware of the impact on both health outcomes and financial metrics by achieving pay equity. Further research is required, and clinician groups must be encouraged to improve, monitor, and audit pay practices and internal policies. State and federal legislative action will likely be required to align incentives to true pay equity. 

The Task Force Recommends:

1. Routine collection of data on pay and total compensation by all large medical groups, academic institutions, and coalitions of smaller groups, carried out with attention to demographic factors and any factors that may account for differences in compensation, with special attention to groups that have not yet been well evaluated;
2. Consideration for protecting privacy and confidentiality in developing methods of data collection and sharing;
3. Governmental support and funding for data collection and pay disparity research;
4. Standardization within medical institutions and groups of starting position salary based on specialty, rank, and region;
5. Omission of questions about previous compensation during the application, interview, and hiring process;
6. Routine audits of total compensation (clinical and non-clinical) for large clinician practices performed by outside consultants, with results of the analysis shared with a diverse supervisory and accountable leadership group or with the division director;
7. Incorporation of equity metrics into quality targets or annual evaluations of organizational leaders;
8. Transparency on how initial and subsequent salary is determined and data on current compensation levels (including information on rank, years of employment, gender, race, and other pertinent demographic data);
9. Adjustments in salaries made if unexplained differences are identified;
10. Compensation based on a broad range of factors that value the overall experience of the clinician beyond FTE and productivity;
11. Implementation of compensation models that reduce inequities, such as: salary-only structured compensation models incorporating national benchmarks and clear standardized pay steps and increments, structured compensation models based on rank and time-in-rank in a given subspecialty, value-based compensation systems, and development of an “academic RVU” measure that can also be used to determine compensation;
12. Public access to national salary data such as the AAMC salary report;
13. Evaluations of compensation that include a comprehensive view of compensation including: retirement benefits, disability/malpractice insurance, health benefits, access to pay for performance or bonuses; research support; division of work between clinical, teaching, committee, and research responsibilities; access to leadership opportunities; and factors impacting clinical workload for individual clinicians;
14. Avoidance of patient satisfaction metrics such as Press Ganey or HCAHPS as factors in deciding compensation, bonus, and advancement unless there are robust data demonstrating that patient bias has no statistical effect;
15. Consideration for differences in risk levels of patient panels when using quality of care measures to determine compensation, to avoid penalizing clinicians for caring for more complex groups of patients;
16. Precise promotion guidelines (e.g. number of papers, size of grants) for academic positions and availability of an experienced senior faculty member who can counsel faculty on readiness for promotion;
17. Consideration of valuation of citizenship work (e.g. committee, mentoring, service work); rewarding activities central to medicine like teaching and committee membership;
18. Specific criteria for earning add-on bonuses available and achievable by all the members of the group, with routine updates on progress toward the goal provided by leadership;
19. Performance reviews coupled to routine assessments for compensation adjustment;
20. Human Resources involvement in countering forces pushing toward compensation inequities, by evaluating job offers to ensure they’re based on the value the position brings to the organization and not on what the candidate earned previously, participating in routine pay equity analyses to determine if pay is based on relevant variables like market value, experience, last three performance ratings, utilizing peer group settings to discuss and defend the distribution of raises; and monitoring hiring, promotions, and raises to ensure they are bias free and explicit regarding who is responsible for equitable pay;
21. Term limits for leadership positions;
22. Standardization and transparency related to how decisions about part-time status and family/medical leave impact advancement, bonuses, and expectations about productivity in a given period of time;
23. Research to identify the policies, procedures, leadership, and/or culture that promote equity in some specialties in order to determine best practices and target the effective remedies to disparities in all specialties; and
24. Federal and state legislation to address wage gaps such as the Paycheck Fairness Act.

 

Advantages of a Diverse Workforce

The goals of improved diversity in the physician and PA workforce include improving patient care and satisfaction, increasing workforce resources in the setting of clinician shortages, advancing the quality of scholarly work, and improving ethics and justice within the profession.

Historically, efforts to increase equity and equality have targeted the barriers a specific group face. However, many people have identities that intersect multiple categories that are more significant when experienced together than would be one single identity characteristic alone. For this reason, the Task Force addresses issues of equity more universally recognizing that issues related to gender, racial and ethnic identities, and sexual orientation and gender identity cannot be examined and addressed effectively alone.

Defining the characteristics that warrant close attention and concern as they appear to represent the most significant barriers to careers in medicine is important when furthering research, understanding, and identifying interventions. According to the Association of American Medical Colleges (AAMC), “underrepresented in medicine” (URiM) is defined as “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.” At the time of this report, these groups include Blacks, Mexican‐Americans, Native Americans (American Indians, Alaska Natives, and Native Hawaiians), and mainland Puerto Ricans.¹ Other populations may also face barriers, but have been more successful at increasing representation in the profession. The Taskforce examined the impact of diversity characteristics on achieving the goals of excellence in our healthcare system.

Gender diversity on medical teams benefits the profession, as well as the people and communities served. There are documented differences in the way women practice medicine, including increased adherence with clinical guidelines and preventive care recommendations, a patient-centered communication style, and longer visits with patients.^2,3,4,5,6 Recent studies demonstrate improved clinical outcomes for patients cared for by women. In one study, elderly hospitalized Medicare patients treated by female internists had lower mortality and readmissions compared with those cared for by male internists.⁷ In another study, after accounting for patient, surgeon, and hospital characteristics, it was found that patients treated by female surgeons had a small but statistically significant decrease in 30 day mortality, length of stay, complications, and readmissions compared with patients of male surgeons.⁸ The presence of women clinicians may benefit care by adding a different perspective and unique talents, qualities, attributes, and insights. 

Other kinds of diversity on medical teams have been shown to add to the effectiveness of the team as well. Racial and ethnic diversity among teaching faculty increases the quality of training for all students in caring for racially heterogeneous populations and promotes scholarly activities related to racial and ethnic health disparities.⁹ Racial and ethnic minority clinicians are more likely to practice in underserved communities, including caring for racial minorities and uninsured patients.^{10,11,12,13,14} Physician diversity and increased diversity among medical teams is linked to better patient outcomes in primary care.¹⁰ Physician-patient race concordance is associated with higher levels of African American patient satisfaction with care, and improved communication and better pain management are listed as benefits.¹⁵ Ethnic minorities tend to receive better interpersonal care from clinicians/physicians of their own race or ethnicity.¹⁶ Race and gender concordance between Black men and their physicians has been shown to significantly increase uptake of evidence-based effective care.¹⁷  

Race bias produces worse clinical results. White medical students and residents have demonstrated false beliefs about biological differences between Blacks and whites including bias in perception and treatment of pain.¹⁸ Reports of substandard care including omission of physical exams, inappropriate diagnosis/treatment, and difficulty receiving referrals have been reported with discordant physician-patient ethnicity or race.¹⁹ Bias and care quality improves when the diversity of the clinicians increases. The National Academies of Medicine states that a main factor for health inequity for LGBTQ+ patients is the lack of clinician training in this area and limited availability of clinicians with expertise.^20,21 Improved training and competency in the care of LGBTQ+ patients and equal representation of this community in all medical specialties represent methods of improving the delivery of appropriate care to this population. 

Healthcare studies show patients generally fare better when care is provided by more diverse teams. Studies outside the healthcare field find improvements to innovation, team communications, and improved risk assessment. Team diversity in healthcare “facilitates friction that enhances deliberation and upends conformity,” resulting in better decisions and improved financial performance, consistent with evidence from the non-healthcare arena.²² Increased gender diversity on teams is directly associated with more cooperative behavior; male physicians who have more exposure to female physician colleagues are better able to treat female patients.²³  

We see a connection between collaboration across diversity and increasing impact of scientific work, and, in one study, ethnic diversity was found to have the strongest correlation with scientific impact.²⁴ All this can lead to better science, better patient care, better population outcomes, and more impactful healthcare systems. 

Finally, evidence from outside medicine indicates that diversity on teams is good for business. Diversity on teams allows companies to outperform their competitors, helps leadership teams overcome adversity, and flourish by improving their decision making, elevating creativity and innovation, and significantly improving financial performance.^25,26,27 

Terminology

Clarity of terminology is important when discussing aspirational change. As the research and potential solutions to our diversity, equity, and inclusion challenges in medicine are discussed in the documents in this report, we will use these words with specific meanings in mind. The concepts described by these words can be easily misunderstood, so developing a common language will improve communication with readers and allow for an evolution in thinking. 

Diversity is often thought to represent gender and race, but in reality, is broader than identity alone. The concept of diversity is better thought of as bringing together people with diverse identities and ways of thinking to broaden the “cognitive repertoire” (scholar Scott Page). These people bring diversity of thought, providing increased capacity and power for tasks and teams. Grouping people of diverse perspectives and skills to work together creates opportunities for more problem-solving and creativity, as well as better recognition of possibilities and risks. 

Inclusion is a complementary and essential partner to diversity because it creates a culture in which every individual’s contribution is valued and heard. If the culture is inclusive, the team respects each member, and each member feels safe and valued when contributing. Interacting in a constructive and productive way, the inclusive team is able to benefit from diversity.

Equity involves intentional, consistent, culture-building efforts to optimize the organization’s understanding and handling of the lifetime of implicit bias faced by people from diverse groups. The goal is to provide access and opportunities to every member of the team. Thoughtful leadership and systems change are often necessary to mitigate implicit bias and approach or achieve equity.²⁸

The term clinician is used to be inclusive of both physicians and physician assistants. The OMA is composed of both physician and physician assistant members. When other terms are used, it is to more accurately reflect the scope of a specific study and is not meant to exclude either type of training or professional affiliation. 

Pathways into the Medical Profession

For underrepresented minorities, including African Americans/Blacks, Mexican Americans, Native Americans (American Indians, Alaska Natives, and Native Hawaiians), and mainland Puerto Ricans, the barriers to entry into the health professions begin long before professional training. These groups comprise approximately 41 percent of the United States population but represent only 12.9 percent of practicing physicians¹ and 13.3 percent of practicing physician assistants.²⁹

When compared to US census data, African Americans/Blacks, American Indians/Alaskan Natives, and Native Hawaiians/Pacific Islanders have less representation in the medical school population than expected, while Asian medical students are represented higher than expected.³⁰ This is predominantly explained by the fact that members of these racial groups remain underrepresented among medical school applicants and matriculants.¹⁰

According to data collected by the AAMC, from 2013-2018, the rates of graduation from medical school for American Indians/Alaskan Natives remained at 0.2 percent of women and increased from 0.1 to 0.2 percent of men. Native Hawaiians/Pacific Islanders remained at less than 0.1 percent of medical school graduates. Hispanics, Latinos, and those of Spanish origin dropped from 5.6 to 5.4 percent of women graduates and increased from 4.7 to 5.3 percent of men graduating from medical school during this time period.¹

While already significantly represented, Asian students made additional gains from 21.5 to 22.7 percent of women graduating and from 19.8 to 20.6 percent of men graduating from medical school. The representation of African Americans/Blacks increased slightly from 7.8 to 8.0 percent for women, and 3.9 to 4.6 percent for men during those years.³¹ However. it is important to note the overall downward trend for African American/Black men from 1986 to present.^32,33

Women, overall, have actually surpassed parity with men in the number of applications to medical school.¹ This is poorly reflected in the appearance of the profession beyond medical school because of the impediments to career advancement women encounter beyond graduation.

In the Physician Assistant Education Association program survey, published annually, students are categorized as “male,” “female,” or “unknown gender.”³⁴ According to the 2019 report, 72.2 percent were female, 26.4 percent were male, and 1.3 percent unknown. It should be noted that the report does not feature an option to include data on students who are non-binary. 7.6 percent of students identified as “Hispanic, Latino or Spanish in origin,” 0.5 percent identified as “American Indian or Alaskan Native,” 9.9 percent as “Asian,” 3.9 percent as “Black or African American,” 2.2 percent as “multiracial,” 1.6 percent as “Native Hawaiian or Pacific Islander,” and 69.4 percent as “White.” 

In 2009, the WHO recommended increasing workforce diversity to address social accountability within healthcare and to alleviate health inequity.³⁵ Numerous studies demonstrate that increased representation of URiM improves the health of patients and communities. Racially and ethnically concordant patient-physician relationships lead to a greater degree of trust, patient satisfaction, equitable care, and better health outcomes for disadvantaged populations. The lack of diversity in the medical profession is seen as a major contributor to the disparately poor health outcomes seen in people of color in the United States.^36,37,38,39 To correct the underrepresentation of minorities in the health professions, interventions must be applied early in the pathway. 

The extent of disparity varies by specialty. In one longitudinal study of 16 specialties, Black and Hispanic/Latinx physicians showed a significant trend toward reduced representation in most specialties from 1990-2016. The only notable exception was Black women physicians in academic obstetrics/gynecology.⁴⁰ 

The number of African American physicians in the United States continues to be unrepresentative of the US general population. The current system is inadequate in generating a workforce that represents the diversity of the United States. Only 10.8 percent of all practicing physicians are Black/African American or Hispanic, and they are not evenly distributed among specialties.¹ A number of specialties report a general lack of diversity, including radiology, oncology, emergency medicine, orthopedic surgery, obstetrics and gynecology, and ophthalmology.^{12,41,42,43,44,45,46,47} Among physicians in primary care, underrepresented groups (Black, Hispanic, and Native Americans) together constitute 13.4 percent of practicing physicians. Nonetheless, the diversity of these primary care physicians does not reflect the population diversity of the nation, where these groups represent a much larger fraction of the overall US population (30.5 percent).¹¹

According to the American Academy of Physician Assistants (AAPA) demographic data on active PAs, the profession is predominantly white (88.5 percent). Only 2.7 percent of PAs identify as Black/African American, 3.4 percent as Hispanic/Latino, and 3.9 percent as Asian.⁴⁸ However, it is important to recognize that many organizations, including the AAPA, only collect data on active members within the organization. As a result, statistics on minority individuals within the profession as a whole are often not accurate. The certifying body, NCCPA, has reported the profession to include 86.7 percent white, 3.6 percent Black/African American, 6 percent Asian, 0.3 percent Native Hawaiian/Pacific Islander, and 0.4 percent American Indian/Alaska Native.²⁹

In this section, we will describe some of the many issues that impact progress in this area. The resistance to progress is primarily an issue of the American structural culture that has permeated healthcare. The paucity of URiM clinicians entering the profession and advancing cannot be attributed to a lack of talented members of these communities. Educational, social, structural, and cultural barriers woven into the fabric of this country significantly limit opportunities and constrain pathways to higher institutions of learning for nontraditional students. 

At the end of the pathway, these students face the existing culture, social mores, and norms of academic health centers, which have endured for over 300 years and were originally established by predominantly white, upper-middle class Northern Euro-American heterosexual men, for the benefit of none other than the same. These continue to pose a barrier to those falling outside this antiquated standard for the profession. Those who live at the intersection of multiple nontraditional identity characteristics face even greater challenges. Change to this system, which stands as the pathway and portal to entry into the medical profession, has been very slow and is unlikely to be more than incremental without intentional and targeted action.

To address the urgent need for a diverse health profession workforce, the barriers to entry for URiM must in turn be identified and addressed. For underrepresented minority students, barriers exist at various time points in the pathway that prevent these groups from entering the profession and achieving their goals. These barriers start early in their educational process and continue until late in their careers. Disparities in K-12 education, increasing tuition, lower acceptance rates, and social isolation have all been shown to serve as barriers for underrepresented minorities attempting to enter the health professions. 

The lack of diversity in the health professions is, in major part, a reflection of our nation’s unresolved issues, with race and racism resulting in fundamental social inequities. These inequities are reflected within our public-school systems and result in unequal opportunity and access to knowledge for minorities. Bias-influenced practices lead to sorting and stratifying of URiM students by race and ethnicity and not by intellectual potential, motivation, and effort.⁴⁹ These practices disproportionately exclude URiM students physically from advanced academic classrooms and psychologically from believing they are meant to participate fully in academic institutions. Biases may also influence teachers to have lower expectations for minority students in comparison to their white peers.⁵⁰

The implicit and explicit bias experienced by URiM students can affect their attitudes toward learning in general. Black and Latinx students are consistently punished more severely than white students for the same infractions.⁵¹ Students of color are disproportionately disciplined in schools. African American/Black students are nearly four times as likely to be suspended from school as are white students, nearly three times as likely to be removed from class but kept in school, and almost three times more likely to be expelled. They are also about three times more likely to be referred to the police for an incident on school grounds and 3.5 times more likely to be arrested for an incident on school grounds during school activities. 

Such disciplinary actions are associated with a spectrum of negative life outcomes, including involvement with the criminal justice system. A Princeton University study found a direct relationship between the level of implicit and explicit bias in a community and the level of bias in the schools of that community with respect to discipline. This was true across the United States.⁵² According to a 2014 report by the US Department of Education’s Civil Rights Office, there are widespread disparities in how schoolchildren are punished, such that Black and Latinx students are punished more severely for the same infractions.⁵³ Zero-tolerance policies appear to be responsible, but the policies are clearly discretionary in their application, with a bias favoring white children.⁴⁹

Impact of Educational Factors

The barriers that exist for URiM students at the kindergarten level through 12th grade include limited resources in public schools in lower socioeconomic neighborhoods, limited exposure to STEM programs and health careers, poor advising, and bias from teachers and other staff.⁵⁴

To increase the possibility of success for minority high school students interested in a career in the health professions, individualized guidance and exposure to health professions and minority health professionals is critical. These factors can impress upon a student that they are capable and that they have a place in the institution of medicine. Exposure, access to knowledge, mentorship, and appropriate guidance are necessary to broaden and smooth the pathway from kindergarten to a medical profession.^55,56

On-campus enrichment programs such as OnTrack OHSU and Summer Internships provide K-12 students with early exposure to healthcare professions. These programs have been identified as one of the most effective recruitment strategies for recruiting URiM students to graduate PA school.⁵⁷

Barriers at the Elementary School Level

Academic disparities are apparent as early as kindergarten. Black and Hispanic children are more likely to live in poverty,⁵⁸ a condition that research suggests is associated with lower than average academic performance that begins in kindergarten⁵⁹ and extends through high school, leading to lower than average rates of school completion.⁶⁰ Efforts to achieve racial and ethnic diversity in the healthcare profession must begin early and be sustained from the preschool through secondary school levels. Given the progressive nature of education, the earlier interventions begin, the more likely they are to be effective.⁶¹ 

Well-designed early childhood interventions programs have demonstrated benefits in a wide range of areas, including academic achievement, behavior, educational progression and attainment, delinquency and crime, and labor market success. The results, although not uniform, are improved by better-trained caregivers and smaller child-to-staff ratios. The return on investment to society ranges from $1.80 to $17.07 for each dollar spent on the program.⁶¹ Beyond improving education overall in communities of color, generating interest in the medical field represents an additional challenge.⁶¹ Racial and ethnic minorities in the United States tend to live in lower socioeconomic neighborhoods. Since public schools are most often predominantly funded locally, lower socioeconomic districts generally do not have the resources to attract and retain strong, engaged teachers or fund STEM labs.⁶² Poorly-equipped schools with limited resources are unlikely to yield large numbers of medical school candidates. Students from such schools historically underperform their peers who have access to better resources. This dearth of resources contributes to lacks in other areas, namely adequate science knowledge, interest in science, health career options, correct information about academic requirements, access to technology, and effective study skills. There is strong evidence that programs designed to recruit and prepare URiM students for careers in the health professions improve students' academic achievements, including improved grades, likelihood of high school graduation, SAT scores, and college entry.³²

Barriers at the Middle and High School Levels

Teachers’ belief or confidence in their students’ academic skills and potential is “a vital ingredient for student success” because it is linked to students’ beliefs concerning “how far they will progress in school, their attitudes toward school, and their academic achievement.”⁶³,⁶⁴ Student attitudes about education and its potential in their lives have a significant impact on their self-efficacy, which in turn impacts student academic performance and career aspiration.

Studies have demonstrated significantly higher high school dropout rates for URiM students. One such study published in 2004 showed that more than one in five Latino students and one in ten African American/Black students have dropped out of high school, while the incidence of dropout for white students is only one in seventeen.⁶⁵ More recent data from the US Department of Education National Center for Education Statistics have shown improvements in these trends, namely: “From 2000 to 2016, the Hispanic status dropout rate among 16 to 24 year-olds decreased from 28 to 9 percent, while the Black rate decreased from 13 to 6 percent, and the White rate decreased from 7 to 5 percent. Nevertheless, the Hispanic status dropout rate in 2016 remained higher than the Black and White rates.”⁶²

Although members of the Hispanic community are generally considered together for statistical purposes, there are significant differences in their experiences based on country of descent. According to the US Department of Education, in 2016, among Hispanic 16 to 24-year-olds in the United States, the high school status dropout rate ranged from 2.4 percent for individuals of Peruvian descent to 22.9 percent for those of Guatemalan descent. Similarly, among Asian 16 to 24-year-olds, dropout rates ranged from 0.7 percent for individuals of Korean descent to 29.7 percent for those of Burmese descent.⁶²

Although the trend is improving, the loss of URiM students at the high school level continues to contribute to the limited pool of URiM students in institutions of higher learning, significantly limiting the pool of potential future URiM health professionals.⁶⁵

The impact of guidance counselors and teachers is even more significant and can be less readily corrected due to the compounding effects of the aforementioned barriers. Advice or guidance from school counselors and teachers often differentially nurtures the potential of students on the basis of race and ethnicity, to the detriment of URiM pupils. 

Similarly, reduced expectations from teachers can lead to what President George W. Bush described as “the soft bigotry of low expectations.”⁶⁶ When a teacher underestimates a student, it affects not only that one student-teacher relationship, but also the student’s entire self-concept, as well as more tangible measures like their GPA. In fact, the 2002 Education Longitudinal Study found that “Teacher expectations were more predictive of college success than most major factors, including student motivation and student effort.”⁶⁷ 

LGBTQ+ students face similar early discrimination in K-12 education where, especially in high school, social interactions and sexuality become important to identity formation and the ability to “fit in.”  Discrimination and marginalization impact students’ ability to succeed academically by denying them an environment in which they feel supported and affirmed.⁶⁸ State and local K-12 education policies with clear language regarding protection of LGBTQ+ students from bullying and discrimination are associated with positive school climates and with student wellbeing and success.⁶⁹ 

Like racial minority students, LGBTQ+ students have fewer role models in the workforce and perceive less support and guidance compared with their heterosexual peers, which can negatively impact their choice of vocation. The experience of discrimination and bias in the college environment can also influence professional identity and career development.⁷⁰ There are limited data on this issue, in part because disclosure of diverse sexual orientations or genders can lead to retaliation and harm. 

Challenges Outside the Classroom

Children of low-income families experience challenges that extend far beyond the classroom, and poverty impacts African American and Latinx families disproportionately. Since 1966, Coleman and others have concluded that the socioeconomic status of families is more important than schools as a factor for academic achievement and this is not unique to the United States.^58,71,72 Reardon has compiled data showing that student test score differences related more strongly and negatively to poverty than any differences associated with race.⁷³

Residents in low-socioeconomic neighborhoods are disproportionately exposed to various hazards, including increased noise levels from traffic and freeways^74,75 or environmental toxins in water (as in Flint, Michigan),⁷⁶ air,^77,78 and ground (from landfills or toxic waste treatment facilities.⁷⁹ Lead poisoning disproportionately impacts children of color.⁸⁰ Exposure to violence, domestic, community, or through public media, is statistically more likely in communities of color.^81,82 

These factors not only contribute to health disparities in the US but can have direct or indirect effects on the abilities of children to perform well in school. Other factors suggested to affect children’s learning include the physical environment at school and nutrition, both of which can be negatively impacted by segregation and poverty.⁸³

Social “inequities are related to elevated stress in families from many factors including (a) being unable to meet basic financial obligations for food and shelter, (b) living in high risk neighborhoods with elevated levels of violence and depressed levels of social capital, and (c) not having the means to provide educational and social opportunities to enrich children’s development, which may involve placing children in high quality child care, public or private schools, and affording selective or elite colleges and universities.”⁸⁴

As the socioeconomic divide continues to increase, it is important to acknowledge the impact on URiM students of lower socioeconomic status. Reducing educational disparities may be a critical component of reducing other kinds of inequities in the United States.⁸⁵

With the multiplicity of impediments and adversity these students face, their resiliency in merely showing up in the classroom deserves to be acknowledged. The ones who succeed despite all these disadvantages often do so at an additional price. They accomplish their goals with limited resources, but with ingenuity and drive. 

Early exposure and mentoring enables members of underrepresented groups to see a medical profession as an accessible career option, especially exposure to or interaction with ethnically concordant mentors.⁸⁶ However, due to the paucity of URiM healthcare professionals in the community and general lack of access to health professionals, envisioning these careers as an option continues to be a challenge for URiM students.

Barriers in Undergraduate Education

As previously mentioned, a student’s experience in school is vital as they develop their interests and gain support in entering career pathways. Students who feel at risk of “stereotype threat” experience lower academic performance.⁸⁷ Due to this phenomenon, one study implemented an affirmation intervention to groups of students in an introductory biology class. The students were asked to make connections between positive values to themselves. The researchers discovered that the affirmation benefited URiM students and white males in their performance with a 4.2 percent increase in male URiM students on average and 2.2 percent increase in female URiM students on average. While the author points out potential limitations, this study indicates that the environment and psychological support can reduce barriers to success in STEM and facilitate retention through breaking the stereotype threat.⁸⁷ 

Perceived bias also exists among URiM students. Tour of Diversity in Medicine, a program consisting of minority physicians and dentists, visited colleges in 2012 and 2013 and held focus groups to examine barriers in the undergraduate setting that hindered entry to advanced healthcare training, specifically careers in medicine and dentistry. Among the 82 participants from 11 colleges, challenges such as inadequate clinical opportunities, family pressure, and inadequate guidance and mentoring on career development all factored into the decision to remain in the pathway to a medical or dental career.⁸⁸

In addition, URiMs are more likely to switch from a science major to a non-science major. In interviews with 27 African Americans and 22 Latino Americans, a study identified four common themes among engineering majors. These themes included alienation and invisibility, lack of racial concordance in peers and faculty, difficulty applying theory, and lack of college preparation.⁸⁹ This study further supports the need for early intervention in the pathway process to support underrepresented minorities on the path toward a STEM career.

Historically, rubrics for admission to medical and PA programs have prioritized success in foundational sciences and top standardized exam scores. Use of the MCAT for admission decisions may disadvantage some capable students, and this test has not been shown to be a better predictor of success in medical school than prior academic achievement.⁹⁰ However, success in undergraduate sciences and standardized test-taking are influenced by social and economic factors. Emphasis on these criteria alone may be a barrier to diverse applicants who demonstrate behaviors and characters that are essential to success as a clinician.^91,92 Holistic admissions can help capture capable students who will bring strong academic and personal qualifications to their work.⁹⁰ 

Incorporation of a holistic admissions process is an important area for consideration of a diverse applicant pool. Holistic admissions processes give consideration to each candidate as an individual and account for factors that are correlated to success as a clinician. A candidate’s relevant life experience such as accomplishments (volunteering, leadership, employment, shadowing), academics (GPA exam scores), disadvantaged status (first generation, geographic location, economic status), and ability to manage significant adversities encountered along their journey towards medical training (educational, family, cultural) are reviewed. The process is applied equitably across the applicant pool at the time of admission application reviews and throughout the entire admissions process. Holistic admission processes have demonstrated success in diversifying medical cohorts. A more diverse student body not only better reflects the diversity of the general population; these cohorts have also been observed to be more collaborative, supportive, and open to new perspectives.⁹¹  

In addition to assessing the admission process and providing holistic reviews of candidates, we must also recognize and address the presence of implicit biases, whether intentional or unintentional, that may contribute to the persistence of underrepresentation in medical education. A study at Ohio State University College of Medicine (OSUCOM) in 2012 reported that, collectively within the admission committee, there existed implicit white preference after taking the Black-white implicit association test. This introspection fostered more self-awareness that led to the most diverse class in the OSUCOM history in the following interviewing cycle.⁹³ With the increase in application competitiveness, it is important to implement holistic reviews and assess soft skills, especially if underrepresented applicants had above-mentioned barriers to access pre-medical opportunities that could strengthen their applications. 

Due to the competitive nature of medical school admission, many students who are not admitted in an application cycle often take a gap year to strengthen their applications through various avenues. One of these is attending a post-baccalaureate program to increase the student’s grade point average and to better demonstrate readiness for intense science courses. A study with 516 participants from one medical school showed that 15 URiM had completed a formal post-baccalaureate program, while 58 students had independent post-baccalaureate work before matriculation. Of the 73 students in the study, those that completed a post-baccalaureate program showed competency in the first year of medical school as compared to their traditional student counterparts, despite having lower MCAT scores and college grade point averages. 

This indicates a post-baccalaureate program may represent an appropriate preparation for success in medical school.⁹⁴ In a 2016 publication, about one third of the 200 post-baccalaureate premedical programs in the AAMC website were listed as having special focus on URiM for economically or educationally disadvantaged students in efforts to close the gap in healthcare disparity.⁹⁵ As previously mentioned, many students who identify as URiM also associate with hailing from low socioeconomic backgrounds. This financial burden may present as an additional barrier to attending a post-baccalaureate program, retaking standardized tests, or reapplying to professional healthcare programs.

Representation in Medical School

Minority physicians face many barriers contributing to reduced representation in medical training programs. While attempts such as affirmative action on higher education have created conversations on diversifying medicine through admission, progress has been slow and the rate of increase in graduates from this underrepresented group remains low.^33,96 Expansion of medical schools changed minority student numbers little, although new schools did enroll more racial/ethnic minorities and lower socioeconomic students.⁹⁷ From 2015 to 2019, there was just a one percent increase in the number of African American medical school graduates in the United States.⁹⁸ Despite a very gradual increase in the number of Black college graduates over time, there were fewer Black men entering medical school in 2014 than in 1978.³³

There are historical reasons for the lack of diversity in healthcare professions. Historically Black medical schools have faced inadequate funding and access to facilities compared to historically white institutions.⁹⁹ In addition, changes in medical school curriculum have created downstream consequences in the overall diversity of the healthcare workforce. The 1910 Flexner Report examined medical school entrance requirements, the size and training quality of facilities, the size of endowment and tuition, the size of laboratories, and the availability of teaching hospitals and their clinical teaching staff in order to standardize admission requirements and design medical school curricula to include both basic science and clinical exposure.⁹⁹

As a result of this report and subsequent changes in medical programs, 13 of the 17 historically Black medical schools were closed.⁹⁶ A recent economic impact analysis shows that if only five of these 13 closed schools had remained opened, an additional 27,773 Black doctors would have graduated from the year of closure to 2019, if each program had maintained steady expansion.⁹⁶ Complicating interest in recruiting a more diverse group of students to medical school is the declining racial and ethnic representation in academic medicine.⁴⁰ 

Trends in medical schools are mirrored by poor diversity in the PA profession and difficulty increasing diversity.⁴⁶ PA programs in general have greater proportions of women than men among both the faculty and students (61.3 and 72.9 percent, respectively), making women PA students and faculty overrepresented when compared with the US population.¹⁰⁰ 

Nonwhite PA students encounter numerous challenges during PA school, measured by the number who delay their graduation. 94.3 percent of students who identify as female and 91.5 percent who identify as male graduated or expect to graduate on time. 91.6 percent of Hispanic, Latino, or Spanish-origin students, 90.6 percent of American Indian or Alaskan Native students, 92 percent of Asian students, 81.2 percent of Black or African American students, 95 percent of multiracial student, 97.9 percent of Native Hawaiian or Pacific Islander students, and 94.6 percent of white students graduated or expect to graduate on time.¹⁰⁰ A delay in graduation can increase the cost of tuition and delay time to entering the job market and earning a salary. Potentially, this could also cause attrition.

We have limited information about the LGBTQ+ community and how clinicians and physicians are impacted by this perceived difference.¹⁰¹ There is some evidence that this group also faces barriers from the start of medical education. There are approximately 3.5 percent, or 9 million, adults in the United States who identify as lesbian, gay, or bisexual, and 0.3 percent, or 700,000, as transgender, according to a 2017 study.²¹ Data on the degree to which these groups are represented in the medical profession in the literature at the time of this report were very limited. 

A medical school survey directed at all medical students in the US and Canada during the 2009-10 academic year showed that approximately 30 percent of LGBTQ+ students conceal their sexual orientation identities in medical school. Approximately 40 percent were afraid of discrimination when identified as non-heterosexual.¹⁰² While there are no large-scale studies on representation among resident physicians, practicing physicians or physician leaders, the AAMC now tracks the percentage of graduating medical students who identify as bisexual (~5 percent) gay or lesbian (3.8 percent) and transgender (0.7 percent), with the most recent data from 2019.¹⁰³ 

Barriers to Success in Medical School

Apart from the application process, the monetary costs of health profession education are another significant barrier to entering the field, regardless of the URiM pathway. Underrepresented minorities, more often than not, come from an economically disadvantaged background, which requires them to take out more loans or scholarships. However, barriers such as financial credits to apply for loans and the necessity of a good academic standing to apply for scholarships could further inhibit students from receiving support.¹⁰⁴ A report from UCSF shows that the amount of debt carried on average is larger for URiM than white matriculants to US medical schools. In 2015, 35.8 percent of white matriculants had student debt prior to medical school, while American Indians, Latinos, and African Americans were 46.2, 46.3, and 62.1 percent, respectively.¹⁰⁵

Outside of the rising cost of tuition for medical school, an entire industry has been built around preparation for national board examinations that are required for advancement and graduation. Examination scores can further bar students from entry into specialty programs; however, USMLE scores do not correlate with success on medical rotations or within residency programs.¹⁰⁶ The USMLE Step 1 exam has received recent attention for the inequities seen in exam scores. People of Color, namely Black persons, score lower on-board examinations than their peers.¹⁰⁶ 

In addition, women have been found to score lower than their male counterparts.¹⁰⁷ Despite significant differences found in standardized test scores, a student’s USMLE score was not predictive of student success in the clinic. Data on Hispanic Latino and Native American students are lacking and are a future area for research. From multiple studies, it is apparent that Step 1 score has little predictive value in identifying future success in residency programs. Compared to Step 1, the Step 2 CK exam is a stronger predictor to residency success and in-training examinations, along with emphasis on honors in clerkship and membership in the Alpha Omega Alpha Honor Society.^106,107,108

Other factors aside from standardized score performance also affect the success of students during medical training, specifically for URiMs. Overall, traditional-aged students who are less than 25 years of age at matriculation performed better on Step 1 and Step 2 than did non-traditional-aged students. Male students performed better on Step 1 than did females, per a longitudinal study across five graduating classes at the University of Minnesota Medical School.¹⁰⁸ 

However, a different study shows that women were more likely to pass Step 2CK on the first attempt, indicating that women improve during clinical years.⁹⁵ This study also demonstrated that older students greater than 24 years of age who initially failed Step 1 were less likely to pass Step 2 CK on their first attempt.⁹⁵  Financial barriers also play a role in student success on national board exams, with differences in Step 1 scores seen between those who received need-based financial scholarships versus those who did not receive scholarships. This could potentially be explained by these students’ inability to access supplemental materials or exam preparatory courses prior to medical school. However, more studies are needed to explore the correlation.¹⁰⁷ 

In addition, the passing rate for Step 1 on the first attempt also differed by race and ethnicity: 93.4 percent for white, 86.8 percent for Asian, 77.5 percent for Hispanic, and 58.2 percent for African American.⁹⁵  Each residency program and specialty has a different score threshold for residency applicants. African American applicants were 3 to 6 times less likely to be offered an interview at internal medicine residency programs compared to the non-African American counterparts if the Step 1 score was used as the primary determining factor for granting interviews.¹⁰⁶

Success in medical school can also be affected by inclusion in honor societies and biased evaluations. Underrepresented minorities are less likely to be nominated to the Alpha Omega Alpha Honor Society (AOA) in medical schools, possibly reflecting bias in selection.¹⁰⁹ Odds of AOA membership for white students was six times greater than for Black students and two times greater than for Asians, although no significant differences are found in median time dedicated to leadership activities and community service between AOA and non-AOA students.¹⁰⁹ 

Students in minority groups report racism and prejudice during their education and continuing throughout their professional careers.²⁰ Discrimination between clinicians as well as from institutions is cited. The higher rates of mistreatment experienced by female, URiM, Asian, multiracial, and LGBTQ+ students, as discussed in the Workplace Culture document of this report, further impact grading and written evaluations.¹¹⁰ Prejudice and bias can discourage career advancement in the workplace, contributing to disparities further discussed in the Workplace Culture and Pay sections.¹¹¹

Initiatives to improve diversity in the health professions will require analysis, and possibly intervention at every level of pathway process. We conceive of this first as bringing a diverse population of candidates to the doors of the schools that train physician assistants, medical doctors, and osteopathic doctors. 

Beyond this, the schools themselves should not present an environment hostile to diversity, because enabling the ultimate transition of this polychromatic group of students into the medical profession should be considered as being in the best interest of the future of healthcare in the United States. Once these members have enriched our ranks, their talents and voices must be heard and should influence decisions affecting care teams and our systems of care. Short of this, we would be losing the benefits diversity can provide.

 

Workforce Culture

Workplace culture can be defined as a construct that is “the sum of jointly held characteristics, values, thinking and behaviors of people in workplaces or organizations.” This can be shortened to “the way we do things around here.”¹¹² This can be influenced by both the larger organizational culture that is present at the hospital or health system level and the unique workplace culture that exists at the unit, department, or healthcare professional level.¹¹³ Though culture can be changed, there is an enduring and historical aspect to it. 

Workplace or organizational climate is more narrowly defined as the emotive feel as people interact with the culture and each other and also includes their behaviors in response. It is thought to include relationships and attitudes, engendered through interactions with organizational structures and processes.¹¹⁴ Essentially, workplace climate consists of people psychologically reacting to their work environment, i.e. “How does it feel to work here?” 

Perceived tolerance of harassment, microaggressions, discrimination and/or violence based on gender, race, ethnicity and/or sexual orientation—usually in environments where men outnumber women and whites outnumber people of color—as well as protectionism and uninformed leadership within institutions all work to create an organizational climate that negatively impacts the workforce.^{115,116,117,118}

In medicine, hierarchical relationships create a power structure that persists in all levels, from training through to the workplace despite proven negative effects on patient care and patient safety, as well as professional wellbeing and development. These further strains the culture within medical institutions.^119,120

Without a culture of inclusion that can give voice, leverage, and fair access for promotion to new arrivals, retention of new clinicians may be at risk. Turnover is estimated to cost the healthcare system between $400,000 and $600,000 per physician.¹²¹ Retention saves the healthcare industry money. 

Discriminatory culture of a workplace environment is the primary factor impacting turnover of physicians from underrepresented groups.^122,123 Systemic racism has helped shape the current norms for workforce culture and furthers the inequities seen in the workforce and healthcare system. 

The health of a workforce culture can be measured in part by how individuals perceive the institution, trust leadership, and enjoy institutional support with robust resources designed to support underrepresented people in medicine. A positive healthcare workplace culture has been associated with a wide range of improved patient care outcomes, including lower mortality, lower rate of adverse events and medication errors, lower rate of hospital-acquired infection, patient satisfaction, and many others.¹¹³ Strong team culture has also been associated with lower burnout among clinicians in the primary care setting.¹²⁴ However, while the benefits of a positive workplace culture are numerous, the experience of workplace culture varies among groups, with racial, ethnic, and sexual minority groups and women often experiencing negative workplace cultures in medicine due to their identities. 

Discrimination

URiM residents experience discrimination frequently as microaggressions on the basis of race, ethnicity, and perceived status as “other” or foreign.¹¹⁶ This is true for attending physicians as well, and may contribute to lower career satisfaction, turnover, and avoiding seeking leadership positions.¹²² 

Physicians of color, especially Black physicians and women physicians of color, experience a high prevalence of workplace discrimination.¹²³ This discrimination was associated with adverse effects on career, health, and work environment. Critical to retention of these clinicians is the workplace environment. Institutions must work to create welcoming workplace environments that do not serve as additional cultural barriers in the long line of impediments URiM individuals face throughout their pathways into medicine. This includes identifying and changing policies that disproportionately and adversely affect certain groups in medicine based on race, ethnicity, gender, or sexual orientation.

Gender-based discrimination is also alarmingly common in medical practice and academic medicine. A study that sampled over 3,000 full-time faculty found that women were 2.5 times more likely than male faculty to perceive gender-based discrimination at work.¹²⁵ Women also experience stigma and discrimination due to decisions around pregnancy and family, contributing to work-family conflict and ultimately to burnout.¹²⁶ 

Aside from race and gender issues, sexual orientation and gender identity adds another layer of difficulty to navigating a career in medicine and poses an increased risk of discrimination and harassment. A 2014 study reports that among the LGBTQ+ healthcare professionals and trainees, 41.9 percent of study participants avoided disclosing their sexual orientation due to fear of negative consequences: harassment or discrimination. Some individuals report being refused privileges, being denied promotions or employment, and/or experiencing verbal harassment from colleagues.¹²⁷

More research is needed to understand the workplace experience of clinicians who are transgender, gender nonconforming, lesbian, gay, or bisexual. One study has found that although overall rates of discriminatory behaviors are decreasing, micro and overt aggressions including derogatory comments about the LGBTQ+ community in general, refusal to write letters of recommendation, and overt harassment are still commonly experienced and observed.^118,128

Furthermore, a 2017 study of transgender and non-binary physicians and medical students found that 42.9 percent of respondents reported facing barriers due to their gender status in applying to residency/fellowship and 69.4 percent had witnessed negative comments about transgender and/or non-binary individuals in their training or practice.¹²⁹ While the Supreme Court of the United States has ruled it is prohibited to discriminate based on sexual orientation and gender identity in the workplace, workplace cultures still need to shift to eliminate discrimination and retain these clinicians.¹³⁰

The intersectionality of race and gender compounds all these challenges and worsens the effects of discrimination and systemic inequities related to compensation and career advancement.¹¹⁶ Increasing institutional support for URiM, women, and LGBTQ+ people, as well as robust processes for reporting, may help retention of members of these groups.^114,116,131 Fundamentally, organizations must fully integrate and center diversity as part of the overall mission to increase institutional commitment and reduce discrimination.¹³¹

Sexual Violence

Sexual violence includes harassment, unwanted sexual attention, non-consensual acts, and sexual coercion. Sexual violence is power based, sustained over time, and function as methods to assert power, control, or intimidation over other people. Workforce culture, power dynamics, and hierarchies all allow the perpetuation of sexual violence in medicine. Gender-based harassment and macroaggressions can originate from peers, supervisors, and patients.¹³² False reports are rare, illegal, and occur at a lower rate for sexual violence than they do for all other major crimes.¹³³

In 2018, the National Academies of Sciences, Engineering, and Medicine¹¹⁵ released a report on sexual harassment of women in academia.¹¹⁵ The report shows that medicine as a profession has a culture of harassment and assault driven by organizational climate.¹¹⁵ The research found that students and trainees in science, technology, engineering, and mathematics (STEM) are 96 percent more likely than non-STEM majors to experience sexual harassment by peers.

When compared with students in other fields, women medical students were more likely to experience sexual harassment by faculty. In graduate medical education, 45 to 50 percent of female-identifying medical students reported gender harassment or sexist hostility by faculty or staff. Students are also frequently harassed by their peers.^{134,135,136,137,138} An American Association of University Women study found that 80 percent of harassed students reported that the harassment came from peers or former peers.¹³⁴ The peer-to-peer violence data for medical training are lacking and represent an area for future research. 

Women are also frequently harassed by coworkers and other employees.^{134,135,136,137,138} The hierarchical nature and predominantly male leadership within the field of medicine creates a power differential that enables sexual harassment. Additionally, in the medical field, patients are also potential perpetrators of sexual violence. One study found that more than 25 percent of male and female surveyed physicians experienced at least one incident of sexual harassment from patients.¹³⁹ In addition, the assumption some patients make that female clinicians are non-physician members of the support team may impact patient care by eroding the patient-clinician trust relationship. 

The experiences and numbers of LGBTQ+ medical clinicians continue to be understudied. The few studies that exist indicate these individuals experience and expect harassment and may conceal their sexual orientation as a result.^140,141

The impacts of sexual violence are long-lasting. Survivors face worse mental health and physical outcomes, feel less safe on campus, and report doing poor work more often.¹⁴¹ Barriers to reporting sexual violence include fears of retaliation, physical harm, or not being believed.¹⁴² The fear of retaliation is a major barrier to reporting and ultimately to addressing and preventing sexual violence within medical institutions. The NASEM report found that 28 percent of medical students did not report incidents of offensive comments due to fears of retaliation.¹¹⁵ Retaliation can have long-lasting impacts on career trajectory for an individual, and the inability to report or seek resources without fear of retaliation allows continued harms and prevents progress toward a violence-free workplace. This may also further contribute to burnout experienced by healthcare clinicians.

Institutional betrayal is defined as “wrongdoings perpetrated by an institution upon individuals dependent on that institution, including failure to prevent or respond supportively to wrongdoings by individuals.”¹⁴³ When institutional betrayal occurs, both pragmatic and psychological harm to an individual can occur.¹⁴³ This concept has been demonstrated in recent history by the response or lack of action in regards to sexual assault. Increased research, training, transparency, and support services are necessary to best address gender-based violence in medicine. 

The time and monetary burden placed on survivors to pursue civil, criminal, or institutional reporting pathways, as well as outside resources for support and advocacy, are additional barriers to reporting violence. The perception of a risk to career and that reporting will result in no shift in culture also negatively impact the likelihood of reports being made.¹⁴⁴ Confidential advocates are a vital resource for supporting survivors of sexual violence.¹⁴⁵ Advocates can help survivors navigate civil, criminal, and institutional reporting pathways, provide and connect survivors to resources, facilitate academic support, formulate safety plans, and help work to prevent  sexual violence in the institutions they serve. These experts should be sought out for guidance in institutional policies and fully funded in medical institutions to support survivors who work in medicine. 

Harassment

Harassment in the workplace results in lower career satisfaction and higher levels of burnout.^132,146 Many female clinicians, clinicians from URiM backgrounds, and clinicians who identify as gender minorities report harassment and workplace bias as factors that contribute to their decision to leave their practice or exit the medical profession altogether.¹⁴⁷

Minority Tax

A disproportionate burden is placed on URiM faculty in medical education. Women of color in medicine experience even greater barriers to advancement or attainment of leadership positions than do their white female counterparts.^148,149

The responsibility for expanding diversity, decreasing racism, and mentoring, is sometimes referred to collectively as the “minority tax,” and falls disproportionately on URiM healthcare clinicians.¹⁵⁰ This may demand additional time and energy, as underrepresented minorities and women clinicians are often called upon to act as ambassadors, carrying out work related to diversity and inclusion for their respective institutions on top of the demands of their daily practices.¹⁵¹

Women in medicine readily volunteer for committee assignments, interviewing, and other uncompensated service tasks more often than do their male counterparts. These activities benefit their organization or practice, but they are not weighted equally with other activities when considering promotions. These additional tasks add to workload and can put clinicians at higher risk for burnout.¹⁵²

This labor is generally not recognized in promotion portfolios and goes uncompensated. Because these individuals spend a disproportionate amount of time mentoring students, contributing to community outreach, and providing education on bias, there is less time to spend on research, publishing, or other scholarly activity commonly recognized as requirements for promotion and career advancement. 

Representation and Mentorship

The lack of diversity in medicine has been a persistent problem, with little progress made over the past 30 years.^116,153 Proportional representation is an issue of access, mentorship, recruitment, discrimination, and many other factors. Many authors note social isolation and lack of mentorship to be significant challenges.^20,154 Many of these concerns are tied to the culture of medicine in an individual workplace and in the workforce as a whole. Workforce culture may be one of the factors contributing to the lack of women and URiM clinicians in positions of leadership. The negative impacts of culture within a workforce are likely amplified when an individual belongs to multiple minority racial, gender, and sexual orientation groups. 

LGBTQ+ individuals face unique challenges. To even quantify LGBTQ+ individuals in healthcare is a daunting task, as many see advantages in avoiding disclosure of their sexual orientation.¹⁰¹ While workplace discrimination based on sexual orientation and gender identity is illegal, fear of discrimination in other aspects of an individual’s life can serve as an impediment for LGBTQ+ people to live openly, let alone serve as role models and mentors for a new generation of clinicians. This suggests that proportional representation may be more difficult to achieve for this group, as potential entrants into the field will necessarily have fewer visible role models and mentors.¹²⁷ 

Furthermore, the percentage of sexual gender minorities in each specialty is found to be inversely related to specialty prestige and positively correlated to perceived inclusivity.¹⁵⁵ Since sexual gender minorities are more likely to indicate the influence of choosing a specialty based on the culture around sexual and gender identity, it is imperative to foster an inclusive workplace to provide healthcare equity in all specialties.¹⁵⁵

Generally speaking, women now enter the profession at the same rates as men; however, they still face barriers to advancement into leadership positions.¹⁵⁶ In the United States, women represent 51 percent of medical school applicants and 48 percent of graduates, illustrating that women and men enter medical practice at similar rates. Over the past decade, the proportion of women in full-time faculty positions has increased, and as of 2018, women constituted 41 percent of this workforce sector.¹⁵⁶ 

However, the percentage of women in academic medicine decreases significantly with increase in promotional rank. According to the Association of American Medical Colleges (WII), only 18 percent of department chairs or deans in 2018 were women.¹⁵⁶ We can perceive the same imbalance with academic rank, with women representing 58 percent of instructors and only 25 percent of full professors.¹⁵⁶ More data are needed to illuminate inequitable representation on institutional C-suites and boards of directors throughout Oregon, as well as the resulting impact on diversity throughout the career pathway.

For people of each group and for people situated at the intersection of multiple groups, finding mentors to advise on career direction and advancement is difficult due to this underrepresentation, furthering this disparity. Specialized and long-term faculty development programs may result in an increase in recruitment and promotion, but it takes time for any program to have a measurable increase.^157,158 We must interrupt the cycle of underrepresentation leading to under-mentoring, which in turn leads to under-promotion, to improve the overall culture. 

Paradoxically, without this change in culture, improving representation is challenging. Intersectionality must be prioritized in the creation and implementation of solutions when addressing workforce culture in medicine.

Career Advancement

The barriers faced in workplace culture may play a role in the maldistribution of underrepresented groups in many specialties.^{12,41,42,43,44,46,47} In addition, underrepresented groups in medicine face an additional complex set of challenges that pose barriers to advancement in the profession. 

Barriers to career advancement based on gender has had more research. Women’s disadvantages are present in the lack of parity in rank and leadership, as well as in retention and compensation. The factors that contribute to gender disparities are multifactorial, including expectations that women’s careers will follow the same trajectory as men’s without attention to the impact of the life cycle.¹⁵⁹ Women’s academic productivity appears to peak later in their careers in terms of overall publication rates, although the publications they do have are noted to have higher impact based on citations rates. Lower early-career research productivity may contribute to women’s difficulties with career advancement.^59,160

Women clinicians who stay in practice are often overlooked when leadership opportunities arise. Few healthcare systems or practices have transparent, standardized processes in place to identify high-potential talent, resulting in biases when selecting a successor, often leaving women out.¹⁶¹ Not only do women face challenges from outside forces, women clinicians are impacted by forces that appear on the surface to be internally imposed: imposter syndrome, limited skills at self-promotion, difficulty with salary negotiation, and limited flexibility to move or travel for career advancement. Imposter syndrome may be a reflection of the impact of cultural norms and gender expectations.¹⁶² 

Women’s difficulties with negotiating are complex and may represent sensitivity to the social costs of negotiation. Female candidates are penalized more than male candidates for initiating negotiations in the workplace.^164,163

Women may be overlooked in other ways as well, possibly representing bias in systems and among decision-makers. For example, women in some specialties have lower rates of NIH funding and may be less likely to attempt to renew research project grants.¹⁴¹ Other studies cite differences in lab space, funding, personnel, and protected research time as vital to academic success.¹⁶⁵ 

Women have been reported to be more likely to perceive inadequacy of access to human resources—specifically administrative and statistical support—and more likely to have requested a reduction in their clinical hours.¹⁶⁵ They have also been more likely to have raised with their superiors concerns about unfair treatment.¹⁶⁵ Women have fewer opportunities for prestigious speaker engagements and are underrepresented among recipients of recognition awards presented by medical societies, potentially impacting career advancement.^166,167,168

Women face well-documented barriers to publishing, with limited representation of women on editorial boards of major journals.¹⁶⁹ Evaluations of women faculty and trainees show significant quantifiable linguistic differences, concerning for potential impact on promotion and retention.^170,171 A dearth of women on recruiting panels, leadership teams, and department oversight bodies results in magnification of bias in decision-making. Career advancement may also be impacted by caregiving responsibilities (as further outlined in the Caregiving section of this report). 

Research on how career advancement is adversely impacted for other underrepresented groups in medicine is lacking. Of those entering academic careers at US medical schools, promotion rates for Black and Hispanic/Latino physicians were lower compared to white faculty.⁹ Problems with career advancement has become a measurable parameter for women because of the achievement of parity in numbers in the ranks. For URiM, parity is not even close to being achieved, as discussed elsewhere. When underrepresented minorities are more proportionately represented in the medical field, the issue of career advancement can be better studied. 

Not only is an informed standard for promotion and opportunities essential, but the creation of equal opportunities supported by resources and funding can help support the career advancement of diverse employees. Changes in the workforce are also needed to increase the value of interpersonal skills, mentorship, and soft skills, and to ensure equity in funding opportunities.¹⁷² These changes will better recognize the achievements of diverse members of the professional community.¹⁷²

A combination of solutions and modifications must be established to mitigate the barriers underrepresented racial and ethnic minorities in medicine, women, and LGBTQ+ clinicians face. 

Caregiving Responsibilities

Diversity and equity initiatives must consider that the responsibilities of caregiving are not equitably distributed, and that circumstances, especially in regard to gender and cultural considerations may influence the extent of caregiving responsibilities for any particular healthcare professional. In the healthcare profession, when hours are often long and inflexible, the conflict between work and caregiving responsibilities can create tension, which affects burnout rates, retention of clinicians, and the overall effectiveness of the healthcare system. 

Pregnancy and Family Planning

Medical education and training together involve years of intensive effort usually in a person’s twenties and thirties, a period that coincides with prime reproductive years. Consequently, American female physicians report attempting to delay pregnancy, “timing” pregnancy to better fit demands of training, and even terminating pregnancies because of their careers, all at higher levels than seen in the workforce in general.¹⁷³ The biological realities of family planning and pregnancy are such that women who delay or attempt to “time” pregnancies optimally can experience increased struggles with fertility. Notably, pregnancy itself is a condition requiring frequent medical follow-up, and medical students and residents perceive low support for their pregnancies.¹⁷³  

Inequalities enter the field relatively early in the process, with women trainees feeling relatively more discouraged from pursuing specialties seen as unfriendly towards concerns around marriage or children.¹⁷⁴ Currently, medical schools lack a standardized approach to family leave policies, and those schools that do make policies regarding the issue are restricted by the relatively inflexible timelines of medical training, with historically strict deadlines for residency applications and testing.^175,176 As trainees enter residency, equally inflexible deadlines for fellowship applications affect their ability to take leave to care for their children or other family members, with research demonstrating that a 12-week leave during residency delays fellowship by a year in most specialties.¹⁷⁷ For many years, there existed no standard approach or policy to provide residents with family leave and because of this, guidelines within programs lacked clarity.¹⁷⁸ Female trainees have been affected disproportionately by this situation as the burdens of pregnancy and caregiving predominantly fall upon women.¹⁷⁷ Female attending physicians experience similar concerns, with many reporting conflict between domestic responsibilities and the workplace.¹⁷⁹ In the long term, this affects the likelihood that women will seek leadership roles, contributing to organizational climate and further perpetuating the problem.¹⁸⁰ Overall, conflict between workplace and caregiving responsibilities leads to depression and burnout, which results in an enormous cost to the clinician, to the organization, and to the field of medicine as a whole.¹⁸¹

Fortunately, deficiencies in resident family leave policies are increasingly being acknowledged by specialty organizations, and review and revision of policies to offer more support for resident and fellow trainees has begun. The American Board of Medical Specialties is working toward providing a minimum of six weeks of parental, caregiver, and medical leave without requiring an extension in training.¹⁸²

Parental Leave and the Transition Back to Work

Given that the landscape of family leave policies is in the midst of revision, it is important to consider what components should be considered during a design and implementation process.¹⁷⁸ The WORLD Policy Analysis Center states that six months of paid leave is the ideal goal for parents of infants, with three months of paid leave as a minimum.¹⁸³ As even three months of leave can have the effect of a substantial delay on training, the implementation of a six-month leave policy poses significant difficulties to trainees and institutions.¹⁷⁷ Part of the rationale for this length of leave is that it provides support for breastfeeding and for the provision of high-quality child care.¹⁸³ Workplace lactation interventions, such as lactation rooms and protected time, have the potential to ease the transition back to work without significantly compromising breastfeeding success, and laws governing their provision vary throughout the United States.¹⁸⁴ Other significant contributors to negative return-to-work experiences include difficulties obtaining childcare, stemming from inflexible schedules and differences in pay if part-time work or consistent hours are sought.¹⁸⁵ Implementation of on-site affordable childcare, schedule flexibility, and opt-out family leave policies have the potential to significantly improve the careers of clinician parents (CG) (CM). Complicating factors to the implementation of these programs include the effects on colleagues, including other trainees, which may lead to stigma.¹⁷⁸ Pregnant trainees witness and experience negative comments about pregnant trainees, and perceive stigma and pressure against their choices.¹²⁶ As pregnancy, breastfeeding, and responsibilities for the care of newborn and young children fall disproportionately to women, it is critical to address these factors to improve retention of women at all levels of training and leadership.¹⁷⁹ Additionally, LGBTQ+ parents can face discrimination if their employer’s parental and family leave policy is not gender-neutral. In a 2018 survey of LGBTQ+ employees, only 45 percent indicated that their employers have LGBTQ+-inclusive leave policies.¹⁸⁶

Elder Care

Caregiving responsibilities are not limited to minor children, but also include aging parents.¹⁹³ The elderly population is expanding as baby boomers age and adult mortality declines. By 2030, it is estimated that 1 in 5 persons in the United States will be over 65 and their number will exceed the number of children.¹⁸⁸ Dementia and chronic disease rates are expanding proportionally. Often, the option of “formal” or paid care is unaffordable and impractical. The tremendous burden of care for these parents and grandparents is taken on by the families of their adult children, and disproportionately by women in the family who may be, otherwise, fully employed. This creates an additional (unpaid) work shift, or even a third if they have children.¹⁸⁹ The economic value of this unpaid work was estimated at about 20 percent of total national health care expenditures in 1999 with this percentage likely to be higher now due to the increasing number of elderly in our population.^190,191 The term “sandwiched couples” is applied to families faced with both childcare and elder care responsibilities. These “sandwiched couples” experience increasing stressors and worsening wellbeing, with this effect being especially pronounced among women.¹⁹² Differences between racial groups are also pronounced, with Asian and Hispanic caregivers spending more hours on caregiving than other groups.¹⁹³ 

 

Patient Relationships 

Relationships between patients and clinicians are the fundamental basis for the healthcare system. It is the consensual relationship between clinicians and patients that fosters mutual respect in autonomy, confidentiality, informed consent, and commitment of care. While these relationships can be a source of comfort and support for both patients and clinicians, failure to recognize challenges or maintain a positive dynamic by either party can have outsized consequences on clinician retention, patient care, and overall effectiveness of the healthcare system. These disruptions in patient-clinician relationships exist in multiple forms, both explicitly and implicitly. Discrimination, bias, and mistreatment all impact the foundation of quality care. Since bias and discrimination in a patient-clinician relationship often have bidirectional causation, both bias from and bias toward clinicians have been included, as well as patient-clinician mismatch, as well as systemic factors. While no discussion of these factors can be exhaustive, we address important examples of each in turn below.

Clinician Bias Toward Patients

Bias and discrimination by clinicians against their patients can exhibit some of the most corrosive effects on the patient-clinician relationship. A systematic review of 15 studies of implicit racial and ethnic bias found that most clinicians have both a positive implicit bias toward white patients and a negative bias toward people of color.¹⁹⁴ Further, these biases have significant effect on patient-clinician interactions, treatment decisions, treatment adherence, and patient health outcomes.¹⁹⁴ For example, one study has shown that racial bias and perceived discrimination impact adherence to treatment recommendations.¹⁹⁵ Another demonstrated that white medical students and residents who adhered to false beliefs about biological differences between white and Black patients were more likely to rate Black patients’ pain as lower and to make less-accurate treatment recommendations.¹⁸

The 2015 National Healthcare Quality and Disparities Report documents how white patients receive better quality of care than Hispanic, Black, American Indian/Alaska Native, and Asian/Pacific Islander patients.¹⁹⁶ In another example, a study of women ages 18-55 found experiencing perceived discrimination was associated with lower preventative screenings such as Pap smears, mammography, and breast exams.¹⁹⁷ Similarly, multiple studies have shown implicit bias by clinicians against sexual and gender minorities sufficient to negatively affect patient outcomes through negative impact on patient-clinician interactions, clinical decisions, and patient perceptions of care.¹⁹⁸ 

Despite these issues, physicians and PAs are often ill-trained to address issues of bias. With regard to race, as one review states, “The standard practice for teaching about race and health in medical and public health schools is one in which race is often discussed, but conversations about racism are sidelined.”¹⁹⁹ At least two surveys surrounding training and attitudes around care for transgender and gender-nonconforming patients, one of emergency medical service clinicians and one of medical residents, show that many clinicians considered themselves and their peers as being insufficiently trained to support this population, despite their desire to provide quality care.^200,201 This failure can occur even at all levels of training—a survey of medical schools suggests that implicit bias is not routinely addressed in medical school curricula, and that training directed toward competency with vulnerable populations is infrequent.²⁰² 

Indeed, one review suggests that the impact of clinician bias may worsen as professionals progress in their training, possibly as ingrained attitudes about particular populations based on biased personal sampling of patient interactions.¹⁹⁴ Additionally, even when training does attempt to address issues of cultural understanding, many training programs can devolve into “exoticiz[ing] patients while obscuring social context, medical culture, and power structures.”²⁰³ By contrast, approaches based on structural competency, cultural humility, and cultural safety may provide a better way forward, encouraging commitment to “self-reflection and mutual exchange in engaging power imbalances along the lines of cultural differences.”¹⁹⁹ Further work is needed to develop robust education that can better provide clinicians with the critical and communicative tools to connect with their patients and understand the systemic context around their patient encounters.^199,203,204 

Patient-Clinician Mismatch

In the US, it is very common for patients to have a clinician of a different race. Due to the racial and ethnic makeup of U,S. healthcare clinicians, non-Hispanic white clinicians more frequently provide care to racial minorities than do minority health professionals.²⁰⁵ Racial or ethnic concordance may be preferred by many patients, especially when those patients have experienced communication problems in the past.²⁰⁶ One study found an association between race and ethnicity concordance and likelihood of patient visits in Asian and Hispanic patients.²⁰⁷ A large systematic review found that while Black patients experienced poorer communication quality, information-giving, patient participation, and participatory decision-making than white patients, racial concordance improved communication across many domains, including communication satisfaction, partnership-building, and length of visit/time and talk-time ratio.²⁰⁸ 

A 2017 survey showed that gender concordance between patients and physicians led to more preventive screenings in breast cancer, cervical cancer, and colorectal cancer. However, the study also showed that ethnic concordance of Hispanic patients and Hispanic clinicians led to less breast and colorectal cancer screening compared to Hispanic patients with non-Hispanic clinicians.²⁰⁹ Another study in 2011 indicated that dual concordance in ethnicity and gender between clinicians and patients did not result in high ratings in clinician communication.²¹⁰ In addition, patients in gender-concordant relationships were more likely to report mammography adherence, and dual concordance was associated with higher second-year physical health status.^209,210 

Nonetheless, these two studies showed relatively small effect size and may be confounded by factors such as sampling limitation, perceived bias, effect of translators, insurance status, and clinician and patient attitudes, making the causal relationship difficult to delineate. Furthermore, mismatch report discrepancies could be due to the difficulty in translating subjective factors such as culture, language, and social characteristics into objective causalities. It is clear that more research needs to be performed on objective and subjective effects of patient-clinician mismatch.

Patient Bias Toward Clinician

The patient-clinician relationship may also be negatively affected by patient bias or behavior. Racism, sexism, and discrimination against gender and sexual minorities present a strong barrier for the development of positive patient-clinician relationships that can last long beyond a single discriminatory encounter. While discrimination against women clinicians has been studied for years, sexual harassment of women clinicians continues to be considered a routine “hazard of the job”.^211,212

Similarly, refusal of care based on clinician race is a known problem in many institutions, yet little guidance is provided for navigating the ethical responsibilities, both to the patient and to the clinician, inherent in such situations.²¹³ Another study found that more than 30 percent of patients indicated that they would change clinicians if they discovered their doctor was gay.²¹⁴ Beyond the obvious immediate harm, clinician harassment may increase rates of clinician burnout. Two studies, one on vascular surgery residents and one on general surgery residents, found high rates of reported gender and race based discrimination and associations between discrimination and burnout, with patients and patients’ families being the most common reported sources.^215,216 Another study, this time of pediatric trainees, reported a similar connection between patient and patient family discrimination and physician burnout.²¹⁷ While requests for accommodations based on race, gender, or sexuality may sometimes be appropriate and beneficial in terms of patient-clinician concordance, reasonable limits may be placed on patient conduct, and clinician comfort must be considered as well.²¹³ Working to address patient needs without compromising personal safety and principles takes practice.²¹⁸ 

Institutions should support clinician efforts to create a safe work environment while still supporting good patient care. In order to do this, institutions need to develop explicit systematic approaches to management of patient bias. These approaches should include procedures that account for the clinical roles and services, establish trainee-specific procedures, make considerations for the role of bedside nurses, create a mechanism for reporting incidents of patient bias, designate a team to support staff and implement the policies and procedures that have been developed, ensure tracking and data collection, and ensure adequate training for addressing bias-based patient behavior.²¹³

Systemic Factors

Patient-clinician relationships are deeply founded upon the interaction between two parties to ensure concerns and treatments are shared adequately with compassion and empathy.²¹⁹ One factor that negatively impacts the experience is restriction on the time a clinician can spend with a patient. A study asked the question “How many patients can one doctor manage?” and suggested that there are limits to the number of patients one clinician could effectively care for.²²⁰ 

It is imperative for clinicians to recognize the upward limit on the panel size, as too much workload would lead to a decrease in quality of care and increase in patient wait time. By defining the panel size, clinicians allow patients the flexibility to choose clinicians, allow clinicians to define workload and predict demands, and allow themselves to track performance and patient outcome. This exercise should further be emphasized if there are large differences in panel size or patient complexity/needs between clinicians.²²⁰ 

Additionally, at least one study has found a connection between panel size and clinician burnout, but concluded more evidence was needed to establish the association.²²¹ Further, as patients seek out clinician concordance, patient panels—and the attendant expectations that come with them—may disproportionately affect certain types of clinicians. For example, women physicians have been found to have higher percentages of women patients as well as psychosocially complex patients, and with these a pressure for longer visits that are often not supported institutionally.²²² This can lead to increased feelings of burnout.²²²

It is also worth noting that clinicians practicing in a rural setting may have different experiences than those who practice in non-rural settings. Rural populations have increasingly comprised elderly persons, as shown by an average age of over 65 in hospital admissions, while clinicians have to overcome barriers particular to rural medicine, including lack of coordination between healthcare systems, lower presence of specialty care and technology, lack of transportation, and socioeconomic determinants of health.^223,224 While rural clinicians may feel deeply connected to their patients and communities and the patient-clinician relationship may remain a primary motivator for clinicians to practice in a rural setting, some clinicians report racial and ethnic, sexual, and gender biases and discrimination on an institutional level. When clinicians fail to find acceptance in the rural setting, this may worsen both the deeply valued patient-clinician relationship and, eventually, clinician retention rate.^147,225 Every institution and community plays various roles in impacting clinician and patient experiences; therefore, it is important for each workplace to proactively recognize areas of improvement and prevent over-generalization.

 

Pay 

The Association of American Medical Colleges defines salary equity as “whether or not individuals have access to opportunities that allow them to earn and be paid similar compensation for comparable work, given shared qualifications, regardless of differences in individual characteristics such as gender, race, age, sexual orientation, religion, and disability.”²²⁶ 

Substantial differences in pay exist for women and ethnic and racial minoritized groups in the medical profession when compared with white and/or male counterparts. This is repeatedly demonstrated in studies and is persistent despite attention called to these differences. The lower pay when compared to physicians and PAs who are white and/or male is not accounted for by potential explanatory factors such as age, years of training, work hours, choice of specialty, clinical and academic productivity, rank, and leadership positions. 

In studies that examine these differences, the pay gap is statistically significant, starts early in the career, does not get better over time, does not get better with career advancement, is not accounted for by clinician choices or preferences, and penalizes retirement security for those affected. Correcting pay inequity in the medical profession is fundamental to and tied to correcting inequity overall in the field. Equitable compensation is more likely to be achieved after also improving advancement strategies, inclusion, and culture. Shifts in culture coupled with transparency create the opportunity to challenge and push for change. These changes will come when a diverse workforce is embraced as an imperative. 

The gender gap in pay can be found throughout the course of a career, and explanations remain elusive. One study, based in the state of New York from 1999-2008 examined the difference in pay for newly graduated physicians, demonstrated that the gender gap in pay at the start of career has increased from a $3,600 to a $16,819 difference during that timeframe. Adjustment for possible explanatory factors did not erase this difference.²²⁷ 

Furthermore, these researchers have demonstrated that the gender difference in pay for new graduates has not improved on its own, despite increased representation of women in the profession over time. Adjusted differences in mean starting salary, controlling for other factors, increased from $7,700 in 1999 to $20,200 in 2017.²²⁸ In the academic environment, Jagsi et al. showed a substantial unexplained gender difference in salary within a cohort of early-career physician researchers as well (+$10,921, P<0.001). This was persistent even after adjusting for specialty, academic rank, work hours, research time, and other factors. Adjustment after consideration of spousal employment status (hypothesized to explain men needing a higher salary due to the notion of a “family wage”) left 10 percent of the salary disparity unexplained.²²⁹ 

This difference does not appear to improve over the course of an academic career. An earlier study by Jagsi et al. also demonstrated that among a homogeneous population of mid-career physician scientists, male gender was associated with higher salary (+$13,399; P = .001). Again, this difference was found even after adjustment for specialty, academic rank, leadership position, publications, and research time.²³⁰ Furthermore, when examined, trends do not show resolution of these differences. A study examining data from the Current Population Survey compared median annual earnings over the interval from 1987-2010 and demonstrated that the difference between earnings of male and female physicians across occupations, adjusting for age, sex, race, hours worked, and state, continued to be 20 percent higher for male physicians with no statistically significant improvement over time. Limits of this study included a lack of survey data on specialty, practice type, procedural volume, and insurance mix.²³¹  

These results and trends are reported repeatedly in surveys and studies seeking explanations for differences in pay based on gender.²³² Jena et al. looked at data on more than 10,000 academic physicians in 24 US public medical schools in 12 states using public information ranging from 2011-2013 and found that female academic physicians had annual salaries 8.0 percent ($19,879) lower than those of male physicians, representing 38.7 percent of the unadjusted difference in salary between men and women. In this study, adjustments were made accounting for age, experience, specialty, faculty rank, and measures of research productivity and clinical revenue. Magnitude of sex differences in adjusted salary were noted to vary across specialties and institutions but were present at all faculty ranks.²³³ 

High representation of women in a specialty has not been shown to mitigate this effect. Pediatrics is the specialty with the highest percentage of women represented, as six out of ten practicing pediatricians, and seven out of ten graduating pediatric residents, are women. Female pediatricians report earning 76 percent of what men earn, or approximately $51,000 less annually. After adjustment for a comprehensive set of characteristics, women’s reported earnings were around 94 percent of men’s earnings, or about $8,000 less. In this study, it is suggested that earnings gaps may be related to mothers who might prioritize job flexibility and that periods of part-time work and not working are related to earnings.²³⁴ When female physician prioritization of job flexibility over pay is examined carefully, however, studies provide mixed results. In a study looking at women hospitalists, women were found to earn $14,581 less than their male peers, despite adjusting for age, pediatric specialty, practice model, geography, type of clinical work, and productivity measures. Women hospitalists were noted to be generally younger than their male colleagues, less likely to be in leadership positions, worked fewer full-time equivalents, worked more nights, and reported fewer daily billable encounters. When considering job satisfaction, women ranked substantial pay fourth among their priorities, whereas male colleagues ranked pay second. In this study, women prioritizing pay below other priorities appeared to partly explain their lower earnings.²³⁵ By contrast, another recent study using formal statistical decomposition techniques to assess impact of work-life preferences among other factors (including relationship status and family factors) found that salary differences were impacted only negligibly (<$1,000) by physician prioritization of work schedule control and flexibility. Additional analysis was restricted to primary care fields (internal medicine, family medicine, pediatrics) in which there is good representation in the data by both genders. The results were qualitatively similar and retained their significance.²²⁸ 

In another study examining physician compensation in internal medicine, the differential between men and women was higher among physicians who were practice owners than for employees ($72,500 vs. $43,000) and most pronounced between men and women in solo practices ($70,000).²³² More research is needed examining pay disparities outside academic practices, including in the independent practice arena, in which clinicians are often employees and to better understand gender differences for practice owners.

While less researched and less well-documented, salary inequities are also found for underrepresented minorities in medicine. A recent Medscape Physician Compensation survey in 2019, the most comprehensive and widely used physician salary survey in the United States, provides results from almost 20,000 physicians in more than 30 specialties. As in prior years, this survey demonstrates white physicians earn more than physicians of other races, with a range from $319,000 for white physicians, $303,000 for those of mixed or Latinx race, $300,000 for Asian, and $281,000 for Black physicians.²³⁶ This supports persistence in the trends reported in multiple earlier studies looking at race and annual incomes based on specialty. 

The additional intersectional impact of gender on race is noted to significantly compound or increase the difference in income for Black women physicians in pediatrics, internal medicine, obstetrics and gynecology, general surgery, and primary care in the 1990s.^{237,238,239,240,241} Noting that the size and persistence of differences in annual income between Black and white US physicians from these prior studies relied on small samples of Black physicians and contained surveyed income data from nearly two decades before, Ly et al. reexamined the trends in data over 2000-2013 from the American Community Survey (ACS),a nationally representative, cross sectional survey of approximately three million households annually, administered by the US Census Bureau. Consistent with evidence in the overall economy that Black workers earn less, the ACS confirmed persistent adjusted differences in median income over this time especially between white and Black male physicians. Differences in median income by gender were also present and of larger magnitude than differences in race overall.²⁴² More research is needed to better understand any differences that may be present in compensation for URiM subgroups and the factors impacting these differences.

Observable trends in physician salaries are mirrored in the compensation disparities seen for physician assistants. In one study published in 2009 examining data from the American Academy of Physician Assistants (AAPA), new graduates demonstrated a significant gender gap in annual income.²⁴³ This was confirmed in a later study looking at multiple specialties including orthopedic surgery, emergency medicine, and family practice. Male physician assistants reported a higher total income, base pay, overtime pay, administrative pay, on-call pay, and incentive pay, independent of clinical experience or workload.²⁴⁴ Female PA educators also earn less than male counterparts, and this difference was not explained by education level, rank or position.²⁴⁵ These differences in compensation are also present in repeated studies, even when controlled for experience, hours worked, specialty, postgraduate training, region, and call.²⁴⁶ 

Studies on racial and ethnic differences in physician assistant salaries are less definitive due to the very low percentage of minorities found in the field. In one study, racial and ethnic differences in salaries for physician assistants were examined using AAPA data from 2009 examining white, Black, Hispanic, Asian, and other groups. Results were controlled for many variables including education, specialty, hours worked per week, years in specialty, and size of city. No differences were found by race and ethnicity when the other variables were included in the analysis, but there were very low percentages of minorities found in the field.²⁴⁷ In another study, minority PAs had a trend to make slightly higher income than white counterparts, but this result was not statistically significant.⁴⁸ A bias in the AAPA data is suggested due to lack of minority representation. A follow-up study looking at results from the American Community Surveys data shows that the salaries of Black and Hispanic physician assistants lag significantly behind the salaries of their white counterparts and that the salaries of female PAs are substantially below those of their male counterparts.²⁴⁸ More studies are needed, as well as a better understanding for the low representation of URiM in the PA community.

Existing literature related to the US medical system has not examined the effect of sexual orientation and gender identity on compensation for physicians and physician assistants. However, literature looking at discrimination targeting LGBTQ+ members of the general workforce demonstrates significant pay differences, though data are limited; this is likely a consequence of the United States’ history of legalized discrimination policies in employment and other facets of daily life. Until a June 2020 US Supreme Court decision,²⁴⁹ it was still legal to discriminate in employment on the basis of sexual orientation in over half of US states. Previous federal administrations have issued executive orders that provide piecemeal protections that have been subsequently revoked by later administrations. 

Although data on economic disparities affecting the LGBTQ+ community are sparse and superficially conflicting, a high quality meta-analysis of published literature has shown that gay men earn on average 11 percent less than heterosexual men.²⁵0 The evidence is even stronger that partnered gay men suffer an earnings penalty, though some data from more recent studies show a smaller difference than studies from longer ago. Partnered lesbian women enjoy a 9 percent earnings premium compared to their heterosexual counterparts. Some studies find these disparities fade when non-coupled individual sexual minorities are included. However, this has been shown to be likely due to unmarried gay men being able to disguise or mask their sexual orientation. Bisexual men also earn significantly less than otherwise similar heterosexual men. And finally, lesbian women consistently earn less than men, demonstrating that gender discrimination has an even greater impact on wages than sexual orientation discrimination.^{251,252,253,254}

Several studies have objectively demonstrated discrimination in hiring practices of LGBTQ+ workers.^254,255,256 In self-report surveys, 15-43 percent of LGB respondents reported discrimination in the workplace. A similar number of transgender workers also report employment discrimination.²⁵⁷

A large US-based national longitudinal study had several notable findings. Compared to heterosexual cohorts, sexual minority women and men were both less likely to be homeowners. Many inputs likely contribute to this, including earnings, non-equitable access to health insurance, only recent nationwide access to the benefits of marriage, strained parental relationships resulting in limited familial assistance, and intergenerational transfers. And though SM men were more likely to have completed higher levels of education than their heterosexual counterparts, they were more likely to earn under $10,000 annually and be unemployed. Adjusting for education magnified the inequities, suggesting likely significant discrimination.²⁵⁸

Sexual orientation-based and gender identity discrimination has been demonstrated to be a common occurrence in many workplaces across the country, and such discrimination often translates into lower pay.^257,259 While no known data exist regarding the effects of LGBTQ+ status in the healthcare workforce, it is likely that the medical profession is not exempt from this problem. More research is needed to confirm that disparities in pay and advancement found for other minoritized groups in medicine also apply to the LGBTQ+ members of the medical community.

Opportunities and Challenges for Correcting Pay Inequities in the Medical Profession

As we aim to create a more diverse medical workforce to serve an increasingly diverse population, attention must be given to equitable pay practices. Research outside the medical profession has demonstrated that employees who believe they are paid fairly are more engaged, less likely to quit, experience less stress at work, feel healthier physically and emotionally, and are more satisfied in their personal lives. In addition, gender discrimination lawsuits are costly, result in lost productivity, and destroy morale while damaging the business’ reputation.²⁶0 These findings also apply to the medical profession, as inequitable pay practices in the medical profession have a significant impact on retention and job satisfaction for underrepresented minorities; racial and ethnic minority faculty are significantly less satisfied with their careers and are more likely to leave academic medicine within 5 years.²⁶¹ Women and minority faculty cite multiple reasons for leaving medical school positions, including issues with career advancement, low salary, and chairman/department leadership issues.²⁶² 

Advancement and Promotions

Advancement and the factors affecting advancement in the profession have an impact on annual compensation. Many reported barriers impeding the entry and advancement of women, URiM, and LGBTQ+ physicians and PAs exist in the medical profession, and these need to be addressed. These include: biases in hiring and decisions about advancement (in this case including impact on starting salary and pay raises); linguistic biases demonstrated in letters of recommendation and evaluations that can affect these decisions; biased decisions regarding funding for research and publication of research; biases in decision-making for medical society leadership and awards; selection biases in opportunities for networking and prestigious speaking engagements; and limited opportunities to join networks of influence within medical groups and organizations. 

All these factors influence compensation decisions in subtle or overt ways and must be corrected to improve pay discrepancies. Additional differences faced disproportionately by women in the workplace include decisions related to fertility and family constraints on the job hunt, which can limit the breadth of opportunities sought and found. Family care responsibilities, both for children and for elders or those with healthcare needs, fall disproportionately on women resulting in reductions in FTE with pay decreases, use of PTO for family care responsibilities, and even use of FMLA leave (which is without pay).  These all can impact pay, advancement, and leadership opportunities inside academia and outside. 

Payment Systems

The payment system under which a medical professional provides care can pose difficulties unique to that practice environment. Compensation in medicine in this country has traditionally been based on a productivity model, fee-for-service, with services assigned a certain value and insurance or payors covering that cost.  Alternative models have been developed—including episode-based payment and population-based payment—which differ in how well they constrain spending, promote quality, and support clinicians. Each payment system comes with advantages and disadvantages and attention must be placed on the care delivery being incentivized.²⁶³ 

In a healthcare system that now consumes about 18 percent of gross domestic product, control of rising costs is a primary focus and forces scrutiny of any adjustments in the system. Therefore, if one person or group is provided with richer compensation, another will be provided with poorer, and adjustments are expected to affect other members of the department or team. This creates tension in how best to adjust the standard payment models for those factors that disproportionately affect women, underrepresented minorities in medicine, and LGBTQ+ clinicians. A decision to make such changes will reflect commitment to justice and willingness to challenge older standards.

Starting Salary

Achieving equity in the starting compensation for newly graduated trainees will require some standardization. Relying on human factors such as negotiation and decisions made by hiring teams automatically places some applicants at a disadvantage. Women have been shown to negotiate job offers less frequently than men and to suffer a “social cost” from negotiating when they do. Women do tend to be more successful negotiating higher salaries when their role is to advocate for others as opposed to negotiating for more for themselves.¹⁶³ Literature has shown similar negative impacts for negotiation by Black prospective employees.²⁶⁴ Once basic equity is achieved in the starting compensation, there are many factors at play that can affect pay or workload as a clinician advances in their practice. 

Fee-for-Service

For those practicing in a fee-for-service (FFS) environment, insurance mix and referral base can impact compensation. Number of clinical encounters affects pay, and factors that slow encounters can have an impact on compensation, as well. Some examples of such factors include language barriers requiring use of interpreter services (also at cost to the medical practice) and socioeconomic barriers to the plan of care, which can prompt extended visits while negotiating the realities of a patient's resources. Distribution of patients in a clinical practice is usually not random, as patients with certain characteristics often self-select for one clinician over another (i.e. female patients selecting female clinicians, Asian patients selecting an Asian clinician, etc.). This has impacts on the practice that are not usually accounted for in the FFS environment. Female patients tend to generate more visits than male patients with rates of preventive care visits 69 percent higher.²⁶⁵ In one study, 64 percent of all visits were by female patients, and these patients reported poorer health and higher rates of anxiety and depression, had more medications prescribed, and raised more emotional issues than men.²⁶⁶ These differences represent increased complexity in the visit, which tends to impact time spent in care and workload. The differences affect female clinicians disproportionately compared with male clinicians, given female patient self-selection for female clinician practices. The time and effort needed to deliver care is not adequately captured by current payment models and disadvantages female and URiM clinicians. Bonuses based on RVU productivity will amplify these inequities and benefit those whose practices have high-volume, lower-complexity visits. 

Capitation System

In a capitated system or population-based payment model, determining how the workload is defined becomes even more important. For those providing longitudinal care, differences in patient panel composition (gender, race, age, socioeconomic status, health literacy, primary language, etc.) can be drivers of visit frequency, complexity of issues addressed in the office, frequency of ED visits and hospitalizations, need for specialty consultation, and need for complex care coordination. Such drivers of care complexity are time-intensive, reduce the number of encounters/appointments one can have in a day, and overwhelm the resources of an individual clinician. This may result in decisions to reduce clinical hours and accept a reduction in pay while working beyond acknowledged or scheduled hours to meet the needs of the assigned patients.^221,267 Distribution of patients between clinicians is often influenced by factors such as the clinician’s race or gender, and (again) can result in clustering of demographics in a medical practice. Additionally, clinicians may prefer a certain focus for their practice resulting in a patient population heavily weighted toward added complexity. Panel adjustment for patient mix and patient complexity is an imperfect but necessary solution for a large group practicing under this payment model.²⁶⁸ 

Patient Satisfaction, Quality Scores, P4P

Patient satisfaction scores and quality scores as measures used in determining compensation can also be problematic. Physician race and gender have been shown to influence Press Ganey survey ratings, which are widely used to evaluate physician and institution quality and performance.^269,270^,271 Patient race and cultural factors influence Press Ganey survey ratings as well, but these effects are not currently accounted for in most health systems.²⁷0^,272 Use of pay-for-performance to improve the quality of care of a group of patients seeks to incentivize improving outcomes. However, baseline reimbursements need to reflect a population’s risk levels, and while P4P is a potential tool to monitor and improve health disparities, often performance measures do not address risk factors such as population disease burdens, access disparities, geographic and socioeconomic disparities, and race and ethnicity as independent health risk variables. Access to population management tools are needed to achieve successes in care of populations with significant healthcare inequities.²⁷³ URiM and women in medicine are at risk of increased negative impact from use of patient satisfaction and quality scores.

Systems of Care

Academic Practice

The academic practice and added complexity of demands from teaching, research, and other roles within an academic institution adds to the challenges of correcting compensation inequities. Discretionary funds and resources may not be distributed in transparent ways. These resources can include seed funds, administrative support, professional allowances, and publication fees, and can all affect clinical productivity, quality of work, time spent at work, service, and scholarly output. Academic bonuses may be based on subjective valuation of contributions. Gendered and racial differences in research packages,²⁷⁴ startup resources, and expectations about clinical workload impact downstream scholarly productivity and advancement. Endowed professorships, chairships, and appointed leadership positions add significantly to compensation packages but have not been similarly offered to women and underrepresented members of the profession. Finally, the impact of part-time status on tenure track, advancement pathways, and promotion criteria have not been clear historically and expectations may be measured against the benchmark of full-time colleagues. The full-time standard can impede the progress up the academic ladder, which is ultimately reflected in pay disparity. This may have a disproportionate impact on those whose career trajectories and other responsibilities do not mirror those of more traditional white male academic clinicians. Forcing faculty to choose between career and family hurts the profession’s ability to recruit and retain the best and brightest candidates. Some would suggest that the culture of academic medicine must change to one in which flexibility and work-life integration are core parts of the definition of success.²⁷⁵ Certainly, difficulty in retaining and advancing diverse members of the medical profession contributes to compensation disparities.

Hospital-based and Procedural Practices

For those whose practices are primarily based in the hospital (e.g. hospitalists, intensivists) and procedural arena (e.g. surgeons, interventional radiologists), there are additional challenges.  Reimbursement can have a complicated relationship to referral patterns, and biases can be introduced that can have an impact on ultimate reimbursement. Relationships to payers for such practice types can be fee-for-service, individual contract-to-hospital, or group contract-to-hospital. For FFS, work is reimbursed by RVUs. Although some RVU assignments may be questionable, there are no clearly defined differences that can be related to gender, sexual orientation, or race/ethnicity. Individual contracts to hospitals are not protected from biases because the process is frequently opaque. How group contracts are handled with groups can vary considerably depending on group size, multispecialty vs. single specialty, and other characteristics. Transparency can be complicated in smaller groups as individuals can consider income confidential information. This, again, leaves room for bias to intervene, in addition to potentially causing friction on other levels. Transparency of how the contract payments are disbursed would appear to be the best defense against bias in contractual relationships. Differences in types of shifts and allocation of shifts can result in undesired differences in income. Department bias in distribution of highly sought-after shifts may have an unmeasured impact on compensation for individuals within a group. Distribution and reimbursement of cases and procedures may also demonstrate bias. For example, gender specific-matched Current Procedural Terminology (CPT) codes have revealed reimbursement bias favoring male urologic procedures compared with similar female gynecologic procedures.²⁷⁶ CPT codes also do not pay equally for procedures depending on the surgeon performing the procedure. Different specialties receive different pay rates for similar procedures. One example includes normal spontaneous vaginal deliveries which are paid differently if a Family Medicine, OB-GYN, or midwife is the clinician for this particular procedure.

The community in which the hospital or practice is located directly affects insurance mix or rates of uninsured and underinsured in the patient population. Bias in referrals and department processes for distributing cases may also have an unmeasured impact on compensation differences for targeted groups in medicine. 

Employment in Large Health Systems and Government Practice

As the numbers of physicians and PAs working in employed positions in large health systems increases, there is loss of autonomy to manage practices and workload. This loss of autonomy impacts the ability to choose practice characteristics that may impact quality of care provided, workload, and compensation. Even physicians in government settings experience gender gaps in compensation, although in at least one study, significantly less than physicians in other systems, likely for similar reasons.²³² Systems for accounting for differences in medical practices need to be developed to reduce inequities in pay as well as multiple other downstream effects of inequities in workload and pay, such as reduction in work hours, burnout, worsened quality of care or outcomes, and attrition from the profession. Especially in large health systems, robust data, and transparency about the conflicting issues at play will be needed to inform change.

 

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Equity Task Force Members

Jenny Silberger, MD; Co-Chair

Fred Williams, MD; Co-Chair

Cynthia Caraballo-Hunt, MD

Jerry Chen, student

Esther Choo, MD

Ryan Fox-Lee, student

Monique Hedmann, student

Amy Jones, student

Sharon Kenny, MD

Emily Lane, student

Henry Lin, MD

Mollie Marr, student

Melinda Muller, MD

Lillian Navarro-Reynolds, PA-C

Marianne Parshley, MD

Preston Peterson, MD

Kevin Reavis, MD

Reva Ricketts-Loriaux, DO

Alison Schue, student

Katherine Tierney, MD

John Turner, MD