Keywords

Background

In addition to limited representation, multiple reports document challenges in achievement of traditional metrics of academic performance, retention and success of minoritized faculty members [1]. Whereas, approximately 19% of Americans identify as Hispanic or Latino [2], the Association of American Medical Colleges (AAMC) reports that 5.9% of total faculty listed in their 2021 roster from allopathic medical schools were Hispanic, Latino, or of Spanish Origin, whether single or multiple race/ethnicity, compared to 62.3% White non-Hispanic faculty [3]. This disparity is more evident in the advanced ranks of the professoriate, whereby AAMC reports that Hispanic, Latino, or of Spanish Origin, whether single or multiple race/ethnicity, faculty represented 6.7% of instructors, 6.8% of assistant professors, 5.4% of associate professors, and 4.3% of full professors [4]. The American Association for Colleges of Osteopathic Medicine (AACOM) report that 1.7% of total faculty listed in their 2016–2017 roster were LHS+ [5]. AACOM reports similar trends to AAMC whereby in 2016–2017 LHS+ faculty represented 3.5% of instructors, 4.9% of assistant professors, 2.5% of associate professors, and 1.5% of full professors [5]. The lack of LHS+ individuals is also evident on the medical school dean level whereby in December 2022 there were only 5 Hispanic identified Deans of a U.S. LCME accredited medical school; 1 on the mainland (Juan C. Cendan, M.D., Dean of Herbert Wertheim College of Medicine) and 4 on the island of Puerto Rico (Yocasta Brugal M.D., Dean, San Juan Bautista School of Medicine, Caguas, Puerto Rico; Jose Capriles M.D., Dean, Universidad Central del Caribe School of Medicine, Bayamón, Puerto Rico; Interim Dean Humberto M. Guiot, University of Puerto Rico School of Medicine San Juan, Puerto Rico; Olga Rodríguez de Arzola M.D., Dean, Ponce Health Sciences University School of Medicine Ponce, Puerto Rico). Among accredited osteopathic medical schools, there was only one LHS+ identified dean Italo R. Subbarao, DO, MBA of William Carey University, College of Osteopathic Medicine [6].

Studies on LHS+ faculty in academic medicine are limited, however extant work in higher education demonstrates that LHS+ faculty uniquely engage students, improve LHS+ students’ higher education retention and degree completion rates, and conducting academic research on racial/ethnic communities [7].

LHS+ faculty are as productive as their White colleagues and found to be more involved in their departments or campuses than their White colleagues [8]. LHS+ faculty may be particularly subject to cultural taxation, as the number of LHS+ faculty has not kept pace with the growth of LHS+ student enrollment leading to additional stresses and burdens placed on this group, while productivity expectations are not reconsidered [8]. The low representation of LHS+ among the faculty, together with projected growth in demand among LHS+ students, suggests that there will be more future demands on the time of LHS+ faculty members serving as role models, advisors and champions [9]. Additional time spent on service activities and teaching and/or mentoring minoritized students may also result from LHS+ faculty members’ strong sense of responsibility to serve their racial/ethnic communities, as other minoritized faculty often do.

As a minoritized group in medicine, similar studies documented that a promotion disparity exists between minoritized faculty in medicine and White faculty. Minoritized faculty are more frequently found in early career positions than leadership positions and promoted at lower rates, while lacking institutional and formalized mentorship [10, 11]. Minoritized faculty tend to be disproportionately positioned to engage in service work such as diversity and inclusion efforts, institutional, and clinical service activities [10, 11]. Moreover, they are rarely trained on how to document service-related work as scholarly work (e.g. peer-reviewed publications) or for promotion purposes. This commitment to service and promotion and tenure results in emotional burnout for many LHS+ faculty members [12]. Because salary is also dependent on academic rank, clinical and research efforts, even financial incentives contribute to pay-inequities [13].

While discrimination of LHS+ faculty can happen in several domains, significant narratives have centered on culture and credentials [14]. According to Verdugo scholars have shown that LHS+ faculty believe they are discriminated against due to appearance and accusations that their positions are a result of diversity initiatives [14]. Scholars have also demonstrated how cultural differences cause LHS+ faculty to feel excluded from available opportunities and abstain from participating. These perceptions produce barriers to engagement and credibility, precluding LHS+ faculty from being positive role models for LHS+ students [13, 14].

The low proportion of LHS+ faculty especially in visibly impactful positions, challenges the social and academic success of LHS+ students who are themselves minoritized (11.5% of incoming matriculants at allopathic medical schools and 6.8% of incoming matriculants at osteopathic medical schools in 2021) [15, 16]. Although it is important to acknowledge the generous contributions by non-LHS+ equity minded senior faculty who mentor and train LMSA students, residents, and early career LHS+ faculty, the gap in ethnic/cultural concordance between faculty members, trainees, and the communities we must serve is perceived as an obstacle affecting satisfaction and benefit from the relationship [17].

Concordance between patients and physicians may be of particular importance when working with less acculturated LHS+ communities given the linguistic, literacy, socioeconomic, and other cultural elements that impact wellness, health concepts, health seeking, and acceptance in this community [18]. Our chapter describes asset-based efforts to support faculty development, some of which may be applied to individuals along the continuum of academic development including efforts to encourage and prepare trainees along the aspiring pre-faculty pathway.

Socialization

Socialization is the process through which individuals acquire and incorporate understanding of the institution with shared attitudes, beliefs, values, and skills [19]. Socialization can positively affect LHS+ faculty retention and promotion, and student’s introduction to the academy. Therefore, impacting the personal, professional and academic development of LHS+ students. The difference in experiences and belonging in academic medicine can be addressed through anticipatory socialization, strong mentoring networks, extensive networking opportunities, focused priorities, and intentional or goal-oriented work demands [19]. Literature on the socialization of URM individuals often includes the very important pre-faculty phases, yet the assessment of impact of socialization on faculty success is less well studied.

Various studies found that Latina/o doctoral students utilized family and community members as support systems, particularly for emotional support when navigating hostile environments [20,21,22,23,24] and revealed that LHS+ medical students do not have access to privileged knowledge that can only occur through faculty mentoring [25].

Multiple variables predict the career selection and success of medical school faculty such as: the aggregate of the individual’s inspiration, preparation, experiences, and identity prior to joining the faculty ranks; commitment of the institution to the academic mission over common competing demands; availability of qualified and committed mentors and content experts; development of writing skills and habits for scientific audiences and granting agencies; access to project based research training-experience; leadership skills development; balanced portfolios of teaching, and service that are congruent to the content of the faculty member scholarship focus, and work-life balance; among others.

LHS+ faculty often have experiences and trajectories less concordant with traditional markers of advancement [26], however focused forms of support for pre-faculty and early career academics [27] which optimize asset-based development opportunities may be the best form of ensuring success [28].

LHS+ Faculty Development

Faculty and educational development focuses on the continuous improvement of individual’s instructional and educational skills, including their professional and personal development opportunities that contribute to career advancement [29, 30] We have strong evidence that faculty development programs increase retention, productivity, and lead to tenure and promotion [31].

Successful faculty development programs include: effective mentoring panels; focused instruction on areas of excellence such as clinical, teaching, and research skills; recurrent networking spaces; and reduced administrative or clinical expectations in order to facilitate scholarly productivity [30, 31]. They often include funds towards protected time and institutional seed money for pilot projects [31]. However, there is a limited number of programs tailored towards minoritized faculty and even less targeting LHS+ faculty.

In assessing the status of tailored programs for LHS+ faculty we recognize that many institutions have sponsored spaces and faculty communities for LHS+ faculty. However, a number of these spaces originate from grassroot efforts and the level of professional development opportunities vary greatly.

The professional development spaces developed for LHS+ faculty are few and far between. Colleges of Medicine in the U.S. are likely to have offices of diversity, many have active programs promoting compositional diversity and inclusive climates, and about half of them report hosting programs tailored to support historically underrepresented faculty (51.2% mentorship and 42.7% leadership development), few address specific populations such as LHS+ individuals [32], and the proportion of LHS+ faculty when reported tends to be modest.

The success of minoritized faculty development efforts when measured are highly variable and believed to be associated with the greater intensity (time and quality of commitment), broader scope (including mentoring, career development, social climate, pilot funding), and greater longevity (>5 years) of program activity [33]. Broad efforts to assess the impact of existing programs in LHS+ pre-faculty and faculty may help inform future LHS+ academic career development support design.

It is worth highlighting some of these programs. The Hispanic Center of Excellence at New Jersey Medical School provides a program dedicated to the advancement of Hispanic faculty [34]. The Hispanic Center of Excellence Faculty Development Program at University of California, San Diego is designed to “improve recruitment, retention, and success of URM faculty in academic medicine at UC San Diego” [35]. At the national level, the Hispanic Association of Colleges and Universities offers a leadership development platform [36]. The American Association for Hispanics in Higher Education represents Hispanic academics, researchers, educators, and Hispanic students. Through their platform they offer several opportunities including a fellowship and leadership academy [37].

Institutions with external funding to support faculty development tend to be hosted at sites where the demographic representation of traditionally underrepresented individuals and impactful leaders from congruent backgrounds may coincide. The Health Resources and Services Administration (HRSA) Centers of Excellence are funded programs with comprehensive goals to advance the institution’s ability to serve the needs of their diverse communities. Hispanic Centers of Excellence across the nation contribute locally to the recruitment, retention, and success of Hispanic Faculty members within specific colleges of medicine and at times collaborative consortiums [34]. The impact of these programs may be variable, and formal evaluation of broad impact is lacking.

Hispanic advancement organizations such as the National Hispanic Medical Association and the Hispanic Serving Health Professions Schools (HSHPS) have hosted professional development workshops and faculty development in support of Hispanic Medical (Health Professions) Faculty Development however they seem to be subjected to the time limitations associated with grant funding or short term collaborative opportunities. Similarly, AAMC Minority Faculty Leadership Development Seminar, and the AAMC Mid-Career Minority Faculty Leadership Development Program, although not specific for LHS+ faculty, they are designed to support individuals who aspire to leadership positions in academic medicine by helping individuals identify professional development goals and design a career path, learn the skills and tools to succeed, and expand their network of colleagues and role models. A number of scientific and professional societies, private research and benefit foundations also contribute to the piece meal opportunities described above. The National Institutes of Health have made important efforts to support the career development of individuals underrepresented in the biomedical sciences.

Funding support from mentored career awards (K-series), career development award (KL2) components of the Clinical and Translational Science Awards, multiple R25 funding mechanisms to support research career training and development. These are amazing opportunities for those who are competitively placed and seeking research careers. There is clearly a need for larger scale, durable, expert designed and longitudinally delivered faculty development program to support LHS+ faculty whose careers in academia may not follow the traditional independent investigator route, and who represent the overwhelming majority of LHS+ faculty serving in smaller, newer, educationally intensive institutions, or hospital based programs where opportunities for academic success are more limited.

Cultural values bring us together and there is great value in LHS+ tailored faculty development programs. In fact, LHS+ faculty conveyed these programs as important in several respects: tailored programs create spaces for networking, for relationship building, accountability and affirmation. Most importantly, these faculty development spaces reaffirm that microaggressions, discrimination and overt racism are not isolated events [12, 13]. Table 13.1 provides a sample of themes to be included in these training.

Table 13.1 LHS+ faculty development Topics [13]
Full size table

Mentoring

Mentors are an essential component of the LHS+ and other minoritized in medicine faculty member’s support-network impacting retention and advancement. Mentors may help demystify professional environments providing vital information and support to facilitate inclusion in important opportunities; they can help balance contributions to diversity efforts and ensure adequate compensation or acknowledgement; assist at dealing with internal conflict resulting from feeling responsible for serving their communities, and taking on too many service commitments; help understand the nuances of academic medicine culture and expectations; promote a sense of community decreasing feelings of isolation due to a lack of critical mass; and increase the sense of value minimizing stereotype threat, increasing resilience and improve coping with bias [38, 39].

Programs to enhance mentoring opportunities and skill development have been importantly promoted over the last decade. Of relevance, significant resources to develop and tailor specific trainings can be accessed from the University of Wisconsin-Madison Institute for Clinical and Translational Science. This team leads the coordination center for the National Research Mentoring Program (NRMN), an NIH consortium that strives to enhance diversity in the biomedical research workforce by serving mentors and mentees [40]. It is important to ensure that mentors and mentees receive training on various aspects of giving and receiving mentorship. Elements of training include the importance of developing a mentoring plan and contract, ideas for maintaining effective communication, aligning expectations, addressing equity and inclusion. A good mentee will have openness and desire to learn and benefit from the relationship, will take initiative, be prepared, responsible at completing tasks enthusiastically and in a timely fashion, and have a sense of ownership of the outcomes of the relationship dyad. A good mentor will be accessible, committed to the mentee and their relationship, eager to continually improve, embrace diversity, and have faith and respect for the mentee. A good mentoring contract includes descriptions of frequency and type of contact to be had, how the time will be utilized, what mechanisms for feedback and assessment of the dyad will be in place, among other commitments volunteered by the members. Although many of the above-mentioned approaches have been supported with data and observational reports, the effectiveness of NRMN and collaborative programs in the success of LHS+ faculty and trainees specifically has not been documented to this date.

Importance of Culturally Relevant Faculty Mentoring

As programs also focus on developing mentors, they need to also acknowledge that being mentored by someone from a similar LHS+ background might be at odds with what the representational numbers indicate. LHS+ faculty need more than career advice. Mentoring relationships must recognize the many assets that LHS+ faculty have to offer and their strong commitment to service. Mentors can practice cultural curiosity and familiarity in how they develop relationships. Mentors must socialize faculty into the academy, introduce them to the community, build mentoring networks of champions, sponsors, role models, advisors, institutional agents, etc. [41] This process should start as early along the LHS+ pre-faculty continuum as possible. LHS+ postgraduate trainees report less interest in academic medicine careers than their peers, report not having enough mentoring to pursue a career in academic medicine and are less likely to credit their mentors and role models with pursuit of academic medicine [17].

LHS+ students and faculty alike do not leave their cultural values “at the door” [42]. In order to persist, mentoring models should address collaborative relationships dealing with power, establishing connections among community and providing support to succeed [42].

Charting Your Course

Most academicians fill their days—often beyond work schedules—with urgent, dutiful, and exciting or rewarding experiences, many of which may have limited impact in the main academic outcomes of retention, promotion, and content related success. LHS+ faculty may benefit from carefully constructing an individual academic plan that is informed by the individual’s values, and the articulation of their academic vision and mission. Once the values/vision/mission are clear, an intentional plan must be put in writing along with an timeline and metrics of success to include: Establishing career development goals; Identifying area of research/scholarship niche; Pursue/obtain grant funding; Improve skill set; Conduct ongoing studies/scholarly projects; Participate in education/teaching; Participate in outreach/service/professional network; and Life balance.

Informed by a clear understanding of the rules and practical options for promotion within assigned rank, faculty members must identify top priorities, set deadlines, and track metrics. Having a visible document with the timeline for one whole academic year allows us to plan the rhythm of national meetings, submission of abstracts, publication timelines, and facilitates the balance of teaching and service requirements which ideally should congruently flow. This is then converted to a monthly, weekly, and at times daily goals that inform our intentional investment of amount and quality of time, and effort. Adherence to such timeline allows us to separate the urgent from the important, the enjoyable from the relevant, and the distractors from the focused contributions that result in impactful coherent narratives of our value.

Strategies that allow us to maximize outcomes based on time is: organizing your office and outside life in addition to organizing your schedule, making lists, minimizing distractions, putting a time to each effort so keep meetings brief, having visible clocks and make others aware of the value of your and their time, learn to and practice delegating, support students and other team members to collaborate with you towards goal completion, align the various efforts so that it all counts towards your goals, manage email time, and be selective about what you agree to do [43]. As LHS+ faculty members master the skills listed above, they become a better equipped role model and can in turn work with trainees to guide them through similar process that matches their stage of pre-faculty development.

Career Advancement

Given the disparities in career retention and advancement in LHS+ faculty, faculty development efforts must be built upon a clear understanding of the value, process, and specific deliverables required for promotion in the individual faculty member’s rank and track.

A very user friendly and valuable tool to use is “The Promotion Game” [44]. Early career faculty members often are ill informed about the tracks available at their institutions and unclear about the promotion timeline or targets associated with the track they agreed to be hired under or were assigned to without discussion. The implications of “playing the promotion game” before knowing the object of the game, the rules of engagement, and the cost of wining or loosing represents a major disadvantage, hence pre-faculty scholars would also benefit from having keen awareness of these rules. With a full appreciation of the criteria for promotion in their department, faculty must assess if the track is right for them, are the requirements consistent with how they spend their time, what activities and other requirements (scholarship, teaching, and service) fulfill those criteria.

With this knowledge aspiring and current faculty must revisit their personal/professional IAP goals paying attention to how achieving their individual goals moves them toward their target for initial appointment or promotion, and how their personal goals align with and support institutional and departmental roles, mission and goals. The ideal job lives at the intersection of the individual’s values, preferences, passions, and ability to contribute.

Faculty progressing through the academic path should be encouraged to maintain a positive learning attitude, taking advantage of self- and external- assessments. Being an active seeker and participant during the Annual Reviews process with their Department Chairperson or Section Chief. In addition to obtaining feedback on accomplishments, as you talk through your plan for the year, use the opportunity to ask: Am I on track for promotion? Does my productivity and my workload assignment match my promotion targets? Are there areas in which I need to be more productive? What types of journals, conference presentations should I pursue? What service opportunities are most appropriate given my goals and interests? What else do I need to do? Similarly, pre-faculty scholars would benefit from assessing their progression and consider path adjustments to increase their competitiveness for faculty appointment and success.

Mid-Cycle Reviews are required for tenure track, but optional for other tracks. They tend to be a “Dress rehearsal” for promotion, it is an opportunity to update and assess if your CV is in the appropriate format, reflective of your efforts, and consistent with promotion requirements. This also allows you an opportunity to prepare and refine your candidate statement, including re-evaluating your workload assignments, and receive formal input from the departmental Promotion and Tenure committee about being on track for promotion, and suggestions to strengthen aspects that may require additional production or focus.

Academicians along the development continuum often wonder about how much to contribute to committee work. This is an important question since future and current LHS+ faculty members often are taxed with additional service demands. Although one must be vigilant not to be unduly burdened by committee work, this form of service can be an important avenue to learn about and be part of the institutional structure, expand networks, gain visibility and credibility, develop and practice governance skills, that open doors and leadership opportunities. In summary, some strategies to make this service stand out towards promotion and tenure involve the strategic and intentional participation in committees, outreach activities in our communities, and seeking to serve official positions within professional organizations.

It is important to note that in disrupting the current standards of promotion and tenure we should be engaging in conversations and action towards challenging colonial ideals in higher education. Higher education has evolved. Furthermore, in the context of academic medicine, our connection to education and health systems demands changes that push forward traditional areas: clinical, research and teaching and add service as an equal pillar. Hence, not small ‘s’ for service, but large ‘S’.

In relation to leadership, every aspiring and current faculty member should ask themselves “What leadership role(s) do I want to have in 5 years?” Whether content-based roles (research team leader), structured-based roles (section chief/department head), or group representative, you need to do a gut check to make sure you will be committed to the effort, and then accept or create leadership opportunities with incremental responsibility. Before you accept or develop an opportunity consider who do you want in your team/group, how can participation benefit them (not only the team), what will their questions/concerns be, what resources do we need, who can advise you? Individuals should continuously work on their accountability mechanisms, grow their leadership skills through training and the mentorship of successful leaders, and grow their credibility.

Credibility is supported by three components: trustworthiness (how likely you are to do what you say you will do), expertise (do you know what you need to know and do to accomplish the task), ethical integrity (do you behave in a manner consistent with your stated values, and with moral and ethical principles). Behaviors based in an asset-based model that builds credibility include: (1) do what you say you’ll do, (2) honor appointments and be punctual, (3) prepare and be organized, (4) be present and pay attention during meetings, (5) model valuing yourself avoiding self-criticism, (6) being prudent with personal information, (7) be transparent and keep the team informed, (8) honor and acknowledge contributions of others, and (9) use graceful self-promotion [45, 46].

Successful Academic Writing

Academic writing is an often misunderstood and neglected skill that can certainly be developed. Given that writing is often seen as the thing we do when we find a big block of time, get inspired, face a deadline or other external pressure, or wait for everything else and everyone else to be done so we can “move to write”, many academics engage in writing binges. Binge writing has disadvantages such longer periods without writing, more time required to warm up or catch up to previous progress, more fatigue and describe writing as grueling rather than enjoyable and have less creativity during their writing.

Empirical research supports the benefit of regular/scheduled writing in which near daily periods of less than 90 min are scheduled and honored as writing time [47].

Constancy with moderation matched with S.M.A.R.T. (small, measurable, achievable, relevant, time-based) writing goals leads to greater satisfaction, sense of accomplishment, greater productivity, and innovation. Additional strategies include dividing your efforts into generating versus editing minimizing perfectionism; writing something else of relevance even if altering the order or if it contributes to a different product; letting experience and past performances predict your realistic goals; defend your writing time within reason; measure your productivity for self-accountability, and assess your quality by inviting review and feedback from fair critics you trust [48].

The latter is particularly important for novice and non-native English speaker writers for whom being part of a peer writing group or formal skills development group can help develop confidence in writing conventions, linguistic knowledge, grammar, vocabulary, and thinking strategies that match academic expression.

Distinct Characteristics of Faculty Development in Puerto Rico

As previously noted throughout the book, Puerto Rico has 4 LCME accredited medical schools, San Juan Bautista School of Medicine, Universidad Central del Caribe School of Medicine, Ponce Health Sciences University School of Medicine, and the University or Puerto Rico School of Medicine. The experience of LHS+ faculty at the four medical schools in Puerto Rico is quite different than LHS+ faculty in the Mainland U.S. The majority of faculty at the four medical schools in PR are LHS+. Thus, socialization, mentoring, and support systems are developed and delivered by and between LHS+ faculty. The faculty development programs at each institution focus more on developing the teaching and research skills needed for retention, promotion, and tenure, and on specialty specific training. The four schools have different systems of assessing the needs of their faculty and, based on those needs and the current educational trends, they design their programs for each academic year. In addition, the fours schools have faculty with expertise, be it masters or Ph.D. degrees in education, educational technologists, and/or training in research and grant writing.

The Student as Teacher model has served a meaningful pathway for the development of skilled LHS+ faculty. Induction into the roles and responsibilities of a faculty member could begin as early as the first year of medical school. The Universidad Central del Caribe School of Medicine (UCCSoM) relies on a two-fold approach to enable the socialization of students into faculty roles. Early in the process faculty mentors identify students who demonstrate potential to become teachers. These students in turn are recommended to serve as classmate’s tutors in addition to receive one-to-one advising on effective teaching methodologies. They are also invited to participate in faculty development activities aimed at helping them master best teaching practices. During the student’s senior years, they participate in an elective course titled, “The Student as Teacher”. This includes a one-to-one experience with a faculty member where the student is expected to demonstrate accomplishment of the course goals by designing educational objectives, a learning experience, and the corresponding assessment of the student learning.

Evaluations of these experiences suggest that effective mentoring plays a key role in supporting the development and strengthening diversity among medical educators. Opportunities to perform as effective teachers, in the safe environment of medical schools and under close guidance of a faculty mentor, reinforces self-reliance and confidence as medical students serve as residents and future faculty. Puerto Rico medical schools’ model for medical student development presents a highly effective and meaningful pathway for the development of skilled LHS+ faculty.

In Closing

LHS+ pre-faculty- and faculty development efforts are important to ensure that LHS+ medical students receive optimal training delivered in part by culturally congruent individuals who are themselves successful in their academic careers and inspiring role models to medical students and members of the pre-health pathway, as we seek to address the health needs of LHS+ individualss in this country. Although multiple examples exist of episodic and localized efforts to support LHS+ faculty development, little evidence exists for a one specific approach to enhance the skills, career success and impact of these faculty or pre-faculty. The opportunity exists to develop a carefully tailored longitudinal program of national scale to advance our ability to support LHS+ faculty through empirically validated interventions. Efforts beyond specific training programs are necessary to comprehensively address socialization and other topics identified as important for LHS+ faculty development [30] and individuals should feel encouraged to grow their developmental networks as they meet their identified needs. This includes finding a good team of mentors, sponsors and champions, as well as addressing cultural needs; develop a career development plan informed by personal values and mission; be mindful and proactive at career and leadership advancement; be a successful writer of grants and scientific production; and keep committed to serving students and patients importantly supporting those of LHS+ origin.