Rethinking the Routine in the Pursuit of Inclusion

By David Wu, MD, Johns Hopkins Medicine, Janiece Taylor, PhD, MSN, RN, Johns Hopkins Medicine, Rebecca Wright, PhD, RN, Johns Hopkins Medicine, Danetta Sloan, PhD, MSW, MA, Johns Hopkins Bloomberg School of Public Health, and Patricia Davidson, PhD, MEd, RN, University of Wollongong

“Big wins will come from interrogating seemingly mundane practices and processes . . .”- Dr. Melissa Thomas-Hunt, Head of Global Diversity and Belonging for Airbnb

The broad and deep systemic problems of health disparities and structural racism require dramatic change at the level of policy and advocacy. But small changes in local team dynamics matter too, and they’re often easier to achieve. In that spirit, we offer a couple of lessons we’ve learned from our own efforts to pursue inclusion, diversity, and equity, that are possible here and now. We share not as wise sages who have it all figured out, but rather as fellow pilgrims walking toward a common destination. Here’s what we’ve learned: 

1. We’ve diversified our team quickly, both professionally and socially, by thinking creatively about how to define “team.” Interprofessional team members bring a rich variety of perspectives about and experiences with patients and families that can lead to better whole person care, particularly for historically excluded populations.

Research supports an association between the social diversity of a team (like ethnicity and/or geography) and such strengths as better problem solving, more innovative thought, and more publications. Therefore, it stands to reason that a diverse team, especially one that reflects and includes the community it serves, provides more equitable care.   

Bonded by the common mission of improving palliative care communication with diverse patient populations, we formed an intentionally diverse team that extends across nursing, medicine, and public health at Johns Hopkins: the Palliative Interprofessional Collaborative for Action Research (PICAR). This partnership has organically branched out beyond any one project to blur traditional boundary lines between departments and professions, as well as research and clinical spheres. We share ideas, projects, community partners, mentors, and mentees, and we aim to involve patients and families as active members of our team at all junctures (for example, in quality improvement and curriculum design). Our work in caring for our community is the better for it. 

2. We seek to level the hierarchy within our team by openly addressing and refuting stereotypical expectations attached to roles, gender, class, race, and/or ethnicity. The voices of the most wonderfully diverse team in the world may be silenced by the power dynamics in healthcare. Mutual respect and open discussion of these unwritten traditional hierarchies are critical. Being comfortable enough with each other to gently tease each other’s titles (while still respecting roles and expertise) goes a long way. The concept of shared leadership is helpful here, a model in which all team members feel empowered to speak, take initiative, and exercise autonomy over their areas of expertise.

Acknowledging the validity of different views on this topic, we’ve found that being on a first-name basis among our team helps us stay on a level playing field. Importantly, this rule of thumb includes trainees, who have told us how using first names helped them feel valuable and empowered to speak up. Among our trainees are some of the brightest minds of the next generation, and we don’t want hierarchy to keep their fresh insights from being heard. 

We hope the above ideas might be useful for healthcare team members working to be effective agents of change in medicine. To be sure, vast systemic changes are crucial and we need to do our part to pursue them and/or support those who are. At the same time, we should humbly and thoughtfully consider how our approach to more routine team dynamics contributes to, or stands against, the pursuit of diversity and inclusion. After all, a team fueled by different perspectives will be better equipped to care for all patients and families. And never has the aim of inclusion and health equity been more important than now.