Have you ever done something where you’re not quite sure why you did it at the time, but later on you realize it was part of some larger cosmic purpose, and you go, “Ahhh, now I understand…that’s why!”? Call it a fortuitous coincidence. Or a subconscious act of anticipation. Maybe a little push from God.
Dr. Leslie Flores
Last summer, as SHM’s Practice Analysis Committee was planning the State of Hospital Medicine survey for 2020, we received a request from SHM’s Diversity, Equity & Inclusion (DEI) Special Interest Group (SIG) to include a series of questions related to hospitalist gender, race and ethnic distribution in the new survey. We’ve generally resisted doing things like this because the SoHM is designed to capture data at the group level, not the individual level – and honestly, it’s as much as a lot of groups can do to tell us reliably how many FTEs they have, much less provide details about individual providers. In addition, the survey is already really long, and we are always looking for ways to make it shorter and easier for participants while still collecting the information report users care most about.
But we wanted to take the asks from the DEI SIG seriously, and as we considered their request, we realized that though it wasn’t practical to collect this information for individual hospital medicine group (HMG) members, we could collect it for group leaders. Little did we know last summer that issues of gender and racial diversity and equity would be so front-and-center right now, as we prepare to release the 2020 SoHM Report in early September. Ahhh, now I understand…that’s why – with the prompting of the DEI SIG – we so fortuitously chose to include those questions this year!
Here’s a sneak preview of what we learned. Among SoHM respondents, 57.1% reported that the highest-ranking leader in their HMG is White, and 23.5% of highest-ranking leaders are Asian. Only 5.5% of HMG leaders were Black/African American. Ethnicity was a separate question, and only 2.2% of HMG leaders were reported as Hispanic/Latino.
I have been profoundly moved by the wretched deaths of George Floyd and other people of color at the hands of police in recent months, and by the subsequent protests and our growing national reckoning over issues of racial equity and justice. In my efforts to understand more about race in America, I have been challenged by my friend Ryan Brown, MD, specialty medical director for hospital medicine with Atrium Health in Charlotte, N.C., and others to go beyond just learning about these issues. I want to use my voice to advocate for change, and my actions to participate in effecting change, within the context of my sphere of influence.
So, what does that have to do with the SoHM data on HMG leader demographics? Well, it’s clear that Black and brown people are woefully underrepresented in the ranks of hospital medicine leadership.
Unfortunately, we don’t have good information on racial diversity for hospitalists as a specialty, though I understand that SHM is working on plans to update membership profiles to begin collecting this information. In searching the Internet, I found a 2018 paper from the Journal of Health Care for the Poor and Underserved that studied racial and ethnic distribution of U.S. primary care physicians (doi: 10.1353/hpu.2018.0036). It reported that, in 2012, 7.8% of general internists were Black, along with 5.8% of family medicine/general practice physicians and 6.8% of pediatricians. A separate data set issued by the Association of American Medical Colleges reported that, in 2019, 6.4% of all actively practicing general internal medicine doctors were Black (5.5% of male IM physicians and 7.9% of female IM physicians). While this doesn’t mean hospitalists have the same racial and ethnic distribution, this is probably the best proxy we can come up with.
At first glance, having 5.5% of HMG leaders who are Black doesn’t seem terribly out of line with the reported range of 6.4 to 7.8% in the general population of internal medicine physicians (apologies to the family medicine and pediatric hospitalists reading this, but I’ll confine my discussion to internists for ease and brevity, since they represent the vast majority of the nation’s hospitalists). But do the math. It means Black hospitalists are likely underrepresented in HMG leadership ranks by something like 14% to 29% compared to their likely presence among hospitalists in general.
The real problem, of course, is that according the U.S. Census Bureau, 13.4% of the U.S. population is Black. So even if the racial distribution of HMG leaders catches up to the general hospitalist population, hospital medicine is still woefully underrepresenting the racial and ethnic distribution of our patient population.
The disconnect between the ethnic distribution of HMG leaders vs. hospitalists (based on general internal medicine distribution) is even more pronounced for Latinos. The JHCPU paper reported that, in 2012, 5.6% of general internists were Hispanic. The AAMC data set reported 5.8% of IM doctors were Hispanic/Latino. But only 2.2% of SoHM respondent HMGs reported a Hispanic/Latino leader, which means Latinos are underrepresented by somewhere around 61% or so relative to the likely hospitalist population, and by a whole lot more considering the fact that Latinos make up about 18.5% of the U.S. population.
I’m not saying that a White or Asian doctor can’t provide skilled, compassionate care to a Black or Latino patient, or vice-versa. It happens every day. I guess what I am saying is that we as a country and in the medical profession need to do a better job of creating pathways and promoting careers in medicine for people of color. A JAMA paper from 2019 reported that while the numbers and proportions of minority medical school matriculants has slowly been increasing from 2002 to 2017, the rate of increase was “slower than their age-matched counterparts in the U.S. population, resulting in increased underrepresentation” (doi:10.1001/jamanetworkopen.2019.10490). This means we’re falling behind, not catching up.
We need to make sure that people like Dr. Ryan Brown aren’t discouraged from pursuing medicine by teachers or school counselors because of their skin color or accent, or their gender or sexual orientation. And among those who become doctors, we need to promote hospital medicine as a desirable specialty for people of color and actively invite them in.
In my view, much of this starts with creating more and better paths to leadership within hospital medicine for people of color. Hospital medicine group leaders wield enormous – and increasing – influence, not only within their HMGs and within SHM, but within their institutions and health care systems. We need their voices and their influence to promote diversity within their groups, their institutions, within hospital medicine, and within medicine and the U.S. health care system more broadly.
The Society of Hospital Medicine is already taking steps to promote diversity, equity and inclusion. These include issuing a formal Diversity and Inclusion Statement, creating the DEI SIG, and the recent formation of a Board-designated DEI task force charged with making recommendations to promote DEI within SHM and in hospital medicine more broadly. But I want to challenge SHM to do more, particularly with regard to promoting diversity in leadership. Here are a few ideas to consider:
- Create and sponsor a mentoring program in which hospitalists volunteer to mentor minority junior high and high school students and help them prepare to pursue a career in medicine.
- Develop a formal, structured advocacy or collaboration effort with organizations like AAMC and the Accreditation Council for Graduate Medical Education designed to promote meaningful increases in the proportion of medical school students and residents who are people of color, and in the proportion who choose primary care – and ultimately, hospital medicine.
- Work hard to collect reliable racial, ethnic and gender information about SHM members and consider collaborating with MGMA to incorporate demographic questions into its survey tool for individual hospitalist compensation and productivity data. Challenge us on the Practice Analysis Committee who are responsible for the SoHM survey to continue surveying leadership demographics, and to consider how we can expand our collection of DEI information in 2022.
- Undertake a public relations campaign to highlight to health systems and other employers the under-representation of Black and Latino hospitalists in leadership positions, and to promote conscious efforts to increase those ranks.
- Create scholarships for hospitalists from underrepresented racial and ethnic groups to attend SHM-sponsored leadership development programs such as Leadership Academy, Academic Hospitalist Academy, and Quality and Safety Educators Academy, with the goal of increasing their ranks in positions of influence throughout healthcare. A scholarship program might even include raising funds to help minority hospitalists pursue Master’s-level programs such as an MBA, MHA, or MMM.
- Develop an educational track, mentoring program, or other support initiative for early-career hospitalist leaders and those interested in developing leadership skills, and ensure it gives specific attention to strategies for increasing the proportion of hospitalists of color in leadership positions.
- Review and revise existing SHM documents such as The Key Principles and Characteristics of an Effective Hospital Medicine Group, the Core Competencies in Hospital Medicine, and various white papers and position statements to ensure they address diversity, equity and inclusion – both with regard to the hospital medicine workforce and leadership, and with regard to patient care and eliminating health disparities.
I’m sure there are plenty of other similar actions we can take that I haven’t thought of. But we need to start the conversation about concrete steps our Society, and the medical specialty we represent, can take to foster real change. And then, we need to follow our words up with actions.
Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Conference Committees and helps to coordinate SHM’s biannual State of Hospital Medicine survey.
