PHILADELPHIA - Marginalized groups of people value professionalism more -- and are more likely to leave a job at an institution due to issues of professionalism -- compared to their white, male counterparts, according to a Penn Medicine study of staff, faculty, and students who were affiliated with a large, academic health system in 2015 and 2017. The findings, published today in JAMA Network Open, suggest that health care institutions must reevaluate and redefine professionalism standards in order to successfully make the culture of academic medicine more inclusive and to improve the retention of minorities and women.
This study is one of a series of research projects launched at Penn Medicine, under the leadership of Vice Dean Eve J. Higginbotham, MD, SM, as part of Office of Inclusion and Diversity's mission to chart Penn Medicine's course toward inclusivity for all groups.
"What does it actually mean to operationalize an anti-racist, inclusive workplace? It means understanding the factors in an environment that allow women and minorities to thrive in your organization," said Jaya Aysola, MD, MPH, assistant dean of Inclusion and Diversity at the Perelman School of Medicine and executive director at the Penn Medicine Center for Health Equity Advancement. "We wanted to look at the ways that marginalized groups perceive and experience professionalism, so that we could move toward standardizing policies in a way that is really inclusive for all. Recruiting female and minority students and employees is not enough if an organization cannot retain them."
Professionalism has been implemented as a core competency for medical education to govern how physicians conduct themselves in public, be it with patients or with each other. However, the medical field lacks a concise, unifying, and operational definition of professionalism, and the word is often misused or overused. Moreover, the historic definition of professionalism has largely centered around white, heterosexual male identity, and therefore the current understanding of what is deemed professional can often be non-inclusive or discriminatory. For instance, because of these cultural norms, the way that certain groups dress, speak, eat, or wear their hair might be deemed unprofessional.
The study authors wanted to examine perceptions and experiences of professionalism among faculty, trainees, staff, and students, in order to better understand, and then perhaps reevaluate, how professionalism standards are applied to different groups.
In the first part of the study, the researchers analyzed answers collected from the Diversity Engagement Survey, which is administered by Datastar, from February to April 2015. The dataset included 3,506 respondents -- faculty, trainees, staff, and students -- from two Philadelphia-area health systems and four medical/health professional schools.
On the survey, respondents were asked to rate their responses (from strongly agree to strongly disagree) to three statements related to professionalism: (1) "I have considered changing jobs due to inappropriate, disruptive, or unprofessional behavior by a coworker or supervisor." (2) "I value institutional initiatives, policies, and/or educational resources related to professional behavior in the workplace." (3) "My institution supports a culture of professionalism."
In response to the statement "I value institutional initiatives, policies, and/or educational resources related to professional behavior," 52 percent of women and 54 percent of
Black individuals agreed or strongly agreed, compared to 45 percent of male and 49 percent of white respondents.
Respondents who self-identified as female, LGBTQ, non-Hispanic Black individuals, when compared with white, heterosexual men, were also statistically significantly more likely to report considering changing jobs because of "unprofessional" behavior. No statistically significant adjusted differences were found among respondents who agreed with the statement "My institution supports a culture of professionalism."
Aysola said that she suspects the greater value women and underrepresented minority groups place on professionalism may stem from what they perceive to be lacking in their work environment, as well as gaps that they perceive between institutional values and their lived experiences.
To probe that hypothesis further, the research team also analyzed responses to the open-ended question: "Tell us a time that you felt valued or devalued, or welcomed or not welcomed by your organization." The researchers solicited narratives via email in 2017 from faculty, trainees, staff, and students across the organizations studied. They then analyzed 52 narratives pertaining to professionalism.
Many narrators who self-identified as members of marginalized populations expressed infringement on their professional boundaries during interactions at work or learning environments.
The infringements reported ranged from microaggressions to blatant racism, sexism, xenophobia, and homophobia. Other narratives stated that professional standards were applied differently to certain groups, and those groups perceived that they were subject to greater scrutiny. Experiences cited ranged from facing differential disciplinary practices and feeling unwelcomed, to experiencing pressure to conform and being asked questions about childbearing, living situations, and tattoos.
A consistent theme throughout the stories was that the respondents from underrepresented groups felt they were subjected to greater scrutiny, while simultaneously reporting greater infringements over their professionalism boundaries.
"The narratives that we collected reveal disparities in how we assess professionalism, with minorities and women reporting a microscope over their behaviors." Aysola said. "A common theme was that being different was not perceived as being a good 'fit,' forcing individuals to alter their authentic selves to feel included.'"
These findings, according to Aysola, underscore the need to revisit the professionalism standards, which govern the practice of medicine and the engagement between members of the medical profession. These standards, she said, must be informed by diverse perspectives, in order to be more inclusive. They also must be operationalized in a way that ensures behaviors are subject to equal scrutiny, irrespective of the culture or background of the individual, she added.
"We have to take every single policy and practice that governs culture, and we have to put it through an inclusion filter," she said. "Inclusion and diversity cannot exist in silos; they must be designed into the fabric of an institution."
Penn authors Dominique Alexis, Corey Williams, Chang Xu, and Eve J. Higginbotham contributed to this research.
JAMA Network Open