Medicine must choose its leaders fairly by Shannon Ruzycki

The lack of diversity among medical leadership gap is well-described. Men, white physicians, and white men physicians are overrepresented in leadership, academic, and decision-making roles relative to their proportion in medicine. This is best highlighted in specialties that are predominantly women, like pediatrics and obstetrics, where most of leaders are still men. This gap is not well explained by maternity leaves, lack of interest, age or seniority, or lack of skills among women and other underrepresented groups – though these issues would still be worth addressing if they explained the lack of diversity in medical leadership. But after over 30 years of describing the lack of diversity in medical leadership, we appear no closer to addressing it.

The lack of progress in diversifying medical leadership is multifactorial but an important barrier to progress has been a firm belief in the meritocracy held by many physicians. The meritocracy is the belief that there is a single best or most deserving candidate that can be identified by objectively measured criteria. The meritocracy ignores ample evidence of how bias (explicit, implicit, and structural) influences how we evaluate applicants and apply selection criteria. Further, the assumption that there is unlikely a single ‘best’ person for any role does not stand up well to close scrutiny or empirical data – clearly the best physician to care for you may not be the best physician to care for me. Addressing how medicine selects its leaders and decision-makers is a critical step in diversifying these roles. Fortunately, other fields, including business, government, and athletics, have confronted underrepresentation of women and other marginalized groups by applying innovative methods for identifying, evaluating, and selecting successful candidates. Lessons from these fields can guide current medical leaders on how to avoid the problems inherent to the meritocratic approach to selection and promotion.

A key strategy for quickly and effectively diversifying candidates considered for selection is quotas. Quotas have been used in law forms, corporate boards, and the National Football League to address the lack of diversity in these spaces. Quotas improve the quality of candidates and increase the number of decisions that are viewed favourably by women. There are multiple quota policy designs that could be adopted by medical organizations, though these policies may be viewed as controversial at first. Leaders could consider implementing candidate selection quotas, where a minimum threshold of applicants for a position must come from an underrepresented without mandating the demographics of the successful candidate. This threshold would depend on the goals of the program, though 30% of candidates is generally considered effective.

In lottery systems, all applicants who meet a minimum standard are entered into a random draw to fill open positions. Lottery strategies have been used to select medical students in the Netherlands for decades – the ‘success rate’ of selected medical students is only slightly greater than lottery students and there is no difference between these groups in academic performance, attrition, or professional behaviour. Leaders can weigh different metrics, such as an h-index, a standardized test score or a demographic characteristic, to give applicants more entries into the lottery. Using lotteries to select candidates may be most appropriate when the selection criteria associated with success in a role is not known – for example, it is not known which criteria are most important when admitting medical students. Rather than arbitrarily choosing selection criteria that may not predict performance in the role, it may be more fair to ‘arbitrarily’ select candidates using a lottery system.

In opt-out selection strategies, all candidates who meet a minimum threshold are entered into the selection process and those who do not wish to be considered must opt-out or remove themselves from consideration. Opt-out selection addresses the reluctance to self-nominate and avoidance of competition that is common among professional women and removes the social penalties for women who violate the gender norms by ‘leaning in’. Rather than simply encouraging women to act more like men, opt-out framing removes confidence as a selection criterion. Opt-out framing may be helpful for academic promotions or in brainstorming solutions for organizations.

Masking refers to removing all identifying information from application packages, including names, references to religious organizations, and pronouns. Though intended to remove factors that may activate implicit or explicit bias among evaluators, masking has a conflicting impact on the diversity of selected candidates – while masking increases the diversity of conference presenters and the authors of published manuscripts, it led to decreased diversity in grant attainment. Opponents of masking argue that masking at the time of application does not address inequities throughout an applicant’s career and losing that context can disadvantage candidates from underrepresented groups.

Medical leaders are situated to make the structural changes needed to diversify medicine and medical leadership. Leaders must accept the overwhelming evidence and shift from the false paradigm of meritocracy as the only way to evaluate and select ‘the best’ candidates. Leaders should consider the strengths and limitations of alternative selection methods, as described above, and trial these in their own settings as ways to diversify medical leadership and more fairly chose the next generation of leaders.

Dr Shannon Ruzycki

Shannon Ruzycki is a general internist and clinical assistant professor in Calgary, Canada. She has research interests in EDI in the workforce and in perioperative quality improvement.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.


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