Academic departments across the country and across disciplines have been grappling with the consequences of racism and the question of how to take action against it. Departments of psychiatry are in a particularly challenging position. This article describes steps that academic departments can take toward racial equity.
Role of Race in Academia
As psychiatrists, some of us have understood just how much suffering is caused by racism. And yet, departments of psychiatry find themselves in this moment with a striking lack of representation of Black faculty, long-standing racial disparities in access to mental health services, and an awareness of having done nothing to contest the structural racism that is reproduced in the field of medicine, within our organizations (as departments of psychiatry and schools of medicine), and within our larger institutions (state and national policies). This structural form of racism in the United States is no longer being overlooked and is now recognized as the result of a nation that was purposely constructed to uphold a system that affords resources and opportunities implicitly based upon race.1 We seek here to describe the current impact of various levels of racism on academic departments of psychiatry and to offer an organizational approach to begin dismantling the structural stronghold of racism within an academic department, as well as to work against its sequelae. Our use of the term “organizational” is purposeful in this effort given that organizations are key to operationalizing (or challenging) the structural facets of racism because they are by definition inhabited spaces where relations and processes are formed, transformed, perpetuated, and/or destroyed.2 Whereas seasoned social scientists will argue our nation's racialized hierarchical system precludes any real change, they do identify social movements as one of the few mechanisms, and perhaps the only, that can potentially dismantle racism, at least within organizations.3,4 Therefore, addressing structural racism within academia is not only warranted, but the timing is critical for greatest impact to be realized and potentially sustained.
Disparities in Black Faculty
According to the most recent Association of American Medical College survey, 3.5% of medical school faculty identify as Black and 3.2% as Latinx, with an additional 2.3% identifying with multiple races including Latinx.5 In departments of Psychiatry, 3.6% of full-time faculty identify as Black, 3.5% identify as Latinx, and 2% identify as multiracial including Latinx. Similarly low proportions of Black- and Latinx-identifying full-time faculty in academic departments of Psychiatry are medical doctors (2.3% and 2.4%, respectively). At the time of the survey, there were 18 (1.7%) Black and 29 (2.7%) Latinx tenured faculty in departments of Psychiatry in the US. There were 34 (2.6%) Black and 38 (3%) Latinx faculty on tenure tracks. These proportions translate into an overwhelming majority of Black and Latinx Psychiatry faculty holding lower ranking appointments of Instructor or Assistant Professor (73% and 72%, respectively).5 Nationwide, 2% of psychiatrists, 2% of psychologists, and 4% of clinical social workers identity as Black.6 Lett et al.7 have shown that despite some attention to the issue of representation, under-representation of Black and Latinx faculty worsened in psychiatry from 1990 to 2016, as it did in medicine in general. There has been little improvement in rates of matriculation of under-represented students in medical schools.8 Additionally, faculty belonging to groups under-represented in medicine (URiM) are half as likely as White and non-URiM faculty to be retained in academic centers.9
Problems of pipeline and retention are compounded by racial disparities in National Institutes of Health (NIH) funding to individual Black and White investigators. These disparities persist when traditional measures of scientific achievement are taken into account, suggesting that racism contributes to the disparity. White investigators are up to 1.7 times more likely to have an R01 grant funded.10 It has been shown that 20% of this disparity can be attributed to institute preference for research topics related to cellular and molecular science as opposed to population-based interventions in which health disparities research is most prominent.11 Whereas the NIH places disproportionately lower value on this type of research (based on funding priorities), Black investigators are more likely to propose research on these topics.11 Although NIH grant reviewers preferred basic science and biologically informed clinical research grant proposals over grant proposals focused on population health and intervention research (typically employed in the study of disparities), there was no empirical justification for this preference when scientific impact was measured.11 In fact, disparities research topics were found to be more scientifically influential than the basic science research topic areas. This represents a core structural obstacle for tenure appointments and promotion for Black researchers in academia given that securing NIH funding is the primary metric for faculty promotion and retention in academic organizations. However, recommendations to remedy or at least contest this faculty racial disparity continues to rely upon diversity strategies of increasing the number of Black investigators and in some instances improving mentorship without any acknowledgment or actions against the racialized organizational and institutional inequities that underlie these disparities and, in turn, render such diversity efforts futile.
Offices of diversity in academic centers are often performing herculean tasks related to community engagement, faculty recruitment and retention, and the medical center culture and environment for under-represented faculty and learners. Very often, diversity leaders perform this work across an academic organization with fewer resources than are typically allocated for much smaller, intra-departmental operations. The majority of staff and leaders who run offices of diversity are Black and Latinx. Similar to the lack of value attributed to disparities research by NIH, disparities in resources allocated to faculty recruitment and retention within academia reinforces a racist ideology that diversity and inclusion work is not valued, less impactful, and, therefore, less worthy of resources, support, and merit than that afforded to “mainstream” funding needs.12
The conditions of Black faculty in departments of psychiatry are most certainly connected to current racial mental health disparities. Black patients have disproportionately low rates of receiving outpatient psychiatric care or a prescription for psychiatric medication across illness severity.13 However, Black patients are over-represented among psychiatric inpatients, indicating a significant unmet mental health need. This unmet need can be attributed in part to lack of access to adequate insurance and/or affordable mental health care.13 It is also known that when Black patients are able to access treatment, that treatment is less likely to meet basic standards of care.14 It has been repeatedly shown that patient satisfaction, participation, and adherence to care, which are factors that are likely to improve health outcomes, are improved in Black patients in particular by access to a Black physician.15,16
Root Cause of Structural Racism and Disrupting Its Reproduction
The United States was founded upon an unfair social structure based on race, which in turn reinforced organizational formation (eg, medical schools) with hierarchies and processes that have not been racially contested. Instead, academic environments have operated as race-neutral spaces where the more visible form of racism—racism experienced on a personal level—is typically acknowledged. However, the “invisible” form of racism—racism experienced through the structural formation of academia—has largely remained overlooked. It is not a surprise, then, that multiple levels and forms of racism affect the physician workforce, the availability and advancement of research focused on race-driven disparities, and patient outcomes. Centuries of unchallenged structural racism in the US has erupted into national and global protests that were understandably triggered by the Black Lives Matter (BLM) response to the murder of George Floyd, and the subsequent ongoing killings of Black people by the police. Leaders from both public and private sectors have publicized written responses of solidarity with BLM.17 Immediately following expressions of commitment, these leaders have been called upon to do more than express support for and promises of creating equity in their organizations, including academia. Although there is wide agreement that statements of solidarity for anti-racist and equity movements are insufficient, how to successfully approach departmental and organizational action is not yet known.
There is debate about whether strategic plans are helpful or whether they offer only a false sense of having addressed problems of representation.18 It is widely agreed upon that improving representation is necessary but not sufficient to reduce racism in health care and in health care professions, but how inclusion and equity work should begin prioritizing how to contend with racialized organizations and larger institutions remains an open question. Discussions of who should lead anti-racist efforts often lead to concern about the “minority tax” or the “majority subsidy.”19,20 Although suggestions to remedy these concerns often suggest sharing of work against racism with URiM and non-URiM faculty, these efforts should clearly be led by people under-represented in medicine and public health.
It remains unclear how best to approach the removal of racist ideology and accompanying practices among faculty and physicians. Many organizational leaders have instituted either mandatory or voluntary implicit bias training for their employees, using Harvard's well-known Implicit Association Test ( https://implicit.harvard.edu/implicit/index.jsp), which has been shown to affect patient experiences and outcomes. However, it is not clear if and how these trainings might modify implicit racist attitudes identified, and what type of follow-up training and education should follow.21 For instance, even if someone discovers they may have an unconscious bias against a particular type of person or group, such information does not necessarily translate into anti-racist behavior. Even if the Implicit Association Test reveals empirical evidence of impact on individual behavior, it cannot be the primary strategy for undoing structural racism, which requires going beyond the individual (eg, hiring, retention, and promotion processes; unyielding support for equity efforts; leadership-supported equity efforts to contest racialized hierarchy).
Educational approaches centered on a patient's individual culture are similarly narrow and oversimplified, risking further entrenchment into racist stereotypes and ideas.22,23 For instance, the idea of becoming “competent” in a culture suggests that the provider enters into a place of “knowing” about that culture (after attending a training in cultural competency), and this opens the door to unintentional bias, causing more damage for the patient. Structural competency education offers an educational approach that seeks to include structural determinants of health and the ways in which a mental health provider may work to address structural barriers to care.24 Unfortunately, cultural competence in its most narrow form persists in medical school and residency curricula, and although well intended, more research is needed on how to put structural competency into practice without risk of stereotypes.
The conflicts we have presented in both practice and ideology surely cause an adequate level of incoherence to preclude meaningful action of any kind. Work against racism in medicine operates similarly as in other organizational sectors of society, with unspoken racial hierarchies established at the founding of American society.1 This social construction of race not only created whiteness as a “credential,” but gave it legal status for the sole purpose of attaching material and nonmaterial resources and power to those defined as White, and nonattachment to resources to people legally defined as Black.2,25 Although legal definitions of race have been removed from state law in the US, being a White person continues to provide access to organizational resources, legitimizing work hierarchies. We can use our expertise as academicians, researchers, and clinicians to develop initial approaches to address racism within our departments with the understanding that each department will need an individualized plan that will shift as the needs of the department do.
Beyond Traditional Diversity and Inclusion Strategies to Contest Racism
We offer an approach that is foundational rather than singular and that begins to address the multiple issues that we have described above and that have served to perpetuate lack of diversity, inequity in working conditions and patient care, and racist conditions in academic departments of psychiatry. This will be particularly challenging to faculty members given our tendency to work toward developing specific expertise and progressing within that area. Because of the systemic and ubiquitous nature of racism, departments must address racism clinically, educationally, and organizationally, using all the skills required of academic faculty. This work must be done in a manner that resists the traditional racist hierarchies through which White faculty members are celebrated and Black faculty are unrecognized—both implicitly and explicitly. Finally, if this work is to be shared among the department (and this is the primary goal), then anti-racist organizational processes can begin to take form, a more fair and just departmental structure begins to be created, and no particular person(s) effort is relied upon, resulting in a new equitable organizational norm. In the following text, we describe the pillars of a strategy for organizational equity in academic departments of psychiatry, one that our own department is working to implement and evaluate.
Departments of psychiatry will need to invest in hiring or transitioning faculty to lead efforts against all levels of racism. We suggest a team of at least two people at the Director level or above rather than a single leader, and this team should have paid, dedicated time for these leadership positions and will work primarily within their departments as well as across their wider institution to draw upon different perspectives and expertise. Administrative support, direct reporting to the department Chair, and Chair-supported discussion with the executive leadership are important to ensure wide engagement and support for anti-racist initiatives. This leadership team will require institutional resources for recruitment and retention efforts, including resources needed to facilitate promotion of Black faculty to meaningful leadership positions.
To address the difficult issues of hiring faculty into positions that often result in feelings of isolation and low satisfaction, cluster hiring, in which an intentional cluster of faculty are recruited to promote impactful scholarship in a particular shared area of focus and/or to promote faculty diversity, should be considered.26 For example, a department could commit to building departmental excellence in the area of mental health disparities. Hiring would prioritize diversity and should be flexible in terms of academic seniority and specific areas of expertise according to that department's existing strengths and needs.
Assessment to Guide Action
Every department will undoubtedly need to address representation and racial equity for faculty and trainees, faculty and trainee development to recognize and act against racism, and racism in patient care. However, the extent and nature of these challenges will differ across departments. We suggest regular assessments of faculty pay and promotions by race as well as assessments of current representation of Black and Latinx faculty and trainees to compare to the patient population served by the department. We suggest that departments develop hiring plans and examine pay and promotion policies that reproduce structural racism and address any specific disparities and diversity needs that are found. Similarly, we suggest that departments survey faculty, trainees, and staff for racist attitudes and beliefs to guide development of targeted training and curricula based on these findings. These attitudes and beliefs should be tracked over time for course correction. A scholarly practice of sharing the results of this work is recommended, as in any area of faculty development and trainee education. In addition to diversity and educational needs, we recommend assessments of clinical services from the perspectives of patients, faculty, trainees, and staff for racist and anti-racist practices and/or experiences. Finally, ongoing investigations of disparities in mental health outcomes are needed, including access and engagement in quality care to further guide ongoing quality improvement for Black patients.
Building faculty and trainee capacity to engage in conversations about race that goes beyond individual identity or personal experiences is essential to the goal of revealing racialized organizational structures that have existed as mainstream operations and processes, and to creating “agency” within the department that resists the macro-level institutionalized racism within which the department resides. Human agency within organizations can create new mechanisms to adjust departmental culture such that anti-racist processes become the normative mainstream processes and relations of the department.
We suggest required faculty and nonclinical staff development training on the root causes of structural racism, white privilege, and allyship, as well as department-wide conversations about these topics.27 Departmental leaders should also participate in inclusive leadership training with a goal of understanding their specific roles, responsibilities, and entry points to move forward anti-racist efforts. Understanding that members of a department may bring forward concerns at different times, listening sessions and multiple routes for engagement are essential, as are model interracial conversations about structural racism and inequity.
It is very clear that working toward racial equity is essential. However, leadership must buy into explicit efforts to challenge organizational hierarchy and partner with Black faculty designated to lead these efforts. Without initial bold support from White organizational leaders, even high-ranking faculty of color charged with diversity and equity efforts will be burdened with expectations to conform to expected normative relations and hierarchies, will experience racial discrimination, and will be forced to navigate White emotional discomfort and/or expectations. We can and must commit to acting against racism, collaborating across departments to share resources and lessons learned, and building on this literature and experiences (good and bad) to determine best practices. These are efforts currently underway, including in our own department, with evaluations to come over the next 12 months.
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