Diversity in academic medicine: the stages of change model.

THE BENEFITS OF INCREASING the diversity of leadership in academic medicine have been reviewed and confirmed by a number of expert groups,1–6 yet women and underrepresented minorities are not rising through faculty ranks or entering leadership in academic medicine at rates predicted by their proportions in medical school over the past 30 years.7,8 This is an issue that must engage all stakeholders in academic medicine in order to ensure a healthy future for academic medicine as well as a healthy future for our nations. We have found that smoking provides a useful metaphor for diversity. No one contests the profound change in cultural norms for smoking over the past 30 years. Smoking is an issue to which nearly everyone has some personal connection either as a current or former smoker, the friend or relative of a smoker, or as a witness to the remarkable transformation of institutions— even bars—from smoking to nonsmoking. Many middle-aged physicians, for example, went to medical school at a time when professors lit up cigarettes in the classroom, nurses and doctors smoked in hospitals, and airlines handed candy cigarettes to child passengers. Such behaviors would be unthinkable today because they violate current cultural norms. We submit that the goal in academic medicine is to achieve a similar transformation in cultural norms so that a lack of institutional gender and ethnic/racial diversity, particularly among decision makers, engenders the same response as smoking in a classroom—it is undesirable and unhealthy both for the individual and for the institution. With liberal interpretation, the stages of change model applied to smoking cessation9 pertains equally well to diversity. The five stages of change are (1) precontemplation (unaware that a problem exists), (2) contemplation (aware that a problem exists and thinking about making a behavioral change in the future), (3) preparation (feeling confident that making a change is possible and planning to make a change in the immediate future), (4) action (making a change), and (5) maintenance (continuing to engage in the new, desirable behavior and avoiding relapse). The smoking metaphor for diversity can be scaled down to refer to an individual (e.g., Harvard President Lawrence Summers being perhaps in precontemplation) or scaled up to the discussion of whole institutions (e.g., Harvard being perhaps