It’s not rocket science — it’s harder

Ahmaud Arbery. Breonna Taylor. George Floyd.

2020 was rocked by a series of killings of Black Americans. Subsequent protests across the country strove to call attention to the racial injustice that permeates every level of American society. Academic medical centers are not immune.

In 2019, the Association of American Medical Colleges reported that medical school faculty across the nation were 84% white or Asian. At the time, 79% of Stanford’s medical faculty were white or Asian; only 1.7% were Black or African American, and 4.3% were Hispanic, Latino or of Spanish origin — despite the fact that these minorities make up about 32% of the population of the United States.

“You can’t tell me there isn’t a problem at Stanford,” said Yvonne Maldonado, MD, the senior associate dean for faculty development and diversity at Stanford Medicine. “The problem is, we often refuse to see it. But there’s no utopia anywhere. There’s no completely equitable and fair place.”

In October, Stanford Medicine launched the Commission on Justice and Equity to amplify efforts to dismantle systemic racism and discrimination against underrepresented groups within the institution and around the world. In a joint statement, the leaders of the School of Medicine, Stanford Health Care and Stanford Children’s Health affirmed their intent to address racial inequality as an urgent public health issue.

By championing diversity, celebrating inclusion and committing to equity at every level of the institution, the leaders are aiming for Stanford Medicine to become a pacesetter in the organizational and cultural change necessary to transform the medical playing field into one that everyone can access equally. The commission’s initial recommendations are expected this spring.

“After the George Floyd murder, our Stanford Medicine community came together to declare, ‘enough is enough,’” said Terrance Mayes, EdD, associate dean of equity and strategic initiatives and executive director of the commission. “We pledged that Stanford Medicine will no longer remain silent. We will do everything we can to effect meaningful change.”

A place doesn’t become equitable and fair simply by increasing minority representation, however. The numbers are simply a proxy for an undertow of inequality and inequity that can leave underrepresented minorities fighting to stay afloat.

To make a real difference, Maldonado emphasized, it’s important to recognize the unconscious bias and invisible barriers faced by minority community members, and to dismantle systems and policies that allow inequities to persist and thrive.

“These are thorny issues,” Maldonado said. “I really can’t imagine a topic that’s any harder to deal with, frankly. But our leadership has been very supportive.”

“Diversity and inclusion have long served as institutional values here,” said medical school dean Lloyd Minor, MD. “With these at the heart of what we do, we’ve made encouraging progress. But the road ahead remains long, and it’s become clear that achieving change at the scale required demands that we take a more direct approach.”

In answer, Stanford Medicine is calling for a tidal wave of change that will ripple outward and carve out a new landscape of public health in this country.

“We have to reject the myth of meritocracy, the idea that you can succeed if you just pull yourself up by your bootstraps. Not everyone has bootstraps.”

Terrance Mayes, EdD, associate dean of equity and strategic initiatives

Efforts to address racial inequity at Stanford Medicine are not new. In 2004, the medical school focused on gender and racial diversity, creating a new leadership position meant to attract women and underrepresented minorities to post-graduate and faculty positions — the senior associate dean for diversity and leadership. Professor of medicine Hannah Valantine, MD, was the first to hold the post.

Conversations with faculty of color revealed a lack of community and a feeling of being dismissed. “People felt isolated, not just socially, but also in their research lives,” said Valantine, a cardiovascular specialist. “Some expressed feelings that others were not interested in their work, or that their contributions weren’t valued.”

From 2004 to 2012, the number of underrepresented minorities on the faculty increased from 51 to 92, or 5.9% of the total. From 2012 to 2019, the number increased from 92 to 161, or about 6.8% of the total.

“There’s been a slow drift toward better representation, but it’s far, far, far too slow,” said Valantine.

Some of the most pervasive stumbling blocks to progress are difficult to remove because they are built into the fabric of higher education in the United States.

“We have to reject the myth of meritocracy, the idea that you can succeed if you just pull yourself up by your bootstraps,” Mayes said. “Not everyone has bootstraps. We also have to interrogate what we mean when we use words like ‘excellence,’ which can be a very loaded word in academia, and we have to reject the notion that diversity and excellence are mutually exclusive goals.”

In the years since Valantine’s appointment, Stanford Medicine has implemented dozens of programs for students, residents, postdoctoral scholars, and young and established faculty members to promote diversity, equity and inclusion.

Building on this work, the new commission brings together a body of external experts like commission chair Rosalind Hudnell, former chief diversity officer at Intel, with internal stakeholders like Valantine and Mayes to facilitate these efforts.

“There is a lot of good work already underway,” Mayes said. “The commission is not meant to stifle existing programs, but to complement, amplify and help accelerate outcomes.”

In a talk to the Stanford Medicine community in November, Hudnell emphasized that the commission will work to ensure that existing efforts to promote diversity, equity and inclusion are aligned, integrated and consistent across every level of the organization, while also driving strategies that build on successive small achievements.

“What you really want to do is dismantle the processes and procedures and policies that enable racism to flourish. You can’t say, ‘OK, tomorrow everyone is not racist.’”

Rosalind Hudnell, chair of the Stanford Medicine Commission on Justice and Equity

“We talk about ‘dismantling racism,’” Hudnell said. “But what you really want to do is dismantle the processes and procedures and policies that enable racism to flourish. You can’t say, ‘OK, tomorrow everyone is not racist.’”

The commission began by initiating a series of conversations with members of the Stanford Medicine community, including Black student and faculty leaders, LGBTQ+ leaders, and leaders of the Stanford Medicine Abilities Coalition.They wanted to hear directly about challenges facing underrepresented groups at Stanford Medicine — which included a lack of Black representation in leadership and faculty positions, frustrations with retention of underrepresented community members, and a lack of transparency and accountability when instances of racism are reported.

“One of the commission’s many deliverables will be to contrast the reality we experience today with the vision of where we hope to be,” Paul King, president and CEO of Stanford Children’s Health, said.

“The commission will identify that gap. We recognize that not all problems will be solvable overnight, but we are committed to taking strong action that will effect lasting change. Together, we will erase that gap.”

Supporting students

One issue the commission is exploring is how best to support minority medical and graduate students as they progress through every stage of their training, from residents and postdocs to young faculty members.

When Dorothy Tovar, a sixth-year graduate student in microbiology and immunology, arrived at Stanford in 2015, she felt isolated and lonely and had a hard time finding other students of color.

The daughter of Haitian immigrants, Tovar chose Stanford for graduate school because she was impressed by the resources available to graduate students and the care with which the faculty shepherded their students during their training. But she quickly realized there were very few people who looked like her.

“When I finally spoke with other Black students on the medical campus about this, I realized they were feeling the same way,” Tovar said. “There wasn’t an intentional community to share our experiences and challenges.”

“I would wake up and hear that another Black man was killed, but I would still have to show up in lab and go to meetings as if nothing was wrong.”

Dorothy Tovar, a sixth-year graduate student in microbiology and immunology

The deaths of Philando Castile and Alton Sterling at the hands of police and the subsequent protests in the summer of 2016 left Tovar feeling further adrift.

“I would wake up and hear that another Black man was killed, but I would still have to show up in lab and go to meetings as if nothing was wrong. It seemed that the university, my professors and my peers were ignoring a racial reckoning that directly impacts minority students,” Tovar said.

As Tovar’s experience shows, it’s critical to foster a sense of community and belonging.

Ayodele Thomas, PhD, associate dean for graduate and career education and diversity, understands this need. Thomas is a descendant of enslaved people on both sides of her family, and her parents and grandparents were active in the civil rights movement.

After receiving her PhD in electrical engineering from Stanford (the first Black woman to do so), she pivoted to a career focused on increasing diversity and combating racism in higher education.

Yet, “When I walk into a room, there’s never the assumption that I am the leader,” Thomas said.

To address what she sees as a need for a greater sense of community among minority students, Thomas teaches a graduate-level seminar called Graduate Environment of Support. Although the seminar is diversity focused, any student can enroll.

“We talk about challenges like imposter syndrome and discuss how to approach problems and take advantage of resources,” Thomas said. “Basically, it’s all the things I wish I had known before I entered graduate school, with a focus on fostering a sense of inclusion and belonging.”

At times, students like Tovar have also taken things into their own hands. In 2016, Tovar and three other graduate students launched the Stanford Black Bioscience Organization to build the community they were missing.

She and four other students also worked with the dean’s office and the Diversity Cabinet to obtain funding for the Diversity Center of Representation and Empowerment, or the D-CORE — a gathering and group-working space within Lane Medical Library for any member of Stanford Medicine interested in issues of diversity and inclusion.

Mentoring students, trainees and faculty

There are no surefire ways to immediately increase diversity and equity throughout Stanford Medicine. Although the incoming medical and graduate student classes are far more diverse than in the past, that change is trickling up slowly. In 2020, 38% of the incoming medical class identified as Hispanic/Latino, Black/African American, or two or more underrepresented minorities. There is a similar upward trajectory in incoming graduate students.

“The incoming PhD cohort has been more than 20% historically underrepresented minority students for several years,” Thomas said. “So we’re seeing a change in the face of the student population overall. But the racial composition of the faculty hasn’t changed at all for the most part. There’s a mismatch.”

The commission is identifying blind spots and pinpointing vulnerabilities that can lead to attrition of minority students, residents and faculty members at critical career pressure points, said Mayes. “What is it that we aren’t seeing, that we aren’t thinking about? How do we create a place where everyone can thrive, regardless of their background?”

Attrition isn’t unique to medical or graduate school, however. Frequently postdoctoral scholars, medical residents and young faculty members of color struggle to find mentors who not only look like them but also understand their struggles.

“The transition from a postdoctoral scholar to a faculty member is the most difficult,” Valantine said. “Many institutions focus on medical and graduate student classes and think they have done a good job. But these trainees are looking up through the ranks, searching for role models. And they are not always finding them.” Having a good mentor can make all the difference.

“As a first-generation American, I was the first in my immediate family to attend college in the United States,” said clinical associate professor of neurology and neurological sciences Reena Thomas, MD, PhD, whose mother is from El Salvador and father is from India.

“These trainees are looking up through the ranks, searching for role models. And they are not always finding them.”

Hannah Valantine, MD, professor of medicine and Stanford Medicine’s first senior associate dean for diversity and leadership

Thomas was looking for someone to help navigate the early phases of her career when she met Maldonado through a minority faculty networking event sponsored by the Office of Faculty Development and Diversity. Soon the two were meeting regularly to discuss opportunities and the next steps of Thomas’ career, and Thomas became a liaison between the neurology department and Maldonado’s group.

In August 2020, Thomas became the inaugural associate dean of diversity in medical education to support medical trainees along their path to positions in academia, from premedical students to medical faculty members.

“I love connecting with medical students and clinical subspeciality trainees who share a similar background as mine and helping them into the next phase of their careers, just as Bonnie did for me,” Thomas said.

The office also offers skill-building workshops and leadership programs for faculty on leading diverse teams; implicit bias; the roles of diversity, equity and inclusion in professional development; and the Department Diversity Liaison program, which focuses on empowering faculty members leading DEI efforts in their departments.

“We want to make lasting changes at the department level by raising awareness of the general issues and challenges,” said Magali Fassiotto, PhD, the associate dean for faculty development and diversity. “Culture is characterized at the top levels of an institution, but it really lives at the local level.”

Anti-racism in medical practice

Diversity is more than just a numbers game. Increasing the prevalence of minority physicians and researchers and the awareness of all medical providers about racial inequality in medicine has a direct effect on public health.

In 2017 Fernando Mendoza, MD, associate dean of minority advising and programs (now emeritus), gathered a group of medical school faculty, including Daniel Bernstein, MD, the associate dean for curriculum and scholarship, to discuss ways in which medical school education could better address issues of anti-racism, social justice and health inequities in the doctor-patient relationship. [See sidebar here.]

But efforts to increase awareness about racial inequities in health care don’t stop with students.

The Stanford Medicine Health Equity Committee, co-chaired by Maldonado and anesthesiologist Amy Lu, MD, is gathering data on Stanford’s patients to better understand health disparities arising from the unequal treatment. Lu witnessed such treatment firsthand when, as a child, she translated for her Chinese-speaking grandparents at a public hospital in California.

“Is there a particular population that is affected? If so, we need to understand why, what is the case, and get to the root of it. Is it because we are delivering care inequitably? Are certain kinds of care being withheld? Are patients who are coming to give birth being offered less pain medication if they are African American?” said Lu, the associate chief quality officer for Stanford Health Care.

“We’re talking about building a culture of addressing real, systemic racial inequities at every level. No aspect of this is simple, straightforward or easy to measure.”

Yvonne Maldonado, MD, the senior associate dean for faculty development and diversity at Stanford Medicine

There’s no shortage of ways to improve.

But challenges remain.

One challenge is supporting the change-makers themselves. Tovar’s extracurricular efforts to create D-CORE are an example of what’s known as the minority tax, or the expectation by non-minorities that people of color should serve on diversity committees, mentor younger minority students, give talks about their personal experiences with racism, or carry out any of a plethora of other tasks — all without any direct benefit to their own career or professional development.

“We’re talking about building a culture of addressing real, systemic racial inequities at every level,” Maldonado said. “No aspect of this is simple, straightforward or easy to measure.”

These overtures are often made with the best of intentions but without recognition of the impact of being asked to serve as “a token,” according to Fassiotto.

She recalls an instance in which a white male faculty member, intending to support his colleague’s career, asked a female faculty member of color if she’d like to participate in a department committee. He was taken aback when she said she felt like she was valued more for her “otherness” than for her expected contributions.

“I suddenly realized that I didn’t know anything,” the male faculty member recounted to Fassiotto.

An undercurrent of skepticism often greets any new effort to promote diversity and inclusion. So many committees over so many years. Why should this new push be any different?

“One of the blessings of the current moment is that people are asking questions and having conversations that they wouldn’t have been willing to have several months ago,” Ayodele Thomas said.

“At least people are talking about it. In the past, someone would have said ‘I’m not a racist’ and just kept moving on with their life. But now we’ve been forced to slow down a bit and really think about the components of racism and how to address them.”

“After the George Floyd murder, our Stanford Medicine community came together to declare, ‘enough is enough.’ We pledged that Stanford Medicine will no longer remain silent. We will do everything we can to effect meaningful change.”

Mayes, executive director of the Stanford Medicine Commission on Justice and Equity

Members of the commission have spent the past six months in conversation with people across Stanford Medicine to identify problems and brainstorm solutions.

“Addressing systemic racism must begin by taking a brave and honest look within, and fundamental to this process is the act of listening,” said David Entwistle, president and CEO of Stanford Health Care.

“For months, the Commission on Justice and Equity has met with all community stakeholders to solicit their ideas and input. This dialogue must continue after the commission delivers its recommendations. Stanford Medicine has a tremendous opportunity to grow more inclusive through this journey and set an example for others.”

“Diversity is not rocket science. It’s harder,” said commission chair Hudnell. “Stanford is trying to do, within the walls of its community, something that — it’s clear if you just turn on the news — the world hasn’t figured out how to do. But we have three leaders who are aligned in their mission. Now we need to devise strategies and actions that drive this alignment throughout the organization.”

Preliminary ideas driven by the learning sessions include bolstering the organizational capability to promote diversity, equity and inclusion; working toward parity and equity for Black and underrepresented groups in the community; increasing trust and accountability around issues of equity and justice; and creating a coordinated, holistic approach to combating racial health disparities.

“Our leadership has put the institution’s full weight behind confronting discrimination and creating a more just and equitable environment here at Stanford Medicine,” said Priya Singh, the chief strategy officer and senior associate dean for strategy and communications.

“Through the lens of our tripartite mission — research, education and patient care — the commission we’ve convened will help us strengthen our internal programs and identify opportunities to assert national leadership on addressing disparities that continue to harm the health of historically marginalized groups.”

Mayes agreed. “Our country is different than it was a year ago; the campus climate is different; and the commitment by the three leaders of Stanford Medicine is sincere, authentic and unwavering. I do think this time we will see real, meaningful change,” said Mayes. “As an institution, we have committed to racial equity, diversity and inclusion, and we will continue to denounce racism in all its forms, including recent instances of anti-Asian violence. But we aren’t perfect. There is room to grow.”