In the face of threats to <scp>DEI</scp>, investments in women and Underrepresented in Medicine leaders are needed more than ever

In March, Representatives Brad Wenstrup and Greg Murphy, both doctors, introduced congressional legislation to ban race-based mandates at American medical schools. The authors of the bill argue that this legislation “keeps our nation's future doctors focused on caring for patients.” This follows multiple state-based efforts to ban diversity, equity, and inclusion (DEI) initiatives at public institutions. As of May, there have been nine states with such bans with 30 bills currently in the works for consideration. While most of these bills are aimed at race-based initiatives, in some cases gender-related programs have been targeted as well. These efforts imply that DEI initiatives that focus on efforts to advance Black, Indigenous, and other people of color (BIPOC) and women distract medical schools from their mission. The benefits of efforts to increase racial and gender diversity in medical schools and the educational pipelines that feed them go beyond reflections in the student body. Patients tend to have higher satisfaction and better preventive care when treated by racial- and gender-concordant providers. Underrepresented in medicine (URIM) individuals are more likely to serve medically underserved communities in the United States.1 Initiatives that do not result in meaningful change can often lead to the opposite of the intended effect. DEI efforts that focus on checkbox initiatives such as brief limited training sessions rather than real change at organizations can result in performative diversity fatigue. In the aftermath of George Floyd's death, many medical institutions committed to increase DEI related activities, with the number of DEI staff increasing from 75% to 96% from 2018 to 2021. Despite this, DEI leaders have noted that they face multiple challenges at their institutions. Diversity efforts are often siloed and not integrated into broader medical school initiatives.2 Medical schools with diversity in their mission statements have seen increases in URIM students; however, these increases have been very modest.3 Such efforts are often not supported by a sufficient infrastructure or are left to be done by the work of a few faculty from URIM backgrounds.2 While expanding the number of chief equity officers is admirable, often these candidates are overlooked for key leadership positions that are authorized to make a difference in overall diversity efforts. It is important to consider URIM candidates for other leadership positions or appropriately empower chief equity officers. We should use such impending legislation as a wake-up call to reflect on what medical schools can do to continue to promote the recruitment and retention of URIM and women emergency physicians in academic medicine. A 2022 Association of American Medical Colleges report showed that despite all schools surveyed having admission policies designed to support a diverse pool of medical students in their class only 63% have a formalized plan to recruit faculty of color and women faculty and only 44% consider faculty service related to DEI efforts in promotion efforts.4 This is reflected in the paucity of URIM and women at the upper echelons of medical school leadership. While women made up 44% of clinical faculty in 2023, they represented just over a quarter of all medical school deans of any type.5 In emergency medicine, less than 16% of all chairs are women.5 Just four of these women chairs are Black or Hispanic.5 In fact, the percentage of women and URIM in EM leadership roles was stagnate from 2015 to 2020.6 The number of EM chairs who are women and URIM are much lower than in other fields, such as family medicine, in which 29% of chairs are women and 17% are URIM.7 Twenty percent of surgery chairs are women but none are URIM.8 Those women in surgery leadership roles are more likely to be in positions that presently do not lead to further career advancement, such as vice chair of DEI or of faculty affairs.8 The causes of this are multifactorial. In a recent survey of emergency medicine chair positions, male chairs were found to be more likely to consider themselves on the path to leadership early in their careers; women were more likely to consider the job to make a positive change for a department struggling with challenges.6 Often applicants of color and women are discouraged from applying to positions due to both internal and external forces. Some women and URIM individuals who could be potential leaders may convince themselves that they do not have enough qualifications to obtain the position. The “imposter syndrome” affects women more than men in academic medicine.8 Externally women and URIM faculty may have hurdles such as lack of sponsorship. Sponsorship is different from mentorship and is particularly important as a means of gaining access to positions of leadership. In sponsorship, individuals in positions of power actively put forth and vouch for an individual for specific leadership position. Female chairs in emergency medicine note that they are less likely to have benefited from sponsorship opportunities compared to male colleagues.9 Few senior faculty get training on what sponsorship is and how to accomplish it. Such lack of career opportunities can contribute to burnout and ultimately attrition for women and URIM faculty. According to the Workplace Change Collaborative, a Health and Human Services–funded initiative, this perception of inequity in the health care workforce and lack of opportunities for advancement are core drivers of burnout and moral injury. We cannot expect to encourage URIM and women providers to thrive without concrete efforts to enhance their work. DEI efforts are more important now than ever, but they must be intentional and effective. Medical school deans, EM chairs, and program directors should strengthen efforts to recruit women and URIM faculty and residents and provide a supportive environment that allows them to flourish and feel valued. This includes opportunities such as cluster hiring, peer mentorship, and sponsorship. Cluster hiring, the process of simultaneously hiring individuals of shared research interests or backgrounds, facilitates the community-building process and can reduce isolation and burnout. One of the biggest ways to encourage diversity, however, is by promoting diversity in leadership positions. There should be dedicated efforts to recruit more URIM and women as deans, chairs, and program directors. Candidates cannot be expected to succeed at securing these positions without mentorship and support. Leadership training opportunities for women and URIM faculty must be presented early in their career. This includes working with them to set career goals, providing coaching experiences, establishing mentorship teams, promoting leadership training, and offering sponsorship opportunities.10 Deans and chairs should also recognize and reward activities that are traditionally championed by URIM faculty and women, such as DEI recruitment efforts, faculty development, and resident and student education. Often faculty are expected to participate in such activities without compensation or recognition. Instead, such work should be considered an asset in consideration for leadership and promotion opportunities. By investing in leaders of color and women, we ensure better education for our residents, a more diverse emergency medicine workforce, and better care for all of our patients for years to come. The authors declare no conflicts of interest.