Women of Color and Intersectionality Initiative: A Workgroup Report on the Continued Need to Support and Retain Women of Color

Abstract

Background:

Unprecedented stressors have significantly impacted our nation. These occurrences compounded the prepandemic structural factors that disproportionately affect historically, economically, and socially marginalized communities of color and women as highlighted by the National Academies of Sciences, Engineering, and Medicine. In response, health care organizations and regulatory bodies have shifted from the quadruple aim to the quintuple aim to conceptualize health care improvement by adding to the prioritizing of the health workforce’s well-being and advancing health equity (Nundy, Cooper, & Mate, 2022). The literature presents limited and conflicting information regarding workforce well-being based on demographic background. A 2021 report by the National Academies of Sciences, Engineering, and Medicine described the potential for race, ethnicity, gender identity, sexual orientation, age, and disability status to alter or amplify the career impacts of COVID-19 (National Academies of Sciences, Engineering, and Medicine, 2021).

Methods:

Results:

Based on a rigorous review of existing data and national trends, the group concluded that WOC continue to exist and work at the margins and that the threat of “not belonging” is a key factor impacting their well-being. The authors, who are members of this AAMC WOC Intersectionality Initiative, identified key strategies in the domains of intersectionality and equity, work-life boundaries, gendered divisions of labor, and mental health and well-being for implementation and evaluation in future studies.

Conclusion:

Over the last 4 years, the health and scientific workforces have encountered staffing shortages, increased attrition rates, and an overall decline of wellness. Authors and thought leaders in this space have postulated the need to refine tools and methodologies to capture intersectional differences to inform strategy. This article presents recommendations from the Initiative that include solutions that prioritize intersectionality, which can be adopted by academic health systems to support the well-being of WOC.

Introduction

Over the last several years, unprecedented stressors have significantly impacted our nation, including the COVID-19 pandemic. These occurrences compounded the prepandemic structural factors that disproportionately affect historically, economically, and socially marginalized communities of color and women.¹ In response, health care organizations and regulatory bodies have shifted from the quadruple aim to the quintuple aim to conceptualize health care improvement by adding to the prioritizing of the health workforce’s well-being and advancing health equity.² The diversification of our health care workforce is an evidence-based strategy to foster excellence and improve the quality of health care in all our nation’s communities.^1–2 While most medical school graduates are women, the proportion of women who are leaders in academic medicine is still deficient. While 45% of full-time faculty are women, only 29% of full professors and 27% of medical school deans and health system leaders are women.³ In the last decade, gaps persist among women who are from racial/ethnic backgrounds in faculty representation.³ Women leaders in decanal leadership positions are more common in faculty affairs, student affairs, and offices of diversity, equity, and inclusion.³ While pathway programs and recruitment have been emphasized as strategic tools in workforce development, organizational culture and values have been recently described as critical drivers of well-being, engagement, retention, and productivity.²

Recent data regarding the status of our health care workforce (composition, engagement, and well-being) reflect an increasing gender and racial/ethnic diversity, with lower representation within specific subpopulations (e.g., American Indian and Alaskan Native physicians and scientists) and a lack of reporting on other demographic dimensions of diversity (e.g., sexual identity).¹ In addition, the literature presents limited and conflicting information regarding workforce well-being based on demographic background. The National Academies 2021 report on “The Impact of COVID-19 on the Careers of Women in Academic Sciences, Engineering, and Medicine,” described the potential for race, ethnicity, gender identity, sexual orientation, age, and disability status to alter or amplify the career impacts of COVID-19.¹

In 2020, the Association of American Medical Colleges (AAMC) convened a Women of Color and Intersectionality Initiative (“Initiative”) to understand better and address factors contributing to the well-being challenges encountered in health systems by women of color (WOC). Based on a rigorous review of existing data and national trends, the group concluded that WOC continue to exist and work at the margins and that the threat of “not belonging” is a key factor impacting their well-being. The authors, who are members of this AAMC WOC Intersectionality Initiative, identified key strategies in the domains of intersectionality and equity, work-life boundaries, gendered divisions of labor, and mental health and well-being for implementation and evaluation in future studies. This article presents recommendations from the Initiative and highlights specific strategies that prioritize intersectionality, which can be adopted by academic health systems to support the well-being of WOC. While this article focuses on issues about WOC, we acknowledge that based on the existing literature, persons belonging to gender minority groups are also experiencing biases and that these social identities may exponentially increase distress.¹ Here, we focus on issues specifically about WOC.

Background and Key Concepts

Across industries and the globe, organizations are leading efforts to improve work and learning environments. The World Health Organization (WHO) has described healthy, safe, and resilient workplaces as places where all people can perform their jobs (1) without getting sick or injured because of their work, (2) with opportunities to enhance their physical and mental health and social well-being, and (3) while preserving harmony with nature and being protected in case of disaster in the community.⁴ The WHO and others have documented the adverse effects associated with occupational stress and burnout, as well as the impacts of inequality on health within academic medicine specifically, studies of WOC indicate workplace challenges that impact well-being. For example, according to the AAMC’s Standpoint Survey of 17,235 faculty members (59% response rate represents 18,797 from 27 schools surveyed between April 2020 and June 2023):

Women were significantly more likely to be disrespected than men.

Black/African American women and multiracial/ethnic women were significantly more likely to report being disrespected than White non-Hispanic women in the workplace.

Significant differences in perceptions of institutional culture promoting inclusion were noted across racial and ethnic groups of women.

Perceptions of institutional culture being promotive of faculty wellness differed significantly between White, non-Hispanic women and Asian women, Hispanic women/Latinas, and American Indian/Alaska Native women.

In addition, overall higher rates of self-reported levels of burnout were noted in women compared with men; most women from racial and ethnic groups reported higher levels of burnout than White counterparts, except among Asian and Black/African American women (Table 1).

Table 1.

Association of American Medical Colleges’ Standpoint Survey Data (April 2020 to June 2023)

	Enjoy work	Stressed	One symptom burnout	Symptoms not going away	Burnout need help	Total N	Aggregated burnout (three burnout categories—any people experiencing one or more symptoms of burnout
Asian women	464	719	432	144	39	1798
Asian women	25.8%	40.0%	24.0%	8.0%	2.2%	100.0%	34.2%
Black women	87	160	90	27	9	373
Black women	23.3%	42.9%	24.1%	7.2%	2.4%	100.0%	33.8%
Latina women	97	174	124	40	14	449
Latina women	21.6%	38.8%	27.6%	8.9%	3.1%	100.0%	39.6%
Hawaiian/OPI women	1	3	6	0	0	10
Hawaiian/OPI women	10.0%	30.0%	60.0%	0.0%	0.0%	100.0%	60.0%
White women	837	1918	1155	450	141	4501
White women	18.6%	42.6%	25.7%	10.0%	3.1%	100.0%	38.8%
Women of other races/ethnicities	15	12	12	4	0	43
Women of other races/ethnicities	34.9%	27.9%	27.9%	9.3%	0.0%	100.0%	37.2%
Women of multiple races/ethnicities	50	99	74	26	6	255
Women of multiple races/ethnicities	19.6%	38.8%	29.0%	10.2%	2.4%	100.0%	41.6%
American Indian/Alaskan Native women	3	5	2	0	1	11
American Indian/Alaskan Native women	27.3%	45.5%	18.2%	0.0%	9.1%	100.0%	27.3%
All women	1,554	3,090	1,895	691	210	7,440
All women	20.9%	41.5%	25.5%	9.3%	2.8%	100.0%	37.6%

Although differences were not noted for Asian or Black/African American women, these data may reflect methodological limitations, institutional safety concerns, or normalized levels of stress that were not considered worthy of being reported.^5
–7 Underreporting may also be an issue in data assessments. This may be due to the perceived lack of safety in the academic institutional environment and/or resignation to the working conditions. These findings support organizational culture’s critical role in promoting wellness, how institutional activities to encourage wellness are presented, and perceptions about who needs them most and who can openly engage in them.

To better understand the experiences of biomedical professionals and administrative staff in academic health systems who are WOC, intersectionality is a key concept central to this analysis. Over time, intersectionality has been adopted across disciplines including higher education, and applied to various marginalized identities as an analytical framework. The working definition for this article applies intersectionality in its more expansive meaning to include the experiences of faculty, residents, and administrative leaders at U.S. academic health systems who identify as WOC with a full array of other identities, including ability status, religious affiliation, sexual orientation, and gender identity.

This article provides strategies to support wellness for WOC based on the findings of the AAMC’s WOC Intersectionality Initiative between 2020 and 2023. We recognize this as an under-addressed yet critical aspect of retaining talented WOC faculty and leaders and engaging their full potential in academic medicine.

Strategies

To build cultures that support WOC’s well-being, leaders can consider utilizing an ecological framework (e.g., intrapersonal, interpersonal, institutional, community, and society) to inform organizational actions. Optimizing culture through conscious inclusion is a key strategy for leveraging a diverse workforce, promoting well-being, and facilitating access to professional opportunities.^8–9 The following strategies are institutional and individual actions informed by local, state, and federal policies and law. Additional information is also available in the AAMC’s WOC toolkits.^10–11

Institutional strategies

Supporting the well-being of WOC requires transforming the culture of academic medicine. Diversity, equity, inclusiveness, and accessibility (DEIA) drive institutional excellence and help to achieve institutional missions.¹² Within the context of state and federal guidelines, the incorporation of DEIA practices into the fabric of institutions will foster engagement and support wellness for everyone in academic medicine. The concept moves beyond embracing difference to strengthening the connectivity and supportive measures within the health systems for WOC.

The minority tax is a major barrier to the recruitment, retention, and advancement for WOC in academic medicine and health care.¹³ The minority (or cultural) tax is defined as “the burden of extra responsibilities placed on faculty of color to achieve diversity and inclusion,” and this additional responsibility “contributes to attrition and impedes academic promotion” of faculty who are underrepresented in medicine.¹⁴ This tax exacerbates inequities in clinical and research productivity and hinders the promotion.

The culmination of the pressure to serve on multiple committees to benefit the institution, the desire to practice medicine and conduct research in health equity spaces, results in scholarship that is often single-site qualitative or feasibility studies, which are neither valued by high-impact journals nor by Promotion and Tenure committees, directly impeding the academic advancement of WOC. Furthermore, there is gender segregation with the clinical efforts of women primarily in nonprocedural medical specialties.¹⁵ As a result, it becomes a challenge for WOC faculty to reach scientific productivity and financial benchmarks established by the departments or employing hospitals.^16

–19

To mitigate and circumvent the impacts of minority tax, academic health systems should, for example, focus on modifying existing policies and practices to ensure meritorious acknowledgment of scholarship and clinical care of medically historically underserved populations and institutional committee participation. The authors suggest practical strategies for implementation within the context of state and federal legislative parameters.

Weighting equity work efforts

Compensating the minority or cultural tax: As noted previously, WOC and others may be invited to participate in service activities at higher rates. Committee membership may offer limited protected time, entails intensive work, and has limited visibility. Chairs and leaders can acknowledge the significance of this work by raising the visibility of diversity and/or health equity-related committee membership, advocating for protected time to participate, and connecting participation to the promotion and tenure process.

Restructuring promotion and tenure processes: If health care organizations recognize that the path toward success entails obstacles, organizations can be well positioned to mitigate gaps through the enhancements to their promotion and tenure process. In addition, the modification of educational, clinical, and research productivity metrics for the inclusion of equity-related efforts, including health equity and community advocacy, is recommended. An impactful approach to implement is a more “holistic” review of the quality, peer review, and dissemination of the scholarship acquired, which often defers to traditional products.²⁰ Along with structural changes, education for leaders plays a key role in identifying and addressing when faculty well-being is in jeopardy due to excessive demands.

Institutionally sponsored support systems for WOC

Personalized mentorship and sponsorship by trusted senior experts(s) who work to advance the WOC mentee’s visibility within and external to their organization and actively involve them in experiences that will expand their professional network and result in career advancement. Implementing a culturally responsive approach to mentorship, advising, and sponsorship by organizations is required to meet the needs of women from diverse backgrounds.²¹

Employee resource groups: WOC-focused affinity groups and employee resource groups (ERGs) have proved effective in maximizing the engagement and advancement of participants.^22–23 The affinity groups require defined metrics, organizational support, and evaluation for continuous quality improvement. In addition, intentional structures designed to foster a sense of belonging, professional fulfillment, and well-being for WOC are necessary. For example, the development of intentional institutional efforts to develop WOC for leadership, current and future positions (e.g., identifying rising WOC leaders and building formal structures such as sponsorship programs that include them in important leadership meetings/events), is essential for achieving a critical mass of WOC in academic medicine and science.²⁴ Organizations can leverage networking opportunities (e.g., historically marginalized groups and women caucuses/alliances/affinity groups) specifically designed to build community among and foster WOC career advancement are facilitators of connectedness, belonging, and well-being.

Organizational efforts to diversify the workforce: Institutional leaders can develop programming to facilitate the professional development of WOC across all mission areas. They can also facilitate the participation of WOC faculty in externally funded programs intended to support their career advancement in research, education, and respective clinical specialties. As an example, the Association of American Medical Colleges, and the Executive Leadership in Academic Medicine for Women offer a variety of opportunities for the professional development of women faculty in medicine and science.

Individual strategies

Although career choice is influenced by a myriad of factors, a common hurdle experienced by many WOC is the pull of multiple expectations beyond typical gendered work–life integration challenges. Unseen and unnamed, these factors can erode self-esteem and confidence. Reframing expectations, both internal and external, is essential.

Cultivating self-efficacy

Seek and implement self-validation mechanisms ²⁵: Developing self-affirming safeguards that foster resilience over time is essential. Individual strategies for self-validation can serve as protective factors to mitigate negative perceptions of bias. A framework to promote protective factors within the workplace include the five A’s; assessment, affirmation, acknowledgment, accessibility, and application. WOC can assess the current state of well-being while addressing intrinsic and extrinsic motivators that impact unprecedented challenges. In addition, the personal acknowledgment of the need for social support through connecting peers at work is critical. The significance of WOC accessing professional resources includes connecting with a sponsor, coach, or mentor to aid in nurturing professional identity. Lastly, this happens when ensuring proper application through shared narratives and coping strategies that cultivate strength and resilience.

Deploy a daily practice of self-care: Reframing from being outwardly focused on what others need—significant others, children, parents, friends, colleagues—to what is needed as an individual is essential for thriving. This takes intentionality and time to be fully present and requires regular reflection to identify what would be helpful, which may change over time. For many, being present helps to reconnect with joy. For others, self-care might focus on caring for one’s body (e.g., eating and sleeping well). Similarly, attending to psychological and spiritual needs can be accomplished by making space for reflection, creative activities, prayer, or meditation. These are strategies that can help with managing the stressors of life better and have consistently demonstrated efficacy in the literature over the years.²⁶

Intentionally make time and effort for community

Creating safe spaces: Interpersonal conflicts, microaggressions, and the weight of the minority (or cultural) tax can coalesce to create a hostile and toxic environment, resulting in a loss of psychological safety.²⁷ WOC in academic medicine could benefit from finding their own communal spaces for support and encouragement. These venues may be ERGs, or other informal gatherings of faculty, staff, and students with shared identities. They can be within the organization or external, such as national organizations. Such spaces can galvanize shared identities, common concerns, and mutual accountability to form a place for authenticity, cultural heritage, genuine concern for well-being, and collective empowerment.²⁵

Anticipate variability and broadly cultivate relationships: Leaders can effectively navigate systemic institutional challenges by avoiding the reductionist thinking that all WOC are homogeneous with similar experiences, backgrounds, and perspectives. Developing a broad, comprehensive, and deep network of support requires interest and avidity in cultivating relational connections. Across difference, others can help WOC grow, learn, and understand experiences that have not been part of one’s life circumstances. Having conversations about bias and barriers may be an optimal practice for all mentor–mentee connections.²⁸

Ensure the default is allyship: In addition to seeking structured communities of support, WOC can embody community for one another by initiating relationships, mentoring, sponsoring, creating opportunities, and leveraging our agency on behalf of another. When opportunities arise to elevate new or emerging voices or when proverbial seats at the table are vacated, WOC can ensure that the women in their networks are informed and given equal access to pursue opportunities. As a community, WOC can amplify the concerns of junior faculty and publicly celebrate their achievements. Inclusion requires acknowledgment of the accomplishments WOC bring to the academic medicine and health care community. Because there is not a “one-size-fits-all” strategy, solutions must be generated iteratively, engaging WOC faculty in the strategy to cultivate an environment where individuals with varied interests and talents can grow, thrive, and succeed.

Discussion and Future Directions

This article has provided background and tangible strategies on how individuals and institutions can support the well-being of WOC in academic medicine. Implicit in this discussion of wellness is a need to discuss the assessment of and evaluation practices for wellness. Several instruments designed to assess wellness lack the intersectional lens to capture the experiences of WOC comprehensively. The authors recommend a restructuring and redesign of wellness instruments to improve the capturing of individuals from all backgrounds. In addition to revising the instruments themselves, future well-being assessments could benefit from analyzing broader dimensions of diversity to delineate differences between certain groups (e.g., Black/African American Women and Asian Women). The reported differences between different racial/ethnic groups of women in this article stress the importance of disaggregating the data to understand experiences, protective factors, and ways institutions can support these unique community needs.

Many recent actions provide examples of how the academic medicine community can move forward on these issues, and we provide some guidance for future directions. The AAMC launched the WOC and Intersectionality Initiative in 2020 and has incorporated this work as a regular and ongoing activity of the AAMC’s gender equity portfolio, which aims to take a comprehensive and intersectional approach to these issues. The AAMC also hosted a session on WOC during the 2022 AAMC Learn Serve Lead Annual Meeting and collected feedback from over 200 participants on addressing and supporting WOC moving forward. A collated list of the key issues raised during this session is given in Table 2. These direct responses from WOC serve as a call to action for leaders in academic medicine.

Table 2.

Responses to “What Is the One Thing the Women of Color Initiative Should Focus on Over the Next Year?”

Connect WOC at different institutions

Establish standards for institutions to help broaden and build diversified and talented candidate pools

Challenge stereotypical notions of what WOC leaders look/act like

Create structures of accountability for medical schools to diversify leadership

Help institutions actively dismantle systemic barriers

Build toolkits to support institutions in addressing disparities and promoting equity for WOC (including salary equity, committee service, DEI-related policies and procedures)

Hold leaders accountable for progress in broadening and building diversified and talented candidate pools

Implement formal mentorship programs for URiM women faculty, also providing formal training to the mentors working with URiM faculty

Standardize equity data that all institutions are expected to track, which should include intersection of gender, race, and other historically marginalized populations

Compensate “nonclinical work” (e.g., education, DEI work, community advocacy)

[Educate everyone] in academia to become effective allies and upstanders

DEI, diversity, equity, inclusiveness; URiM, underrepresented in medicine; WOC, women of color.

Conclusion

Over the last 4 years, the health and scientific workforces have encountered staffing shortages, increased attrition rates, and an overall decline of wellness. WOC are vital contributors to medicine, science, and health care. As the literature describes, they face additional external pressures that can limit their well-being and overall success. The tracking and monitoring the impact of these external stressors within this population have yielded mixed results. Authors and thought leaders in this space have postulated the need to refine tools and methodologies to capture intersectional differences to inform strategy. Optimizing the well spaces for WOC entails the need for an ecological approach to mitigate headwinds.

Footnotes

Acknowledgments

The authors thank Diana Lautenberger and the entire Women of Color and Intersectionality Working Group, of which the authors are a subset. The authors would also like to extend appreciation and gratitude to all the panelists who participated in the Women of Color and Intersectionality Webinar Series.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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