Mutually Inclusive

With a new action plan, the Medical School strives to make medicine as diverse as the society it serves.

When Tracey Guthrie, MD RES’99 came to Providence in 1995, as an intern in Brown’s psychiatry program, she joined a residency class with people from Pakistan, Eastern Europe, and other far-flung places. United by their shared passions for psychiatry, learning, and the University (not to mention the “amazing food” they made for each other), Guthrie says they were able to build an inclusive, supportive community.

“While I did not look around and see a lot of people that had my exact background, I didn’t feel marginalized,” says Guthrie, who is African-American. She became chief resident and then, in 1999, joined the faculty; she’s now a clinical associate professor of psychiatry and human behavior and of medical science, and the director of the General Psychiatry Residency Program. “Brown is such a warm place,” she says.

But, she’s quick to add, “That is not to say that that’s everyone’s story.”

It wasn’t for Bryan Leyva MD’18 when he arrived at Brown nearly 20 years later. A native of Colombia who grew up in Central Falls, RI, Leyva knew he’d be one of the few Latino men at Warren Alpert Medical School. But he was caught off guard by how isolated he felt.

“The fact that I wasn’t represented in my faculty,” he says, “and the fact that there weren’t as many black or brown males in my class and in the classes after me—those things really, really affected me.”

Guthrie and Leyva are working to make inclusiveness, rather than isolation, the norm for new medical students, residents, and faculty. Both sat on the task force that drafted the Medical School’s new Diversity and Inclusion Action Plan (DIAP), released last fall, which enumerates priorities, proposes timelines, and establishes accountability. It spells out, with statistics and unflinching prose, the sometimes grim reality at Brown: that 2 percent of clinical faculty are Hispanic or Latino, and only a little more than 1 percent are black or African-American; that students need support services to deal with the racism, sexism, homophobia, and other forms of exclusion they report; that medicine in general has a “history of colonialism, racism, bigotry, and violence against marginalized people.”

“Diversity” is a much-maligned term in some circles, but it’s misunderstood.

“Diversity is not just about numbers or quotas, or checking a box that labels a person’s race or ethnicity,” Guthrie says. At Brown, she says, it’s about creating an inclusive community that welcomes and encourages people of all backgrounds and perspectives. It’s a more rigorous academic environment, a modernized curriculum, and a more culturally competent medical workforce. It’s an explicit message to groups who historically have been underrepresented or overlooked in medicine: “Brown is not a closed door to you,” Guthrie says.

Joseph Diaz MD’96 RES’99 F’01 MPH’09, the chair of the DIAP task force, says fostering a physician population that reflects the US population overall “just makes perfect sense.”

“The whole reason that we’re going to medical school, teaching medical students, training medical residents is the community,” he says. “Whether it’s here in Providence, or in Rhode Island, or in the US, or around the world, we’re taking care of an incredibly diverse group of patients and communities.”

Furthermore, different people from different backgrounds bring different experiences and ideas—which benefits students and physician colleagues, as well. Research clearly shows, Diaz says, that with “a more diverse and inclusive workforce in business or health care, you have more innovation and better ideas and different perspectives, which leads to better quality and better care for patients.”

‘A Lot of Work to Do’

Diaz has cared for underserved communities since before he even wanted to be a physician. A Pennsylvania native, he earned a history degree at Boston College and moved to Los Angeles to work for a social services agency, connecting clients with health and other resources. He came to see medicine as an ideal way to help people, completed his postbaccalaureate at Bryn Mawr, and linked to Brown. As he continued through residency and fellowship, and ultimately joined the faculty, Providence’s diverse patient population further honed his interests in health disparities and the cultural and linguistic barriers to care delivery.

Now the medical director of population health and Medicaid for Care New England’s ACO, a preceptor for the Student Free Clinic at Clínica Esperanza in Providence, and codirector of the Medical School’s Scholarly Concentration in Caring for Underserved Communities, Diaz was a natural fit to lead the Office of Diversity and Multicultural Affairs (ODMA) when the School was looking for an interim associate dean in 2015. (He was named associate dean in November 2016.) “The other work that I do, it’s consistent or synergistic with the work in ODMA,” he says, “but I was doing it without necessarily having the label, ‘ODMA.’”

Michele G. Cyr, MD, who as associate dean for academic affairs oversees the office, says Diaz “emerged as an ideal candidate” not only because of his commitment to caring for underserved populations and to increasing diversity at the Medical School, but because “he’s had administrative and educational leadership roles at all levels of training.”

For 40 years, the ODMA has worked to foster and support diversity among students, residents, and faculty, including individuals who identify as LGBTQ and groups underrepresented in medicine (URM), meaning racial and ethnic populations whose representation in the medical profession is lower relative to their numbers in the general population. Shortly after Diaz took the helm of the ODMA, the University released an action plan, Pathways to Diversity and Inclusion, which lays out specific steps to achieve its goals and charged each school to write its own DIAP. Now Diaz’s office had a mission: he headed up the Medical School task force of faculty, students, residents, alumni, and staff, who identified six priority areas and, for each, defined the actions to be taken and how to measure them, as well as the individuals or offices responsible for each step.

“People” is the first priority area, for good reason: although, relative to all US medical schools, Warren Alpert Medical School has higher percentages of URM students, its racial diversity doesn’t reflect the nation’s. Faculty statistics lag even more. “We have a lot of work to do,” Cyr says.

To that end, the Medical School DIAP prioritizes recruitment of URM residents and faculty, and directs each clinical department to write up its own diversity plan. Because the affiliated hospitals select residents and hire clinical faculty, the Medical School is collaborating with representatives at the respective health systems. The ODMA is helping them draft their strategies, says Allan R. Tunkel, MD, PhD, associate dean of medical education.

“If you have diversity in the faculty, you’ll have the role models, the mentors, the sponsors [who]may encourage our diverse medical students to stay on in our programs to do their residency training”—which in turn is a pipeline to join the faculty, Tunkel says. “The accountability piece of [the DIAP]is also critical. We have to create an environment where expectations are high around diversity and inclusion. That will be important to moving this plan forward.”

Zoila Quezada, MEd, who is in her ninth year as assistant director of the ODMA, says the office has a renewed focus on faculty recruitment. Already, she and Diaz are meeting with representatives from clinical departments. “The programs are actually reaching out to Joe, too, to meet with candidates,” Quezada says. The hospitals understand “how important it is for us to recruit URM faculty for the sake of teaching our students, because our students are very sheltered here in the building, but once they go to clerkships, they say, there’s no one here that looks like me, that I can identify with.”

“Seeing someone who represents you in medicine … that’s such a critical thing for someone learning to be a physician,” Ry Garcia-Sampson ’12 MD’19 MPH’19 says, adding that LGBTQ underrepresentation in the curriculum, faculty, and student body “is something that has been a real struggle for me as an openly genderqueer student.”

Guthrie says the hospitals and the Medical School have “a mutually agreed-upon goal: we should provide the best.” She adds: “That’s the benefit of being an academic environment—the growth that occurs at many levels. The challenge to your thinking at every level is why we’re all here.”

Cyr, who chairs the Committee on Medical Faculty Appointments and oversees the Office of Women in Medicine and Science, says she’s learned over the years that increasing diversity “is very labor intensive.” “It requires calling department chairs across the country, asking, who is your up-and-coming star who might be appropriate for this position? And then individually contacting them,” she says. “And it requires somebody in a position of authority to drive this initiative and to fully support it. That makes all the difference in the world.”

That’s why Tunkel says one of the most important proposals in the DIAP is the diversity council. Composed of associate deans (including Tunkel, Cyr, and Diaz); a medical student, resident, and alum; and representatives from clinical departments, the affiliated health systems, the Providence VA Medical Center, and the community, the council will report to Dean of Biology and Medicine Jack A. Elias, MD, and health system leaders. “The fact that we’ll be engaging the leadership of the Medical School and the health systems in this process will be critically important in moving initiatives forward,” Tunkel says.

The University’s leadership has been critical to these initiatives as well. Quezada says support from President Christina Paxson, Provost Richard Locke, and Brown’s Office of Institutional Diversity and Inclusion “has helped us tremendously.” She adds: “When we were drafting the DIAP, the president came and sat with our students. That was amazing.”

“Without institutional commitment, without leadership being on your side, you’re always going to be pushing upstream,” Leyva says. “And I think we’ve been lucky that the administration has recognized the need for enhanced attention to diversity and inclusion.”

In addition to the DIAP task force, Leyva sits on the Diversity Recruitment, Social Mission, and Race in Medicine task forces—all of which the Medical School administration supports and encourages, he says. “Everyone is coming together around a common issue and a common goal,” he says. “I think this larger commitment can really propel Brown to really be a thought leader and a change agent.”

Core Support

The DIAP calls for expanding the role of the ODMA to address and implement its goals—and more staff to make that possible. For years the office has consisted only of a full-time assistant director and a part-time associate dean (like his predecessors, Diaz is maintaining some of his other responsibilities, including his clinical practice). Now the office is creating new positions, two of which they filled this spring: a student fellow, Garcia-Sampson; and a core faculty member, Guthrie.

“I’m really thrilled and honored to be able to be part of this very significant and important undertaking,” Guthrie says. Among her priorities is developing a minority faculty association and mentorship program. “That sounds fun,” she says. “I’m looking forward to getting to know [other URM]faculty members. We’re very siloed because we’re not in one main hospital.” By spending more time at the Medical School, she’ll also get to meet first- and second-year students.

It’s a great fit for Garcia-Sampson, too, who will take a year off for the paid, one-year fellowship. “I really wanted to spend a year doing something that felt meaningful to me, getting experience and skills that I wouldn’t get just through medical training,” Garcia-Sampson says. In addition to promoting the office’s diversity initiatives, “moving forward, a lot of work I want to do is with people who are underserved: people of color, LGBT, low income, who have addiction, who are homeless. [The fellowship] feels like a natural way for me to be able to spend time connecting with organizations who do this work.”

Under the DIAP, recruiting and supporting students will continue to be a key focus for the ODMA. The office organizes networking events and a mentoring program to connect underrepresented students, residents, and faculty; supports professional development opportunities and memberships in local and national organizations that promote diversity; and is working with the Office of Medical Education to review the curriculum for unscientific and biased teaching and to incorporate more inclusive content.

The ODMA also is partnering more closely with the Office of Admissions. “We are very active from the time [students]come here to interview to the time that they actually graduate,” Quezada says. They greet applicants and answer their questions on interview days; call to congratulate them when they’re accepted; and hold a reception during Second Look, so admitted students can mingle with current students, residents, and faculty, “and know that there’s a community here beyond just me and Joe,” she says.

She laughs, but it’s serious business: “Even after we do all the things we do, there are still people who are like, no. Still doesn’t feel like home,” Quezada says. Garcia-Sampson says the number of students of color who are admitted yet decide to go to medical school elsewhere “speaks to the work that needs to be done to support and encourage those students to see Brown as a place where they’ll be supported.”

Students can turn to the ODMA if they experience discrimination, for documentation as well as a sympathetic ear. “There is mistreatment in the clinical years,” Quezada says. Leyva learned this firsthand last year. He was shadowing his Doctoring mentor in the emergency department when a patient came in, who “happened to be a dark-skinned woman,” he says. A nurse asked him “to move out of the way, confusing me as the relative of this patient.” Leyva was wearing a shirt and tie and his white coat; but also, “I was the only person of color in the room. I think it makes you feel a certain kind of way when you’re told to step out of the room because of how you look.”

It’s a textbook example of implicit, or unconscious, bias: “how we make assumptions so quickly about people based on what we see,” Cyr says. “It’s a shortcut. And it’s what everybody does, unfortunately.” To raise consciousness about unconscious bias, the DIAP calls for staff and faculty training sessions at the Medical School, other areas of the University, and at the hospitals. (Diaz and Quezada are trained unconscious bias educators.) “It’s a real eye-opener for a lot of people,” Cyr says.

And it can make for better care providers. The Accreditation Council for Graduate Medical Education, Guthrie says, “wants our residents and future doctors to be educated on these topics. This is the community you’re treating. You should know something about how you interact with them and how they interact with you, and how to do your best to be able to recognize anything that could be in the way.”

She adds: “I think that people have also done a very good job of removing the stigma of unconscious bias. It’s, like, we all have it. Let’s just admit it and move on.”

Begin at the Beginning

Implicit bias is insidious because it can be internalized, and at a young age. “Representation matters. Kids’ early experiences shape what they imagine to be possible,” Leyva says. “That’s why it’s important for young black and Latino boys to see physicians who look like them and come from where they come from. It’s empowering.”

For that reason, the Medical School DIAP calls for reaching students a whole lot earlier. “Grammar school is where things start to diverge,” Diaz says. Children who are members of underrepresented groups are statistically more likely to attend underresourced schools and lack access to educational opportunities, not to mention mentors and role models.

“There is not a great pipeline,” Tunkel says. “We’re looking to reach back into high schools and even middle schools, to engage underrepresented students early in the science disciplines—and get them excited, perhaps, about careers as physicians.”

The ODMA supports, to varying degrees, pipeline programs like Pathways, which pairs med student mentors with local high school students interested in careers in health care; Summer@Brown, an intensive pre-college program; and the Early Identification Program with Tougaloo College, a historically black college in Jackson, MS. This summer the ODMA is piloting a Medical School partnership with the Leadership Alliance, a national research program for undergraduates underrepresented in the sciences, to bring three students to Brown to work in the labs of physician faculty and prepare them to pursue admission to competitive MD-PhD programs.

The office also promotes ideas they get from students, Diaz says, like a workshop to help local premed students from underrepresented groups navigate the medical school application process, from the MCAT to the personal statement to financial aid. “They had great success,” Diaz says of the first workshop, held last year. “There’s at least one student who attended who has been accepted” to Warren Alpert Medical School.

It’s just one student, at a small, New England school. Many medical schools across the country struggle with these issues, and at least one is in danger of losing accreditation because it has not met the Liaison Committee on Medical Education’s standards for diversity/pipeline programming. But with students and administrators working cooperatively, and with a leadership team that has committed to the real investments in personnel and dollars that it will take to move the needle, there’s more optimism that Brown’s initiatives will be successful.

“Generations cause shifts. This generation is causing a shift,” Guthrie says. “It’s a movement that is, I hope, unstoppable.”