Diversity, Equity, and Inclusion in the Pediatric Pulmonary Workforce An Official American Thoracic Society Workshop Report

Workforce diversity drives innovation and excellence in medicine, resulting in improved patient outcomes and satisfaction. Racial and ethnic concordance between physician and patient leads to increased trust, greater use of preventative care, improved adherence, increased patient satisfaction, and better health outcomes, reducing health disparities. Demographically, the majority of U.S. children under 16 years belong to a non-White racial or ethnic group, with nearly 40% identifying as Hispanic/Latino or Black, underscoring the need for the pediatric workforce to reflect the populations served. The Association of American Medical Colleges defines underrepresented in medicine (URiM) as racial and ethnic populations inadequately represented relative to their numbers in the general population, including Black, Hispanic/Latino, and Indigenous people. Recruitment and retention of URiM physicians remain a challenge in pediatrics broadly and pediatric pulmonology specifically. A 2014 survey of board-certified pediatric pulmonologists reported a workforce of 73% White, 10% Hispanic/Latino, 3% Black, and <1% Native American, largely unchanged over nearly two decades. In 2019, only 18.6% of pediatric pulmonology trainees were URiM (5.6% Black, 9.7% Hispanic/Latino), far below U.S. population demographics (13.4% Black, 18.3% Hispanic/Latino). Combined with a projected shortage of pediatric pulmonologists, there is a critical need for strategies to recruit and retain a more diverse workforce to address inequities and disparities in the field. This report reviews the formation and progress of the ATS Pediatrics Assembly DEI Advisory Group (DEI-AG), the development and results of a DEI Needs Assessment Survey, proceedings from a 2-day ATS-sponsored workshop, and proposed solutions to improve recruitment, training, and retention of a diverse pediatric pulmonary workforce.

The report synthesizes literature demonstrating that physician-patient racial/ethnic concordance improves trust, use of preventive services, adherence, patient satisfaction, and outcomes, contributing to reduced health disparities. Prior workforce studies show persistent underrepresentation of URiM physicians in pediatrics and pediatric pulmonology, with minimal demographic change over decades. The report references successful pathway and pipeline initiatives in other specialties and across educational levels (secondary to residency), highlighting core components such as mentorship, financial support, academic and psychosocial support, research opportunities, and engagement with professional organizations. It also cites evidence on minority tax burdens, the importance and limitations of diversity training, and strategies that enhance recruitment, retention, mentorship, accountability, and compensation equity in academic medicine.

The ATS Pediatrics Assembly formed the DEI Advisory Group (DEI-AG) in 2020 in response to heightened awareness of racial and ethnic disparities and observed lack of diversity within pediatric pulmonology. The DEI-AG included approximately 30 members (about 70% URiM), ranging from trainees to senior faculty, including international medical graduates and a Canadian member. Three subcommittees were established: 1) Pathway into Pediatric Pulmonology, 2) Fellowship Training, and 3) Faculty Development and Retention. The DEI-AG developed and distributed a Pediatric Pulmonology DEI Needs Assessment Survey across the United States and Canada to collect demographic information and characterize DEI climates, experiences of discrimination, and perceptions and recommendations. Quantitative data were analyzed descriptively using Microsoft Excel. Qualitative free-text responses were analyzed using Braun and Clarke’s thematic analysis: two independent coders created a preliminary codebook based on survey questions, iteratively refined it, and applied it to all responses to elucidate key themes and select representative quotations. In July 2022, the DEI-AG convened a 2-day virtual workshop with DEI leaders (including a medical school dean, pediatrics department chair, and institutional DEI official) to review survey results, share best practices, and develop actionable strategies for recruitment and retention of URiM trainees and faculty. Following the workshop, an Official ATS Workshop Report was prepared: co-chairs and moderators contributed to an outline; subcommittees set goals; members reviewed relevant literature; and drafts were compiled, circulated, and edited by the committee to finalize recommendations and strategies.

• Survey participation: 317 respondents from the U.S. and Canada (72 trainees; 245 pediatric pulmonologists, predominantly academic faculty). This represents the largest known dataset describing demographics and experiences of current and in-training pediatric pulmonologists but is voluntary and not necessarily representative.
• DEI climate: About half perceived institutional, departmental, and divisional buy-in to improve DEI, yet fewer than half were aware of specific DEI hiring policies. Most reported DEI programs and implicit bias training at the institutional level, but fewer DEI programs existed specifically within pediatric pulmonology divisions. Twenty-seven percent were unaware of a formal reporting system for DEI concerns.
• Experiences of discrimination: High prevalence among both trainees and faculty.
  • Trainees: 65% experienced and 84% witnessed at least one of racism, discrimination, microaggressions, or gaslighting. Although 75% knew how to report incidents, only 60% felt empowered to report.
  • Faculty: 63% experienced and 78% witnessed at least one of these behaviors; fewer than half felt empowered to report.
• Qualitative themes from 347 free-text comments (149 respondents):
  • Need for sustained, resourced DEI efforts (not voluntary add-ons); calls for protected effort/FTE for DEI work; avoid overburdening URiM faculty (minority tax).
  • Improve institutional culture, transparency, and accountability (e.g., salary equity, clear promotion criteria, objective and transparent decision-making, safe and effective reporting systems with visible outcomes).
  • Enhance recruitment, training, and retention across the pathway via early exposure, mentorship, research opportunities, financial support, and engagement with professional organizations; increase visibility of URiM faculty and inclusive leadership.
• Recommendations synthesized into actionable strategies (Table 5) across stages: secondary/undergraduate (STEM exposure, mentorship, financial aid), medical school (targeted electives, mentorship, outreach to URiM organizations), residency (early subspecialty exposure, research/QI authorship, ATS scholarships), fellowship (inclusive curricula, DEI training, structured reporting, mentorship/sponsorship, scholarship recognition), and faculty (transparent promotion and compensation, address minority tax, leadership training with DEI competency, mentoring models including reverse mentoring and telementoring, salary equity analyses, and institutional accountability metrics).

The survey and workshop addressed the core question of how to improve diversity, equity, and inclusion within pediatric pulmonology by identifying current demographics, DEI climates, and experiences of discrimination, and by generating concrete strategies to enhance recruitment, training, and retention of URiM individuals. Findings revealed substantial gaps in divisional-level DEI infrastructure, limited awareness of hiring policies, high rates of experiencing or witnessing discriminatory behaviors, and limited empowerment to report incidents. These gaps directly hinder recruitment and retention, perpetuate the minority tax, and obstruct advancement of URiM trainees and faculty. The proposed multi-level interventions—ranging from strengthened pipeline programs and early exposure to inclusive curricula, structured mentorship/sponsorship, recognition and compensation for DEI contributions, transparent promotion and salary practices, and robust reporting and accountability systems—offer a roadmap to translate DEI commitments into measurable action. Implementing these strategies within pediatric pulmonology training programs and divisions, supported by institutional leadership and professional societies, is expected to improve workforce diversity and, ultimately, patient care and outcomes.

Significant uncertainty remains regarding how to operationalize anti-racism and DEI in pediatric pulmonology; however, this workshop report establishes a foundation by quantifying demographics and experiences across the workforce and by compiling evidence-based strategies and resources. The DEI-AG of the ATS Pediatrics Assembly proposes concrete actions to recruit and support URiM trainees and faculty, address minority tax, enhance mentorship and professional development, and improve institutional transparency and accountability. These recommendations aim to increase workforce diversity and can serve as a model for other ATS Assemblies and pediatric subspecialties. Future work should focus on implementing, evaluating, and iterating these strategies; building robust metrics for accountability; and expanding DEI initiatives to encompass broader domains and intersectional identities.

• Scope limited to AAMC-defined URiM racial/ethnic groups; does not comprehensively address LGBTQIA+ communities or international medical graduates, though many concepts and recommendations are applicable across these domains and intersectional identities.
• Voluntary, individual-level survey with potential selection bias and non-representativeness; demographic data cannot be assumed to represent the entire pediatric pulmonology community.
• Potential overrepresentation of respondents interested in DEI issues; however, respondent demographics (67% White; 10% Hispanic/Latino; 7% Black among 317 respondents) are consistent with prior data for the field.
• Data collected from individuals rather than institutions; limited ability to verify or generalize institutional policies and climates across settings.