Implementing Systematic Culture Change to Improve Diversity in Graduate Medical Education

Diversity, equity, inclusion, and justice (DEIJ) are all pivotal elements in bettering our world. Yet, we have insufficiently understood the impact of these elements in health care and sparsely identified ways to prioritize them for eliminating health care disparities. As physicians and educators, we can no longer accept the status quo. Yet graduate medical education (GME) is embedded within sponsoring institutions (SIs), is challenged by funding limitations, and often struggles with recruitment and retention of diverse faculty and trainees. The task may seem insurmountable, and we may stagger along the way, but to transcend the existing barriers we must collaborate. We must persevere, identify solutions, and utilize metrics to restructure our organizations and change behaviors. This Rip Out summarizes critical steps in leading a systematic culture change to improve DEIJ in medicine.

The reasons to address diversity in GME are clear: diversifying the health care workforce promotes more culturally responsive care, improves access to high-quality health care for underserved populations, and broadens research agendas, all components necessary to eliminate health care disparities. While some in GME see recruitment as a medical school issue, the culture of a GME program and its SI can have a strong influence on whether applicants, be they medical students or faculty, apply, interview, and accept a position. The GME community can be leaders in creating an inclusive DEIJ culture.

Changing culture is a time-consuming, arduous, iterative process with each step of a change cycle resulting in progress toward achieving the aim. Yet culture is an amorphous concept that involves the intersection of individuals and their identities with the shared values and assumptions of those in a workplace or profession and the evolving practices.¹ There are numerous change models available (eg, Kotter, ADKAR, Lewin, balanced scorecard, Gantt charts) based on policies, needs, values, and identities of individuals in one's organization, each rooted in a perspective (organization, identity, practice).^1,2 Typically these models outline a stepwise sequence and have common elements: assessing the opportunity or problem motivating the change; creating a guiding change coalition and formulating and communicating a clear, transparent, and compelling vision of the change to empower others to act; identifying short-term wins to reinforce the change process; and monitoring (at individual, program, SI levels) and strengthening the change process over time toward institutionalization of the change.² Skills in leadership, negotiation, collaboration, and conflict resolution combined with persistence, agility, tenacity, and sometimes a “thick” coat are required elements, as detractors may seek to disrupt progress in achieving DEIJ in GME.

Kotter's 8-step model for organizational culture change³ has been utilized in its original form or an adapted version to transform businesses and health organizations alike and has been adapted to frame what GME faculty and leaders can do now as action steps.

Culture change is not easy. It requires continuous investment and engagement. What factors can promote sustainability of DEIJ change in GME?

1. Integration. Wherever possible, integrate the work into existing practices. Incorporate at least one DEIJ-related program improvement goal into the annual program evaluation processes to frame the work and accountabilities in a context known to GME educators. Embed DEIJ efforts into the annual performance evaluations of faculty promotion and tenure processes. Include specific elements of cultural competence and cultural humility into trainee assessments, such as identifying and addressing biases that impact clinical decision-making and respectfully participating in efforts to address and eliminate health care disparities.

2. Sustainability. Identify what resources were required during your change cycles for effective implementation and assessment of outcomes. Identify the expertise(s), skills, and time needed to form a plan and budget accordingly. Do you need to contract with experts in diversity data tracking, policy writing, or with content experts in DEIJ and health? Investing deliberate time and effort will promote sustainability of this community.

3. Internal Team Building. Identify allies who can become a community of support and transformation from within and beyond your institution. Identify, reach out, and include as local resources people at your institution with shared goals within GME and across the continuum of medical and health professions education. Ensure that non-DEIJ members invite DEIJ leaders to the team.

4. External Team Building. Explore your discipline's professional organizations and national medical education and health organizations for discussions, committees, and available educational products (curricula, workshops) focused on DEIJ work.

5. Contribution to National Change. Enter discussions in addressing accreditation standards, GME funding, and policies to include issues related to historically marginalized communities and the effect on the health of those communities.

1. Stouten J, Rousseau DM, De Cremer D. Successful organizational change: integrating the management practice and scholarly literatures. Acad Manag Ann. 2018;12(2):752-788. doi:https://doi.org/10.5465/annals.2016.0095

2. Watling CJ, Ajjawi R, Bearman M. Approaching culture in medical education: three perspectives. Med Educ. 2020;54(4):289-295. doi:https://doi.org/10.1111/medu.14037

3. Kotter. The 8-step process for leading change. Accessed January 26, 2022. https://www.kotterinc.com/8-step-process-for-leading-change/