Background

Equity and diversity in medicine are the subject of an important, ongoing discussion for medical professionals and patients. Greater equity and diversity in the medical workforce will improve system adaptation and patient care, but many barriers need to be addressed for the profession to move forward.

To better understand and address these barriers, the CMA launched a conversation with CMA members and stakeholders on equity and diversity in medicine in January 2019.

Members and stakeholders were encouraged to ponder questions such as:

  • In your opinion, what are the most prominent issues or challenges related to equity and diversity facing the medical profession?
  • What actions or solutions, big or small, might lead us toward a more equitable and diverse future for the medical profession?
  • How can an increasingly diverse profession positively affect patients?
  • What role should the CMA play in improving equity and diversity to support you as a member?

Since receiving and reviewing feedback, the CMA has developed a draft policy on equity and diversity in medicine to promote increased equity and diversity in medicine and to foster a more collaborative and respectful professional culture. By developing this policy, the CMA aims to identify a set of guiding principles and commitments to achieve these goals. It provides support for the view that improving circumstances and opportunities for physicians and learners is essential in creating a more equitable and sustainable culture and practice of medicine.

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Defining equity and diversity

Equity refers to the treatment of people that recognizes and accommodates their differences. Equity relates to the opportunities of any given person, with their own identity, culture and characteristics, to create and sustain a career or to receive medical care without discrimination, harassment or cultural- or characteristic-related negative bias.

Diversity includes those (observable and non-observable) characteristics that are constructed — and sometimes chosen — by individuals, groups and societies to identify themselves (e.g., age, culture, language, gender, sexuality, health, cognitive abilities, socioeconomic status) in different contexts and that may describe them in relation to others in those contexts. It describes them in relation to other people (e.g., age, socioeconomic status, geographic location, health).

Feedback options

The consultation period for reviewing the draft policy closed on Nov. 18, 2019. Thank you to all stakeholders who shared their thoughts. 

  • I applaud this policy. It is a good start. As a Black female physician, I know how deep systemic racism runs in this country (as confirmed by the United Nations), which traces back to our violent history as a nation and persists within our institutions, including healthcare. But I truly believe we are in a season of meaningful, positive change. I read most of the comments here, and I'm trying to understand the different perspectives on this, especially those that I do not agree with.

    But my main message is to all the young people - medical students, residents, fellows, who I found out have read some of the comments here, and are feeling afraid, excluded, or frustrated by some of the comments here. I am speaking to both those who feel marginalized, and those who are in their own journeys to be allies. I'm sure that these are trainees who are going to be major players in the future of medicine, and some of the comments hit them hard. If the description above resonates with you please know:
    This policy is a great first step. The road to collective understanding will be long. Try not to be discouraged by those who do not know what it is to prepare for, study and thrive in medicine while being part of a community that exists in the margins. You have a voice, and you are amazing to have been able to come this far. Remember, there are so many of us older physicians, who applaud you and celebrate you!
    Whether you have experienced inequities due to indigeneity, gender, race, religion, sexual orientation or identity, ability, socioeconomic background, or any other identity that makes you feel "othered", please know that the future is bright... and DIVERSE!
    Be bold, be proud, stay connected, and have faith that we are all headed together, as a profession, in a good direction, that will make us more compassionate to ourselves, each other, and our patients!
  • “Individual protection from bias and discrimination is a fundamental right of all Canadians.” I wholeheartedly agree with this statement which is at odds with the substance of this policy. The policy document presents hypotheses as statements of fact without supportive data. This policy is partisan and will dissuade many Canadians with mainstream political beliefs from pursuing careers as physicians.

    Giving preference to one individual over another based on sex or ethnicity is unethical, yet this policy advocates such practices. If we wish to overcome racism and sexism we should treat people based on their individual merit not by group identity. How can we claim to seek to treat all individuals fairly if we judge different individuals by different standards based on their race or sex? If we wish to ensure people are protected from bias and discrimination we should give greater weight to objective measures of assessment such as standardized tests.  The document proposes “Considering subscribing to a holistic process of defining pools for medical training interviews” This kind of process which at Harvard means that for a given SAT score an applicant would have a 25% chance of admission if they belong to one minority but 95% if they belong to another. 

    Bigotry is directed at individuals based on group identity, but is not necessarily a uniform process. Some members of an identity group may experience bigotry, but others may not. If bigotry prevents an individual from achieving their potential, setting a lower bar for another individual who shares group identity but who has not been victimized does not bring justice to the victim. In order to lower the bar for one, the bar must be raised for another, another who must be discriminated against based on group identity. Where is the individual protection from discrimination? This policy espouses regressive concepts of group merit and guilt. To borrow from Bari Weiss; in practice, intersectionality does not dismantle the caste system but functions to replace it with a new one. This does not advance the cause of justice.

    If Applicant A belongs to a group that is overrepresented in the medical community but is otherwise in the 85th percentile of all applicants, should she be passed over for Applicant B who is in the 10th percentile but from an underrepresented group? Who will define what group identities merit consideration and what weight will be given to each intersectional factor? The potential for bias and abuse in such a system should preclude giving it any further consideration. It will likely lead to the same outcomes seen at Harvard.

    Will Applicant B serve patients better than Applicant A? If patients become aware that standards are lowered based on group identify what unintended consequences might arise? Would parents consider a physician’s skin colour or other group identity when choosing who they entrust with the care of their children?

    The central tenet of social justice is implicit in this policy. I’ve recently seen it  expressed as follows on social media:

    Coleman Hughes refers to this as the disparity fallacy.”The disparity fallacy holds that unequal outcomes between two groups must be caused primarily by discrimination, whether overt or systemic.” 

    Clearly beliefs, culture, and biology impact outcomes. Patients who refuse blood transfusions will be less likely to survive a severe GI bleed. If a woman can’t become pregnant, she will not suffer an ectopic pregnancy. A culture which supports physical activity will likely see lower rates of obesity than one which does not. Clearly discrimination plays a role in outcome differences, but we cannot assume that outcome differences are solely the result of discrimination.

    While one of the aims of this policy is to foster a culture of diversity, it will likely only foster the skin deep forms of diversity and deter many people with mainstream political beliefs. How will this “create, foster, and retain a community of physicians and learners that reflects the diversity of the communities they serve?“ 

  • The intent of this document is to be equitable, which is defined as the quality of being fair or impartial.   Unfortunately the document inadvertently achieve the opposite by codifying reverse discrimination.  We should neither favour the previously privileged nor the less privileged, so as to not propagate inequity in the name of progress.

    An emphasis on humility, compassion, character and empathy will go much father than rules about conduct to help make medicine a truly equitable profession.

  • Thank you for this opportunity. I would encourage you to expand the definition of equity to include  the opportunity to "create and sustain a career" without negative bias based on their religious convictions that are part of their identity.  The right to decline participation in MAiD, either by performing the procedure or providing a direct referral should be protected by every provincial college

  • I apologize I have commented a few times today and deleted posts because I didn't know to uncheck the "Enter to Comment" box. I have read the policy and agree with the comments that this is a needed policy. I am a medical student and parent with two little kids on a one-year leave in the middle of my MD program, and have a special interest in addressing interpersonal violence and in particular, I raise awareness of brave men. I mention this because it give me a unique perspective and relates to my input below.

    1) The policy mentions "bias, discrimination, and harassment". I suggest considering an interpersonal violence lens. The vast majority of physicians are not familiar with interpersonal violence as defined by the WHO and many people I have spoken to do not like this terminology and are reluctant to name an equity problem in medicine as violence. Upon reviewing the WHO definition, it is unmistakable that there is violence in Medicine and I believe it should be named as it is harm in the environment that is related to equity and diversity. I have heard of "incivility" in healthcare which is not the same thing as it generally pertains to bullying or mistreatment between/among peers and not situations where there is a power differential.

    In terms of training/education recommendations, I suggest including a plan to incorporate basic training on interpersonal violence (e.g. 1 hour would be a great start) for physicians and in curriculum for trainees, most of whom do not know what "violence" is from a public health perspective. This training would also provide context for clinical presentations related to violence (e.g. intimate partner violence, sexual violence, child maltreatment, etc.). Medical students learn about IBS and Crohn's in one block, and Type I and Type II diabetes in another block. We are not learning about violence against men (e.g. gang violence, violence against aboriginal men, bullying and physical violence of boys, or child sexual abuse of preschool boys) alongside violence against women/girls and other genders and I feel that this is part of the reason that conversations on topics like campus sexual assault break down or have mixed results. An example of a curriculum that has already been developed is at http://medicalpeacework.de/. I have not had time to take this course yet, but it seems to me that through a "violence as a public health issue" lens, MD-trained people can better make sense of discrimination and harassment in the context of other things like interpersonal and even mass violence.

    2) The policy mentions "age, culture, language, gender, sexuality, health, cognitive abilities, socio-economic status". I believe that caregiver status should also be explicitly mentioned and perhaps even briefly addressed in a paragraph.  8-9% of medical students in my class were parents. Parents (of all genders) in medical school are uniquely disadvantaged time-wise by significant caregiver obligations. Moreover they are generally older and may have health issues that more commonly affect older people. Because of having less discretionary time to spend, many parents do not participate in "lunch with the dean", respond to surveys, or give feedback on policies, procedures, or processes, even when they are more disadvantaged in some respects and directly affected by issues. Medical students have written a paper on the topic in the past. https://www.cfms.org/files/position-papers/agm_2017_support_of_parents.pdf

    3) From some of the comments on this policy that have been posted here, it seems that systemic discrimination is not well understood. Broken rungs for some groups are invisible and do not look like discrimination in the blatant way one might expect to see it. For example, this article highlights the question of feedback received by working women and is changing expectations of women in the workplace: https://www.wsj.com/articles/the-reasons-women-dont-get-the-feedback-they-need-11570872601

    However, if discussing issues affecting women for example, some men would connect to this better if more diversity of examples affecting other genders were provided, including examples affecting men whose problems are not necessarily apparent to historically under-represented groups. The Good Men Project has updated their list of the most pressing issues affecting men: https://goodmenproject.com/featured-content/talk-men-top-10-issues-today-gmp/

    The policy recommends training on "allyship", and I believe it needs to go one step further and also recommend training on "community organizing" to allow men, specifically, to also organize around allyship and organize around the problems affecting them, with the caveat that their work goes hand in hand with the work of historically under-represented groups. The trouble is that many people of all genders struggle to organize in a way that is in cooperation instead of in opposition and so it would be beneficial to engage people who have experience in doing this. Next Gen Men and The Alberta Men's Network are two groups in Canada that have been somewhat successful in this respect and could potentially help develop a Masculinities in Medicine program. Under-representation is not only related to gender, but gender is the area I am most familiar with so that is all I have spoken to.

    4) The policy mentions programs for cultural competence, humility, and transformation, which I agree with. My only remaining comment is that these programs may not run deep enough to effect "transformation" unless they tackle violence and healing, and if they do, I suggest that they be implemented using trauma-informed approaches whenever possible.

    Long post, but you asked for feedback - and I probably would not have made time to respond if I had not been able to take a year off from school, even though I have something to contribute to this conversation. Thank you for all the work that has been done to date on this issue. I may not have survived in medical school a generation ago, but many changes have been implemented that make it possible for me to do it now.