Promoting Equity, Diversity and Inclusion in Academic Neurology

The University of Maryland School of Medicine (UMSOM) has long been committed to maximizing the diversity among its workforce and student body. However, since 2018, when the school adopted its Cultural Transformation Initiative, it has intentionally created a safe, respectful and inclusive environment that seeks to transform UMSOM into a national model of inclusion. These efforts not only imbue the school's professional environment with equitable opportunity, but cultivating a diverse group of attending physicians means better care for the widely multicultural patient population treated at the University of Maryland Medical Center campuses in downtown and midtown Baltimore.

To that end, the University of Maryland Department of Neurology commenced the 2020-21 academic year with an inaugural Diversity Day Grand Rounds – executed in true 2020 fashion by Zoom webinar – to acknowledge the ways in which the discipline of neurology currently lacks diversity and to discuss how the field can provide more opportunity for underrepresented minority groups.

"Our department embraces diversity in all of its expressions," says Peter Crino, MD, PhD, Chair of the Department of Neurology at UMSOM, who hosted the event. "With the recent attention given to systemic racism and bias – which make us less than we can be – we wanted to address some of the issues related to bias in medicine," he continues. Dr. Crino intended for the event to build awareness of the current diversity-related deficiencies in academic neurology so they could be discussed through a frank discussion, thus paving the way for what he calls "new and bold strategies to get rid of bias." As a grand rounds event, the didactic presentation on diversity and subsequent town hall meeting had an added benefit of reaching clinicians and residents early in their training, making them aware of the dangers of implicit bias in patient care so they can mindfully develop ways to overcome it.

Defining Diversity in a Setting of Academic Medicine

The event opened with remarks by E. Albert Reece, MD, PhD, MBA, Vice President for Medical Affairs at the University of Maryland and the John Z. and Akiko K. Bowers Distinguished Professor and Dean of UMSOM, that set the tone about what is meant by diversity.

"Diversity refers to any difference – large or small – that includes race, gender, upbringing, interests, personal values, identity or more," said Dean Reece. "And these differences may represent opportunities for various solutions, insights and breakthroughs. The way we listen and the way we speak to each other, as well as the way we treat each other on a daily basis, determines how we accept these opportunities and reflect in our general value of diversity – and really our genuine value of each other."

At the heart of the event was a keynote address by Roy Hamilton, MD, MS, FAAN, FANA, Vice-Chair for Inclusion and Diversity, Department of Neurology, and Assistant Dean for Cultural Affairs at the Perelman School of Medicine at the University of Pennsylvania. As a cognitive neuroscientist and behavioral neurologist, Dr. Hamilton's academic and clinical work focuses on neuroplasticity and treating patients with dementia and stroke; additionally, he is heavily involved with studying and promoting diversity, inclusion and health equity in medicine. He has analyzed the ways academic neurology lacks diversity and the challenges it faces in building it, and he has proposed ways to overcome these obstacles.¹

Why Diversity, Equity and Inclusion in Neurology Matters

Dr. Hamilton's talk, entitled "Diversity, Equity and Inclusion in Neurology: Where they are missing, why they matter, and how we achieve them," consisted of an overview of the lack of diversity among academic neurologists as a group and how this deficiency affects patient care. The final part of the address struck an optimistic note as he explained what his own department at the University of Pennsylvania has been doing to increase diversity among its faculty and residents.

"[D]iversity and inclusion are beneficial for academic departments, including neurology departments, irrespective of those departments fulfilling their obligation to social justice," said Dr. Hamilton. He stressed that diversity when "drawing together talent" both enhances the performance of groups and outperforms individual ability. As such, ensuring diversity – that is, pulling from all domains of difference and including a variety of perspectives – is in any academic department's best interest. In fact, one study that analyzed 2.5 million scholarly publications showed a positive correlation between the diversity of an authorship group on a research paper and the subsequent impact of that publication.²

According to Dr. Hamilton, inclusion is "making all the individuals who you brought together feel like the environment to which you've brought them is the kind of place that they belong to, that belongs to them and where they can thrive." Only when people have a voice and feel like they belong will inclusion be achieved. This concept raises the question as to whether underrepresented minorities feel welcome in academic neurology or whether they move out of the training pipeline to another specialty, primary care or even out of medicine altogether.

"Academic neurologists do not mirror the U.S. population with respect to representation and, in particular, there is underrepresentation of Black or African American individuals, Hispanic or Latino individuals, and … American Indian or Alaska natives," said Dr. Hamilton.

Together, diversity and inclusion enhance equity – that is, equality of opportunity. However, when only 4 percent of neurologists (9 percent in medicine overall) are from underrepresented racial and ethnic groups compared with 30 percent of the U.S. population, equity is lacking and, as Dr. Hamilton pointed out, "neurology has a specific problem." These disparities become more pronounced as academic rank rises and percentages of Black, Hispanic, American Indian/Alaskan Natives and women decrease – acutely so at the associate professor level and beyond. Clearly, these disparities in promotion suggest that people's backgrounds currently influence their opportunities for advancement in neurology. Moreover, this lack of diversity harms the discipline as a whole.

Factors that Contribute to Professional Disparities

Dr. Hamilton addressed some of the factors that act as career obstacles for underrepresented minorities: implicit and explicit biases, financial need, process knowledge gaps, lack of mentoring and networking, even the lack of time and energy – due to other exigencies – for activities that develop competitiveness among academic physicians. He noted that there is a "diversity tax" in which women and some racial and ethnic minorities tend to spend more time on service to their universities and mentoring than their white and Asian male peers, limiting the time they can devote to their own academic pursuits.

"Women of color: Well, it's almost like they have a second part time job on top of their academic vocation," stressed Dr. Hamilton. Moreover, unconscious judgements are made even today at the hiring level, and perceptions of race and gender influence the quality of the performance reviews that instructors give trainees.

The Importance of Diversity for Patient Care

"Diversity and inclusion also interact importantly with health equity in neurology," said Dr. Hamilton. Patients greatly benefit by being seen by a physician with a similar cultural background as their own.

Dr. Hamilton pointed out that studies show that clinicians of the same race as their patients demonstrate better non-verbal communication and even stand closer to them. He also stressed that medical faculties that are "more diverse-engaged" have an easier time managing care for and interacting with diverse patient populations.

"And, importantly, … there's much more avid recognition of racism and of differential treatment of patients based on either overt or unconscious biases," said Dr. Hamilton of these departments that take it upon themselves to become more culturally competent.

Strategies to Achieve Greater Equity in Academic Neurology

Equity cannot be achieved by providing everyone with the same exact thing; purposeful policy and practice are required. Dr. Hamilton shared some of the strategies his own department implemented that have resulted in more residency program applications from underrepresented racial and ethnic groups and better retention and promotion of underrepresented faculty. These efforts commenced in 2017 with the creation of a leadership role centered around equity, diversity and inclusion, which Dr. Hamilton himself was appointed to. A Diversity and Inclusion Committee was also formed to promote workplace diversity, educate about health disparities and cultivate an inclusive departmental culture. One of the first things he and the committee did was an environmental assessment.

"We took a survey of diversity engagement that was administered throughout the school," explained Dr. Hamilton, noting the high level of response to the survey. This survey revealed "how people felt about the diversity of the environment, how much they felt appreciated and included, how they felt about their immediate leadership … and also how they felt about the overall leadership of the institution and whether it was true to its mission and values."

Dr. Hamilton said that the results showed that men were more satisfied with the department's leadership than women, non-heterosexual persons had lower satisfaction with diversity and overall institutional support, and non-white respondents – grouped as a composite because the numbers for specific populations were low – had lower satisfaction in all categories.

"[The environmental assessment] gave us a sense of … the kind of work that we need to do and that there was a valuable role for [my] position and for our committee," said Dr. Hamilton.

To bring together a more diverse group of residents, the department adopted a holistic recruitment process involving everything from how applications are viewed to who potential residents get to meet on interviews. To enrich the training of neurology residents, the committee developed a health equities curriculum to educate about implicit bias, cultural competence, social determinants of health and specific disparities in neurologic care. Including instruction about diversity in medical training helps clinicians better recognize implicit racism and biases, and ultimately makes them more comfortable in caring for diverse patients.

Dr. Hamilton's department also focused on faculty education, and in 2019, they hosted a neurology grand rounds with Dorothy Roberts, JD, who spoke about the fatal dangers of racialized medicine and the problems with seeing race as an inherently biological category rather than a social construct. The department also adopted diversity standardization in faculty searches, appointments and promotions, which has led to women being better represented if not yet underrepresented racial and ethnic groups. Even so, the department is now retaining and promoting underrepresented minorities in greater numbers than before.

"Diversity is essential for excellence; it enhances everyone's intellectual performance; it improves delivery of care; it raises everyone's awareness of biases in care delivery," concluded Dr. Hamilton. "So diversity isn't just there for the individuals who come from underrepresented or underserved backgrounds. Diversity serves everyone."

Diversity Panel Discussion and Town Hall

Dr. Hamilton's address was followed by a panel discussion and town hall meeting in which he participated with University of Maryland School of Medicine faculty members to further the conversation about how the disparities in academic neurology may be able to be redressed. The panel itself (see inset) was made up of individuals who hail from underrepresented groups in academic medicine. As such, they shared about some of their own professional experiences – quite poignantly at times – and provided insights about how academic medicine might do better in mitigating bias.

Watch the recorded meeting of Dr. Hamilton's keynote address at UM Department of Neurology's inaugural Diversity Day Grand Rounds as well as the subsequent panel discussion. Contact Jamesha Perkins, Program Administrative Specialist, at jperkins@som.umaryland.edu for the password and link for access.

Diversity Day Panelists

Camilo A. Gutierrez, MD Associate Professor of Neurology, University of Maryland School of Medicine, Department of Neurology Equity, Diversity, and Inclusivity Officer
Roy H. Hamilton, MD, MS, FAAN, FANA Vice-Chair for Inclusion and Diversity, Department of Neurology, and Assistant Dean for Cultural Affairs at the Perelman School of Medicine at the University of Pennsylvania
Sandra M. Quezada, MD, MS Associate Dean for Medical School Admission; Assistant Dean for Academic and Multicultural Affairs; Associate Professor of Medicine, University of Maryland School of Medicine
Kristin Powell Reavis, MD Director of Student Diversity and Inclusion in the Office of Student Affairs; Assistant Professor of Family & Community Medicine, University of Maryland School of Medicine
Lisa M. Shulman, MD Eugenia Brin Endowed Professor in Parkinson's Disease and Movement Disorders; Professor of Neurology, University of Maryland School of Medicine
Rodney J. Taylor, MD, MPH Professor and Chair, Department of Otorhinolaryngology-Head & Neck Surgery, University of Maryland School of Medicine

While the University of Maryland Department of Neurology's inaugural Diversity Day Grand Rounds event focused specifically on achieving better equity, diversity and inclusion among neurology faculty rather than on producing health equity among patient populations, the two efforts are closely related. Here is a brief glossary of terms one might encounter while participating in a discussion or learning about health equity.

Cultural Competency – The goal of health equity education is to become culturally competent; that is, to develop a better understanding of people with diverse backgrounds and to be aware of potential implicit biases that may influence the interactions one has with others. When one is culturally competent, these biases can be overcome, allowing one to provide culturally appropriate, personalized care for each patient that results in more equitable outcomes.

Health Disparity – Any difference in clinical outcomes between minority and non-minority populations that are not related to patient preference or appropriate care for the patient. Examples of health disparities in neurology are that underrepresented minorities are 70 percent less likely to be offered epilepsy surgery and also less likely to receive tPA for ischemic stroke even with presenting with the same symptoms as their white counterparts.

Implicit Bias – Unconscious stereotypes or attitudes that influence how people are viewed and impact professional and personal interactions. Some common implicit biases in health care include the perceptions that women overreport symptoms, Black men are less compliant patients and white men are more likely to sue their doctors. People tend to rely on implicit biases – which are mental shortcuts – when they are under heavy cognitive loads. However, such biases have the potential to be dangerous for patients; for example, non-whites and females are 40 percent less likely to be referred to cardiac catheterization because of them.

Social Determinants of Health – Conditional, rather than strictly physical or biological, factors that influence health outcomes. For example, living under chronic stress and not feeling included will adversely affect one's health. Residing in a geographic "food desert" where fresh produce is difficult to obtain would be another social determinant of health. Another would be living in a rural area where fewer neurologists are available to see patients. Because social determinants of health are widely influenced by environmental, socioeconomic and political forces, in many cases they are institutionalized.

¹Hamilton RH. Enhancing diversity in academic neurology: from agnosia to action. Ann Neurol. 2016;79:705-708. doi: 10.1002/ana.24635

²Freeman RB, Huang W. Collaborating with people like me: ethnic co authorship within the United States. J Labor Econ. 2015;(33)51:S289-S318. doi: 10.1086/678973