Never Felt at Home: A Qualitative Study of the Experiences of Faculty From Underrepresented Groups in Family Medicine and Strategies for Empowerment

Historically, multiple groups have been underrepresented in leadership positions in medicine—a trend that continues today. ^{1, 2} Sponsoring, mentoring, and coaching (SMC) are tools to advance the careers of junior faculty members and help close this gap in leadership representation. ^{3, 4} For members of underrepresented groups (URGs) who have obtained executive leadership positions, the existing literature is unclear regarding how much SMC has impacted their career trajectories or how they employ these tools themselves. We conducted a qualitative study using semistructured interviews with US family medicine department chairs to describe these leaders’ experiences and identify practices that promote diversity and inclusion.

Ensuring physician diversity is in the nation’s interest. ^5-7 Physician ethnicity and race are strong predictors of choosing primary care specialties and of caring for Medicaid and uninsured populations. Patients are more likely to adopt recommendations provided by culturally concordant physicians. ⁷ Hispanic and Black patients are more likely to live in lower socioeconomic communities than their White counterparts. ¹ Therefore, Hispanic and Black physicians have a larger role in caring for economically disadvantaged Hispanic and Black patients. ^{1, 2}

Academic medicine lacks faculty diversity, with URGs having minimal leadership representation. ⁸ URGs in medicine can include women, individuals from historically marginalized communities such as racial/ethnic minorities, sexual and gender minorities, and persons with disabilities. ⁵ For decades, the rates of matriculation for men and women have been similar. However, even with increased numbers, women dominate only at the instructor level. Women made up 13% and 12% of faculty in 2018 and 2019, respectively, mostly as assistant professors. Just 18% of department chairs were women during that same time period. ⁹ White men remain overrepresented in medicine. ¹⁰ Council of Academic Family Medicine (CAFM) data reveal that fewer than 30% of department chairs, program directors, medical student education directors, and research leaders identify as non-White, and less than 6% identify as Hispanic. About 12% to 13% of family medicine department chairs are Black, and only 30% are women. ^{11, 12}

In response to this underrepresentation, the Liaison Committee on Medical Education established diversity accreditation standards in 2009. Since then, the formerly declining numbers of women and Black matriculants have risen again, while the upward trend for Hispanic matriculants has continued. ¹³ Academic organizations are now apologizing for perpetuating, promoting, and failing to address racism, discrimination, and hate. ¹⁴ Additionally, more majority educational leaders are acknowledging the racial privilege that favored their access to medical education and leadership. ^{15, 16} Many in predominately White institutions understand the link between systemic marginalization of groups and their own privileges, derived from a racist system. ¹⁵ Increasingly, people are aware of their role in systemic racism, inequality, and stereotyping. ^{16, 17}

A CAFM task force focusing on identifying ways to enhance diversity in family medicine leadership concluded that the sponsoring, mentoring, and coaching of URGs needs improvement. ³ Moving forward, including URGs necessitates deliberate SMC, especially by senior leaders. Each of these activities is crucial for cultivating future health care leaders. ⁴ However, we previously found that academic leaders see mentoring, a longitudinal process aimed at career development through dialogue-based guidance, as more important than coaching and sponsoring. ¹⁸ Additionally, members of URGs are more successful when they receive high-quality mentorship. ¹⁹ However, few studies have explored URG’s mentorship experiences, and even fewer have explored their sponsoring and coaching experiences. Most studies highlighting the disparities have not suggested solutions.

URGs have worked in a psychologically unsafe environment for far too long. Edmondson described psychological safety in 1999 as “a shared belief held by members of a team that the team is safe for interpersonal risk taking.” ²⁰ More recently, psychological safety has been identified as the number one characteristic of successful high-performing teams, especially in work environments where employee and customer safety are critical, such as in health care. ^21-24 Our study focused on URGs’ experiences with SMC during their career development and their use of SMC in leadership roles. We also evaluated the provision and reception of SMC by URGs, even at senior levels, by studying family medicine department chairs’ experiences; given their extensive academic experience, their insights highlight the experiential differences between URGs and the majority. ¹⁸ Additionally, we identified strategies from their experiences that could enhance the SMC experiences of URG faculty and help create a more psychologically safe space.

Our study used semistructured interviews with US family medicine department chairs, conducted between December 2020 and May 2021. We employed a purposive sampling strategy, prioritizing the inclusion of URG chairs based on race, gender, and sexual orientation. Additionally, we focused on the geographic diversity of departments and institutional size to ensure representation from institutions across the country. Participants were recruited through email invitations for virtual interviews. Given our team’s composition, which included two chairs with a broad understanding of the chair community and the executive director of the Association of Departments of Family Medicine (ADFM), we had privileged access to a comprehensive list of chairs, complete with detailed demographics. In selecting URG chairs, we targeted individuals who either self-identified or were recognized within their communities as belonging to one or more URG categories. For non-URG chairs, our selection aimed to provide a contrast in experiences and perspectives, ensuring a wide-ranging understanding of the leadership landscape within family medicine departments.

The detailed methods, including the interview guide, were published previously. ²⁵ We aimed to understand the factors influencing the provision and reception of SMC. We focused on both the chairs’ experiences with and use of SMC in their current positions. After gathering the chairs’ experiences, we posed two reflective questions on how personal attributes impacted their SMC decisions and whether they perceived differential treatment in receiving SMC related to their attributes. These prompts centered on URG faculty leaders’ experiences and strategies supporting faculty development. Our study’s methodology aligns with phenomenological research, ²⁶ because it focuses on the lived experiences and perspectives of URG chairs in academic medicine. Participants self-identified their demographics at the interview’s end.

Our team included the project lead, M.A., a family physician, research methodology PhD, and immigrant who identifies as Arab; D.S., a White family medicine department chair; J.S.P., the first Black and first permanent women chair at her medical school; T.R., a White family medicine faculty member; and A.W., the executive director of ADFM, who has a decade of experience with department chairs. The diversity of the team contributed to a rich perspective during our analysis. Two team members (J.S.P. and D.S.) also were interviewees. All interviewees were deidentified, and their quotations were merged into the larger data pool without specific identification. Deidentified codes were reassigned toward the end of the analysis, ensuring impartiality and that the findings accurately reflected the collective experiences of the entire group, not merely a subset. The University of Washington Institutional Review Board approved the study.

M.A. and T.R. conducted Zoom interviews, which were audio-recorded and transcribed commercially. M.A. led data coding with NVivo 11 Pro (Lumivero) qualitative research software. In our initial coding of the interviews for the thematic analysis, the team explored the experiences of the department chairs, dividing the strategies they used to address challenges into coping strategies (by the person) and supportive strategies (by others). Our initial codes delved into a range of experiences that URG chairs encountered, such as feeling isolated, experiencing aggression, and facing the minority tax. From these observations, we identified key themes in the interviewees’ experiences. We revised our initial schematization of strategies as we saw potential alignment with a socioecological model, which added nuance and enhanced the potential usability of the strategies. This approach is consistent with the Association of American Medical Colleges’ (AAMC’s) framing of strategies for advancing diversity, equity, and inclusion in academic medicine. ²⁷ We adapted these spheres into individual, interpersonal, departmental, academic community, and institutional categories for our context. We developed, explained, and summarized themes from our analyses, supporting them with direct quotations. We ensured trustworthiness through consistent peer debriefing, iterative coding, and reflective practice, and by leveraging our team’s diverse backgrounds during the analysis.

We interviewed 20 chairs with a variety of backgrounds (Table 1). The participants shared their career experiences and perspectives, and outlined strategies to support URGs.

We identified themes in the experiences of URG chairs. Those themes, along with longer and exemplary quotes, are included in Table 2 and explained in the text that follows.

URG leaders were rare. Many chairs noted the severe underrepresentation of URGs as peers and role models during their careers and their experience of being surrounded by White male leaders. They also noted the strikingly low representation of Black men: “There are fewer black males in medical schools now than there were 30 years ago” (118). Despite this, some departments, notably those at historically Black colleges and universities (HBCUs) and those with a majority Hispanic faculty, maintained diversity.

Not walking into my grandmother’s kitchen. Amid departmental homogeneity, URG faculty often felt alienated, unacknowledged, and underestimated, commenting, for example,

Many women interviewees shared similar experiences of feeling overlooked at social events or during key conversations. When asserting themselves, Black faculty were often labeled as “angry.”

Experiencing aggression. Beyond subtle discrimination and microaggressions, some URG chairs faced harassment, intimidation, and derogatory comments. Power differentials in the White male-dominated environment were significant factors:

Some White male leaders continue to be oblivious of the experiences of URG faculty. Many participants felt that leaders supported those resembling themselves, primarily White men. While some White male participants recognized lack of understanding of URG faculty perspectives, others claimed color blindness, focusing solely on skills or qualities. Some even suggested that being White occasionally hindered their chances when selection favored URG, including women, for example, “Maybe I received more or better opportunities because I am a White male. And if anything, maybe sometimes it is a disadvantage, too, right?” (108).

Burdened with minority tax. URGs often overwork to prove themselves. Having few minority faculty members in departments leads to overburdening the few senior URGs, whose expertise as mentors is often sought from outside their institutions. Extra responsibilities come from diversity activities or committee service that benefit the institution more than the individual faculty member. Although minority status implied an excessive burden for many, some saw it as a door opener.

Moving to a more supportive institution. With little mentoring and support, some URG faculty felt stunted in their career development. When reflecting on their careers, many participants identified times when they felt they could not move forward or receive promotions and consequently left to find a more supportive environment, including HBCUs: “I needed to be in a different environment that is going to allow me to grow and develop” (104). At times, the hostility a person felt was related to a particular unsupportive leader, and the environment felt safer and more supportive when that leader was no longer there.

Building resiliency and antiracist work. Many URG leaders were motivated by a mission to serve the community and those who had been underrepresented: “That’s been kind of a driving force of in my career” (111). They also found refuge and a home in antiracism work, especially when surrounded by supportive colleagues, through whose lenses they saw the potential in others and recognized their own struggles.

We offer strategies recommended by our participants for empowering URG faculty. For brevity, a summary description from our analysis across all interviews as well as example quotes representing each of these strategies are included in Table 3, Table 4, Table 5.

Individual Strategies (Individual Faculty)

• Be proactive and confidently advocate for those with less power

• Seek honest feedback about your performance

• Identify the institution’s priorities and use them to select areas for your growth

• Do not underestimate your potential; embrace your vantage point

• Identify your allies and lean on your support system

Interpersonal Strategies (Faculty and Those Who Support Them)

• Develop genuine relationships and broad networks

• Find allies within the team

• Use your lens to identify those who need different or additional support

• Seek to understand the impacts of previous experiences while supporting individuals based on their goals and passions.

• Identify and consider the impact of your own biases

Departmental Strategies (Departmental Leaders)

• Offer mentors and coaches at the appropriate leadership level

• Find ways to measure career advancement using performance metrics that augment traditional value tools

• Promote involvement in state, regional, and national organizations

• Lead and be supportive when efforts to enhance antiracism and diversity present themselves

• Be aware that what works for one group may not work well for another

Academic Community Strategies (Organizations and Other

Formal or Informal Communities)

• Create diverse and welcoming environments

• Identify and address violations such as racism and sexism immediately

• Empower the person to say no

• Resist the minority tax

• Create additional opportunities for those who are impacted by bias

Institutional Strategies (Medical Schools, Health Systems, and Other Institutions)

• Create policies addressing inequity

• Provide opportunities for everyone

• Correct injustices

• Implement initiatives that center the community’s voice

Our study revealed the experiences of current URG family medicine department chairs. During their careers, they often have felt isolated and invisible, or worse, suffered discrimination. Our study identified multiple strategies that can be useful in improving the experiences of URGs in academia.

Many URG faculty described feeling isolated, or as one participant poignantly put it, not “walking into my grandmother’s kitchen.” As the usual pressures of academic productivity, administrative responsibilities, and even conflict accumulate and impact individual well-being, faculty may feel psychologically unsafe. Psychologically safe environments are those in which individuals feel safe to voice ideas, seek feedback, collaborate, take risks, and experiment. ²⁰ In these environments, employees can be authentic and not rejected by others because of who they are; they are respected and recognized for their competence. A longitudinal assessment by Google’s People Analytics unit found that psychological safety was the number one characteristic of successful high-performing teams ²² and that it is essential to enhancing safety in work environments such as health care and aviation. ^{23, 24} Unfortunately, our current study is consistent with older literature on the experience of URG faculty. In Pololi et al, URG faculty reported a low perception of relationships and inclusions. ²⁸ They judged their institutions lower on equity and efforts to improve diversity. Our study is also consistent with the framing of experiences of minorities influenced by elitism in academic medicine, where individuals experience exclusionary identification, racism, and aggression. ¹⁵

Additionally, URG faculty often are burdened with a minority tax. Our findings are consistent with the existing literature. ²⁸, ²⁹ Many URG faculty find themselves pushed to carry the burden of social justice efforts. The effects of a minority tax can be exacerbated by racism, lack of faculty development, lack of mentorship, isolation, and disproportionate expectations to do diversity work, which can result in minority faculty leaving academe. ^29- 31

Our approach in presenting strategies for support and coping is consistent with AAMC’s framing of strategies that can advance diversity, equity, and inclusion in academic medicine. ²⁷ The multilevel, multidomain approach promises to address the complexity of structural racism implicated in the failure of academic medicine to respond to the needs of communities. ³² Mentoring is crucial, given the experiences that URG faculty have in the unsupportive environments they described. South-Paul et al’s recent article outlined the evidence that mentoring serves as an effective solution for the challenges brought by a lack of diversity within academic medicine. ³³ While mentoring is known to have benefits for career and personal development, it also plays a unique and often unacknowledged role as a buffer for women and people of color, especially when they work in institutions that lack diversity. Mentoring helps in the development of future leadership, research, and programs within academic medicine and the health professions. ³³

Our study has important practical implications. URG faculty need training on strategies to empower their career development, along with funding and resources to attend the training. Some existing programs include Drexel University’s Executive Leadership in Academic Medicine program, ³⁴ the ADFM Leadership Education for Academic Development and Success program, ³⁵ the Minority Faculty Leadership Development Seminar from the Association of American Medical Colleges, ³⁶ and the Society of Teachers of Family Medicine’s Underrepresented in Medicine Leadership Pathways in Academic Medicine course. ³⁷ A notable challenge, as highlighted by a CAFM task force, involves not only the direct costs and time commitments but also the lack of institutional financial support for URG faculty to attend such training. Additionally, the requirement for external referees, who are not always accessible to URGs, further complicates this issue. ³ Department chairs are in a key position to influence the future of URGs in family medicine by directing resources that can positively impact the future of junior URG faculty. The ultimate test of their success will be an increase in URG faculty assuming leadership roles.

Our study’s strengths lie in the diversity of the interviewed chairs, who revealed a wealth of experiences and perspectives. The use of semistructured interviews facilitated the exploration of an array of emergent topics. The limitations of the study include the fact that the interviewees did not represent the entire spectrum of chair experiences, and they did not fully capture the vast ethnic and racial diversity of the United States. As a result, some viewpoints remain unrepresented. Future studies could investigate effective strategies employed by chairs in supporting URG faculty and evaluate the impact of such strategies on career development.