Building residents’ competence to support diverse, equitable, and inclusive environments in emergency medicine must start with the milestones

The death of George Floyd in May 2020 forced many individuals and institutions to look inwardly and consider what advocates for diversity, equity, and inclusion (DEI) had been saying for decades; the behaviors, policies, and practices that support our work often also support longstanding disparities that negatively impact our coworkers, colleagues, communities, and the care rendered to patients.¹ With this has come the welcome addition of new offices of diversity; leadership positions; searches for best practices; and calls for accountability for medical schools, health care systems, and graduate medical education programs.

The Accreditation Council for Graduate Medical Education (ACGME) requires that residency programs, in collaboration with their sponsoring institutions, develop, implement, and evaluate strategies that result in the recruitment and retention of diverse residents, fellows, faculty, and administrators.² Annual ACGME surveys of residency and fellowship programs now assess programs’ efforts and abilities to prepare trainees to interact with diverse individuals, foster inclusive work environments, and employ strategies that support the recruitment and retention of diverse residents and fellows.³, ⁴

This special issue rightfully calls for curricula (along with other educational innovations) as a means to address disparities in patient care and create diverse, equitable, and inclusive environments for those providing that care. This sheds light on the old problem of the consistent lack of diversity, inclusion, and cultural competency curriculum in emergency medicine (EM) programs and is an opportunity for us to build and strengthen educational systems that support and reflect our values as academic emergency physicians.

The atomic unit of a curriculum is the performance indicator, a brief description of a specific, measurable criterion, the achievement of which demonstrates competency in the pursuit of a learning objective. Curriculum designers work backward from performance indicators and learning objectives to develop experiences, resources, and assessments that target these goals.⁵ The ACGME, for its part, asks specialties to organize curricular outcomes in the format of milestones. Based on the educational theory of expertise development, the milestones are performance indicators organized among five levels that demonstrate developmental progress toward learning outcomes and graduation targets over the course of training.⁶ The ACGME and American Board of Emergency Medicine collaborated to create the Emergency Medicine Milestones,⁷, ⁸ a document that outlines training goals and plays a critical role in the development of curricula, assessments, and accreditation for EM residencies. Because of their curricular importance, it is important to know which DEI‐related knowledge, skills, and attitudes have been set out in the milestones as the expectation of EM graduates.

One criticism of the original milestones is that variation between specialties in core competencies like Professionalism, Interpersonal and Communication Skills, Practice‐Based Learning and Improvement, and Systems‐Based Practice limited the opportunity to develop curricula and validated assessment tools despite recognition that many of the objectives reflective of these skill sets should be similar across specialties. In preparation for a major revision called Milestones 2.0, the ACGME undertook a thematic analysis of all specialty milestones in these competencies and ultimately generated model milestones for each. When specialty groups met to revise their documents, they were encouraged to adopt these cross‐cutting model milestones.⁶ The recently released Emergency Medicine Milestones 2.0⁸ reflect this ACGME initiative.

We explored both Emergency Medicine Milestone documents to identify potential DEI‐related outcomes in an attempt to better understand prior and current expectations for the training and assessment of residents with respect to DEI competencies. Our findings are listed in Table 1, which is organized by version (2013⁷ and 2021⁸), core competency, and milestone level. In general, we found that the Emergency Medicine Milestones 2.0 offer some improvements upon the previous version with regard to DEI outcomes, but like their predecessor, they incompletely reflect DEI principles and are limited in scope.

TABLE 1.

DEI in the Emergency Medicine Milestones

Core Competency	Milestone	Milestone level
		1	2	3	4	5
Patient Care	Diagnosis (2021)				Provides a diagnosis for patients with multiple comorbidities or uncommon medical conditions, recognizing errors in clinical reasoninga	Serves as a role model and educator to other learners for deriving diagnoses and recognizing errors in clinical reasoninga
Systems‐Based Practice	Patient Safety (2013)					Uses analytical tools to assess health care quality and safety and reassess quality improvement programs for effectiveness for patients and for populationsa
	Quality Improvement (2021)					Creates, implements, and assesses quality improvement initiatives at the institutional or community levela
	Systems‐Based Management (2013)		Mobilizes institutional resources to assist in patient care	Demonstrates the ability to call effectively on other resources in the system to provide optimal health care Recommends strategies by which patients’ access to care can be improved	Recommends strategies by which patients’ access to care can be improved
	System Navigation for Patient‐Centered Care (2021)	Demonstrates knowledge of population and community health needs and disparities	Identifies specific population and community health needs and inequities for their local population	Effectively uses local resources to meet the needs of a patient population and community	Participates in changing and adapting practice to provide for the needs of specific populations	Leads innovations and advocates for populations and communities with health care inequities
Professionalism	Professional Values (2013)	Demonstrates behavior that conveys caring, honesty, genuine interest and tolerance when interacting with a diverse population of patients and families	Demonstrates an understanding of the importance of compassion, integrity, respect, sensitivity, and responsiveness and exhibits these attitudes consistently in common/uncomplicated situations and with diverse populations	Recognizes how own personal beliefs and values impact medical care; consistently manages own values and beliefs to optimize relationships and medical care Develops alternate care plans when patients’ personal decisions/beliefs preclude the use of commonly accepted practices	Develops and applies a consistent and appropriate approach to evaluating appropriate care, possible barriers and strategies to intervene that consistently prioritizes the patient's best interest in all relationships and situations	Develops institutional and organizational strategies to protect and maintain professional and bioethical principles
	Professional Behavior and Ethical Principles (2021)	Demonstrates professional behavior in routine situations and in how to report professionalism lapses Demonstrates knowledge of the ethical principles underlying patient care	Identifies and describes potential triggers and takes responsibility for professionalism lapses Analyzes straightforward situations using ethical principles	Exhibits professional behavior in complex and/or stressful situations Analyzes complex situations using ethical principles and recognizes the need to seek help in managing and resolving them	Sets apart those situations that might trigger professionalism lapses and intervenes to prevent them in oneself and others Uses appropriate resources for managing and resolving ethical dilemmas	Coaches others when their behavior fails to meet professional expectations Identifies and addresses system‐level factors that either induce or exacerbate ethical problems or impede their resolution
Interpersonal & Communication Skills	Patient‐Centered Communication (2013)			Effectively communicates with vulnerable populations, including both patients at risk and their families
	Patient‐ and Family‐Centered Communication (2021)			When prompted, reflects on one's personal biases, while attempting to minimize communication barriers	Independently recognizes personal biases of patients, while attempting to proactively minimize communication barriers	Acts as a mentor to others in situational awareness and critical self‐reflection with the aim of consistently developing positive therapeutic relationships and minimizing communication barriers
	Interprofessional and Team Communication (2021)	Uses language that reflects the values all members of the health care team (sic)			Acts as a role model for flexible communication strategies, i.e., those strategies that value input from all health care team members and that resolve conflict when neededa Uses effective communication to lead or manage health care teamsa

DEI‐relevant performance indicators organized by core competency, name of milestone, and level.

Abbreviations: DEI, diversity, equity, and inclusion.

^a While these performance indicators could broadly be interpreted as inclusive of efforts to improve and/or support DEI in medicine, demonstration of the knowledge, skills, and attitudes that support DEI are not necessarily required to demonstrate competency in these areas.

PATIENT CARE

For example, within the Patient Care competency, there exist brief references to identification and management of errors in clinical reasoning. There are many causes of diagnostic errors, some of which are related to bias. While these references could be construed as relevant to efforts to minimize the impact of bias on vulnerable patient populations, that is not explicitly described and therefore not necessary to demonstrate achievement of the outcomes as written. To better assess resident competence at the intersection of DEI and patient care, programs would benefit from more explicit performance indicators. Examples could include but are not limited to observable behaviors like eliciting and using the patient's preferred pronouns and gender identity during the patient encounter and when discussing the patient's care with the care team, utilizing interpreters for all patients with language and/or cultural barriers to communication, and serving as a role model and educator for the identification and management of bias in clinical reasoning.

SYSTEMS‐BASED PRACTICE

There is a similar issue in the version 1 Patient Safety milestone and version 2 Quality Improvement milestone, in which residents’ active participation in quality improvement initiatives is assessed. While addressing systemic disparities and social determinants of health could be outcomes for quality improvement initiatives, such outcomes are neither required nor guaranteed. On the other hand, the 2021 System Navigation for Patient‐Centered Care milestone directly addresses health care disparities and residents’ abilities to identify resources and develop strategies that combat them. The explicit nature of these performance indicators is a significant improvement on the version 1Systems‐Based Management milestone's references to access to care without specific mention of factors that result in disparities in access. However, it does not address the inherent conflict presented by the Systems‐Based Practice core competency, with its emphasis on the creating financial gain for institutions that is in part responsible for erecting and maintaining the structural barriers to care for patients who are un‐ or underinsured.⁹

PROFESSIONALISM

While both versions of the milestones rely on long‐held appeals to professional values and ethics to support DEI, the first version is more explicit in its expectations that residents demonstrate tolerance, compassion, and sensitivity toward patients and their families, particularly when their beliefs and values are in conflict with that of the resident, team, and/or commonly accepted medical practices. That said, the choice of the word “tolerance” in this context reveals exclusivity and not an attempt to reach acceptance. Neither document speaks to the professional responsibility of physicians as leaders to foster organizational culture that supports the creation and maintenance of diverse, equitable, and inclusive clinical, educational, and administrative environments. Nor do they address the social responsibility of physicians to advocate on behalf of their patients and communities. This is a critically important omission. For generations, the house of medicine has emphasized professionalism, but it continues to harbor institutional biases and structural barriers that prevent us from achieving diverse, equitable, and inclusive environments of training and practice. We cannot expect to achieve change using the language of the status quo.

INTERPERSONAL AND COMMUNICATION SKILLS

Compared to the prior version, the Emergency Medicine Milestones 2.0 appear to have increased recognition of the important role of communication skills, especially as they relate to the mitigation of bias‐driven barriers and the resolution of conflict. While generally desirable, the language used is similarly problematic to previously discussed performance indicators in patient care and systems‐based practice in that it could be interpreted as inclusive of a DEI‐supporting skill set, but such a skill set is not necessary to demonstrate competence in this area. Given the enormous challenge of overcoming bias and disparity in health care, DEI‐related performance indicators should be explicit rather than potentially implied. Additional specific language that emphasizes setting of positive expectations related to language and behavior among members of the care team and between patients and care team members would be welcome. Physicians must not permit bias in any form to erode team culture or the therapeutic relationship. All physicians possess privilege in varying degrees and should demonstrate skills of ally‐ship with less‐privileged colleagues, coworkers, patients, and communities.

We did not identify indicators of DEI‐relevant performance in the medical knowledge and practice‐based learning and improvement competencies in either document. This may be due to the fact that the performance indicators that support diverse, equitable, and inclusive environments do not fit neatly into any single ACGME core competency. As a result, the disparate performance indicators included in the milestones documents that reflect desirable DEI outcomes do not necessarily adhere to the scaffolded notions of expertise development upon which the milestones and their “developmental progressions”⁶ were based. One solution, as proposed by Castillo and colleagues in Academic Medicine in December 2020,⁹ is the creation of a new competency for “structural competency, health equity, and social responsibility,” that unifies the knowledge, skills, and attitudes of the DEI‐competent physician under a common banner. Such an approach has the advantage of being theoretically grounded while emphasizing the scope and importance of DEI competency. Milestones aligned under a distinct competency would help curriculum developers and evaluators ensure that residents are meeting these goals.

It is easy to argue that the milestones are imperfect and were never intended to be all‐encompassing. Indeed, there are many opportunities to improve them.⁶ However, as we consider how we can create diverse, equitable, and inclusive training, working, and patient care environments, it is clear we can—and must—do better. It is also easy to argue for supplementary curricula, but milestones are the bedrock of EM curricula and program accreditation while secondary curricula are just that—secondary. For example, DEI proponents have for years been advocating for the inclusion of DEI curricula in graduate medical education but have made no real gains in establishing best practice curricula nor improving the percentage of underrepresented EM residents.¹⁰, ¹¹ The major recommended model for establishing DEI curricula in medical education has been the Tool for Assessing Cultural Competency Training,¹², ¹³ which, with its focus on undergraduate medical education, has been challenging for graduate medical education curriculum developers to employ. These challenges reflect some of the previously identified barriers to the implementation of curricula that address bias, social determinants of health, and structural inequality: hidden curricula that contradict DEI curricula, inadequate resources and time devoted to instruction, and learner resistance to the material.¹⁴, ¹⁵ The milestones play an important role in holding individuals, programs, and institutions accountable for achieving curricular goals. Programs and institutions are more likely to invest the significant resources required to address barriers to DEI curricula and competency when doing so is required by the milestones rather than seen as an optional expenditure of limited resources.

We must not allow ourselves to create excuses to deprioritize this work. As leaders, researchers, and advocates for DEI in EM education, we should advocate for meaningful, explicit, developmentally appropriate DEI performance indicators to be included in the next version of the milestones in an educationally sound manner, ideally in a distinct competency. Unfortunately, that revision is likely several years away. In the meantime, we suggest that EM educators, DEI experts, and other stakeholders collaboratively use the curricular outcomes, innovations, and best practices described in this issue and other available resources to generate consensus on a core set of DEI‐related educational outcomes. An unofficial “DEI milestone,” while less than ideal, could be used as a driver for curricular programs and assessments or as a supplement to the current milestones until such time that they fully reflect the values of our specialty. Through such work, EM will continue to lead impactful education‐centric strategies that support DEI.

CONFLICT OF INTEREST

The authors have no potential conflicts to disclose.

AUTHOR CONTRIBUTIONS

All authors meet the requirements for authorship under ICMJE guidelines. Sarah H. Michael and JWG conceived this idea and later refined it with Bonnie Kaplan and W. Gannon Sungar. Sarah H. Michael drafted the manuscript and all authors participated in critical revision of the manuscript for important intellectual content.

Michael SH, Kaplan B, Sungar WG, Ward‐Gaines J. Building residents’ competence to support diverse, equitable, and inclusive environments in emergency medicine must start with the milestones. AEM Educ Train. 2021;5(Suppl. 1):S144–S148. 10.1002/aet2.10673