How Are We Actually Doing? Best Practices for Recruitment of a Diverse Workforce

This guest post is from Artina Dawkins, PhD, MPA, C-TAGME, and Holly Pilson, MD. Dr. Dawkins is the Co-Director of Diversity and Inclusion & Program Manager of Social Impact for the Department of Orthopaedic Surgery as well as Founder and Director of the Kennedy-Hopkins Scholars Mentor Program at Atrium Health Wake Forest Baptist in Winston-Salem, North Carolina. Dr. Pilson is Vice Chair of Social Impact and Co-Director of Diversity and Inclusion at Wake Forest University School of Medicine and Atrium Health Wake Forest Baptist. 

Workforce diversity has been an area of intense focus in the graduate medical education (GME) community for the past several years. On July 1, 2019, several major revisions of the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements went into effect. One major revision included a policy on recruitment and retention, which states that, “(I.C.) The program, in partnership with its Sponsoring Institution, must engage in practices that focus on mission-driven, ongoing, systematic recruitment and retention of a diverse and inclusive workforce of residents, fellows (if present), faculty members, senior administrative staff members, and other relevant members of its academic community.” Access the Common Program Requirements at: ACGME Common Program Requirements (Residency). 

A focus on workforce diversity underscores the critical need for representation and the implications for patient care and elimination of discrimination in the medical field. A qualitative study in JAMA Open Network from 2018 highlights the extra workplace burdens experienced by minoritized residents: Minority Resident Physicians’ Views on the Role of Race/Ethnicity in Their Training Experiences in the Workplace. A 2022 article by Aguwa et al. displays the strikingly low percentage of Black/African, Hispanic/Latinx, and Native American trainees from 2011-2019: Racial and Ethnic Diversity Within U.S. Residencies: Trends from 2011 to 2019. This trend has continued since 2019 as indicated by Table C. 23 in the ACGME Data Resource Book, 2019-2020, 2020-2021, 2021-2022, and 2022-2023. The ACGME Data Resource Book, 2019-2020 also presents data that show that orthopaedic surgery has the lowest percentage of female trainees (16.1%) when compared with other surgical and non-surgical programs. This pattern continued for the academic years of 2020-2021 (16.7%), 2021-2022 (18.3%), and 2022-2023 (20.3%).  

In 2019, we embarked on the journey of countering the narrative of these national trends of racial and ethnic as well as gender disparities in orthopaedic surgery. As inaugural co-directors with years of leadership experience in graduate medical education and diversity, equity, and inclusion (DEI) work, we designed and implemented a strategic plan and framework for department-wide integration of DEI principles and values. While the strategic plan was constructed as a mechanism to positively impact personnel at each level of the department, we initially focused on resident recruitment. 

Through partnerships, persistence, intentionality, trial and error, and leadership, there has been a significant increase in diverse residents recruited for the past 4 years. Several best-practice guidelines emerged from our experience and execution of the strategic goals, including:  

• Build relationships and partnerships 
• Strengthen capacity-building through training and education 
• Employ a data-driven approach 
• Use innovation to create an environment of belonging 

Build relationships and partnerships

One of the most critical strategic goals was to identify and leverage existing relationships as well as to build meaningful partnerships. Without strategic partnerships, a novel program will neither maximize expansion nor thrive within a complex organization—such as an academic medical institution. As program manager of the orthopaedic residency program at the time (A.D.) and as clerkship director (H.P.), we partnered with the program director and program leadership to implement a holistic review process for resident recruitment. Additionally, we collaborated with the institution’s Office of Diversity & Inclusion, which was a valuable resource as well as the convener of a holistic review learning community.  

We incorporated best practices from the Internal Medicine Department at UT Health in Houston, Texas, as captured in Bridging the Gap: Holistic Review to Increase Diversity in Graduate Medical Education, as well as content from the AAMC resources on Holistic Review in Medical School Admissions. Additional partnerships with organizations including Nth Dimensions, The Perry Initiative, the AAOS IDEA Grant Program, and the Orthopaedic Diversity Leadership Consortium established commitments (time, effort, and financial) toward improving our program’s interface with diverse applicants and provided professional development to facilitate our growth as leaders in this space.  

Strengthen capacity-building through training and education

We facilitated Active Bystander training as an intervention to create an environment of greater accountability and cultural awareness. This training module—provided to all faculty, staff, and trainees in the department—comprised content on positive and negative behaviors, harassment, microaggressions, and barriers to being an active bystander as well as strategies on how to mitigate these occurrences. Active Bystander strategies were reinforced via case studies and group discussion. An example of a group discussion focuses on experiences that participants had with negative behaviors or harmful verbal comments. One case study involved review of a scenario where the spouse of a patient assumed that an attending spoke a certain language based on the attending’s last name. Both the group and case study discussions included suggested approaches for how to address future situations. Some of the feedback received from participants regarding the use of and the benefit of the training include: 

• “I hate to see people treated with injustice so this was a great way to learn ways to combat this without escalating issues.” 
• “I have not used this training yet but it will help me moving forward.” 
• “I have used this before. Very helpful!” 
• “I will keep standing up for myself and others.” 

Employ a data-driven approach

Qualitative research is an ideal mechanism to convey a story and elevate the voices of those who may not otherwise be heard. Early in our Co-Director roles, we conducted a needs assessment survey to collect data on the desired DEI goals of fellow co-workers. One of the themes that emerged from the data was the desire for more diversity in the workforce (faculty, staff, and trainees). These and other data points informed our strategic plan and action steps to diversify the workforce.   

Use innovation to create an environment of belonging  

Steve Jobs was quoted as saying, “Innovation is the ability to see change as an opportunity—not a threat.” As DEI thought leaders, we envisioned an environment void of bias and discrimination. Working deductively to the desired end to this environment, we consider questions such as how do you catalyze such an environment within a complex organization? By identifying resources and using multiple strategies, we augmented an ecosystem of discussion, inquiry, and support. Regarding resources, all prospective residency candidates were provided with information about program, departmental, and institutional resources as well as DEI efforts and programming. From having a diverse selection committee, to cultivation of a holistic review learning community, to having a DEI recruitment webinar, we have utilized a multidimensional approach to accomplish workforce diversity.  

Conclusion

With intentionality, focus, support, and resources, we achieved the strategic goal of workforce diversity—which has implications for improved patient care and a decrease in health disparities for historically minoritized populations. Any department or group aiming to achieve workforce diversity should consider a multi-level approach that not only focuses on recruitment but also on catalyzing a welcoming and just culture.