In spite of published reports highlighting the need to increase the number of physicians who identify with groups underrepresented in medicine (UiM), Black and Hispanic individuals each made up only 5% and 5.8%, respectively, of US physicians in 2019.1,2 Due to these small numbers, UiM trainees often lack access to a community of co-residents, fellows, faculty, and mentors from similar racial or ethnic backgrounds. The deficiency of social support from individuals of similar backgrounds has been reported to hinder the personal and professional success of UiM trainees.3–5
Decades Without Adequate Progress
Since 1964, the Student National Medical Association (SNMA) has provided a diverse and welcoming community for medical students. Similarly, since 1895, the National Medical Association (NMA) has provided the same benefits to UiM faculty members.6 These communities are designed to improve the recruitment, success, and retention of UiM physicians. However, there is a gap in a structured community specifically designed for UiM physicians enrolled in graduate medical education (GME). How does a health care system intentionally foster a community for diverse GME trainees and cultivate a support system for UiM trainees? There is a paucity of evidence outlining best practice strategies for building community among UiM GME trainees. We share a guide we used to fill this gap through the creation of a house staff diversity council (HSDC) at Johns Hopkins University School of Medicine and the Johns Hopkins Hospital.
Bridging the Gap
The Johns Hopkins HSDC was created in July 2018 by a small cohort of Black house staff, representing different training programs, for the purpose of supporting UiM peers. Specifically, the mission was to support the well-being of UiM house staff by developing and promoting activities that strengthen a diverse, equitable, and inclusive culture. The HSDC set forth to operationalize the following objectives:
Build collaborative networks with various organizations at the university, medical school, and health systems levels to ensure support for our programs and executive leadership buy-in for our initiatives.
Form affinity groups within the council to lead our initiatives and programs (Table; a list of all programs and activities is available as online supplementary data).
Establish and maintain relevant communication of our programs through various outlets, including a monthly newsletter, group messaging with GroupMe, and social media accounts on Twitter, Instagram, and Facebook.
To accomplish this mission, the council drafted and approved bylaws outlining the priorities of the council, membership roles, and respective duties, as well as the frequency of program activities. Funding was secured from Johns Hopkins School of Medicine's Office of GME and the Office of Diversity, Inclusion, and Health Equity (Box 1). The council's budget supported recruitment activities aimed at attracting a diverse physician workforce through annual attendance at the SNMA Annual Medical Education Conference and other regional diversity recruitment events. The budget also supported activities aimed at increasing equity such as the creation of our “One-Day Medical School” pipeline program for high school students. These programs are aimed at overcoming the societal and institutional racism that contributes to achievement disparities among UiMs. The budget additionally supported inclusion activities such as our quarterly networking and social events that fostered a sense of belonging and support within the Johns Hopkins community.
$15,000 (Financial support from Johns Hopkins School of Medicine, Office of GME)
$4,000 allocated for social events
$2,000 allocated for community service projects
$9,000 allocated for conference attendance (eg, SNMA conference for recruitment activities)
$5,000 (Financial support from Johns Hopkins Office of Diversity, Inclusion and Health Equity)
$5,000 allocated for mentorship programming (URM community investment continuum)
Abbreviations: GME, graduate medical education; SNMA, Student National Medical Association; URM, underrepresented minority.
To constitute the initial council, we contacted each department's residency program director for a list of UiM trainees and invited these trainees to join the HSDC and help guide its direction. Our current council is composed of 70 members. Box 2 summarizes the steps we took to create the HSDC. The institutional support from the GME office and our designated institutional official (DIO) was crucial to the success and sustainability of the Johns Hopkins HSDC.
Identify a cohort of residents willing and able to take the lead and inaugurate a house staff diversity council. This may require reaching out to individual GME program leaders to identify house staff who identify as UiM and eliciting their voluntary participation in development of a diversity council
Draft bylaws outlining the priorities of the council, membership roles and respective duties, and the frequency of program activities
Secure executive level institutional support and funding for council activities and programs
Brainstorm activities to facilitate social support, sustain community building, and foster UiM engagement
Organize a process for feedback and council evaluations (ie, surveys, comments, focus groups)
Abbreviations: GME, graduate medical education; UiM, underrepresented in medicine
Navigating the complex hierarchy of an academic medical institution was an initial impediment experienced by the council. To overcome this challenge, we met with the president of Johns Hopkins Hospital and members of the Johns Hopkins Hospital Diversity Council to emphasize that the HSDC would meet the strategic goals set forth in the institution's strategic plan, in particular its goal to “develop a support and career success group to build an inclusive culture in which a diverse community of residents feel supported, mentored, and valued at all stages.”7 Box 3 offers suggestions for overcoming barriers for institutions that wish to establish a similar HSDC.
Barrier: Academic institutions are complex organizations with intrinsic silos that can be difficult to navigate and obtain leadership buy-in.
Solution: Request a meeting with leadership stakeholders within the school of medicine and/or hospital (may include the dean of the school of medicine, designated institutional official, associate dean for graduate medical education, president of the hospital). Align the planned activities of the council with the strategic goals of the institution to address diversity, equity and inclusion. ACGME Section 1.C. addresses recruitment and retention of a diverse and inclusive workforce and a diversity council aimed at building community for UiMs may serve as a means to improve UiM trainee recruitment and retention.11
Barrier: Securing financial support for diversity council activities and programs.
Solution: Request a meeting with GME leadership to review the fiscal year budget for GME activities and programs. With this knowledge, draft a budget proposal to cover social, community service, recruitment and retention, and other activities relevant to your respective council. This may require negotiation with future funding contingent on program evaluations and feedback. Seeking outside funding through grants and gifts may also be necessary.
Barrier: Continued engagement of UiM trainees with the house staff diversity council, particularly given the many requirements and obligations of house staff during training.
Solution: Seek input from UiM trainees regarding relevant activities that inspire them to engage in council activities. For example, a current issue concerning our house staff was to address racial disparities related to black lives and police brutality following the George Floyd murder. This inspired our council to organize in a solidarity event to recognize and discuss racial disparities in the United States.
Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; UiM, underrepresented in medicine; GME, graduate medical education.
As organizational buy-in and support grew, we were able to coordinate more socially relevant activities that inspired house staff to be engaged in our surrounding community, such as a solidarity gathering coordinated to display the support of Johns Hopkins physicians for Black lives. The success of our programs was recognized by the institution with receipt of the Johns Hopkins University Diversity Leadership Council's 2020 Diversity Recognition Award. To appreciate the impact of our efforts, we have implemented strategies for program evaluation such as an annual survey of UiM house staff and comments from program directors and GME leadership.
Working Toward Progress
Building a community for UiM trainees requires prioritizing the diversification of a physician workforce by expanding the number of UiM trainees. This requires increasing the UiM pipeline into GME, equitably engaging UiMs through pre-medical education and outreach, and supporting the recruitment and retention of UiMs in medical school and during GME. Our first step in this process, jointly championed by the HSDC and institutional GME leadership, required all residency program directors to undergo implicit bias training. For the 2021–2022 recruitment season, we have expanded these centralized efforts and are now requiring all program directors to undergo training in how to mitigate bias in the application and interview process.
We also recognize that implicit biases and racism play a significant role in exacerbating health disparities and disparate educational and training opportunities as well as may compromise efforts to retain UiM trainees into faculty positions upon completion of their training. To combat this, we are creating a standardized and longitudinal implicit bias and anti-racism curriculum for all house staff so that they have an understanding of the impact of race on health, an awareness of their own implicit biases, and the tools necessary to consciously mitigate the negative impact of bias and racism on patient outcomes and their interactions with colleagues, similar to the initiatives at peer institutions.8 Our programs build on the success of similar programs, like the Differences Matter initiative at the University of California, San Francisco, which is aimed at creating and maintaining a diverse, equitable, and inclusive academic environment for UiM trainees.9
Residency is the cornerstone of physician training and development. For UiM trainees who battle inclusion barriers like microaggressions and implicit biases daily,10 it is essential for GME programs to invest in resources that support their well-being during one of the most influential phases of their career. Our approach was to create an HSDC that facilitates an institutional culture and climate that meet the needs of UiM residents. In addition, the HSDC serves as an invaluable partner for the DIO as the GME office seeks to move the institution's diversity, equity, and inclusion efforts moving forward.
If our program is successful, we expect to see an improvement in UiM resident satisfaction and sense of belonging, a more consistent recruitment process with a measurable upward matriculation of a diverse physician workforce, and an increase in successfully transitioning UiM residents into faculty positions upon completion of their training. Our HSDC may serve as one approach to improving the experience of UiM medical trainees in GME programs.
Editor's Note: The online version of this article contains a list of house staff diversity council activities and programs.
Agnes Usoro, MD, was a Resident, Department of Emergency Medicine, Johns Hopkins University School of Medicine, and is currently an Attending Physician, Department of Emergency Medicine, Johns Hopkins University School of Medicine; at the time of writing, Meron Hirpa, MD, was a Resident, Department of Medicine, Johns Hopkins University School of Medicine, and is currently a Public Health Physician, Cincinnati Health Department; Michael Daniel, MD, is a Fellow, Department of Gastroenterology, Washington University School of Medicine; Vandra Harris, MD, is a Resident, Department of Otolaryngology, Johns Hopkins University School of Medicine; Alisha Ware, MD, is an Assistant Professor, Department of Pathology, Johns Hopkins University School of Medicine; Amber Kernodle, MD, MPH, is a Resident, Department of Surgery, Johns Hopkins University School of Medicine; Thomas Elliott, MD, is a Resident, Department of Pediatrics, Johns Hopkins University School of Medicine; and Damani A. Piggott, MD, PhD, is an Assistant Professor, Department of Medicine, Division of Infectious Disease, and Assistant Dean for Graduate Biomedical Education and Graduate Student Diversity, Johns Hopkins University School of Medicine, and Jessica L. Bienstock, MD, MPH, is an Associate Dean for Graduate Medical Education and a Professor, Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Johns Hopkins University School of Medicine; at the time of writing.