Diversity in Health Care Leadership — A Longstanding Problem

Interview · June 27, 2017

Joan Reede and Tom Lee

Read or listen to our interview with Joan Reede, MD, MS, MPH, MBA, Dean for Diversity and Community Partnership at Harvard Medical School.


Tom Lee: This is Tom Lee for NEJM Catalyst, and we’re here today with my current colleague, Joan Reede. Joan is the Dean for Diversity and Community Partnership at Harvard. She was appointed to this new role in 2001, so she’s [had] 17 years in this role, which we’ll be talking about in a few minutes. I will say, everyone at Harvard feels she was the perfect person for the job. She is a pediatrician, a child psychiatrist; she trained at Johns Hopkins and the Boston Children’s Hospital. She has an MBA. She has an MPH. She is a Professor at Harvard Medical School. She’s done a lot. She knows everyone. She has been pushing this very important cause, which we’ll be discussing in a few minutes, and we want to take stock of where we are today. Thanks so much for joining us, Joan, and sharing your insights.

Joan Reede: Thank you, Tom.

Lee: The program you run, as I understand it, is aimed at developing leaders who are minorities, leaders in health care. Before we talk about the program itself, can you give us a feeling for what’s the status of the problem? How bad is it in 2017? Is it getting better? What’s your take?

Reede: When we look at leadership in health care and diversity in leadership in health care, it’s been a longstanding problem. If we think about where we are today in our country, if we look at underrepresented groups — Black, Hispanic, Native American, Alaska Native, etc. — they’re roughly 29% of the population. Nine percent are physicians, [and] only 7% are our faculty in our medical schools. And if you look more closely at those leadership positions in our schools, the representation of these groups decreases as you move up the academic ladder from assistant professor to full professor.

If we turn to the level of our deans and chairs, there’s a continued fall off, so that very few of our deans are individuals who come from racial ethnic groups, particularly from the Black, Hispanic, and Native American [groups], but as you look at leadership there’s something even more striking in this. Oftentimes when we talk about groups underrepresented in medicine, we leave out Asians because while Asians are approximately 5% of our population, they’re just over 12% of the physicians and 14% of our faculty. But you do not see those percentages when you look at our deans and our department chairs.

If we look at our department chairs, to give an example, in the country, very few are from Asian groups, and if you combine this issue of race, ethnicity, and gender, you see a further fall off. As of today, roughly 15% of our chairs are women and 16% of our deans are women. If you add to that, in 2014, of more than 2,500 department chairs across our medical schools, only 29 were Asian women, only 10 were Black women, and only 25 [were] Hispanic women. So, a clear underrepresentation in the leadership in our medical schools.

If we turn to our hospitals we see a similar pattern. If we look at some recent data from a survey put out by the Institute for Diversity in Health Management and the Health Research & Educational Trust, and the American Hospital Association, in their 2015 survey, only 7% of the CEOs and 7.6% of the CMOs of our hospitals were from the Black, Hispanic, and Native American groups. Strikingly, [among] CEOs in 2015, 0.7% were Asian. So it’s important to disaggregate and start to really understand where these disparities in representation lie.

And if you wanted to say, are we really seeing a change? Is there a difference over time? Not really. If you look at our local health departments across our country, between 2005 and 2013, at the percentage of leaders of our top local health department agencies, there was no change for race other than white or Hispanic. It went from 9% to 9%. [This is] a persistent problem — even as our population demographics are changing and our race ethnicity is changing rapidly in our country, we are not keeping up with that in our public health, or our health systems, or our academic systems in terms of representation.

Lee: Those are compelling statistics. It makes the case that it’s not just a matter of time — you need more women in health care, more Asians in health care, and where suddenly there will be increases in the percentage of leaders who fit various groups. There’s something more to do besides wait. What’s your take on the root cause of the problem?

Reede: This is occurring on multiple levels, and I really think about it at an individual [level] and institution [level] and in our society at large. And when I turn to the individual, I think about: how well are people prepared from their education system? [What’s] the quality of education they receive, the kind of opportunities that they have to explore career paths, the kinds of preparation that they have? And for themselves, are they prepared economically to move forward in terms of the finances? Because many of the individuals that we’re seeing are first generation, and to what extent do they even understand the nuances and the bureaucracy, and how to move through to college, to medical school, to fellowship, to faculty, or to other kinds of leadership positions?

When I think about our organizations, it’s historical cultures, policies, and practices of exclusion, and to what extent are our institutions remodeling themselves so that they are prepared to deal with diverse individuals? Diverse in terms of language, in terms of background — socioeconomic, nationality, etc. — and our institutions have not kept up with the changes of our society. And our society itself is struggling in terms of the politics and the policies, and the economics, and to what extent are we prepared to support individuals to move into leadership?

But the other piece of this is, it’s not just a matter of [whether] we get individuals into the system. It’s not just a matter of [whether] they go to school. It’s how do we nurture them? How do we prepare them? How do we train and retain them and advance them in our organizations? In the numbers I shared with you, you see that there has been some change in terms of representation, particularly at the entry levels, but it’s in the leadership we’re not seeing that representation. So how do we think about the kinds of programs that we have in place, but also, how do we think about the mentors and individuals who can sponsor, advocate for, recognize talent that exists, and be willing to put out the effort and energy to move people forward?

Lee: That’s a natural segue to your program. It’s [been] 17 years now, if I am counting correctly, and you can tell us how many young candidates for leadership have come through it. I know that you’re increasing the number of leaders, because I know the graduates are a wonderful social network today, but you’re training them one at a time. So tell us: what do you do, how’s it going, and how are you changing what you do as you learn as time goes by?

Reede: The program actually started in 1996, so before I was dean — I’ve been at the medical school for over 25 years. [It was] started by the Commonwealth Fund, under the direction of Karen Davis, and the purpose was to identify physician leaders who had a capacity to address issues in our health care system that could improve the health of vulnerable populations, and at the same time increase the representation of minority physician leaders who are well trained in terms of clinical medicine, public health, health policy, and management.

Since inception, when the program started in 1996, we’ve trained 130 individuals. They have all remained dedicated to improving health for vulnerable populations. They have moved into the public sector from federal to state to local levels, the private sector, academic institutions, philanthropy. They are publishing, they are leading and working on committees and task forces. Clearly, they are doing what the fellowship planned. I think a large reason why this works is because there’s this understanding, particularly for physicians of color, to work with these populations.

There’s a need for them to have the kind of training and understanding that you’d get from a school of public health about population health — we’re dealing with populations. But also as we deal with these populations we have to change systems, and we have to be at capacity and have an understanding of how you change infrastructure and operation, such that you can address the kinds of challenges and barriers that exist because of economics or cultural or other kinds of issues.

It’s a combined training that leads to a degree at the School of Public Health or the Kennedy School of Government here at Harvard, but it also involves leadership training and a great deal of mentorship from our alumni and individuals across the country who understand the need for this kind of diversity leadership. [It involves] site visits across the country to various agencies, and projects that they work on with communities and organizations so that they can better learn how to address the needs of those organizations, and how to partner, collaborate, and help other individuals and entities better address the needs of populations. So, it’s worked, but there’s a need for many more.

Lee: Your program is wonderful and I know it gets great people and it opens doors for them, but it’s just one program. What’s your prescription for the overall system to take on the kinds of work that you’ve been doing and take it to scale?

Reede: I start with this place that may not seem the most logical, but there has to be an understanding of the value of diversity. That having diverse perspectives, diverse backgrounds, diversity in training actually leads to better outcomes. And that as we think about our systems, there should be a stepping back and saying, “Do we have diversity in the room, or does everyone look like everyone else, and what are we missing when we don’t have that diversity?” That is a number one issue in this, and the value of diversity and achieving excellence and in creating change.

But the other part is also understanding the potential that exists in those we see around us as we look at our students, and our trainees, and our faculty, and individuals in our hospital systems, and across our community. And understand that they have a potential to contribute, to become leaders, to recognize that, to help them understand their potential, and then to sponsor them, to provide opportunities for training, and opportunities and access to resources so that they can continue to advance.

It also means that those systems need to better monitor the kind of representation they have. The kind of programming they have. Are people advancing? Are they living out what they say about diversity in terms of the outcomes that they have across the board? And then this opportunity to build networks. One of the strongest things that’s happened with our fellowship is our fellows have been able to build a network among themselves, a network that crosses our country so that they can support one another, [so that] they can remain connected and do not feel so isolated when they go into spaces where they are the only one.

Lee: It’s a great process you describe. You make the diagnosis by sticking your head up and looking around and assessing the situation, and then beginning to cultivate the personnel who can change the environment and help create a more diverse workforce that takes good care of a diverse population.

I want to thank you for taking the time to talk to us today. I’m sure that we’re going to be checking in with you from time to time as you move ahead so you can share new insights with us, but most of all, I want to thank you for doing the fantastic work you’ve done. And I know that your many mentees will echo that when they get a chance to listen to you online. Thank you again, Joan, and thanks again to our audience for listening in.

Reede: Thank you very much.

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