A study of more than 3000 health care leaders in Canada found that while gender parity was present, racialized executives were substantially under-represented. Diversity among health care leaders in Canada: a cross-sectional study of perceived gender and race was published in CMAJ. It found that at the ministry level fewer than 7 percent of health care leaders were racialized.
The representation gap between racialized executives in healthcare and the racial demographics of the population it serves ranged from a low of 7.3% for Prince Edward Island to a high of 27.5% for Manitoba. The gap was highest in geographic locations with a greater percentage of racialized residents.
On this episode, Drs. Omole and Bigham speak with the lead author of the study Anjali Sergeant, a final year medical student at McMaster University. She describes how researchers determined race, compares results in different parts of the country and discusses how closely the results of the study reflect what she is seeing in her medical school cohort.
Drs Omole and Bigham also speak with Anna Greenberg, the Chief Regional Officer, Toronto and East for Ontario Health. Ms. Greenberg is also the agency’s Executive Lead for Equity, Inclusion, Diversity, and Anti-Racism. She discusses the efforts her agency is making to address this disparity. She also explains why it is important for healthcare leaders to ask themselves, “Why does this matter?”
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
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Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
A study of more than 3000 health care leaders in Canada found that while gender parity was present, racialized executives were substantially under-represented. Diversity among health care leaders in Canada: a cross-sectional study of perceived gender and race was published in CMAJ. It found that at the ministry level fewer than 7 percent of health care leaders were racialized.
The representation gap between racialized executives in healthcare and the racial demographics of the population it serves ranged from a low of 7.3% for Prince Edward Island to a high of 27.5% for Manitoba. The gap was highest in geographic locations with a greater percentage of racialized residents.
On this episode, Drs. Omole and Bigham speak with the lead author of the study Anjali Sergeant, a final year medical student at McMaster University. She describes how researchers determined race, compares results in different parts of the country and discusses how closely the results of the study reflect what she is seeing in her medical school cohort.
Drs Omole and Bigham also speak with Anna Greenberg, the Chief Regional Officer, Toronto and East for Ontario Health. Ms. Greenberg is also the agency’s Executive Lead for Equity, Inclusion, Diversity, and Anti-Racism. She discusses the efforts her agency is making to address this disparity. She also explains why it is important for healthcare leaders to ask themselves, “Why does this matter?”
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
Dr. Mojola Omol...: Hi, I'm Mojola Omole.
Dr. Blair Bigha...: And I'm Blair Bigham. And this is a CMAJ Podcast. Today we're going to be talking about racial and gender disparities in the upper echelons of Canada's healthcare management teams. Jola, you've done a little bit of work in this area.
Dr. Mojola Omol...: I have. I'm on some committees for equity, diversity and inclusion, and anti-oppression. And I do some consultant work in this field. So it's important to me because we need to have a healthcare system that represents and looks like the population it serves. Oftentimes, when you don't have a seat at the table, the conversations that you have around consent, mistrust with the healthcare system, is very different from a black Canadian than it is from a white Canadian. And so if we are not involved in the healthcare leadership, it doesn't trickle down into how we deliver healthcare populations.
Dr. Blair Bigha...: Today's discussion is prompted by a recent CMAJ publication, “Diversity Amongst Healthcare Leaders in Canada: A Cross-sectional Study of Perceived Gender and Race”. The lead author of that study is Anjali Sergeant will be speaking to her along with Anna Greenberg, a senior executive at Ontario Health. Before we get into that, I just want to let all of our listeners know that this week was a crazy week for me in the ICU, and unfortunately, I was in and out of interviews and we had to use my cell phone for this recording. So if the audio is not quite up to your standards, I do apologize, but I was able to listen to the first interview in its entirety before we were able to jump on the line with our second guest.
Dr. Mojola Omol...: Anjali Sergeant is in her final year of medical school at McMaster University. She's the lead author of the study published in CMAJ, entitled “Diversity Amongst Healthcare Leaders in Canada: A Cross-sectional Study of Perceived Gender and Race”. What they found was that among more than 3000 healthcare leaders in Canada, racialized executives were substantially underrepresented. Anjali, thanks so much for joining us.
Anjali Sergeant: Thanks so much for having me. I'm so excited to be here.
Dr. Mojola Omol...: Can you break down what substantial underrepresentation means and what did you find?
Anjali Sergeant: So, we decided to look at representation in terms of the demographics of the local populations around the institutions that we were studying in terms of their race and gender of their leadership. So for race, what we did was we looked at census data that studies the makeup of the population in terms of how they were categorized by race. We then compared that to the percentage of racialized individuals within leadership teams across the country. And so we found really large gaps. Some of the largest gaps were in Ontario and Manitoba, where the difference in whether they were of racialized populations was greater than 20%.
Dr. Mojola Omol...: So how did you guys determine race of the executives?
Anjali Sergeant: Yeah, so this was tricky because there was no self-identified race measures that were collected to our knowledge by the institutions that we were studying, and so without that information, we had to use a different measure of race, which is perceived race. And so what that means is how someone first appears to you on first interaction. So in some ways, the perceived race framing is limited because individuals' self-identified race is really what's important and what drives their experience of discrimination, but perceived race in other ways is beneficial because it might mirror how an individual would be perceived by a selection committee in healthcare that is selecting for a new leader to come in. So in some ways, the perceived race enables us to see what biases might be going on and how individuals might be classified from an outside or societal perspective.
So using that method, what we did was have a team of coders look on websites, all across the country, on the institutional leadership websites, and code what race they perceived the individuals to be. And we had everything coded in duplicate to make sure that the data collection was more accurate.
Dr. Mojola Omol...: So talking about the bias, the results for racial diversity contrast with gender diversity, what did you find in your results?
Anjali Sergeant: Yeah, so we found that for gender, there was gender parity almost across the board, across institutions, both hospitals and provincial health authorities across the country. In some places, there were even slightly more women who took leadership roles or who had attained leadership roles in healthcare. And we also found that, even at the level of CEO and executive director, there was an equal amount of women leaders. Which was a great finding, because I think that it shows that there's been a lot of efforts to increase women in leadership at the highest levels, and I hope that this means that there's been progress in that area. And then in terms of race, unfortunately, we did not find that at all. So it differed between provinces, but across the board, racialized leaders were either not present at all on institutional executive leadership boards or they were present but did not represent the level of diversity of the areas and of the populations that they served.
Dr. Mojola Omol...: I know that your perspective is still that of a medical student, but what would you say if someone says, well, what does it matter if in an area that is 40% Black and, I'm in Scarborough, so Black and Tamil, but the executives at the hospitals, there's less representation from both of those two groups. Why does it matter?
Anjali Sergeant: Yeah, I think it matters for two reasons. First, it matters from the perspective of the population in those areas. We've seen through research studies in the past that individuals feel more welcomed and have better healthcare experiences when they see themselves represented in their physicians. And I think that the same goes for the leaders of the physicians and of the hospitals. So I think just knowing that there are racialized leaders and specifically racialized leaders of that race that is highly represented in the area, like you say, like Scarborough, that might help individuals feel more welcomed and more safe to seek care. So that's the first kind of important point.
And I think, secondly, having leaders who understand the needs of their community can only happen if the leaders understand the specific racial experiences, which are often not positive and specifically the racial experiences within the healthcare system. I think having leaders with that particular understanding will enable them to bring forth new ideas and new areas that require change at the highest levels, because I think that without that kind of structural change there won't be the same kind of benefits at the patient level.
Dr. Mojola Omol...: So you're currently in your final year of medical school, you've been through the Hamilton hospitals. When you compare what you're seeing in terms of leadership in your study and what you're seeing amongst your classmates, how is it different?
Anjali Sergeant: Yeah. So what I'm seeing in my class, and particularly my year in medical school, I'm seeing that there's a lot of South Asian and East Asian representation, but I know for a fact, because it's quite easy to recognize, that there's only two Black students in my whole class. And I think that is-
Dr. Mojola Omol...: Do you guys have any Indigenous students?
Anjali Sergeant: We do have Indigenous students. I'm not sure how many, but I know McMaster has an Indigenous student stream, but we did not have a Black student stream at the time that my cohort went through. And from amazing advocacy from one of my classmates - she has really advocated for the fact that there are so few Black individuals in our class - and I think that has really made waves and really been one of the driving forces for why now McMaster is incorporating a Black student's stream into medical school. But I think that your question kind of addresses a central issue that certain racialized groups are more underrepresented than others, particularly Black and Indigenous students. So I think that the issue needs to be addressed not only at the highest level, but throughout the process, because without looking upstream, I don't think we're really getting to the root of the problem.
Dr. Mojola Omol...: Why did you get interested in studying this in the first place?
Anjali Sergeant: I think that the reason is quite personal actually, because I grew up as a mixed race person and my dad is white and my mom is of Indian ancestry. And so I think that because my parents had very different family cultures and different religions, I was exposed to both at a really young age. And then it always made me hyper-aware of how race and culture and gender play into different social interactions because I felt both a part of many at once, but I was also acutely aware of the times that exclusion happened to me or to others around me. So it carried with me on into medicine, and I think it's an issue that needs to be addressed everywhere and is definitely not just specific to medicine.
Dr. Mojola Omol...: What do you want to happen next? If you were queen for a day, what would you want to happen next?
Anjali Sergeant: If I was queen for a day...
Dr. Mojola Omol...: Obviously you'd get into the internal medicine program of your choice and then what would you want to do in terms of this field?
Anjali Sergeant: So I think that I would... I don't know if I could do this, if this is allowed in my, if I was a queen for a day-
Dr. Mojola Omol...: You are queen for the day.
Anjali Sergeant: ... but I would want people to care about the issue and I would want people to collaborate with other people to solve it. And I think that, like we were talking about, I think the structural change is really important, so if the faculty of med school programs and residency programs and hospital executives could create tangible goals and come together and say, okay, this might be a messy process, but we need to increase the diversity of our institutions. We want to be able to benefit and support marginalized members of our community, and so we're going to try this and this.
And I think that there is good evidence, even though there's not a lot of evidence out there, that certain initiatives have been really helpful, like certain mentorship opportunities with staff who have experienced similar difficulties throughout their medical training, or who might shed a light on some of the politics that still go on, I think in all aspects of medicine, it might feel more daunting to a person who doesn't see themselves represented within the healthcare leadership. It's just one example of an initiative that I would really hope people think hard about implementing in their own institutions.
Dr. Mojola Omol...: For sure. And I think that when we talk about equity, diversity and inclusion, the equity part is when we start taking into consideration the road traveled for some students. And I think that also counts towards leadership, that we will not all have similar trajectories to get to where we are going to and that also has to be taken into account of what have you gone through to get to where you are. And that's when equity comes in.
Anjali Sergeant: Yeah. You said that so beautifully. I feel like I could not even attempt to say that any better.
Dr. Mojola Omol...: So on a side note, I actually do consulting work on EDI.
Anjali Sergeant: Okay. Well, that makes me feel a bit better.
Dr. Mojola Omol...: That's the only reason. Anjali, thank you so much for being here and joining us today.
Anjali Sergeant: Thanks so much for having me, I really appreciate it.
Dr. Mojola Omol...: Anjali Sergeant is a final year medical student at McMaster University, and by the time we're all listening to this podcast, she will be in the internal medicine program of her choice and she is the lead author of the study published in CMAJ, entitled, Diversity Among Healthcare Leaders in Canada: A Cross-sectional Study of Perceived Gender and Race.
Dr. Blair Bigha...: Our next guest is part of the senior leadership team of the agency that oversees Ontario's healthcare system. Anna Greenberg is the chief regional officer, Toronto & East, for Ontario Health. She's also the agency's executive lead for equity inclusion diversity, and anti-racism. Anna, thanks for joining us.
Anna Greenberg: Thanks for having me.
Dr. Blair Bigha...: What was your reaction to this study when you read it?
Anna Greenberg: So I knew this study was in the works and I was really pleased to see it come out because it's something that we have been thinking about as an organization, as a health system, in terms of the overall goal of our health workforce and our health system reflecting the populations that we're trying to serve. And so I was really excited to see the alignment of the inquiry of the researchers on this and the goals that we have as a health system, and to be able see the Pan-Canadian view of it. And, in particular, it allowed us to think about Ontario in relation to other provinces. And, when I think about certain parts of Ontario like Toronto, which is a region that I oversee, and the gap between the diversity of the population and the findings of the researchers.
Dr. Blair Bigha...: Was there anything in the study that surprised you?
Anna Greenberg: I think I was somewhat surprised and I think it's worth taking a moment to celebrate the gender parity. My own experience is that there are many, many women in healthcare, of course, but not necessarily at the leadership level. And I think it's been over the course of my career and even over the course of my lifetime that we've seen that change. And so it did surprise me to see that, but I was not surprised to see the rest of the findings.
Dr. Blair Bigha...: The study found that the representation gap between racialized executives and the racialized population was second highest in Ontario, just behind Manitoba. Why do you think this is a particular challenge for us in Ontario?
Anna Greenberg: I think it's probably a challenge everywhere, but maybe amplified in places where we have significant diversity, and so probably everywhere needs to catch up, but the more diverse an area, the more work that you have to do in terms of exposing people to the right career paths, et cetera, to get the leadership and the health workforce that you want to see.
Dr. Blair Bigha...: So tell me more about that and the big challenges that you would face as a senior leader, or any senior leader in healthcare would face, when they're trying to bring more balanced representation to the top position.
Anna Greenberg: I think a couple of things, one is there is much more we can do among the candidates who might want the jobs in the present time and might be interested in working in your organization in the present time. And that has to do with what is your recruitment strategy? How are you getting the word out, how you're encouraging and how are you attracting people to your organization? And I would say that not being satisfied, if your initial pool isn't diverse. If you're saying your goal is to have a pool of candidates who reflect the population you're trying to serve, and you don't get that the first time, not to be satisfied and try again.
Oftentimes you're in reactive mode and you don't necessarily have the planning that's necessary for that to happen. It's not an excuse. But sometimes you're desperate for a candidate and you give yourself an amount of time that wouldn't allow you to take the time to have a more diverse pool. So that's the candidate pool you might get immediately, who might be qualified and interested. But the main point I want to make is I think that there needs to be a strategy that goes further upstream and a set of targets that your leadership team, as a whole says, “This is something we care about, is important and we want to do, its part of the culture of the organization and it's going to be part of our recruitment strategy, not as a one-off.”
Dr. Mojola Omol...: In your experience, has there been that mandate and culture in leadership that we want to have a diverse pool of applicants for these top executive positions that reflect our population? Has that explicitly been said in your organization?
Anna Greenberg: Yes. It's something that Ontario Health has explicitly said. That we have an equity inclusion, diversity and anti-racism framework, and one of the tenets of that framework is to reflect our communities. And that's in terms of a few things in terms of our staff, in terms of our advisory committees, in terms of our patient advisors. Now I want to acknowledge we have a long way to go, but it is a stated goal. And I actually think that's step one is that it's something that you want to do and you're setting out to do.
Dr. Mojola Omol...: And once you make that goal, how does that work practically in your organization?
Anna Greenberg: So what I would say is we're in our early stages of trying to execute on this. So one thing that's important to me is that I think equity work is actually a skill. And when I think about a board, for example, it wouldn't be enough to just have a board that represents different parts of the population. You also need a skills matrix that says the people on this board know and understand equity, and I think the same thing has to do with staff. I lead a team at Ontario Health, which is our provincial equity office and our provincial Indigenous health equity. And so that's a skill-based recruitment in addition to a diversity recruitment.
But I think really importantly, if there's any point I want to drive home most it's about that we have to think upstream about the pathways and the long term view. I think about medical schools that have taken steps to attract a more diverse pool of students and that it takes many steps upstream to say, “How do you attract students? How do you sponsor students? How do you make sure that they're set up to do the application process, et cetera?” I think the same is true of leadership roles in terms of succession planning development.
And so you asked about my own organization. I think we're at the beginning stages of doing this. We've stated a goal and then now we need to think about not only upstream what we're going to do. And I think about summer students and co-op students, but also in the pool of people that we want to attract. I think the second thing that needs to happen once you do that, I think you also need to think about retention. And I've certainly experienced in my career that you may be successful as an organization in recruiting diverse candidates, but then keeping those diverse candidates requires a strategy of retention so that they don't feel alone and unsupported or perhaps carrying too much of a burden in that representation.
Dr. Blair Bigha...: You wrote a very thoughtful response that was published on the CMAJ website where you asked the question, “Why does it matter?” Tell me a little bit more about your curiosity around that question.
Anna Greenberg: Yeah. My curiosity about that question is that it can be very easy to sit back and say, once we've checked some boxes, and I think we've all heard this cliche, we're okay. So what I like about taking a deliberate strategy is knowing why you're doing it. I believe, its the first step to having a better outcome. So one of the reasons we're doing it and explicitly stating that is that we are a healthcare organization and we're trying to serve a population and reflecting that population is important in our ability to think about programs that are going to meet the needs of that population. So to me, that's an explicit “why”.
Secondly, I think, as I talked about, there is no end of challenging questions and challenging problems that the health system has. And if we only hear the same voices over and over again, especially as the population changes and needs change, I think you're going to get the same answers as opposed to new and different ways of solving problems. So I truly strongly believe that it can't just be about having a diverse team. It has to be about a diverse team that's motivated to look at problems differently on behalf of the people that we're trying to serve.
Dr. Blair Bigha...: That's so insightful. That's a really helpful framework to think about. What do you think the next step is for health leaders who want to make health leadership in Canada more representative to the Canadian communities that they serve?
Anna Greenberg: So I think we need to look at examples that have worked well. And I think that where I've seen good examples and where I've talked in depth with people who've worked at this has been in, for example, medical schools. And I think that's a really good example because it's a multi year plan and it looks upstream by definition. And I would say that if we truly believe that this is the right workforce that we need, that it's both on the professional side, and I would say every kind of professional through allied health to leadership and policymakers and decision makers. So I do think there are some examples where a deliberate strategy, a target and a goal has been set. I think that's what we need to learn from... That's what we need to do, and I think that explicit goal and that “why” is incredibly important.
Dr. Mojola Omol...: When you say target, can you expand a bit about what would be a target?
Anna Greenberg: So I think it's very reasonable to look at, as the researchers did, the makeup of your population. That's the population you're trying to serve, and that is by definition dynamic, and it's also geographic. So in different parts of the province, you might have a different makeup and that should be your guide for what your workforce and your leadership should look like. So that's one form of target. Another form of target is to be planful and say, “By what year should we have achieved this given our starting point?” And to my mind, that's about having some ambition and motivation behind it.
Dr. Mojola Omol...: I have a question. I'm trying to find the right way to word it. Because I have friends, myself also, we've applied for leadership positions within our healthcare structures, within the hospital with jobs, academic jobs, and they interview every single person, every single race and gender, but it always still goes to the white man. And you can't argue that all the time that they are the best for that leadership position. I guess my question is, within that target, should they explicitly state that we need to hire a Black urologist or whatever it is that you're looking for? I don't know if my question makes sense?
Anna Greenberg: No, it does make sense. I'm not an HR professional. I'm not sure if the best way to do that is to say the next candidate we want to be from X community. Maybe, but I do think that you probably want to say at maturity, this is what we want our leadership team to look like, if we're looking at reflecting the community, and then every recruitment is an opportunity towards that. That's the way I would think about that. But I would also unpack your experience and wonder what goal did the recruitment team have and what was the makeup of that team and what were the questions that they asked? Because I think having that goal is important, and knowing whether the makeup of the team would've resulted in the right outcomes, I think is important. So for example, is the panel diverse itself?
Dr. Mojola Omol...: Yeah, they were. And we all joke about it that like for women of colour in medicine, it's not a glass ceiling, it's iron. Because it's very hard for us to reach that, whether it's in academic medicine or in any leadership, it's very difficult. And it tends to be very, like the experiences that I had, very diverse interviewers from diverse backgrounds and questions really dealing with those topics and it doesn't always compute that the person that's been hired is fitting the criteria that they laid at the beginning of the process. So that's just an experience that others have spoken about. And sometimes I wonder if it's easy for organizations to say, we want to be diverse, we want to be inclusive and we're going to have equity, but really it's just what they're saying, it's not really what they're practicing.
Anna Greenberg: Yeah, exactly. And I think that's where if an organization is willing to say by this time, if we say we look at all our recruitments over the next few years and we want to reflect the community that we serve, then you have something to go back on to say, did we achieve that? It might not have been that specific recruitment, but at the end of the day, did we achieve that goal? I think that is much better than, as you say, just saying, this is something we're interested in.
Dr. Blair Bigha...: Can I pin you down on a timeline? What's a good time-bound goal for this type of transformation for organizations that might really be struggling. Is it one year? Is it five years? Is it 10 years?
Anna Greenberg: Yeah. My intuition would say that you take a baseline, and I do want to reflect that more and more organizations are measuring the socio-demographics of their workforce. And that's something that we are very much in our infancy doing. And then you'd have to say, how far are we away? Much like the researchers did, like what's the gap? And then I think what would be incredibly important is to say then what is our plan? What would need to be true for us to be successful at this and how much of our strategy is going to be upstream and how much of our strategy can we achieve now? But I would encourage being ambitious about this because I think part of it is, as Jola has said, sometimes you can't assume the candidates aren't there, you might not have looked in the right places. So I think people should be ambitious in the goal, and try to see as much as possible how much they could do in the near term.
Dr. Blair Bigha...: Anna, thank you so much. You speak so eloquently about this and you brought a lot of clarity in my own mind about how leaders can move forward with this important initiative.
Dr. Mojola Omol...: And since I'm not operating, I'm always free to come work with Ontario Health.
Anna Greenberg: It was an absolute delight to meet you both, and I'd love to talk with both of you more. Thank you.
Dr. Blair Bigha...: Thank you so much. Anna Greenberg is the chief regional officer at Toronto & East for Ontario Health. And she's the agency's executive lead for equity inclusion, diversity and anti-racism. So Jola, what do you think? What are the takeaways from today's talk?
Dr. Mojola Omol...: I would say first is that I was quite awestruck at how thoughtful Anjali Sergeant, soon to be Dr. Anjali Sergeant was in terms of discussing such a nuanced topic. I wasn't surprised about the results regarding racial disparity within healthcare leadership, but I'm left with a bit more questions than answers and how do we achieve parity in this realm?
Dr. Blair Bigha...: Yeah. And I found it so interesting that maybe there are a few lessons to be learned about how gender parity has sort of been developed more and more over the last decade or so that we might be able to apply to racial disparity.
Dr. Mojola Omol...: For sure. I guess what I struggle with is that I think that we've come a long way as a society in terms of how we view gender norms within medicine. Obviously, it's not perfect. You still have commenters making comments about women in surgery and this and that. But when it comes to race, and especially in Canada, we are extremely squeamish to talk about it openly. To talk about there being a lack of parity in racial composition of a healthcare leadership will mean that we will have to admit that we have a systemically racist healthcare system, and I do feel like a lot of Canadians and people in medicine are not equipped to have that conversation and feel very uncomfortable having that conversation.
Dr. Blair Bigha...: Absolutely. I think it is an uncomfortable topic, but one that it sounds like we're having more and more of these days. And hopefully with people like Anna's perspective on how you can really establish this by setting goals for an organization to over time look more like the community it served, maybe we'll be able to move the needle even more.
Dr. Mojola Omol...: One thing that I would say is that the question that I'm left with is, but how do we hold organizations accountable? And that was the question I was left with is that this is great, that a lot of organizations and healthcare organizations are making this commitment to increase their diversity in their system. But how do we hold them accountable that there is diversity and also how do we make sure it's not tokenism? And then thirdly, you are including people into maybe not necessarily the most friendly atmosphere, because they're the one of a kind, they're the first of something. And how do we make sure that when they're there they're actually set up to succeed?
Dr. Blair Bigha...: That's it for this week's episode in the CMAJ Podcast, please make sure you like and share our podcast wherever you download it from.
Dr. Mojola Omol...: Thank you for listening, and until next time, be well.