The COVID-19 pandemic amplified deep-seated health-care workforce inequities and an awareness of them. Women and the Black, Indigenous, and other people of color particularly experience these disparities. Now, as the pandemic is easing, many in the medical world are working to make sure the issues don’t go back into hiding.
As the newly appointed dean for medical education at the University of Chicago’s Pritzker School of Medicine, Vineet Arora is an academic hospitalist, researcher, and a leading advocate for improving the future of health care and a safe working environment. Her academic research has focused on trainee mistreatment, burnout, sleep deprivation, and pathways to promotion in academics. Most recently, she has focused on the best ways to bring diverse teams together to deliver care.
Recently, Arora sat down with Thomas Jefferson University emergency physician Resa E. Lewiss, creator and host of The Visible Voices, a podcast dedicated to these issues and more. They talked about what lies ahead for the health-care workforce. The interview has been edited for clarity and concision.
What does the research show on how 2020 and 2021 uniquely affected women, the community of Black, Indigenous, and other people of color, and other marginalized groups in the health-care workforce?
It was already bad, and it became worse. Unfortunately, the pandemic has “unmasked” these inequities that women, marginalized identities, BIPOC individuals, particularly our Black colleagues, have faced and only been magnified, not just by the coronavirus pandemic, but also the issues of structural racism and police violence. The deaths of George Floyd, Breonna Taylor, and others have really signaled to Americans that we need change, and we need it immediately. We cannot relax, we need it now.
How has this affected patients?
Sometimes people put health care on a pedestal: the idea that we are professionals, that we do not treat people differently. We take an oath to treat everybody the same. Unfortunately, the data do not bear that out. And so with a racial reckoning that’s met with health care, we know that our Black patients, for example, have worse health outcomes, and also face biased treatment.
Decades ago, when I was in school, people would just take it as a given that an underserved area was code for, “the hospital can’t fix this.” Now there is better recognition that this is really the structural oppression of populations that has limited their health and accumulation of generational wealth. And so how can we in health care actually move upstream to help do that? That’s the way we close the gap. We’re not going to close the gap with the same old routine stuff that we’ve been trying.
What does the future of the health-care workforce look like?
That’s a really interesting question. I think that one thing to think about is: Do we have a shortage of health professionals? Historically, there’s been a lot of workforce projections that have been wrong. We’re pretty certain that we have an aging health-care workforce population, especially in nursing. We have a lot of people who are burned out after the pandemic, people who are considering retiring, people who are moving and taking traveling jobs or other types of employment.
So in terms of front-line health care, things have gotten so bad that I do worry that we are bleeding our workforce to the point where we will have critical workforce shortages, particularly in areas that already have shortages.
The real challenge is that we’re going to face not only a shortage, but specifically a shortage in already underserved areas. How do you fix the mismatch and the misaligned incentives so that we can get the health-care workforce to where the workforce is needed? That’s really going to be the future challenge.
How are personal and family needs affecting these shortages?
In the New York Times, there was an article, which profiled a friend of mine. She is a physician here in Chicago. She is an internist in the suburbs, who stopped working. Similar to a lot of physician moms, who are in dual-career marriages, she is facing incredible challenges. Women may be in lower-paying specialties, like primary care, and they are not going to have the child-care support that they needed during the pandemic, and there is a partner or spouse who happens to be in a much higher stress situation.
In fact, research shows physician women with small children are exiting the workforce. I have been anecdotally seeing a lot of pivots. Sadly, we’ve seen a lot of Black women exit academia. I shudder to use the phrase by choice, because usually, if you peel that onion, it’s usually due to decades of microaggressions … and so I do think for intersectional identities, especially Black women, it’s much worse.
Has the spotlight on health care helped at all?
Although the pandemic has fueled interest in health professional workforce careers, in medicine, all the spots are filled … and we’re not creating new spots. In fact, we’ve got hospitals that are closing their residency programs due to the emergence of private equity buying hospitals.
International Medical Graduates (IMGs) actually plug the hole in a lot of medically underserved areas and rural areas and in primary-care fields, and so what people don’t understand is, without IMGs, we simply wouldn’t make it. Roughly half of internal medicine residency spots are IMGs. Family medicine also has huge numbers largely because that’s where they are desired. … We are seeing big growth in the use of physician assistants and nurse practitioners, which certainly will affect physician demand. Regardless, it is hard to say anyone is strategically thinking about the workforce needs of the future population.
If we speak about PTSD, burnout, sexual harassment, how do you see those playing a role? And how can we best address mental health needs?
That’s such a tough question. These are problems in health care that we have to acknowledge. Take, for example, our sexual harassment problem. Our first step on the way to recovery is recognition. It is so troubling to me to see these cases of sexual harassment, and particularly what’s been described as the networked silence around the survivor. We have to accept that we have a problem. It needs to be accepted by the leaders … and in all academic teaching hospitals.
It’s no longer a woman’s problem although it more commonly affects women. It’s everyone’s problem. If women leave the workforce, men suffer, male patients suffer, male colleagues suffer. So it does no good to anyone for women to leave the workforce. And there’s really good data to highlight that workplace environments where women are happy and women are present are diverse and better. They have better [patient] outcomes, they do better, they retain better, and so it is in no one’s advantage for anyone to leave the workforce.
What in the structure of health-care organizations needs to change?
Anytime you have very steep hierarchies, you’re going to end up with bad outcomes and a bad environment. We’ve known that ,for patient safety, steep hierarchies suppress information and harm communication. And so we need to flatten the hierarchy, and enable people who are vulnerable at the bottom to be able to speak up when things are not going their way, in a non-punitive way.
We can learn from other industries that have actually made those changes. Medicine is often slow to change.
How can health systems and people who want to be allies to women and people of color in the workforce take action to help?
I am a big believer in upstander training, and really moving from a bystander to an upstander. To really have a good workforce, we must adopt that approach where we’re all in it together. And so allies really must take it upon themselves to have that upstander training, and to call things out when they see it, to help run interference, to be a partner or a co conspirator.
The real challenge is how do we move people to overcome inertia to have activation energy. That is where leadership comes in. Leaders need to be courageous to address these things.
What gives you the most cause for hope?
I’m really inspired by young people. They are unencumbered by the way it was. They lead with their heart, and the way things should be. And sometimes when we’re in leadership positions, we can feel constrained by the shackles of our organization, and by what we can say, because that’s what our organizations value.
But at the same time, looking at the young people gives me hope, because I was one of those people, and I will always want to say, ‘How can I keep that?’ How can I keep being able to speak up so that it’s clear that we need to change, and that change comes from many, many people calling and demanding the same thing.
I’m looking at the American Medical Association as an example where the House of Delegates endorsed the report that acknowledged the historical legacy of racism in medical education. This effort was led by students … so that we can make those changes.
We can leverage our learners to help lead us and they can mentor us, they can be our reverse mentors. I often do see a lot of people who feel very strongly internally that they are allies, but they are too afraid to say anything. This is particularly men in power because they’re worried that they’re going to say the wrong thing, or that they’re going to get jumped on.
And for the allies, I would say we must create the psychological space for people to mess up and still redeem themselves, because people are going to mess up. Because now their fear drives them into silence. And then the cost of that silence is really, really deafening.
The “Visible Voices” podcast covers topics of health care, equity, and current trends. Episodes drop each week and can be found wherever you listen to podcasts.
Tune in on July 8 at 4:15 p.m. for an Inquirer Live-Health conversation on the Future of Work for Women in Health Care, moderated by health editor Charlotte Sutton, and featuring Lewiss plus Amie Archibald-Varley, RN, quality and patient specialist at Niagara Health and co-creator/co-host of the “Gritty Nurse” podcast; Suzanne Chong, PhD, staff psychologist, Ursinus College, founder of Clarity and Insight Counseling Services; and Natalia Ortiz-Torrent, MD, medical director, consultation and liaison psychiatry, Temple University Hospital. Register at Inquirer.com/HealthReport.