Just under 9% of doctors in the United States identify as black, Native American, Alaska Native, Hispanic or Latino. These groups make up 25% of the U.S. population. These statistics are well-known in the medical community where calls for increased diversity are common. But how seriously, really, do we need to take these calls for action? Aren’t we already doing enough? And what role do medical societies and associations play?
Most people working with nonprofit associations don’t intentionally discriminate in hiring and firing decisions, or when working with volunteer boards and committees. Sometimes we are glad when an officer’s term ends, but those feelings are based on personality, not gender or ethnicity. You might be surprised, then, to discover how many mistakes are made by medical societies that increase liability.
First, however, let’s look more at why diversity is important. Take the case of Lia Lee, a little girl living in Northern California, who started having seizures as an infant. Perhaps you’ve read the book, The Spirit Catches You and You Fall Down? (Anne Fadiman. The Spirit Catches You and You Fall Down. New York. Farrar, Straus & Giroux, 1997.) It’s required reading for many medical students. Lia’s seizure required 16 visits to the emergency room in her first four years of life. After the 16th visit, Lia went into a vegetative state where she remained for the last 26 years of her 30-year life.
Lia’s story is of the ultimate cultural divide. Her parents, Hmong people who immigrated from Laos, were suspicious of the American doctors’ motives, and believed the medicines and treatments were to blame for Lia’s ongoing medical problems. The doctors failed to understand, and disregarded, the parents’ concerns, and blamed Lia’s outcome on the parents’ failures to strictly follow medical treatment plans. This cultural divide, despite the love of Lia’s parents, and the best efforts of Lia’s doctors, contributed to Lia’s horrible outcome. Lia died in 2012.
While Lia’s story is extreme, it’s not the exception. A new study, published in 2018 and updated in May 2019, found that when black patients have black doctors, they are much more likely to undergo preventive care; preventive care that is essential to reducing the black-white male cardiovascular and life expectancy gaps. (Marcella Alsan, Owen Garrick, and Grant C. Graziani, Does Diversity Matter for Health? Experimental Evidence from Oakland, National Bureau of Economic Research, Working Paper 24787, [June 2018, Revised May 2019] https://www.nber.org/papers/w24787.pdf.) Lead author Dr. Marcella Alsan, professor of medicine at Stanford School of Medicine, found that the black patients were 47% more likely to get diabetes screenings, and 72% more likely to get cholesterol tests if they had a black doctor. I now understand the need for the Association of Black Cardiologists (ABC), one of our firm’s clients, but I had no idea why there was an association just for black heart doctors when ABC first came to our firm.
Back to the role medical societies play in the diversity game. Our firm represents a dozen or more medical associations, including associations working on specific health issues, associations of specialty medical schools, medical professionals working in special fields like space, and societies that focus on specific medical research. What we’ve learned in our work is that diversity issues, and discrimination, come up in surprising ways.
For example, let’s talk about photographs. Some of our clients administer central application services for clerkships, residencies and other programs. Applications sometimes require, other times make optional, the inclusion of a photograph. Residency program staff say the photographs help them remember who they interviewed. We tell our clients, however, that photographs also could be used to discriminate, and even if the program doesn’t intend to discriminate, could be used as evidence against the programs. We suggest eliminating the use of photographs with applications.
Also consider eliminating questions about gender, race, and ethnicity from applications. When diversity statistics are needed, consider whether the statistics may be collected after the selection process is complete. Similarly, consider eliminating from applications questions about whether English is an applicant’s primary language, or if the applicant has any disabilities. Do make sure that your website is accessible for the disabled. Check out the Web Content Accessibility Guidelines (WCAG 2.0 AA) as guidance.
Finally, consider linking to third-party eligibility requirements and rules, rather than publishing the information yourself. A medical society recently faced a discrimination complaint after it published residency eligibility requirements that violated federal law. (The residency program stated that U.S. citizenship was required which violates the anti-discrimination provisions of the Immigration and Nationality Act. Only eligibility to work in the U.S., and not citizenship, may be required under federal law.) Even though the association did not set, or enforce, the eligibility requirement, it was still found liable for publishing the illegal rule. Linking to third-party information not only may reduce your liability, doing so also eliminates the need to keep up with changes the third-party makes to its rules and requirements.
Diversity and discrimination issues can sneak up you, even if you think you are being proactively inclusive. The key to compliance is to keep asking yourself whether the information you are collecting, reviewing and publishing is essential to the task at hand.