Outcomes From a Novel Graduate Medical Education Leadership Program in Advancing Diversity, Equity, and Inclusion

While our patient population is rapidly diversifying, there continues to be a lack of diversity in academic medicine, especially in leadership positions.¹  This pervasive scarcity of diverse representation across racial and ethnic minorities, women, LGBTQIA+, and physicians with disabilities is present at all academic levels and across leadership positions.^1–4  There also continues to be a small number of underrepresented in medicine (UiM) individuals, defined as “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population,”⁵  entering medical school. Despite numerous attempts to increase the recruitment and retention of physicians from diverse backgrounds, including the implementation of the Liaison Committee on Medical Education standards on diversity in 2009 and the recent Accreditation Council for Graduate Medical Education diversity requirement in 2019, the numbers of UiM faculty have remained alarmingly low across academic health centers in the United States.^5,6  This is particularly concerning because physician diversity is known for enhancing educational experiences for trainees in academic medicine, as well as improving patient care outcomes and increasing the likelihood of serving the medically underserved.^7–9  Furthermore, the extraordinary impact of a global pandemic, social and political unrest, racial injustice, and the devastating consequences of environmental climate change have expedited the need to prepare a more diverse physician workforce.^10–14 

Literature shows a myriad of barriers for UiM residents and fellows that contribute to challenges in retaining a diverse academic medicine workforce. It is important to recognize that UiM trainees in academic medicine experience heightened levels of implicit bias, microaggressions, racial discrimination, and the minority tax.^15–19  Lack of institutionalized systems to promote diversity and inclusion education in training programs has an adverse impact on recruitment and retention of UiM trainees in academic medicine.^17,18,20,21  Furthermore, imposter syndrome affects all trainees,²²  but it has been shown to have a deleterious impact on UiM trainees and marginalized groups, creating challenges with balancing personal and professional identities.^17,22  The sustained absence of diverse representation undermines medical education, compromises the learning climate, and disproportionately limits the ability of UiM trainees to find effective mentorship, which is critical for successful advancement in academic medicine.^21,23 

Few published programs in graduate medical education (GME) provide a deliberate approach to support UiM trainees and bring together non-UiM trainees (allies) in building their leadership and scholarship capacity for diversity, equity, and inclusion (DEI) work in academic medicine. Most existing GME leadership programs focus on skill and knowledge building aimed at interpersonal dynamics, communication skills, and team management.²⁴  However, there are few educational interventions that focus on increasing leadership diversity for underrepresented minorities and women.²⁵  The New Century Scholars (NCS) Resident Mentoring Program developed by the Academic Pediatric Association provides longitudinal mentoring for UiM pediatric residents in their area of research interest from diverse faculty across various medical institutions.²⁶  Building the Next Generation of Academic Physicians (BNGAP) also has initiatives centered on supporting diverse pre-faculty development, including UiM college students through residents and fellows, to encourage careers in academic medicine by providing scholarly training in publications, research, and support faculty advancement to leadership roles.^27,28  These outstanding programs demonstrate the need for leadership development of UiM trainees, but are limited in their accessibility and reach as they are highly selective and offered only at the national level. DEI-centered leadership programs at the local institutional level could build leadership capacity as well as allyship, potentially addressing institutional structural racism and inequities in academic medicine.

We believe that creating an environment that enhances intrinsic motivation to learn and address critical issues related to DEI will lead trainees who are both UiM and non-UiM allies to have a continued desire to advocate for equity, promote UiM physicians in leadership roles, and enhance the caliber of academic medicine scholarship with a deeper understanding of DEI practices. We hypothesized that a 10-month longitudinal structural support program for both UiM and non-UiM residents and fellows designed to build leadership and scholarship capacity in DEI would address the structural barriers that impact UiM trainees. This program is based on the conceptual framework of self-determination theory, which posits that promoting learner competence, relatedness, and autonomy leads to intrinsic motivation.²⁹  The objective of this study was to describe the creation, satisfaction with, and feasibility of the Leadership Education in Advancing Diversity (LEAD) Program and evaluate scholars' changes in self-efficacy, actual and planned behavior change, and outputs of their leadership and DEI scholarship.

This mixed methods educational intervention study was conducted from August 2017 to June 2020 at a single institution, Stanford University School of Medicine.

During the inaugural program year (2017–2018), all pediatric residents and fellows were invited to apply for LEAD. The second year (2018–2019), residents and fellows were invited to apply from 7 clinical departments, including pediatrics, internal medicine, emergency medicine, psychiatry, anesthesiology, surgery, and obstetrics and gynecology. The third year (2019–2020), the program was opened to all departments in the School of Medicine. Residents and fellows who identified as diverse in terms of race/ethnicity, gender, sexual orientation, disability, and allies were invited to apply to LEAD. We were intentional in promoting this program to all UiM identified trainees through a GME-wide diversity listserv. Allies were also included because we believe that improving the culture of DEI in academic medicine is not the sole responsibility of UiM groups alone (ie, minority tax),¹⁸  but requires the sustained engagement of all physicians.

Interested applicants completed an application in Qualtrics (Qualtrics, Provo, UT) with 3 essay questions: (1) Why are you interested in participating in the LEAD program? (2) What specific goals or skill sets would you like to gain from the LEAD program? and (3) What skill sets or perspectives do you bring to the LEAD program? In addition, applicants submitted a CV and approval from their residency or fellowship program director confirming they were in good standing. Applications were reviewed by the LEAD Program steering committee, comprised of educational program leaders in their respective clinical departments. Given that this was a new educational program and all applicants had compelling reasons to participate, all applicants who applied were accepted.

The LEAD mentors were Stanford School of Medicine faculty and GME administrators (ie, residency and/or fellowship program coordinators, educational managers for their departments) with varying levels of mentorship experience. We sought to have mentors from diverse backgrounds; however, mentors did not have to identify as UiM. All mentors completed a similar application process as the scholars, including essay questions specifically asking about mentorship experience and interests in DEI scholarship.

LEAD is a 10-month longitudinal program that provides residents and fellows with knowledge, leadership training, and mentorship in creating scholarly works around DEI topics.

Academic medicine faculty with expertise in DEI research and curriculum development conceptualized this program. We followed Kern's 6 steps of curriculum development to create the LEAD curriculum. We used recent institutional climate surveys and program leadership feedback as our needs assessment, which enabled us to identify and prioritize a DEI-themed curriculum for trainees and residency program leadership. We completed a literature review in PubMed, MedEdPORTAL, Scopus, and PsycINFO to inform the curricular topics.

This program is based on the conceptual framework of self-determination theory (SDT), which states that feelings of competence, relatedness, and autonomy lead to internal motivation to learn.²⁹  Monthly 2-hour evening sessions are the backbone of this program. The first hour is devoted to interactive, discussion-based sessions on DEI and leadership topics given by content experts recruited from the medical school and Stanford University (“Competence” in SDT; see online supplementary data). The second hour is spent working in mentored small groups, reflecting on the first hour discussion (“Relatedness” in SDT) and then developing workshop presentations, considered scholarship for this program, on DEI topics chosen by the scholars (“Autonomy” in SDT). The longitudinal small groups consist of 5 to 7 scholars and 4 to 5 educational mentors to maximize cross-collaboration across different departments and roles. The LEAD Program culminates in an annual Diversity and Inclusion Forum across the School of Medicine, showcasing the workshops created by the scholars.

All scholars were invited to complete a survey after completion of the LEAD Program (provided as online supplementary data), assessing residents' and fellows' self-reported self-efficacy, actual and planned behavior change, overall satisfaction with the LEAD Program, and demographics. For the self-efficacy questions, we used a retrospective pre-/post-survey design, which allows scholars to reflect on their change in self-efficacy after an educational intervention. Described by Skeff et al, it is considered a stronger way to understand self-efficacy because scholars better understand their changes in self-efficacy once they have gone through the educational program.³⁰  The actual and planned behavior change and program satisfaction questions were open-ended. Scholarly output in the form of workshop presentations and manuscripts was assessed by self-report and then verified from scholars and mentors during and after completion of the LEAD program.

Participation in the study was completely voluntary with no financial compensation provided. All participants gave informed consent to participate. The surveys were de-identified.

Analysis of surveys included descriptive statistics, 2-tailed paired t tests and qualitative analysis. Survey comments were analyzed from 3 open-ended survey questions investigating scholars' self-efficacy, behavior changes scholars had already enacted based on what they learned in LEAD, and scholars' intended behavior change based on participation in LEAD. Two reviewers (C.P., R.B.) hand-coded these answers using conventional content analysis separately, and then met and compared codes line by line, reconciling any differences with a third reviewer (L.Y.).³¹  To measure the impact on scholars' leadership and scholarship capacity, we measured the number of workshops presented at local, regional, and national meetings, publications, and other scholarly works. This measurement of impact is ongoing, self-reported by scholars through annual follow-up emails, and then verified by searching PubMed, MedEdPORTAL, and Scopus databases with no current end date as the LEAD Program is still actively ongoing.

The Institutional Review Board at Stanford University approved this study.

In the first program year (2017–2018), 13 pediatric trainees applied, 13 were accepted, and 13 completed the LEAD Program from the Department of Pediatrics. In the second program year (2018–2019), 28 scholars applied, 28 were accepted, and 25 completed the LEAD Program from 7 clinical departments. In the third program year (2019–2020), 49 scholars applied, 49 were accepted, and 37 completed the LEAD Program from 14 clinical departments. See Table 1 for participant characteristics. Overall, 99% (74 of 75) of LEAD scholars completed the retrospective pre-/post-survey.

In all years, there was statistically significant improvement in scholars' self-efficacy for all LEAD sessions' learning objectives (Table 2).

As of August 2021, scholars have created 15 workshops on various DEI topics (see online supplementary data), representing their small groups. All 3 cohorts have presented at the annual Stanford Medicine Diversity & Inclusion Forum. The first cohort has presented their workshops at 6 local, 3 regional, and 6 national conferences. The second cohort has presented their workshops at 7 local, 1 regional, and 8 national conferences. The third cohort has presented their workshops at 8 local conferences. Of note, all 8 groups in the first 2 cohorts have presented their workshops at a national conference (Figure). Three groups have published in MedEdPORTAL^32–34  and one in a national blog.³⁵ 

All scholars (74 of 74, 100%) felt the LEAD Program should continue and expand to all GME programs at our institution. While the workshop development of the curriculum was key for building DEI-related scholarship and community in small groups, it should be noted that some scholars felt there was an overemphasis on the workshop development process itself.

Importantly, many scholars noted that they were empowered by the LEAD program:

“I always felt I had something to say, but part of me thought my voice shouldn't be so loud. The mentors in this program helped elevate my voice and told me my ideas mattered as much as everyone else's. They helped me have a sense of belonging among a world of accomplished doctors and scholars I once felt distant from. Now, I can see myself tapping into my potential for leadership, and it's exhilarating.”

The LEAD Program has sustained and accepted 67 scholars and 30 mentors for its fourth year (2020–2021) and 69 scholars and 32 mentors for its fifth year (2021–2022) across all GME programs and departments at our institution. The LEAD program operates on a limited budget. In its fourth year, in order to address the minority tax,^19,36  we petitioned to protect the time of the 2 co-directors. See online supplementary data for a sample LEAD Program budget.

Two themes emerged from the open responses. One theme was that scholars identified that the LEAD Program led them to make specific DEI behavior changes and set goals for additional behavior changes. LEAD scholars reported they were more willing to learn and teach peers, colleagues, and patients how to mitigate bias and to promote the “voices” of their colleagues from diverse backgrounds in academic medicine (Table 3). Scholars identified providing effective allyship, sponsorship, and increased intentionality in addressing their own and others' implicit biases as important ways to implement what they had learned. A second theme was that scholars noted that they developed meaningful mentoring relationships during their involvement with the LEAD Program, both with their faculty mentors and with peers in their small groups. This was most evident in the scholars' experiences collaborating to create and present their group's workshop. Scholars identified the greatest benefits of the LEAD Program as mentorship, developing friendships with UiM and ally peers outside of their subspecialty, and confidence in public speaking.

This is the first published institutional GME-wide longitudinal structural support program for both UiM and non-UiM residents and fellows designed to build knowledge, leadership, and DEI-centered scholarship capacity. The LEAD program also provides mentorship to address the structural barriers that impact UiM trainees and empowers all trainees to lead DEI efforts. We found that scholars had an overall increase in their self-efficacy in DEI topics covered within the curriculum and recognized their own agency to implement changes in their training programs through the workshops they developed during the LEAD Program. All scholars were satisfied with the LEAD Program and agreed that this program should expand to all GME programs. Mentorship, networking, developing friendships with peers outside of their subspecialty, and confidence in public speaking were highlighted as strengths of the LEAD Program. The LEAD Program has grown exponentially each year, initially with a cohort of 13 scholars in 2017–2018 to 69 scholars in the 2021–2022 cohort across all GME programs. In addition to building self-efficacy and mentoring relationships, the LEAD Program has developed a community of trained leaders in DEI scholarship.

The LEAD Program's pioneering efforts build on other visionary programs such as the NCS Resident Mentoring Program and BNGAP by adding specific training in how to move forward the DEI mission in academic medicine in a scholarly way.^26,27  As predicted by self-determination theory, scholars who have participated in the LEAD Program identified concrete ways in which they planned to change their own actions and have continued to present their own DEI scholarship across our institution. This demonstrates the potential of developing local GME-wide leadership programs that engage trainees and mentors to be at the forefront of leading institution-level change and improve the culture of academic medicine to value DEI scholarly output.

Though the LEAD Program has many benefits, we recognize that there are challenges to implementing such a large-scale program. The goals of this program had to be balanced with the demands of clinical training and fatigue for scholars, especially across various departments and medical training programs. LEAD requires coordinating curricula and schedules across multiple departments. The scholar and mentor enthusiasm for scholarship dissemination must be balanced with the funding limitations and schedule flexibility to attend monthly sessions in addition to presenting nationally. Since some scholars felt that there was overemphasis on the workshop development in the first cohort, we have been mindful in subsequent cohorts to emphasize that the workshop development is a way of applying leadership and scholarship skills. Furthermore, we could explore other types of capstone projects that would create DEI scholarship opportunities for scholars while leveraging applicable leadership skills.

Institutional engagement and support at the highest levels of leadership are vital to sustaining large scale programs. As noted by the NCS Resident Mentoring Program and BNGAP, we found that scholars need protected educational time and dedicated mentors.^26,27  Mentors were a key part of our instructional design since the literature shows it is important to support trainees in presenting their DEI scholarship and promote the dynamic leadership capacity of residents and fellows who spearhead in this field of research.^37–39  This will enable residents and fellows with support of mentorship to be at the forefront of developing DEI efforts across medical training programs that are strategic in building institutional engagement and capacity for diversity in all aspects of academic medicine.^27,40  Programs like LEAD can foster a sense of belonging for residents and fellows through shared understanding of diverse experiences and building more inclusive communities in academic medicine that have been historically hard to achieve.^41,42  By including allies as well, there is an opportunity to create meaningful culture change.

We recognize in this unprecedented time that tremendous efforts to increase UiM representation through DEI initiatives cannot be meaningfully sustained unless our medical institutions simultaneously recognize and develop new infrastructures to eradicate structural racism embedded within academic medicine that undermines this advancement.^15,43,44  We must develop and empower our next generation of diverse medical leaders now to understand structural inequities. Otherwise, continued inequities will reinforce the “leaky” pipeline⁴⁵  and curtail any progress toward a diversified and accurately representational academic medicine leadership. It is not sufficient to focus only on recruitment without intentional development of inclusive practices, sustained support to develop innovative programs, and metrics to track how success is achieved.^7,39,46,47  The LEAD Program is a framework to address these matters with intentionality, creating a safe space for inclusivity and providing room for curricular adaptation with metrics to tackle our dynamic understanding of DEI-related concepts with tangible strategies.

We recognize that our study has limitations. We conducted our research in a single institution with a self-selected sample. Selection bias may have influenced our results and could limit the generalizability of our findings. To minimize the impact of the biases, we collected perspectives from 99% of LEAD scholars. In addition, our study presents self-reported behavior change and intended behavior change, and future studies should investigate outcomes of changed behavior. Finally, the COVID-19 pandemic may have affected the scholarly output of our third cohort. Despite these limitations, our study offers an important contribution to the existing literature by presenting a novel leadership education program to advance DEI that includes diverse viewpoints from residents and fellows at all levels of training and across multiple subspecialties. Additional studies are needed to measure the long-term benefits of the LEAD Program, including internal motivation, sense of belonging, professional identity formation, and long-term career leadership roles and scholarly output of LEAD scholars.

The LEAD Program is an innovative model for addressing structural barriers to the promotion, inclusion, and retention of UiM trainees by fostering leadership and scholarship capacity in DEI.

The authors would like to thank the LEAD scholars, educational mentors, and alumni for their participation and feedback on the LEAD Program; Dr. Mary Leonard and the Department of Pediatrics, Lucile Packard Children's Hospital, the Office of Diversity in Medical Education, the Office of Faculty Development and Diversity, the Office of Graduate Medical Education, and the Teaching and Mentoring Academy at the Stanford University School of Medicine for their funding and support; and Dr. Natalie Kirilcuk for also serving on the LEAD Steering Committee.