The time is now: A model for diversity recruitment and retention in emergency medicine training programs

Racism in medicine is not a new phenomenon. There have been many well‐documented atrocities that have been committed in the name of science¹, ², ³, ⁴, ⁵; in fact, many have argued that modern medicine was built on the infrastructure of racist clinical and research practices.¹, ², ³, ⁴, ⁵ In graduate medical education, how do we face this undercurrent of racism that we silently walk in every day in our academic medical centers? The answer starts, though it does not end with, diversity and inclusion.⁶, ⁷ Diversity and inclusion have become catch phrases often used to show candidates and/or accrediting bodies that the topic sits as a pillar of every institution's mission. It must be said that there is a difference between appreciating diversity and practicing diversity. Boatright et al.⁸ found that less than half of EM programs had diversity recruitment initiatives. If we are going to change the systemic racism that is ingrained in the fabric of medicine, then we need to put action to the words we speak. It cannot merely be that we have implicit bias training for our faculty and teach our residents how to respond when racist statements are made against them. We must go the next step by protecting our residents from statements made toward them.

Further, we must get at the root of the problem. We must have a diverse workforce so that having only one physician of color in a department is not the expectation.⁹ Rather, having a physician of a diverse background is what the patient expects. Our medical workforce must more accurately mirror our diverse population, and we must put forth efforts to retain these physicians.

Raffoul et al.¹⁰ ask accrediting bodies to set standards and call for academic medical centers to connect their recruitment priorities back to the public health agendas they serve. ACEP wrote a joint policy statement calling for academic medical centers and institutions to work toward the promotion and advancement of women and underrepresented in medicine (UIM).¹¹ It is then that we will be truly practicing more than appreciating diversity and inclusion. To this end, I propose a model that is based on the recruitment and retention of a diverse workforce, which could have a substantial impact on improving the recruitment of trainees in emergency medicine (EM) training programs.

The Diversity Recruitment and Retention (R+R Model; Figure 1) guides departments to work toward developing a diverse and inclusive workforce. It is a framework that can then be molded to fit each emergency department's unique environment.

FIGURE 1.

Diversity Recruitment and Retention (R+R) model: parallel recruitment efforts with supportive retention strategies

Recruitment

The recruitment arm of the Diversity R+R Model starts with a plan to identify the current diverse workforce via a self‐identification survey or a task force invitation. This identification allows the department (in a safe space) to build partnerships with their current diverse workforce including residents, fellows, faculty, and medical students. While avoiding tokenism, it is this workforce that could provide ideas of potential strategies for recruitment within the community and may also recognize local departments that are succeeding and willing to share ideas.¹²

Table 1 outlines potential strategies a department could use to enhance their diversity recruitment efforts. Departments must have a strategic plan, starting with a few attainable goals, and then expanding upon their efforts each year. For example, in the residency interview and ranking process, diversity and inclusion efforts must not be left to happenstance; rather, there must be active planning and implementation centered on the common goal of increasing UIM trainees. After employing a diversity recruitment initiative, Highland EM residency program found a twofold increase in the amount of UIM residents matched to their program.¹³ Even further they found a snowball effect, that is, “Diversity begets more diversity,” and more diverse applicants continued to show an interest in their program.

TABLE 1.

Recruitment and retention strategies

Recruitment
Outreach to historically Black colleges and universities (HBCUs)	Medical student and/or residency fairs Q&A panel discussions Invite guest lecture series Summer/research internships
Diversity, equity, and inclusion events	Recruitment events Lecture series/grand rounds “Getting into residency” Q&As Partnering with college of medicine diversity groups (SNMA, LMSA, WCBL, AMWA, LGBTQ/PRIDE groups)
Interview and ranking process	UIM faculty and resident participation Holistic review of applications Second looks geared toward UIM applicants Funded away rotations/externships
Retention
Mentorship Faculty to students/residents Senior faculty to junior faculty	Promotion and tenure Research Career advice Job search sessions Sponsorship
Communities/support groups Local Regional National	Women, UIM, LGBTQ physician groups (host social nights, lectures, networking, QI/research project working group, safe space support groups)
Implicit bias and cultural humility training (all physician and staff)	Lecture, panels, grand rounds Nontolerance departmental policies Discrimination reporting structure
Diversity, equity, and inclusion committees	Community engagement initiatives Advocacy and policy change at the local and national level Collaboration on each phase of R+R model

Abbreviations: AWMA, American Women's Medical Association; LMSA, Latinx Medical Student Association; SNMA, Student National Medical Association; UIM, underrepresented in medicine; WCBL, White Coat for Black Lives.

How can programs ignite change? Looking in more depth, the residency program leadership must have a candid conversation with all committee members about the goals of their interview and ranking process. It starts with inviting UIM and female faculty to participate on the committee. Even further, ensuring that these faculty are in the program leadership in such roles as program director and/or associate/assistant program director. Denver EM training program took a three‐pronged approach of funded externship, second looks, and increasing UIM faculty presence at interviews, and their number of UIM applicants interviewed doubled.¹⁴ A unifying theme is that the selection committee look beyond the metrics of standardized testing scores, which have themselves been shown to have fault.¹⁵, ¹⁶, ¹⁷ There must be efforts to use holistic approaches to recruitment into residency, which includes placing weight on a candidates’ community service, leadership, and research.¹³ Finally, it must be noted that to draw diverse residency candidates, a department must also prioritize the hiring of diverse faculty. Similar strategies of diversifying the interview committee and creating incentive hiring and benefit packages to help advance and promote women and UIM faculty should be used in faculty recruitment efforts.⁶, ¹¹

Another strategy is partnering with historically Black colleges and universities (HBCUs), which matriculate the largest percentage of Black medical students (14%) in the United States.¹⁸ Goines et al.¹⁹ reported on the collaboration between Emory University and Morehouse School of Medicine and found that of the 115 medical students who did an EM clerkship through Emory (with varying mentorship), 62.6% successfully matched into EM training programs. Such partnerships could expand the volume of UIM recruits into EM residency programs by directing efforts toward schools with the highest census of UIM medical students.

All recruitment strategies should include the precision of counting metrics and assessment of initiatives to evaluate whether a program's efforts are working. Yearly, goal setting and evaluation of outcomes (including number of diverse residents/faculty and job satisfaction indices) will hold department leadership accountable.

Retention

The second arm of this model includes retention (see Table 1). With more women entering medicine (in 2020, 53.7% of medical school graduates were women),²⁰ and more diversity and inclusion recruitment efforts being implemented, the question remains: What are we doing to develop these physicians to ensure their success? For trainees, many doctors of diverse backgrounds feel that they are recruited to fill quotas, but then unsupported once they are in the institution and made to feel that their diverse characteristics need to remain hidden.²¹ For faculty, many published articles have shown that where diversity and inclusion efforts have succeeded, retention efforts often fail because of lack of focus on faculty development.⁶ Rodriguez et al.²² found that a lack of mentorship was a barrier to promotion for underrepresented minority faculty. Diversity inclusion titles are assigned to faculty without appropriate financial support, including the allotted time commitment to allow them to be successful in their diversity and inclusion work.²³

In all retention efforts, it is important to acknowledge and address the discrimination and microaggressions faced by UIM and female trainees and faculty. To retain these physicians, we must ensure that the clinical learning environments are safe and respectful for all, particularly those that are often disenfranchised in our society at large. Aysola et al.²⁴ in a study investigating inclusiveness across three domains: vision and purpose, camaraderie, and appreciation found that women and UIM faculty were less likely to rank their organizations as culturally competent. In a study of UIM residents treatment in the workplace, Oseeo‐Asare et al.²⁵ found that UIM residents more often deal with daily microaggressions and biases. The ACGME also acknowledged the need to protect all residents,²⁶ particularly those identifying from UIM backgrounds, and added requirements, which not only address program and institutional standards to increase diversity recruitment and retention efforts, but also require that institutions maintain safe and respectful clinical learning environments (Section VI.B.6). ²⁶, ²⁷ Programs should ensure that these protections are in place by creating reporting processes for trainees and faculty to raise concerns. These supportive efforts ensure retention of diverse residents and faculty.

Assessment is key in both arms of the model. During each year of the model, the diverse workforce should be surveyed to determine the effectiveness of the strategic plans on recruitment into training programs, job satisfaction, and academic and/or administrative promotion for faculty.

Does diversity work?

Looking outside medicine, Page²⁸ found that a group of individuals with diverse tools, which can equate to a diverse and inclusive workforce, outperforms on markers of both efficiency and accuracy to an equivalent group of individuals designated as having high “ability.” UIM physicians are more likely to work in underserved areas,²⁹ which house medically underserved patients with low socioeconomics, thus creating a cycle of empowering these communities. Whitla et al.³⁰ found that in two medical schools studied, medical students found that interaction with their diverse peers overall enhanced their educational experience. Highland found that with the increase in diversity of their resident body, there was an overall improvement in the cultural competency and social medicine training for all residents.¹³ Ultimately this may lead to the downstream impact on patients by improving patient–physician rapport and health outcomes.³¹

The recruitment and retention programs that had the most success were because of allies and buy‐in from both the faculty and the administration of the department (who can provide funding).¹³, ¹⁴ While erasing the years of pervasive racism that exist within medicine will not be resolved solely by recruitment of more diverse physicians, it will lead us to more diverse perspectives and practices within our training programs. Until seeing a doctor of color in all fields of medicine becomes ubiquitous, our jobs as those leaders in the field are not done. The time is now for us not to ignore the undercurrents of racism that pervade our recruitment into residency programs and retention thereafter. It is time for us to go beyond appreciation and practice diversity and inclusion as a first step to addressing the structural racism that exists in the house of medicine.

Smith TY. The time is now: A model for diversity recruitment and retention in emergency medicine training programs. AEM Educ Train. 2021;5(Suppl. 1):S126–S129. 10.1002/aet2.10659