Inclusive endocrine workforce requires diverse networks, mentors
Diversity and inclusion in the science and health care workforce remain low, and endocrinology is no exception.
Data show racial and ethnic concordance between health care providers and their patients is associated with important and positive outcomes, including improved academic and workforce environments, increased access to care and reductions in health care disparities. Patients and physicians, too, report better communication and higher satisfaction with care, as well as better adherence to therapies, when there is increased diversity among staff and leadership at the office or institution. Still, in 2021, the endocrine workforce remains predominantly white.
“If I look at the majority of my colleagues that I interact with, I can tell you that 95% of them are not endocrinologists of color,” Ricardo Correa, MD, EsD, FACE, FACP, CMQ, program director of endocrinology fellowship and director for diversity at the University of Arizona College of Medicine-Phoenix and the Phoenix Veterans Affairs Medical Center, told Endocrine Today. “I am involved with national organizations that involve people of color, like the National Hispanic Medical Association. There I find endocrinologists from underrepresented groups. I also trained at the University of Miami, which helped me create a network with four friends who chose endocrinology and happened to be Hispanic, but this does not necessarily represent what is out there.”
According to 2018 data from the Association of American Medical Colleges, of the 7,757 endocrinologists/diabetes specialists listed in the AMA Physician Master File, 256 were Black, 574 were Hispanic (alone or with any race) and only six were American Indian or Native Alaskan; 1,971 were Asian and 3,784 were white. Race/ethnicity was “unknown” for 1,024 of the total.
The Endocrine Society told Endocrine Today it does not have available data on the breakdown of its members by race. The American Association of Clinical Endocrinology plans to conduct member research that will assess race and ethnicity this year, according to a spokesperson.
Race and ethnic disparities exist against the backdrop of a shortage of U.S. endocrinologists, in general, and an increasing incidence of endocrine and metabolic disorders, in particular, diabetes that disproportionately affects ethnic minorities. At the same time, a pandemic exposing race and health disparities, along with renewed demands for racial and social justice, puts a sharper spotlight on the need to increase representation in endocrine care, according to experts.
“If we want to have an impact on endocrine clinical care and research discovery, it requires representation, perspective and experience,” Felicia Hill-Briggs, PhD, ABPP, professor of medicine and senior director of population health research and development at Johns Hopkins University School of Medicine, and former president of health care and education for the American Diabetes Association, told Endocrine Today. “Our endocrine workforces in the U.S. largely remain homogeneous, but the populations we serve — and the populations who are most in need — are not. Also, the scope and the scale of the problems we treat are as heterogeneous as the population itself. Diversity must be represented in our workforces if we are going to get what we do right and if we want to ensure our solutions will actually be a fit for the populations we serve.”
Underrepresentation in medicine, research
According to the Association of American Medical Colleges report, Black adults make up 13% of the U.S. population, yet represent only 6% of medical school matriculates and graduates and 4% of physicians and medical school faculty. Asian and white men make up approximately 35% of undergraduate medical degrees and 43% of biomedical doctorates, yet 83% of full professorships in academic medicine.
“The number of Black men attending medical school now is less than the number of Black men attending medical school 5 years ago,” E. Dale Abel, MD, PhD, chair of the department of internal medicine and director of the Fraternal Order of Eagles Diabetes Research Center at the University of Iowa Carver College of Medicine, and immediate past president of the Endocrine Society, told Endocrine Today. “This speaks to the fact that, perhaps, it isn’t just about having a degree. It isn’t just having a good MCAT score. It is also about having access to shadowing physicians, being in a position to go work in a professor’s lab. There are all of these other boxes that need to be checked off to be successful. It becomes very challenging for individuals who are less well connected to check all of those boxes. The bar is set in such a way that it requires a large network of supporting elements that many take for granted to reach it.”
Endocrine conditions also disproportionately affect those from underrepresented groups. Obesity is more prevalent among Black and Hispanic adolescents and adults; type 2 diabetes rates are higher among Native Americans and Alaska Natives, Black and Hispanic adults compared with whites.
“To address these health disparities, it is critically important that the team of researchers addressing these diseases also reflect the communities that are most impacted,” Griffin P. Rodgers, MD, MACP, director of the National Institute of Diabetes and Digestive and Kidney Diseases, part of the NIH, told Endocrine Today. “Diverse researchers can bring vital perspectives to help us better understand not just the genetic bases, but also the social determinants of these health conditions.”
The lack of representation in endocrine care “limits the range of what is possible,” even before a patient enters the room, Hill-Briggs said.
“Solving big problems can only happen effectively when we are able to see from a different vantage point,” Hill-Briggs said. “We must have an alternate perspective from whatever is the established or the norm or the current. Homogeneity kills effective problem-solving.”
Without a diverse clinical staff, there are also “blind spots” when it comes to thinking about biases, according to Camille E. Powe, MD, an endocrinologist, co-founder and co-director of the Diabetes in Pregnancy Program and assistant professor of medicine at Massachusetts General Hospital and Harvard Medical School.
“As a result, we see manifestations of systemic racism and the access to care people are getting,” Powe told Endocrine Today. “One example in my field of diabetes is there has been research suggesting that minority patients with type 1 diabetes do not have access to diabetes technology at the same rate as white patients. It is likely they are not being offered technology at the same level as other patients, and there may be other factors at play, but that is one we as endocrinologists have control over. By including everyone in our clinical workforce, we enhance the care we are able to give to everyone. We can fight against those forces of systemic racism.”
Fighting ‘imposter syndrome’
The reasons behind such workforce disparities are complex, Abel said. Individual and structural racism play a large role; a long history of unequal access to education has shut out many underrepresented groups from opportunities afforded to white individuals for generations. At the college level, individuals from less advantaged backgrounds often are forced to juggle work and school or family obligations, as well as lack of access to support structures.
“All of these things generate significant headwinds toward advancement,” Abel said.
Along the endocrine career track, a lack of training on how to effectively navigate key transition points is another issue, he said — particularly for those without access to a strong network of mentors.
“For example, how does one learn how to successfully compete for the best postdoctoral fellowship?” Abel said. “How do you know how to evaluate what a good mentor looks like? How do you learn to evaluate the funding status of a lab? These are things you may learn through the network, and it’s another reason why there is falloff [along the career trajectory].”
Diverse role models in senior positions are also lacking, Abel said.
“The percentage of Black or underrepresented women who are full professors is 1% or 2%,” Abel said. “If you are an undergrad looking for a role model who may look more like you or have a similar history, guess what? You are not going to see that role model anywhere. And it makes one wonder, is this something I can even achieve?”
All of this can lead to endocrine trainees who may feel like they do not belong, Abel said.
“When I’ve worked with young people through the Future Leaders Advancing Research in Endocrinology (FLARE) program, one thing that has often come up is imposter syndrome,” Abel said. “It is, you’re bright, you’re motivated, but you go into a situation where you are the only person of color and you wonder, what am I doing here? Or is the real reason you are here because a person gave you some special break, or you’re fulfilling a quota? Many people feel this way, and because of that, they may feel inhibited to negotiate for the kinds of things they need to advance.”
Individuals from underrepresented groups take note of the makeup of a program or division, Correa said.
“When I have interviewed for jobs, I have always tried to look at that — is there someone like me in this division?” Correa said. “Also, how is that person treated in the division? If I feel that person is treated like a second-class citizen, then I do not want to be a part of that institution. But if I feel that person is integrated with the group, and their voice is heard, that matters.”
Professional societies along with the NIDDK have made efforts to increase representation in the endocrine workforce.
In 2013, the Endocrine Society launched the FLARE program, with support from the NIDDK’s Partnership with Professional Societies to Enhance Scientific Workforce Diversity and Promote Scientific Leadership funding opportunity. FLARE is designed for trainees and junior faculty from underrepresented minority communities who have demonstrated achievement in endocrine research. The program, which includes in-person (currently virtual) workshops, on-site mentoring and networking events, has funding to support 25 fellows per year. To date, about 150 fellows have completed the FLARE program.
“It’s so important for me, and for a lot of junior minority faculty, to establish a network,” said Powe, also a FLARE fellow. “You need people from outside of your institution who are going to do things like write promotion letters. In fact, because of FLARE, one of the faculty there did write me a letter to help with my academic promotion. Minority trainees and junior faculty sometimes do not have the level of network that people in the majority have. Having something like FLARE to help you establish that network is a real component of the program for me.”
Hill-Briggs, who said her mentors have been primarily men, now strives to mentor other young trainees and junior faculty.
“I have never had, directly, an African American mentor in this work,” Hill-Briggs said.
To counter that experience, she consciously seeks to mentor broadly.
“I accept invitations to speak at large conferences where I will be on the podium and my personhood can be seen. I accept opportunities to talk about these issues, so in as many ways as possible, these messages can be found by diverse folks. I serve as a mentor for the NIH programs to increase the pipeline. I take high school students for the summer programs and bring them in to do research. I mentor junior faculty anywhere in the country who are seeking my advice. People know — it has gotten around — if they are facing a situation and don’t know what to do, if I am able to bring experience to help, I am willing to do that. I like to do that.”
Promising programs and strategies exist to promote diversity, equity and inclusion, said Correa, also a member of the AMA’s International Medical Graduates Section Governing Council. At the leadership level, diversity and inclusion efforts must be integrated into broader efforts by establishing goals and metrics and holding leaders accountable. All search committees should undergo implicit bias training and focus on intervention, not just bias recognition. Training programs must offer leadership internships that target underrepresented groups and leverage existing resources and networks to develop a more robust database of leadership diversity.
In graduate medical education, Correa and colleagues recently introduced a holistic review of applications for residents and fellows that includes blinding gender, ethnicity and race of applicants.“This is about looking at the person as a whole: their CV, the letters of recommendation and personal statement, as well as putting a lot of value in things people have done for diversity and inclusion,” Correa said. “The second part is the interview process, which means training interviewers on unconscious bias, using standardized interview questions, and adding someone from the diversity and inclusion office to come and interview who will ask questions about things like microaggression, bias and inclusion. We have received very good feedback about this.”
NIDDK is developing a 5-year strategic plan, which will include as one of its priorities the advancement of research training and career development to promote a talented, diverse biomedical research workforce, Rodgers said.
“As proud as I am of NIDDK’s strides to strengthen the pipeline of diverse biomedical researchers, we still have much more work to do,” Rodgers said. “The rates at which researchers from underrepresented minority groups are being hired and retained is still much lower than that of their nonminority counterparts. As we move forward, we’ll be examining where along the career trajectory we need to most strengthen our efforts, so that minority investigators have equal opportunities for career advancement and success.”
Correa said it is important for institutions to realize that diversity is not achieved by reaching a predetermined number of hires from underrepresented groups.
“You can be very diverse, but not inclusive,” Correa said. “Both must happen together. Diversity is when you are invited to a party. Inclusion is when you are one of the organizers of that party. This effort is not about percentages. An institution can claim it has a diverse endocrine division, but those from underrepresented backgrounds should also be in a position to make change.”
- AAMC. Diversity in Medicine: Facts and Figures 2019. Available at: www.aamc.org/data-reports/workforce/report/diversity-medicine-facts-and-figures-2019. Accessed: Jan. 26, 2021.
- For more information:
- E. Dale Abel, MD, PhD, can be reached at the University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Fraternal Order of Eagles Diabetes Research Center, 169 Newton Road, 4312 Pappajohn Biomedical Discovery Building, Iowa City, IA 52242; email: firstname.lastname@example.org; Twitter: @IntMedAbel.
- Ricardo Correa, MD, EsD, FACE, FACP, CMQ, can be reached at the University of Arizona College of Medicine-Phoenix, 475 N. Fifth St., Phoenix, AZ 85004; email: email@example.com; Twitter: @drricardocorrea.
- Felicia Hill-Briggs, PhD, ABPP, can be reached at Johns Hopkins University and Medicine, 2024 E. Monument St., Suite 2-518; Baltimore, MD 21287; email: firstname.lastname@example.org; Twitter: @Dr_Hill_Briggs.
- Camille E. Powe, MD, can be reached at Massachusetts General Hospital, Diabetes Unit, 50 Staniford St., Third Floor, Boston, MA 02114; Twitter: @CEPoweMD.
- Griffin P. Rodgers, MD, MACP, can be reached at the National Institute of Diabetes and Digestive and Kidney Diseases, 31 Center Drive, Bethesda, MD 20892; email: niddkmedia@ niddk.nih.gov; Twitter: @NIDDKgov.