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

We encourage you to review the CMA’s feedback guidelines before providing your response.

Fill out the feedback form to provide your input directly to the CMA confidentially or share your feedback publicly for discussion via the comments section below.

This consultation is open until Nov. 18, 2019.

We’d like to hear your views on the following:

  • Do you agree with the guiding principles outlined in the proposed policy?
  • Which elements of the proposed policy are critical to addressing the key issues?
  • What barriers do you feel individuals and organizations would face in aiming to achieve greater equity and diversity in medicine? How can we reduce these barriers?
  • Which proposed recommendations stand out as positive ones that should be implemented immediately?
  • Are there recommendations that would be challenging to implement? Why?
  • Is there anything that was not addressed in the proposed policy that should be included?

 

 

Anonymous
  • 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.

  • Thank you for this first draft. It is a good document which requires some clarification, additions and changes in the next version.

    • In the second document on “Background to the Policy”, I believe that the section on Physician Leadership could deal with leadership and leadership development more specifically. The section mainly deals with academic data only. In addition, I suggest to not limit that section to gender bias, as the evidence shows that both male and female physician leaders are biased against by peers for having “gone to the dark side”. Publications by Spurgeon and others have addressed that issue that, until today, remains rampant.
    • For the “Main Policy”, please accept following thoughts:
      1. Under Rationale: last sentence of second paragraph requires clarification (unless I am the only one who needs clarification to avoid multiple interpretations).
      2. Overall reflection on the Recommendations, I wonder, what is it the CMA can do to action some if not all of these recommendations? What support can CMA offer to make some of the recommendations actionable?
      3. Why is the sentence at the bottom of recommendation #3 formatted as an orphan sentence?
      4. Recommendation #5 iv: while I support the statement in principle, one has to be very careful in the execution of that recommendation, in that equity should exist in access to resources, training and hiring processes, which might not necessarily translate in equity in the outcome. Off course, this comment does not apply in general and only pertains to certain situations.
      5. Educational recommendation 1 iv: while absolutely essential, time will have to be found in already overloaded curricula. As an example, leadership development has been on the radar of medical school curricula for years, and argument continues to be made that there is (too) little time. Having said that, this is an important recommendation.

    Happy to talk on the phone if my words are unclear or can be misinterpreted. Many thanks for doing this important work and allowing to submit comments

    John(y) Van Aerde, MD, PhD, FRCPC

    Executive Medical Director

    Canadian Society of Physician Leaders

  • Having reviewed the policy and background several times , I commend the CMA for their initiative and efforts. I support this policy. The politically correct pendulum is swinging with  much force these days,,, perhaps too much but these issues do need to be dealt with and equalized and addressed within ,,especially our profession which is seen as a leader in this country.   I think that it also opens many doors where some , likely small, amounts of  the 2.6 $ could effectively be applied to strengthen our morale  as a profession and to improve and maintain quality patient care. Motivational education to help understand and change harassment issues  for just one example.  Page 4, Item 3,,,, "Humility is the key"  is a potent statement. Our past and present president have shown strength and leadership with humility and we as a profession should strive to learn from their example. I respect all of my colleagues comments and note that the $$ issue is prevalent on our minds. I have every faith that our CMA will chose wisely in dealing with this issue.

  • This is important work, worthy of using part of the money obtained from the sale of MD Management. This discussion reminds me of a statement I heard on radio, and which I can only paraphrase: "If one is accustomed to privilege, even equality can seem like oppression." I was fortunate to hear a marvelous indigenous MD speak about her experiences. She told a story about talking at a school, and hearing one of the indigenous children say to another, "There she is – that's the doctor" to which the other child replied, "She can't be a doctor. Indians aren't doctors." Often, it's only when we see ourselves in others that we believe it could be us.

    Our trainees, particularly women, are still bullied and harassed during their training, with no obvious route to change. I had hoped it had changed since my training. Marilou McPhedran spoke at our University (with almost none of the administration present) and said she sees no reason to believe things have changed or will change because the system is set up to prevent change. So, this work is even more important to try to develop a culture which doesn’t allow discrimination and harassment and encourages equality. We must realize that it is not a zero-sum game: when we improve conditions for others, we all benefit socially, and importantly, financially.

    Unfortunately, documents like this often contain too much Newspeak and jargon, which inhibits acceptance. Perhaps the CMA can develop documents inapproachable language.