Historically, the field of otolaryngology has been one of the least diverse subspecialties in medicine. Regarding ethnicity, for example, a 2022 workforce study from the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) showed that only 6% of residents were Black, 4% were Hispanic, and 1% were Native American and Pacific Islander. Of practicing physicians, 2.5% were Black, 3% to 4% were Hispanic, and fewer than 1% were Native American and Pacific Islander (Ear Nose Throat J. 2021. doi:10.1177/0145561320922633).
Explore This IssueNovember 2023
Despite the status quo, overwhelming evidence supports the benefits of a diverse workforce. Diversification increases high-quality outcomes, strengthens teams, and promotes health equity, said Mariel Watkins, MD, MHS, house officer in the department of otolaryngology–head and neck surgery at the University of Michigan Health System in Ann Arbor. It isn’t just opinion: Data have shown that a provider population that represents its patient population leads to improved patient outcomes and access to quality care (Ann Intern Med. 2023. doi:10.7326/0003-4819-139-11-200312020-00009).
Furthermore, the visibility of diverse and inclusive academic settings increases psychological safety and camaraderie among faculty and learners. Increased race and gender representation has a summative effect on the success and innovation of ideas, given that they are derived from myriad lived experiences (The Diversity Bonus: How Great Teams Pay Off in the Knowledge Economy. 2018. Princeton University Press; J Manag Stud. 2009. doi:10.1111/j.1467-6486.2009.00839.x).
Given all of these benefits, many schools of medicine have been focusing efforts on diversity, equity, and inclusion (DEI) initiatives. Their goal is to increase recruitment, retention, and career advancement for colleagues from underrepresented groups in the otolaryngology field; to work toward a specialty that reflects patients in as many aspects of identity as possible; and to create a specialty that provides a sense of belonging in any colleague or interested trainee, regardless of their unique combination of identities, said Karthik Balakrishnan, MD, MPH, associate professor in the department of otolaryngology–head and neck surgery and surgeon-in-chief at Stanford Children’s Health in Palo Alto, Calif.
It’s important to note, added Candace A. Flagg, MD, a resident in the department of otolaryngology–head and neck surgery at Brooke Army Medical Center in San Antonio, Texas, that the purpose of DEI efforts is to give merit where merit is due. “DEI isn’t meant to encourage schools and programs to accept sub-qualified applicants in favor of race, gender, ethnicity, and so forth,” she said. “Rather, the point is to open the door and give opportunities to deserving individuals who otherwise would have been passed over.”
Origins of DEI Initiatives
The impetus for DEI efforts can be traced back to systemic inequalities, lack of representation, and the need to address injustices and discrimination, said Michael J. Brenner, MD, an associate professor in the department of otolaryngology–head and neck surgery at the University of Michigan in Ann Arbor. The civil rights movement in the United States, from the mid-1950s to late 1960s, prompted conversations about the need to address health disparities and inequities. Health disparities are closely linked to social determinants of health, which include economic stability, education access and quality, healthcare access and quality, social and community context, and neighborhood and built environment.
Recent national movements have also energized DEI efforts, including the Black Lives Matter movement that began in 2013, the gender equity and inclusion movement that gained momentum with #metoo in 2017, George Floyd’s murder in May 2020, and increased awareness of anti-LGBTQ+ bias (e.g., homophobia, transphobia), along with national discussions on marriage equality and gender-affirming education and medical care, Dr. Balakrishnan said.
Over the last 15 years, otolaryngology has made increasing investments in diversity. AAO-HNS created a diversity task force in 2007, which became a permanent committee in 2008. The committee was charged with educating and promoting diversity and inclusion, as well as promoting cultural sensitivity. Many other otolaryngology organizations have also increased their efforts to promote diversity, establishing committees and mentorship programs and providing financial support for away rotations or to attend meetings, said Valerie Flanary, MD, a professor of otolaryngology and human communication sciences and director of racial equity and inclusion in the Office of Diversity and Inclusion at the Medical College of Wisconsin in Milwaukee.
In 2018, The Accreditation Council for Graduate Medical Education (ACGME) formed a planning committee to assess the state of diversity and inclusion in graduate medical education (J Manag Stud. 2009. doi:10.1111/j.1467-6486.2009.00839.x). In 2019, the ACGME Office of Diversity and Inclusion was established, mandating that programs ‘‘engage in practices that focus on mission-driven, ongoing, systematic recruitment and retention of a diverse and inclusive workforce” (J Grad Med Educ. 2019. doi:10.4300/JGME-D-19-00760.1).
Some medical institutions have started their own initiatives. For example, from 2004 to 2014, The Johns Hopkins University School of Medicine in Baltimore implemented a 10-year diversity initiative to increase the number of women and underrepresented minorities (URMs) in the otolaryngology department, Dr. Watkins said. This resulted in a nearly five-fold increase in women clinical faculty, and an increase in URM faculty from two to four and URM full professors from zero to one (Laryngoscope. 2016. doi:10.1002/lary.25455).
Additionally, the University of Michigan Health System has a longstanding history of training a majority of Black otolaryngology residents in the United States, Dr. Watkins said. In recent years, women have been represented as a majority in its residency program.
Challenges to DEI Initiatives
Even with these efforts, several obstacles have hindered DEI initiatives in medical education. Most recently, on June 29, the U.S. Supreme Court (SCOTUS) voted 6–3 to end the use of affirmative action in college admissions. The justices ruled that admissions programs used by the University of North Carolina and Harvard College violated the U.S. Constitution’s equal protection clause, which prohibits racial discrimination by government entities.
That same day, the Association of American Medical Colleges (AAMC) issued a statement expressing its disappointment in SCOTUS’ decision. “Today’s decision demonstrates a lack of understanding of the critical benefits of racial and ethnic diversity in educational settings and a failure to recognize the urgent need to address health inequities in our country,” the association stated in a news release.
The AAMC subsequently filed an amicus brief urging the court to refrain from a broad prohibition on awareness of an applicant’s race. It stated, “Diversity in the education of the nation’s physicians and other healthcare professionals is a medical imperative. As an overwhelming body of scientific research compiled over decades confirms, diversity [J Health Soc Behav. 2008. doi:10.1177/002214650804900401] literally saves lives by ensuring that the nation’s increasingly diverse population will be served by healthcare professionals competent to meet its needs.”
AAMC’s brief went on to state that “research confirms that being treated by a racially diverse care team, or by doctors with exposure to diverse professional or educational environments, greatly increases the likelihood of positive medical outcomes, particularly for minority patients.” AAMC was joined in the brief by 45 other healthcare organizations interested in the issues.
As a result of SCOTUS’ decision, Dr. Flanary said that many educational programs that address race in any form are being examined, reworked, and, in some cases, dismantled as their legality is challenged. “DEI efforts may need to be reframed into efforts that address health disparities, acknowledge the existence of systemic barriers, and use metrics to demonstrate the impact diverse providers have on the health of disparate populations,” she said.
Other challenges to implementing DEI can arise from competing priorities and resistance to change. “Creating a just society isn’t simple; if it were, we would already live in one,” said Romaine F. Johnson, MD, MPH, a professor in the department of otolaryngology–head and neck surgery at UT Southwestern Medical Center in Dallas. “Inequities often subtly emerge or are deliberately instituted,” he said. “Even institutions with good intentions can face significant challenges that divert their focus, making strong commitments to DEI challenging.”
Resistance is frequently rooted in psychological threats to established groups. “Individuals in majority or in-groups may feel that DEI initiatives diminish their achievements, fearing a scenario where they believe less qualified individuals gain influence,” Dr. Johnson said. “Confronting the possibility that one’s success might be intertwined with an unjust system can also be morally unsettling, further fueling the perceived threat.”
To navigate these challenges, continuous advocacy is essential to cement DEI as a priority, on par with other crucial aspects of healthcare delivery and professional education, he added.
Another significant barrier to wide adoption of DEI initiatives is what has been dubbed the “minority tax,” “cultural tax,” or “diversity tax,” referring to the extra burden or workload that individuals from underrepresented or marginalized groups often experience in professional and academic settings, Dr. Brenner said. Academic medical centers often ask faculty to volunteer for DEI efforts, including committee work, events, recruitment, mentoring, or administrative roles.
“Oftentimes, these efforts aren’t valued commensurately with traditional metrics of academic success,” Dr. Brenner noted. “Such efforts may go unrecognized, unrewarded, and/or uncompensated.”
Another obstacle is a lack of funding—initiatives often require specific funding to ensure success and longevity, and sustaining enthusiasm can also be challenging. “Unfortunately, especially in settings where resources are limited and numerous competing demands exist, DEI initiatives may not be prioritized,” said Jennifer A. Villwock, MD, an associate professor of otolaryngology–head and neck surgery at University of Kansas Medical Center in Kansas City, Kan.
Slow but Steady Progress
While DEI initiatives have been broadly adopted, the strength and intentionality of efforts vary. A 2018 diversity survey (Otolaryngol Head Neck Surg. 2018. doi:10.1177/0194599818770614) distributed among otolaryngology programs showed that most programs reported interviewing at least four URM applicants each year; however, over one-third reported having no or only one URM resident matriculate into their program within the previous 15 years, said Sarah N. Bowe, MD, EdM, program director of otolaryngology at San Antonio Uniformed Services Health Education Consortium, Joint Base San Antonio–Ft. Sam Houston in Texas. Furthermore, most programs reported having no or only one URM faculty.
In graduate medical education and AAMC data, trends in representation vary across races and genders. Limited data are available on international medical graduates, first generation, low-income, LGBTQ+, and able-status populations in the otolaryngology workforce, Dr. Watkins said.
Women have had a significant increase in representation within the OHNS workforce (Otolaryngol Clin North Am. 2020. doi:10.1016/j.otc.2020.05.016), but they remain disproportionately underrepresented in otolaryngology residency and fellowship leadership positions, across professorship levels, and among major otolaryngology editorial boards (Laryngoscope. 2021. doi:10.1002/lary.28958).
Between 1990 and 2016, there were significant trends toward underrepresentation of Hispanic males, Hispanic females, and Black females at the associate and full professor levels (Laryngoscope. 2021. doi:10.1002/lary.28958). “Overall, while representation is increasing, it will take time for the demographics of the otolaryngology workforce to reflect the U.S. population,” Dr. Watkins said.
Regarding diversity in leadership, Dr. Flanary has seen some organizations become much more diverse. In the past decade, some otolaryngology organizations have elected their first Black presidents, board members, and other representatives. There has only been a small increase in the number of diversified otolaryngology department chairs, however, and residency DEI numbers have been stagnant.
More to Do
In order for DEI initiatives to be widely adopted, it’s necessary to study the dissemination and implementation of current initiatives, their effectiveness, and their cultural adaptability (Dissemination and Implementation Research in Health: Translating Science to Practice. 2017. Oxford University Press). “Consistent efforts to create equitable policies and systems that combat our country’s predilection toward systemic racism is a significant factor in the overall effectiveness of DEI initiatives,” Dr. Watkins said.
Allyship can play a critical role in advancing DEI initiatives in medical education, complementing and enhancing mentoring, coaching, and sponsorship efforts, Dr. Brenner added. Allies advocate and work for the inclusion of historically marginalized or underrepresented individuals to overcome inequities. Allies can also help lift others by promoting a sense of belonging within groups and programs or speaking up for patients, students, and colleagues. Allyship in otolaryngology entails confronting unconscious biases, promoting open dialogue, engaging in self-reflection, and assessing and changing policies that perpetuate underrepresentation in residency and fellowship programs.
When looking to promote DEI, Dr. Flagg says, seeing is believing. “When applicants physically see other women or other people of color in the positions they want to attain, they go after it [themselves]. This idea is simple but powerful—diversity begets more diversity.
“If residency programs intentionally seek highly qualified women or underrepresented minority applicants, they’ll probably accept some,” Dr. Flagg continues. “And once a critical mass of minority individuals is reached in a program, diversity will continue naturally because that program will be attractive to more [diverse] applicants.”
None of this is a theoretical excercise: By the year 2060, Black, indigenous, and people of color are expected to comprise most of the U.S. population (Demographic Turning Points for the United States: Population Projections for 2020 to 2060. Vol. P25-1144. U.S. Census Bureau).
“Continued efforts will continue to create an otolaryngology workforce that mirrors the population it serves, and mentorship will be necessary to ensure that otolaryngology as a medical specialty continues to evolve to be in line with the future of the U.S. population,” Dr. Watkins concluded.
Karen Appold is a freelance medical writer based in San Diego, Calif.