key: cord-0741738-nli66ln6 authors: Oh, Laura; Linden, Judith A.; Zeidan, Amy; Salhi, Bisan; Lema, Penelope C.; Pierce, Ava E.; Greene, Andrea L.; Werner, Sandra L.; Heron, Sheryl L.; Lall,, Michelle D.; Finnell, John T.; Franks, Nicole; Battaglioli, Nicole J.; Haber, Jordana; Sampson, Christopher; Fisher, Jonathan; Pillow, M. Tyson; Doshi, Ankur A.; Lo, Bruce title: Overcoming barriers to promotion for women and underrepresented in medicine faculty in academic emergency medicine date: 2021-12-21 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12552 sha: 987bd16c2f9c7df63e37883758cfcc862b25cd4d doc_id: 741738 cord_uid: nli66ln6 Equity in the promotion of women and underrepresented minorities (URiM) is essential for the advancement of academic emergency medicine and the specialty as a whole. Forward‐thinking healthcare organizations can best position themselves to optimally care for an increasingly diverse patient population and mentor trainees by championing increased diversity in senior faculty ranks, leadership, and governance roles. This article explores several potential solutions to addressing inequities that hinder the advancement of women and URiM faculty. It is intended to complement the recently approved American College of Emergency Physicians (ACEP) policy statement aimed at overcoming barriers to promotion of women and URiM faculty in academic emergency medicine. This policy statement was jointly released and supported by the Society for Academic Emergency Medicine (SAEM), American Academy of Emergency Medicine (AAEM), and the Association of Academic Chairs of Emergency Medicine (AACEM). of emergency medicine faculty. 6, 7 Seven percent of associate professors and less than 6% of full professors in emergency medicine are URiM, making equity in promotion even more critical in this cohort. 8 Yet, equitable promotion and academic advancement of women and URiM faculty require ongoing efforts and initiatives beyond the recruitment of a diverse workforce. This paper examines barriers to promotion that disproportionately affect women and URiM emergency medicine faculty. We suggest ways that individuals, departments, institutions, and emergency medicine organizations can help women and URiM faculty overcome barriers to academic advancement. Women and URiM faculty are more likely to achieve promotion if they understand the granular details of the promotion process and have a clear plan for promotion. Open discussion regarding promotion should be initiated early in the recruitment process and revisited at regular intervals after hiring. 9, 10 The department and faculty member should be in sync regarding the value, criteria, and expected timelines for pro- Mentorship is a critical element of successful recruitment, retention, and academic advancement of women and URiM faculty. It is invaluable to personal and professional development. Mentorship has been associated with higher career satisfaction, increased scholarly productivity, successful promotion, and a desire to mentor others in turn. [12] [13] [14] [15] Women and URiM faculty, however, are less likely to have a mentor compared to male or non-URiM colleagues. 14, 15 This may be because of the relative underrepresentation of female and URiM faculty in senior positions. 14, 15 Solutions can be based on systems and networks aimed at enhancing or redesigning the existing frameworks of support. At the departmental level, resources should be allocated to fund mentorship and networking programs focused on URiM and women faculty. On an institutional level, interdepartmental resources and opportunities for mentorship can be centralized. This may include training and leveraging non-URiM and/or male faculty to specifically mentor women and URiM physicians. Prior research has shown that gender concordance between mentor/mentee pairs is not a prerequisite for effective mentorship. 15 Given the aforementioned inequities in academic representation, it is critical to include men and non-URiM faculty as allies and mentors of their women and URiM colleagues. Should women or URiM mentors be needed or desired, department leaders should connect faculty with mentors of similar identity outside of their own department or institution. A lack of dedicated time for mentors has been cited as a major barrier to the development of mentorship programs. 16 Possible solutions include the exploration of creative mentoring models other than a traditional dyad model (experienced mentor paired with mentee). Functional mentorship pairs a mentor with a mentee for guidance on a specific project. 17 Peer mentorship and facilitated peer mentorship, where peer cohorts are overseen by a senior supervising mentor, allow for reciprocal information sharing and mutual support. [16] [17] [18] In group mentorship, a mentor meets with several mentees simultaneously. 18 Telementoring or distance mentorship uses experts from outside institutions or even outside fields (ie, business or government). 13, 17 Ultimately, an expanded view of mentorship that uses some combination of the above models may be more beneficial than a traditional single mentor. It is unlikely that a single person can fulfill all the mentorship needs of an individual throughout their career. 19 Departmental leadership can assist faculty members in creating mentorship networks based on individual needs and preferences. 19 Finally, although mentorship is essential, it is not sufficient for academic advancement and promotion. It is possible to be "over- Many URiM faculty note a misalignment between their distinctive experiences and personal goals and the priorities of their institutions. Several key terms and concepts have been used in the literature to describe the basis of these misalignments. One such term is the "distance traveled," a concept that highlights differences (often related to socioeconomic factors) among some URiM faculty in the path to their present position. 23 Examples of this include extended time to earn a college degree or delayed start of medical school because personal financial obligations. 23 Another term, the "gratitude tax" is the perception of indebtedness that URiM faculty may have towards an institution for the opportunity given to become a physician; the debt is paid by remaining at the institution despite promising opportunities for advancement elsewhere. 23 The "minority tax" refers to extra responsibilities related to diversity committees, community efforts, and mentorship of URiM students. 23, 24 These commitments rarely come with dedicated time or resources. 23, 24 This curtails the time to pursue critical scholarly work that is often more valued in the promotion process. The additive effects of distance traveled, gratitude tax, and the minority tax can delay advancement to senior faculty rank. "Power distance" is defined as the extent to which a person with lower perceived power in an institution or organization expects and accepts that power is distributed unequally. 23, 25, 26 URiM faculty may not challenge department leaders out of fear or inconvenience. When URiM numbers are so few, "the goal is survival." 23 The consequences of not being able to share dissenting opinions may include feelings of isolation and disengagement with the institution. As a result of these "taxes" and barriers, URiM faculty can feel overburdened, undervalued, and demoralized. Recommendations for intervention include familiarizing leadership with the above concepts and allocating more resources and time to individual URiM faculty who have had a longer "distance traveled." Effort can be made to create a workplace culture where faculties feel safe to voice dissenting opinions. 23 During the creation of project teams, the selection of more than one URiM faculty or woman can alleviate additional pressures that stem from fears that failure will reinforce preexisting stereotypes or prejudices. 9 On a national level, professional development groups (PDGs) or specialized academies can help alleviate feelings of isolation. Amplification of achievements by department leadership, colleagues, and professional groups can contribute to a sense of inclusion. 11 Awards committees should track the nominations of deserving URiM and women faculty for departmental, institutional, and national awards. This allows for equity in recognition of accomplishments. Other areas that may contribute to the funding gap include research topic choice, differences in mentorship, size of professional networks, and research productivity. 30 The coronavirus disease (COVID-19) pandemic, however, may be creating gender gaps in publication. 37 Before the pandemic, married or partnered female physician-researchers reported spending 8.5 more hours per week on parenting and domestic activities in comparison to their male physician-researcher counterparts. 38 The work of this "second shift," or labor performed at home outside of professional activities, has increased for both men and women during the COVID-19 pandemic but has impacted women more because of the uneven distribution of labor. 39 In a more recent study, a preliminary analy-sis using author-name recognition of pre-print publications has shown that across disciplines, the proportion of women first authors has decreased during the pandemic and women are also initiating fewer research projects. 37 Promotion to associate and full professor depends highly on a strong national and international reputation, at least partially based on scholarship. Our specialty and society should strive to achieve equity of opportunity in terms of manuscript authorship, peer review, and editorial board membership. Departments and institutions can assist women and URiM faculty by providing targeted funding opportunities for pilot studies, providing scholarships for grant writing workshops, and additional mentorship and sponsorship. Finally, departments and institutions can adopt processes that lighten the load of the "second shift," such as extended hours and emergency childcare services and/or subsidies for faculty with increased time requirements for child, family, and eldercare. In 2015, McKinsey & Company and LeanIn.Org launched a study of diversity in the workplace, gathering data from 600 companies. 40 The study found that the biggest obstacle to climbing to a leadership position occurred early on; women and minority employees failed to advance because they could not step up onto the first rung of initial managerial positions. This "broken rung" impacted the organization by Companies that were effective in repairing the "broken rung" (1) tracked and publicized diversity metrics and goals, (2) set targets for representation in first-level managerial positions, (3) held senior leaders accountable for the hire, promotion, retention, training, and mentorship of women and URiM employees, and (4) incentivized leadership through rewards. 40 Fixing the "broken rung" alone is not enough: only 18% of medical school deans are women and 12% are minorities. 41 Without a major shift in the status quo, it will take 50 years to reach gender parity in academic medicine. 41 Letters for women often emphasize their effort more than their ability Avoid grindstone terms such as "hard-working, tireless" Emphasize talents and unique accomplishments create new opportunities for women and URiM leaders. Planned turnover after a reasonable term length allows for a balance between continuity and the innovation that comes with diverse leadership. 41 A fair promotion process requires a holistic review of applicants and their accomplishments. Decision making for promotion and tenure has been described as a balance between rules and goals. 42 The "rules" may require that the candidate has a certain number of papers, lectures, and courses. The "goals" are more intangible and take into consideration an applicant's qualities such as innovation, leadership, and service. APT committees should be composed of diverse faculty who recognize that career trajectories vary between faculties. Committee members should also receive unconscious bias training. [43] [44] [45] APT committees rely heavily on letters of support written by faculty at or above the level of promotion. Prior studies looking at differences in letters for men and women have noted differences in length and adjectives used. 46, 47 Women are more often described by their work ethic rather than their ability or talent. 47 These differences have the potential to adversely affect a committee's decisions. Disseminating best practices for promotion letters can prompt letter writers to avoid gender bias 48 (see Table 1 ). Box 1 provides examples of biased and equitably written letters. Professional groups can play a crucial role via the formation of letter writer bureaus that can assist in finding letter writers who are aware of these issues for women and URiM faculty. Creating a culture of inclusivity is essential to ensuring the advance- Implementing transparent metrics and tracking at the departmental and institutional level can lead to more equitable processes. 49, 50 Publicizing metrics can drive measurable change. Making information publicly available signals that equity is a priority and a core value of the organization. An individual or task force with administrative support can be designated to track rates of promotion, percentage of leadership roles held by women and URiM faculty, relative attrition rates, and reasons for departure. Adoption of transparent compensation rubrics, including indirect compensation (eg, buy down, administrative support, funding for specific roles/initiatives, travel/CME allocation, and bonuses), and audits of salaries with subsequent adjustment also address potentially hidden biases. Early and mid-career women are more likely to have family responsibilities and life events that necessitate reducing work responsibilities or temporarily stepping away from academic priorities, thus decreasing academic productivity. 51 For example, a study by Ly et al, 52 showed that women spent 100.2 more minutes per day on childcare than their male counterparts. "Stop the clock" policies are essential at institutions with deadlines for promotion and tenure to ensure parity for early and mid-career women. Departments that do not have specific policies or practices related to pregnancy-related scheduling (eg, reduction or elimination of night shifts in the third trimester), family leave, lactation, or graduated return to work, may benefit from a task force to review needs and existing policies. 53, 54 Even later in their careers, women faculty may experience a disproportionate load of domestic responsibility. A total of 61% of elderly caregivers are women; women may find themselves in the "sandwich generation," caring simultaneously for children and aging parents. 55 Workplace and workforce policies that address gender-specific needs can lead to enhanced job satisfaction. 56 Harassment and discrimination occur in many forms, some more obvi- Creating a culture of inclusivity requires deep and critical reflection on the existing culture, policies, and processes of the department. Although it is important to incorporate the voices of women and URiM faculty, it is also important to ensure that they are not solely tasked with the responsibility of improving workplace culture. This is the responsibility of departmental leadership in leading the way and including all faculty members in creating and maintaining a fair and equitable workplace. Championing diversity requires more than a shift in emergency physi- JF is a member of the ACEP BOD. MDL and AEP are members of the SAEM BOD. 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