Introduction

Diversity, equity, and inclusion (DEI) efforts at academic medical centers (AMCs) started prior to 2020, but significantly increased after the death of George Floyd, which resulted in protests and a call for racial justice in the United States. The Centers for Medicare and Medicaid Services defines diversity as characteristics and experiences that make everyone unique, while equity ensures that everyone has fair access to opportunity and experiences, and inclusion aims to make all feel welcomed, valued, and supported (Centers for Medicare & Medicaid Services, 2022). Many AMCs committed and recommitted their support for DEI with displays of statements on their organizations’ websites and social media accounts. The statements were followed by an increasing number of DEI task forces, committees, and postings for executive and senior-level DEI positions—all charged with the goal of improving DEI within institutions (Sotto-Santiago et al., 2021). As discourse amplified, so did the realization that diversity statements may be laden with hollow messages and influenced by isomorphism, or the pressures placed on an organization to mimic the actions of peers (Carnes et al., 2019; Sotto-Santiago et al., 2021). Despite institutions’ public commitment to DEI and anti-racism, there was evidence that AMCs were not truly invested in this work, such as stories that surfaced about mistreatment of minoritized faculty (Blackstock, 2020; Thompson & Lozano, 2021). For this reason, institutions must not only craft statements that decry racism, but also must move beyond their words and follow through with actions to create more diverse, equitable, inclusive, and anti-racist environments. Here, we assert that, for institutions to truly show their commitment, a transparent, continuous, and robust financial investment must be made. This financial investment should focus on (1) advocacy efforts for programs that will contribute to DEI in health, (2) pipeline programs to support and guide minoritized students to enter health professions, and (3) the recruitment and retention of minoritized faculty. While the landscape of DEI work in AMCs can take many forms beyond what is explored here, financial investment represents an important component of a comprehensive approach.

AMCs as Advocates for Increased Funding

Due to budgetary restrictions and complex financing within AMCs, it is often necessary to obtain dedicated funding for individual programs. AMCs are mostly funded by three entities—faculty practice plans and affiliate hospitals, medical schools, and tax appropriations for public institutions (Reuter, 1997). Medicare and Medicaid finance up to fifty percent of patient care revenue for AMCs, and additional Medicare funds are provided for graduate medical education (GME) training of residents and fellows (Association of American Medical Colleges & Task Force on Graduate Medical Education, 2019; Grover et al., 2014). The financing of AMCs is unique in two ways. First, although AMCs account for only five percent of hospitals in the United States, they provide almost 40% of charity care or free medical treatment for people otherwise unable to pay, and 26% of Medicaid hospitalizations (Grover et al., 2014). Second, although Medicare finances a sizable portion of GME, funding allotments were based on the number of residents and fellows from 1996 and were not increased until 2020 (Association of American Medical Colleges, 2020). AMCs have to supplement the additional funding for GME, charity care, and other activities like research within their budgets, which may make it difficult to allocate additional funds to activities focused on DEI (Grover et al., 2014). Thus, it is crucial for AMCs to leverage their resources to advocate for additional monies from government, private, and philanthropic sources, as well as money from their own budget. AMCs can achieve this by ensuring there are roles dedicated to advocacy within the institution and empowering their healthcare workforce to serve as advocates.

Healthcare advocacy can be defined as an “action by a physician [or other healthcare professional] to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being” (Earnest et al., 2010). Healthcare workers (HCWs) are well positioned to promote changes that would improve DEI in healthcare through advocacy. In particular, given their direct interface with the healthcare system and the community, physicians, clinical psychologists, nurses, and other HCWs hold a vast amount of knowledge and experiences that could impact policies and expand access to funding for DEI activities in AMCs. AMCs can encourage HCW advocacy by recognizing it as scholarly work for faculty promotion and other incentives, which has already been proposed and outlined in the literature (Jindal et al., 2020; Nerlinger et al., 2018). Institutions can also provide protected time for faculty to meet with policy makers, to serve on advisory boards or medical societies, and to provide advocacy education to students or trainees (Dharamsi et al., 2011; Landers & Sehgal, 2000; Louisias et al., 2022). HCWs can make a significant impact via avenues such as becoming involved with professional associations, becoming a school board advisor, or writing opinion pieces for newspapers and online media sites (Earnest et al., 2010; Fernandez Lynch et al., 2020). Given time and work constraints, HCWs may be limited in their ability to consistently advocate; however, there have been major healthcare policy successes in the past from advocacy led by HCWs.

A popular example of advocacy to impact is the work done by Dr. Mona Hanna-Attisha, who in 2015 published an article analyzing blood lead levels in children living in Flint, Michigan before and after the source of drinking water changed in the city (Hanna-Attisha et al., 2016). Her findings suggested that the water source change caused a marked rise in elevated blood lead levels among local children. This prompted her strong advocacy efforts, which included holding a press release, reaching out to news stations, writing opinion pieces, contacting government officials, and testifying before Congress. These efforts were crucial in getting the attention of the United States Environmental Protection Agency, which provided a grant to help improve Flint’s drinking water and helped the state pass legislation enforcing stricter interrogation and mitigation of the drinking water (Whitmer, 2021). Similarly, HCWs at AMCs should be encouraged to advocate for funding that could be used for DEI work.

In addition to encouraging HCWs to be advocates, AMCs as entities, including their administrators, need to be strong advocates for changes that would maximize funding for this work. Although money will not fix every issue, major and rapid changes can occur when tied to policy enforced by funding. This was seen in the 1960s after the passage of the Civil Rights Act of 1964. Title VI of the Act prohibited federal government funds to institutions that discriminated against people on the basis of race, creed, and national origin, which included institutions that were still segregated. Prior to the implementation of the Act, only 83% of hospitals in the North offered integrated patient care, while 6% of hospitals in the South did. After two years of enforcing the Act, 85% of hospitals in the country were compliant with Title VI, meaning they were providing integrated care and purported to not discriminate based on race, creed, and nationality (Reynolds, 1997). These changes occurred so quickly because these institutions could otherwise not receive funds from the federal government, which includes Medicare. Rapid change and advancement of work promoting DEI would manifest if AMCs, who are heavily funded by government sources and foundations, supported and advocated for policy changes that tied the elimination of discriminatory behaviors and DEI metrics and outcomes more closely to funding.

AMC’s Financial Commitment to Increasing the Pipeline

DEI efforts in the workplace started in the 1960s and were prompted by the influx of anti-discrimination legislation that passed during that time. Since then, research has shown that a more diverse workforce enhances a company’s productivity (Saxena, 2014). More recently, reports have shown a positive correlation between increasing gender and racial diversity among executives and a company’s operating profitability (Hunt et al., 2018). Likewise, research in clinical medicine reveals that increased diversity, which more easily allows for patient-physician racial and gender concordance, can increase preventive screening and health care utilization among minorities and women and improve Black infant mortality rates (Alsan et al., 2019; Greenwood et al., 2020; LaVeist et al., 2003). Despite evidence of the benefits of a diverse workforce, diversity among practicing healthcare providers continues to lag, making the need for DEI efforts imperative.

From 1997 to 2017, the percent of medical school matriculants from underrepresented groups (American Indians or Alaska Natives, Blacks, and Hispanics or Latinos) decreased 16 percent compared to the number of first-year medical school slots (Talamantes et al., 2019). This trend remains as trainees move up the academic ranks, with 64.4% of faculty positions held by White males, compared to 2.7% of positions held by Black males and 3.3% held by Hispanic males in 2021 (Association of American Medical Colleges, 2021). Given that many AMCs are in underserved and minoritized areas, they have an opportunity to leverage the communities’ strengths, along with their infrastructure and financial resources to develop and strengthen their programs to improve the diversity in the healthcare workforce (Lale et al., 2010).

Pipeline programs, including pre-professional and enrichment programs, aim to target students prior to medical (or other health professional) school to increase interest in the health care field and provide mentorship and guidance (Smith et al., 2009a). Most pipeline programs are funded by the federal government and foundations, with lower levels of financial contributions originating from institutions (Health Resources & Services Administration, 2018; US Department of Health & Human Services, 2009). Institutions that receive funding from external sources are more likely to have established pipeline programs even after the funding period is over; however, without institutional contribution, the programs are only sustainable for a short time (Association of American Medical Colleges Public-School/Health-Professional School Partnerships National Program Office, 2004; Terrell, 2006). A financial investment into these programs from AMCs could be used to hire dedicated staff to run programs that expose minoritized students to various healthcare fields, and provide stipend support for students to carry out research projects or participate in mentorship programs led by HCWs in different fields (Smith et al., 2009a, 2009b; Taylor, 2018). An ongoing financial investment could support data collection and analysis to assess the impact of these programs. Programs that have a positive impact, such as showing students from disadvantaged backgrounds successfully go on to pursue a clinical career, and even return back to the AMC to work, could increase the likelihood of sustainable funding from internal and external sources. AMC’s financial commitment into pipeline programs would help demonstrate the institution's commitment to DEI, which could be discussed as a community benefit and also may be attractive to current and prospective minoritized faculty and staff.

AMC’s Financial Commitment to Recruiting and Retaining Minoritized Faculty

Supporting minoritized healthcare professionals after they have completed their training should be of the utmost importance to DEI efforts at AMCs, in part, because they are typically led by minoritized faculty. These efforts include leading DEI committees, pipeline programs, and research on health inequities. Institutional support for minoritized faculty has been lacking, as evidenced by decreasing rates of racially minoritized physicians ascending the academic ranks (Association of American Medical Colleges, 2021). There are many elements contributing to a lack of faculty diversity, including lower academic salaries for minoritized HCWs and the minority tax—or increased academic responsibilities placed on minoritized faculty in the name of diversity. This is coupled with inadequate compensation for work that often advances DEI, such as providing mentorship and leading DEI committees (Rodríguez et al., 2015). AMCs need to financially commit to improve faculty salaries, provide compensation for DEI work and research, address medical school debt, and expand paid parental leave.

Unpaid labor and a lack of protected time to carry out many diversity-related tasks are often cited as a huge burden for minoritized faculty. If AMCs want to improve DEI at their institutions, it is important to ensure that their minoritized faculty are not burdened by the minority tax. These responsibilities are often uncompensated and unrecognized as scholarly activities. Although AMCs must do many things to improve the minority tax felt by their faculty, their willingness to increase protected time and compensation is one major component that could alleviate the burden, specifically on racially minoritized faculty, and further support scholarly pursuits (Campbell & Rodríguez, 2019).

Salary surveys have shown that there is a discrepancy between the income of Black and other racially minoritized physicians compared to White physicians, even after controlling for specialty, faculty rank, and number of hours worked (Dander & Lautenberger, 2021). In addition to racial disparities, salary disparities exist among gender, religion, and sexual orientation, leading the American College of Physicians to call for increased compensation equity and salary transparency in academic medicine (American College of Physicians, 2017). Although the Association of American Medical Colleges (AAMC) offers a yearly faculty salary report by gender, race, and geographic location, these data are not institution-specific and other existing resources are costly to access. By providing salary transparency and accessibility, especially for senior-level executives, institutions could demonstrate their commitment to equity. This would ensure their minoritized faculty have competitive salaries, as this is one major reason for faculty attrition and a barrier to recruitment in AMCs (Budhu, 2022; Cropsey et al., 2008). In addition to competitive salaries, loan repayment, adequate paid parental leave, and financial support for research are additional tools to recruit and retain minoritized HCWs.

Loan repayment is a form of compensation that can be offered to support recruiting and retaining minoritized faculty, given their disproportionate loan burden (Dugger et al., 2013). Black, Indigenous, and Latinx people in the United States have significantly less net worth in comparison to their white counterparts, which is reflected in the debt burden of medical school matriculants and graduates (AAMC, 2016; Association of American Medical Colleges, 2019; Bhutta et al., 2020). Analyses of federal and state loan repayment programs demonstrate that they are effective in recruiting physicians and other healthcare professionals (Podolsky & Kini, 2016). Junior faculty have cited financial challenges, including debt management, as one of the obstacles to entering academic medicine (Kubiak et al., 2012). Federal loan repayment programs exist for faculty; however, these funds are limited and an institution providing additional loan repayment could help with debt relief more immediately (Duke, 2002).

Paid parental leave is also an effective recruitment and retention strategy for minoritized early career HCWs, given that disparities exist in paid parental leave among minorities. Data obtained from the San Francisco Bay area from 2016 to 2017 revealed that, compared to white women, Asian, Hispanic, and non-Hispanic Black women received 0.9, 2, and 3.6 less weeks of paid maternity leave (Goodman et al., 2021). Paid parental leave within healthcare, especially among physicians, continues to also be extremely challenging (Freeman et al., 2021). This is especially important because paid parental leave can be protective against peripartum health complications, which are higher in minorities (Montoya-Williams et al., 2020; Van Niel et al., 2020). Therefore, AMCs investing in paid parental leave for minoritized faculty stands to not only close the gap in receipt of this benefit, but also is an important investment in the health and well-being of HCWs that demonstrates AMC’s commitment to supporting diverse staff.

Institutional financial support for research activities is also a major challenge. Minoritized faculty are underrepresented among National Institutes of Health-funded researchers, due to many barriers including a lack of institutional support (Shavers et al., 2005). While this must be addressed, bridge or pilot funding for minoritized faculty is paramount to advancing their faculty careers, as it helps to increase their scholarly productivity and develop research skills. In addition, this will make them more competitive as they apply for external funding (Kubiak et al., 2012; Shavers et al., 2005). Along with providing startup funds, AMCs can also increase protected time for minoritized faculty to allow them time for scholarship, research, DEI work, and other activities that contribute to their productivity and overall mission (Daley et al., 2008). Additionally, AMCs can consider early career endowed chair positions to support minoritized faculty and their research, especially those engaged in DEI work.

Potential Costs of These Recommendations

The recommendations for AMCs and other institutions to financially invest in their DEI work is important, however come at two major costs—the financial cost to the AMC and the potential decrease in availability of HCWs to provide direct patient care.

It is important to address the budgetary constraints many AMCs face, that would limit their ability to contribute financially to DEI programs. The COVID-19 pandemic further strained many institutions’ budgets. At a time when the push for anti-racism in healthcare peaked, so too did AMCs’ financial losses, caused in part by a pause in elective procedures and increased cost of supplies that happened during the COVID-19 pandemic (Carroll & Smith, 2020). AMCs and other hospital systems, therefore have been proceeding with caution when adding line items to their budget, while interrogating ways to ensure financial sustainability and longevity for the company.

While this caution is justified, it is important to consider two things. The financial investment into DEI has the potential to have a positive impact on the profitability of the AMC, based on research from companies in the private sector (Dixon-Fyle et al., 2020; Turner, 2018). Also, reallocating monies from executive salaries, which have grown by up to 93% from 2005 to 2015, compared to HCWs’ wages which increased by 8% in the same time frame, could be a feasible option to consider (Du et al., 2018). This is especially pertinent to AMCs given that CEO compensation is highest at major AMCs compared to other hospital types (Saini et al., 2022; Urbaniec, 2020). Although it will not solve all the financial concerns, these are important aspects to consider regarding the financial consequence of allocating money to DEI.

Greater time away from direct patient care that would result from increasing protected time among HCWs to carry out DEI work could also be seen as a negative consequence. This is especially important because minoritized faculty engage in this work the most and there is already a dearth of minoritized physicians, clinical psychologists, nurses, clinical social workers, and other HCWs available to provide patient care (Association of American Medical Colleges, 2021). To alleviate this issue, it is important to encourage non-minoritized faculty to engage in DEI work as well, so the burden does not fall only on minoritized faculty. This would ensure that minoritized HCWs maintain adequate time to provide direct patient care if they choose. It is also important to acknowledge that increased protected time allows for faculty to do work that previously may have been uncompensated, which could help work satisfaction and potentially decrease attrition. Physicians’ intention to leave patient care has been tied to work dissatisfaction and burnout, all of which has been worsened by COVID-19 (Degen et al., 2015; Garcia et al., 2020). In addition, extant literature has shown high attrition rates among minoritized physicians who have been treated unfairly in academia (Avakame et al., 2021; Blackstock, 2020). Therefore, allowing for more protected time could help career longevity that would provide more direct patient care in the long run.

Conclusion

DEI work in healthcare is a complex and continuous process that AMCs can significantly contribute to given their resources and position at the interface of research, education, and provision of clinical care to the underserved. AMCs can show true commitment to this work by allocating consistent funds to improve some of the critical issues within academia, including the diversity of the healthcare workforce and equitable pay for minoritized faculty and staff. In addition to allocating the institution’s funds to these activities, AMCs must promote continued advocacy of this work at a higher level by encouraging advocacy among HCWs and serving as strong advocates themselves. AMCs can use their role in healthcare to truly advance health equity with tangible investments into DEI. While financial investments will not eliminate all DEI problems within AMCs, they could significantly move this work forward and ensure that DEI work at AMCs is meaningful, sustainable, and actionable.