Unique Populations

Dotun Ogunyemi, MD, FACOG, MFM
Senior Associate Dean of Faculty Engagement
Chief Equity, Diversity, and Inclusion Officer
Professor of Medical Education, Obstetrics and Gynecology
California University of Science and Medicine

It is important to recognize that unique populations among faculty will vary in different institutions. For all unique populations (such as underrepresented in medicine, LGBTQ+, or people with disabilities) we suggest the following:

1. Create an environment where everyone feels included and respected. Reach out to all parties to partner and collaborate. It is crucial to work closely with human resources and others involved in ensuring that all populations have an equal opportunity to thrive.
2. Determine the unique populations in your institution and monitor trends.
3. Use a validated tool to measure your institutional climate. For example, the Diversity Engagement Survey is a reliable and valid instrument for assessment, evaluation, and external benchmarking of institutional engagement and whether all populations feel included and valued. The AAMC’s StandPoint™ Surveys offer robust custom engagement surveys that target unique factors known to drive engagement and retention of faculty and staff.
4. Identify and collaborate with your Title IX and Title VII officers and processes.
5. Ensure there are specific affinity groups to support and nurture all your unique populations.
6. Support affinity celebrations for your unique populations, such as Black History Month, Cinco de Mayo, or Pride Month.
7. Participate in and develop programs and events that bring understanding, awareness, engagement, and integration of your unique populations.
8. Implement universal unconscious bias training for all faculty, staff, and students. Consider specific targeted training programs for search, recruitment, appointment, and promotion committee members.
9. Ensure members of unique populations are represented on institutional committees.
10. Partner and collaborate on specific faculty programs to support promotion and success of your unique populations.
11. Facilitate a mentoring program for your unique populations.
12. Provide scholarships, grants, and sponsorships to external programs.
13. Have an open-door policy, regularly meet with representatives of your unique populations, and be a visible advocate.

Underrepresented Groups in Medicine

Data from the AAMC in 2019 showed that medical school faculty continue to be predominantly white (63.9%) and male (58.6%) overall, especially at the professor and associate professor ranks. Underrepresentation of certain racial and ethnic groups and women in medical school faculty positions persists. Only 3.6% of full-time faculty in 2018 were Black or African American, and 5.5% were Hispanic, Latino, or of Spanish origin,² while the overall U.S. population is approximately 13% Black or African American and 29% Hispanic, Latino, or of Spanish origin. These faculty are also linked to a disproportionately heavy workload as opposed to their white colleagues. Increases in student populations from underrepresented groups often require increased teaching and service for faculty of color, thereby impacting their research and publication track. Professors from underrepresented groups have been shown to spend twice as much time mentoring, recruiting, and “serving on various task forces” as their white male counterparts.³

Deans of faculty affairs, faculty development, and academic affairs should acknowledge the specific composition of their faculty body. They should also identify unique populations, advocate for them, and collaborate to meet faculty needs and support programs that ensure that these groups thrive in an environment that is fair, supportive, and inclusive.

Faculty Development

A crucial process for retention and promotion of faculty from different backgrounds and experiences is creating specific faculty development and networking programs within the institution that focus on specific skills such as leadership, research, grant funding, and getting published. The University of California, San Francisco, organized a faculty leadership collaborative using a cohort-based, experiential, interactive, and collaborative learning approach, from 2005 to 2012. The program included 64% women and 13% faculty from groups traditionally underrepresented in medicine. The proportions of graduates attaining leadership positions within the school, such as deans or department chairs, among the program’s women graduates, underrepresented in medicine graduates, and all graduates were 45.5%, 33.3%, and 9.6%, respectively. Results indicated that graduates perceived program benefits at individual, interpersonal, and organizational levels.⁴

Critical Mass

The absence of a critical mass, defined as enough faculty at an individual institution to create community and impact change, has been consistently recognized as an obstacle. Achieving a critical mass of faculty with different backgrounds and experiences will decrease the pressures, workload, volunteer commitments in the community, overrepresentation in committees, and other obligations leading to “diversity exhaustion,” which impedes these faculty from focusing on scholarly activity and promotion.⁵

Climate

Ambrose et al. in 2010 classified the learning and workplace environment as explicitly marginalizing (overtly hostile, discriminatory, or unwelcoming), implicitly marginalizing (excludes certain people in subtle and indirect ways), explicitly inclusive (intentionally and overtly integrates marginalized perspectives), implicitly inclusive (unplanned responses that validate alternative perspectives and experiences).6 Implicitly marginalizing climates were most common across college classrooms.⁶

Senior Leadership

Success in the recruitment, promotion, and retention of diverse faculty occurs when a champion or group of individuals is vested in creating an equal-opportunity environment. Positive climates have often been attributed to the efforts of institutional leadership and authority. The faculty dean should partner with the dean responsible for ensuring equal opportunity for all to advocate for commitment at the dean or provost level.⁵ Support at the highest level of the institution can lead to coordinated programmatic efforts with the resources necessary to address recruitment, retention, and promotion of faculty from all backgrounds.

Mentorship

Effective mentoring can contribute to wellness and career growth and satisfaction. Faculty from underrepresented groups have noted that professional mentoring relationships can be crucial in cultivating a sense of well-being in sometimes “chilly” department climates. However, the same social forces and interpersonal dynamics affecting all relationships can compromise mentoring relationships. This is especially true when issues are compounded by systemic disadvantages due to racism, gender bias, social class, and other discriminatory factors. The Mentoring Across Differences (MAD) sessions “are a workshop designed to develop and nurture skills, tools, self-awareness, and mindful practice in mentors and mentees.”⁷ The workshop helps participants gain confidence in navigating differences across a variety of domains. Participants develop an enhanced awareness of assumptions, specifically highlighting knowledge and tools addressing bias in their roles as mentors and teachers. The MAD workshop is an example of a module for a comprehensive mentoring curriculum. These workshops can fill a critical need for faculty and training institutions to explore the value of having an environment that includes and respects a wide range of perspectives and experiences.⁷

Affinity Groups, Academic Networking, and Leadership Certificate Programs

Affinity groups provide safe havens and opportunities for nurturing, validation, and support for all faculty. These affinity groups include the National Hispanic Medical Association, with a mission to empower Hispanic physicians and improve the health of Hispanics; the National Medical Association, representing the specific interests and concerns of African American physicians and their patients; and the Society for the Advancement of Chicanos/Hispanics and Native Americans in Science.⁸

Encouraging and funding faculty to attend and join professional and scholarly networks can provide opportunities to collaborate, present work, and validate their work, and can increase the number of faculty members from underrepresented groups in academia.^3,9 Faculty can also be sponsored to complete certificate and leadership programs. For example, the AAMC offers the following programs: The Maximizing Impact and Networks for Faculty Advancement and Community (MINFAC) Leadership Development Seminar provides participants with real-world guidance and tools for pursuing career advancement in academic medicine, developing key professional competencies, building skills in grant writing and communications, and expanding their network of colleagues and role models. The Mid-Career MINFAC Leadership Seminar addresses the specific needs of mid-career faculty from a culturally sensitive approach, while offering skillsuilding and strategies for pursuing career advancement in academic medicine. The AAMC Leadership Education and Development Certificate Program is an intensive, one-year, cohort-based leadership-development program that provides a firm foundation in the best practices and recognized theoretical models of effective educational leadership that are key to advancing medical education at all levels.

Equal-Opportunity Statement

A section on efforts to develop a more diverse workforce in the annual performance review can engage faculty in activities to promote a broadly shared understanding of the importance and benefits of an environment that ensures a broad range of backgrounds and viewpoints is represented.

LGBTQ+

LGBTQ+ discrimination is real. LGBTQ+ faculty, staff, and students experience the negative impacts associated with homophobia, discrimination, and perceived or actual threats to their physical safety. Recent campaigns at the state level regarding marriage equality, and at the federal level regarding the repeal of “Don’t ask, don’t tell,” which allowed LGBTQ+ military personnel to serve openly, have further raised the profile of issues affecting LGBTQ+ Americans and their families. Yet, far too many people still encounter discrimination based on their sexual identity, gender identity, and/or gender expression.¹⁰

The United States Constitution and subsequent laws, such as the Civil Rights Act of 1964, protect citizens from discrimination on the basis of race, ethnicity, or sex. But for LGBTQ+ people, the biggest obstacle to full equality is that this community lacks federally protected status.¹⁰ This population faces an array of challenges, ranging from personal attacks, both verbal and physical, to actions (intentional or otherwise) that isolate and alienate LGBTQ+ individuals, to institutional policies that prevent individuals from freely expressing their sexual identity and/or gender identity.¹⁰

Recruitment and retention of LGBTQ+ faculty benefits academic medical centers because these faculty can serve as positive role models, mentors, and advocates for LGBTQ+ students, residents, and staff; they can facilitate a positive pivot in institutional views of LGBTQ+ personnel and patients, stimulate research on LGBTQ+ health disparities, and help promote acceptance, respect, and fairness in the institutional environment. Ensuring a welcoming, supportive, and respectful climate for LGBTQ+ faculty will facilitate their success and encourage these faculty to become partners and advocates for equal-opportunity treatment for all trainees, staff, and faculty. Schoolwide activities designed to enhance LGBTQ+ awareness and acceptance do a great deal to ensure a welcoming environment.^2,3,4

Communication, Education, and Awareness

• In collaboration with other parties, such as human resources and the dean, facilitate communication and awareness demonstrating that LGBTQ+ faculty, residents, and students are not only welcome but embraced by the institution.
• Develop an LGBTQ+ speakers bureau, to allow LGBTQ+ experts to lead panels, workshops, and forums.
• Create an institutional website and/or brochure with LGBTQ+-related information and resources.
• Assure that providing an environment in which everyone feels valued and respected is communicated on all appropriate websites and written material.
• Work to further include LGBTQ+ populations in the curricula.
• Incorporate LGBTQ+ issues in on-campus trainings for relevant personnel.^10,11,12,13

Affinity Groups, Mentoring, and Networking

• Mentoring and networking are critical for LGBTQ+ students, staff, and faculty, to maximize their success in academic health centers.
• Promote and support the development and sustainability of LGBTQ+ affinity groups at all levels in the institution, including faculty, students, staff, and alumni, and meet with members or representatives regularly.
• Encourage the development of a LISTSERV that ensures an ongoing, institutional means of information sharing available at the same email address or link, to maintain continuity.
• Use social media to ensure that LGBTQ+ students, staff, and faculty are well connected and stay abreast of relevant activities and developments at your school. Provide a readily available list of your school’s LGBTQ+ students, staff, faculty, and alumni.
• Establish contacts with other resources^{14,15,16,17,18} and national organizations, such as the GLMA (previously the Gay & Lesbian Medical Association) and the American Medical Association Advisory Committee on LGBTQ Issues.
• Support networking with other institutions with well-developed LGBTQ+ programs, such as the UCLA LGBT Campus Resource Center or Stanford Pride – Stanford’s LGBTQ Alumni Community.
• Provide funding for attendance at major events for LGBTQ+ health professionals and trainees.^10,11

Institutional Inclusiveness, Recruitment, and Retention

• Establish an LGBTQ+ task force or committee with faculty, resident, and student representatives to oversee LGBTQ+ recruitment, admission and hiring, retention, and climate concerns.
• Ensure that LGBTQ+ faculty members are included in all search committees.
• Consider an award or other recognition for LGBTQ+ leadership or achievement, preferably given at a public event. People recognized may or may not be LGBTQ+ themselves since the aim is simply to celebrate contributions to LGBTQ+ fairness and respect.
• Create “safe places” by advocating for LGBTQ+ spaces, and establish a point person to develop an LGBTQ+ resource center.
• Survey LGBTQ+ faculty regularly to assess issues and concerns, allowing for benchmarking efforts, and stay knowledgeable about best practices, to define best practice models within and outside the institution.
• Include LGBTQ+ status with demographical institutional data collection in addition to gender, race, and ethnicity. As with the other attributes, LGBTQ+ status should be self-identified and voluntary. This will allow assessment of the institution’s success.
• Include “sexual orientation” and “gender identity and expression” in the institution’s nondiscrimination policy. Check the language of institutional policies and procedures to be sure LGBTQ+ faculty, staff, and students are included.
• Check bargain contract language to be sure LGBTQ+ faculty is included.^10,11

Equal Benefits

Ensure that benefits offered by the institution to all employees are sensitive to LGBTQ+ lifestyles and unique needs. For example, does your school treat married same-sex spouses in the identical way it treats different-sex spouses? Is health coverage offered to spouses and same-sex domestic partners on an equal basis? Does your school’s health coverage include transgender care? Does your school offer benefits — family leave, discounts, memberships, insurance, loans, fee waivers, and more — to spouses and same-sex domestic partners on an equal basis?^10,11

Social Events and LGBTQ+ Celebrations

Partner with the dean or comparable administrators to provide events that allow LGBTQ+ persons and their allies to get to know one another. One of the most painful aspects for LGBTQ+ faculty is to be “in the closet,” hiding their personal life from their work colleagues. Events such as potlucks, dinners, and educational events allow for a safe sense of camaraderie among LGBTQ+ faculty, residents, students, and their allies.¹¹

LGBTQ+ celebrations include National Coming Out Day on Oct. 11, commemorated for the anniversary of college student Matthew Shepard’s murder in Wyoming in 1998; LGBT History Month in October; Transgender Day of Remembrance on Nov. 20, a remembrance of transgender people who have died in hate crimes, now expanded into a week of transgender awareness; National LGBTQ Health Awareness Week, generally the last week of March; and Pride Month, which is usually June.

Disability and Accessibility

Educating and employing physicians with disabilities can have positive effects on patient care and access for patients with disabilities, as has been observed with other underserved groups, such as low-income people, certain racial and ethnic populations, and nonnative English speakers.

The current conception of “disability,” defined by the Americans with Disabilities Act (ADA) Amendments Act of 2008, includes a broad range of disabilities: physical, sensory, learning, psychological, and chronic health conditions. Since about 19% of the U.S. population identifies as being a person with a disability, a large percentage of the patient population will have disabilities.^19,20

A 2018 AAMC report identified three major concerns about disability in medical schools, including

1. Inconsistent policies and procedures: A lack of standardization in the disability disclosure and accommodation process was common across medical schools.
2. Inconsistent support across campuses: When programs had only a small number of medical students with disabilities, demand for support was minimal. In some institutions, individuals provided disability services as one part of their job — often with little to no training in the area, while other institutions had more robust disability services. These inconsistent resources and experiences led to a wide range of support, from minimal to comprehensive.
3. Lack of understanding of the ADA: The most disconcerting self-reports came from administrators who were unaware of pertinent legislation and case law. Some administrators were also unaware of the institutional obligation to offer a mechanism for self-disclosure of disability and to determine reasonable accommodations.¹⁹

Attention to ensuring that all populations have the equal opportunity to thrive has been a key focus of medical education. Despite this, disability is rarely included in health care planning. Consequently, people with disabilities experience significant barriers to health care, including inaccessible facilities, poor-quality treatment, discriminatory attitudes, and denied care.^20,21

The 2018 AAMC report on students and physicians with disabilities identified structural barriers, including

• Uninformed disability service providers.
• Lack of clear policies and procedures.
• Lack of access to knowledge about nuanced clinical accommodations and assistive technology.
• Lack of access to other meaningful accommodations.
• Failure to publicize technical standards and provide information on accessing accommodations.
• Technical standards that do not reflect current technology and other developments in medical practice.
• Lack of access to health care and wellness supports.

Culture and climate barriers identified were

• Stereotypes and stigma.
• A “clinicalized” culture.
• Negative peer attitudes.
• Restricted views of disability leading to learners being counseled out of specialties.

Interactive Process for Determining Reasonable Accommodations

Provide knowledge, access, and ease regarding appropriate accommodations. Review and revise technical standards in light of current promising practices. The ADA requires schools and employers to reasonably accommodate the documented disabilities of students and employees unless doing so would fundamentally alter a program or result in an undue hardship. Reasonable accommodations are designed to bridge the gap between a barrier to the program and the qualified individual with the disability. An interactive process is the process that programs must engage in to determine reasonable accommodations.

Fostering an Institutional Culture in Which People With Disabilities Feel Included and Valued

• Assess disability services and processes of the institution, obtain feedback from members with disabilities, and consider outside expert consultation. Ensure a top-down commitment to accommodating faculty, staff, and students with disabilities.
• Provide ongoing professional-development training for faculty and staff on communication regarding persons with disabilities; refer to principles of disability and accommodations from a social-model perspective, and integrate culturally appropriate content about disability into curricula, standardized-patient scenarios, and case studies.
• Evaluate curricula and pedagogy to assess whether language and content reflect best practices regarding disability and are accessible and respectful to persons with disabilities.
• Conduct awareness training that highlights successful individuals with disabilities in the medical profession.
• Work toward full accessibility for clinicians, learners, and patients.
• Use a universal design approach inherently accessible to people with disabilities in all instruction and physical space across the institution. Develop an institutional design guide that includes features to maximize usability beyond legally required access. For example, require automatic door openers in all key learning spaces and bathrooms, even if code compliance does not require them.
• Include people with disabilities in planning and decision-making.

Integrate Disability Into Initiatives, Efforts, and Culture

• Ensure that all initiatives explicitly include disability as an aspect of the wide range of backgrounds and perspectives valued in institutions. Meaningfully integrate disability into trainings . Make information about disability services as well as accommodations easily accessible.
• Integrate disability and regularly assess pathway, recruitment, and retention programs. institutional polices, processes, services, and physical space.
• Count individuals with disabilities as part of institutional measures, identify trends in the numbers of learners and staff with disabilities, and use these metrics as an indication of improved efforts at creating environments in which everyone feels included and respected.
• Identify or develop scholarships and support programs for faculty and learners with disabilities.
• Collaborate with others to honor and recognize disability culture and the challenges the disability community faces in health care, learning, and employment. Create an environment in which disabilities are acknowledged and respected.
• Review recruitment and hiring practices to increase the hiring of faculty, administrators, and clinicians with disabilities, which can improve understanding of disability and positively affect the institutional culture toward disability.
• Faculty and staff with disabilities may be willing to serve as mentors for students with and without disabilities. Encourage peer support networks and physician mentors.

Assign a Specialized Disability Service Provider

A disability service provider (DSP) is someone with specialized training in disability services and disability law. This person could be situated in several possible offices. Important elements to consider in placement include confidentiality of documentation, avoiding any conflict of interest (i.e., no supervision by someone in an evaluative role over registered learners with disabilities), and ensuring positive messaging about equal access.

Ensure that the DSP has a designated liaison in the medical school at the assistant or associate dean level who can serve as a source of information and referral to specialist educators within the medical programs, when needed. This professional should receive specialized training in the requirements of the medical school curriculum, with special attention to the clinical components of the curriculum.

Publicize Disability Service Policies and Procedures

• Post clear information about the policy for requesting and accessing accommodations in a manner and location(s) that is easily accessible and ensure that the information is also on the program’s website.
• Include, a supportive statement encouraging students with disabilities to register and request services. This statement can appear in faculty or student handbooks, clinic handbooks, and course syllabi.

Promoting Wellness

• Normalize help-seeking behavior. Encourage faculty and learners to seek mental health services, and make sure these services are confidential and convenient to campus and clinical sites. Support release for appointments.
• Ensure faculty and learners have access to health care that is a reasonable distance away.

Notes

2. AAMC. Diversity in Medicine: Facts and Figures 2019. https://www.aamc.org/data-reports/workforce/report/diversity-medicine-facts-and-figures-2019. Washington, DC: AAMC; 2019. Accessed Feb. 20, 2020.
3. Kalb AC, Smith J. Diversifying tenured faculty: recommendations to increase racial representation. Higher Ed Jobs [blog]. Jan. 16, 2019. https://www.higheredjobs.com/articles/articleDisplay.cfm?ID=1812. Accessed Feb. 20, 2020.
4. Tsoh JY, Kuo AK, Barr JW, et al. Developing faculty leadership from ‘within’: a 12-year reflection from an internal faculty leadership development program of an academic health sciences center. Med Educ Online. 2019;24(1):1567239.
5. Kaplan SE, Raj A, Carr PL, Terrin N, Breeze JL, Freund KM. Challenges in recruiting, retaining and promoting racially and ethnically diverse faculty. J Natl Med Assoc. 2018 Fe;110(1):58-64.
6. Ambrose SA, Bridges MW, DiPietro M, Lovett MC, Norman MK. How Learning Works: 7 Research-Based Principles for Smart Teaching. San Francisco, CA: Jossey-Bass; 2010.
7. Osman N, Gottlieb B. Mentoring across differences. MedEdPORTAL. 2018 Aug. 24;14:10743. doi:10.15766/mep_2374-8265.10743.
8. AAMC Group on Diversity and Inclusion. New Diversity and Inclusion Officer Toolkit. AAMC; 2015. www.aamc.org/media/10281/download.
9. Spalter-Roth R, Shin J, Smith J, et al. “Raced” organizations and the academic success of underrepresented minority faculty members in sociology of race and ethnicity. Sociology of Race and Ethnicity. 2019;5(2):261-277.
10. AFT Higher Education. Creating a Positive Work Environment for LGBT Faculty: What Higher Education Unions Can Do. American Federation of Teachers, AFL-CIOcio (AFT); 2013.
11. Snowdon S. Recommendations for Enhancing the Climate for LGBT Students and Employees in Health Professional Schools. Washington, DC: GLMA; 2013.
12. Kirch DG. Presidential memorandum: announcing a new resource to improve health care for people who are LGBT, gender nonconforming, or born with differences of sex development. Nov. 18, 2014. Accessed Feb. 20, 2020.
13. Kirch DG. Information: institutional program and educational activities to address the needs of gay, lesbian, bisexual and transgender students and patients. March 2007. Accessed Feb. 20, 2020.
14. Pride at Work (prideatwork.org): Pride at Work is the officially recognized LGBTQ+ constituency group within the AFL-CIO. In addition to offering model contract language for LGBTQ+ collective bargaining agreements, it provides important information on LGBTQ+ workplace issues, LGBTQ+ news, and trainings on how to make the workplace of an environment where everyone feels included and respected
15. The Williams Institute (williamsinstitute.law.ucla.edu): The Williams Institute is a think tank, based at the UCLA School of Law, that specializes in LGBTQ+ issues.
16. Campus Pride (campuspride.org): Campus Pride is a national nonprofit group devoted to creating safe college environments for LGBTQ+ people. In addition to providing reports on the campus climate, Campus Pride provides tools and resources to help transform higher education institutions into spaces where LGBTQ+ faculty, staff, and students feel included and valued.
17. The Human Rights Campaign: The Human Rights Campaign, the nation’s largest LGBTQ+ civil rights organization, maintains a list of resources for LGBTQ+ employees, as well as resources for employers.
18. On-campus LGBTQ+ resource centers: Additional resources may be steps away, at your campus LGBTQ+ resource center. It can provide important services for LGBTQ+ individuals and can be a formidable ally in helping to make your union and your campus a space where the well-being of people who are LGBTQ+ is recognized.
19. Meeks LM, Jain NR. Accessibility, Inclusion, and Action in Medical Education Lived Experiences of Learners and Physicians With Disabilities. Washington, DC: AAMC; 2018.
20. DeLisa JA, Lindenthal JJ. Learning from physicians with disabilities and their patients. AMA J Ethics. 2016;18(10):1003-1009.
21. World Health Organization (WHO) and World Bank. Summary: World Report on Disability. Geneva, Switzerland: WHO; 2011. http://apps.who.int/iris/bitstream/10665/70670/1/WHO_NMH_VIP_11.01_eng.pdf.