Call to action in academic emergency medicine: Going beyond the appreciation of diversity, equity, and inclusion to true practice

Medical education, be it didactics, simulation, or bedside teaching, helps shape the practice of each physician whether in training or as a part of continuing education. This educational imprinting helps shape each generation of physicians who will go on to care for a diverse patient population. Particular to emergency medicine, with all its complexities, it is imperative that physicians be equipped with the skills, knowledge, attitudes, and behaviors to address the needs of each individual patient in context with their environment of practice. Trainees must be exposed to curricula that integrate health equity and antiracism education by embracing the history of medicine, social and structural drivers of health, persistent health inequities and injustices, and review of evidence‐based interventions that ensure appropriate care for vulnerable and marginalized populations. Attending physicians, particularly those involved in medical education, must lead in this space and all physicians must care for all patients without bias. Academic emergency medicine must embrace concepts that have been relatively absent from traditional medicine including community‐focused efforts to address health disparities and research that includes historically marginalized patient populations. Leadership within each department must be engaged in addressing disparities, restoring trust in the communities they serve, and ensuring high‐quality care regardless of race, ethnicity, preferred language, or any other variable that leads to minoritization of an individual.

RECRUITMENT

Emergency medicine must consider the reckoning that should take place at the programmatic, departmental, and institutional level starting with the recruitment and development of a workforce who is both knowledgeable and further educated on health inequities and the practice of antiracist ideology within medicine. In recruiting trainees to fill residency slots, an emphasis must be placed on identifying future physicians who will address the acute medical needs of a patient while addressing the social concerns surrounding a presentation to the ED. Recognizing what draws a diverse workforce is important for departments to consider. Medical students who identify as underrepresented in medicine (UIM) are more likely to have intentions to practice in underserved areas,¹ thus creating programs centered around social emergency medicine and identifying and addressing the social determinants of health will likely entice these candidates. However, to recruit trainees, departments should start with the recruitment and development of UIM faculty. Diversity begets more diversity, as has been seen with recruitment of more women and UIM into emergency departments (EDs).², ³ Thus, recruiting UIM faculty will lead to more mentors and a sense of community for trainees. Even more, recruitment of diverse trainees goes beyond selecting the token faculty serving in every diversity, equity, and inclusion role, including the interview process. It requires the commitment of the department leaders to use a holistic approach that weighs experiences of candidates just as heavily as metrics.⁴

RETENTION

In addition, department leadership must be active in the recruitment and retention of diverse faculty with their own different lived experiences and cultural backgrounds. It must not be that a department recruits a quorum of UIM faculty and trainees into departments without providing the appropriate retention and development plans of said faculty. Specifically, UIM faculty must be afforded opportunities for leadership and not limited to diversity roles that are often laden by the minority tax. The leadership in the departments, academic centers, and hospital c‐suites must also be diverse to bring a myriad of perspectives and voices to the table where important decisions are made. Given the minority tax and other expectations placed on UIM faculty, it is essential that promotion committees consider diversity, equity, and inclusion work as weighted categories.⁵

EDUCATION

Faculty must hold themselves accountable for the education and training we provide. Educators must integrate health equity into their educational content. Stillman et al.⁶ describe a theoretical framework to integrate social emergency medicine into residency training for all trainees. Beyond didactics, the tenants of emergency medicine training must integrate public health dilemmas and the structural inequities that lead to disparate health outcomes. Tsai and Crawford‐Roberts⁷ call for medical education to use critical racial race theory in medicine, identifying racism in medicine by name and in practice, to address these issues at the core of our medical education curricula. Diaz and Knight⁸ describe a successful critical race theory curriculum that allows learners to have a safe space to analyze, discuss, and act on sensitive topics as it relates to racism in medicine.

To ensure that physician trainees obtain those aforementioned skills, knowledge, attitudes, and behaviors, expectations for learners must be set in the form of learning objectives and defined milestones that are critiqued with the same rigor as others. Many emergency medicine societies have started to call for more emphasis on diversity, equity, and inclusion. In 2008 the Council of Emergency Medicine Residency Directors (CORD) Panel on Diversity put forth recommendations for programs to increase recruitment and retention of diverse candidates. Here the authors also suggest incorporating training on cultural humility, implicit bias, and community engagement into residency education.⁹ The Liaison Committee on Medical Education (LCME) has recognized the need to not only recruit a diverse physician workforce but also to also incorporate health equity into the standards for undergraduate medical education.¹⁰ Although the Accreditation Council for Graduate Medical Education (ACGME) has also been committed by establishing both institutional and program requirements to address diversity and inclusion within training programs,¹¹ we must go even further. The next step is to have these accrediting bodies take the lead by creating milestones that address the training and competence around topics on cultural humility and social and structural drivers of health.¹² This will ensure that programs integrate this content into their training to satisfy their accreditation requirements.

PATIENT POPULATION: EQUITY IN PATIENT CARE

Academic emergency medicine must lead in addressing the inequities that have plagued medicine resulting in mistrust of the health care system. While this can be done in part by improving workforce diversity and medical education, these interventions will take time to have a large‐scale impact. EDs must reflect on their mission statement to ensure that equity is a cornerstone of medical care. There should be a recognition that in the practice of emergency medicine we must address not just the immediate medical needs of patients but also the social needs identified during patient care.¹³ Improving equity means collecting data on traditional quality metrics and department‐specific measures, assessing the data by race, ethnicity, language, insurance status, and other variables to identify vulnerable patient populations and develop dashboards to ensure that any identified disparities are addressed.¹⁴ Departments must review patient complaints as a source of potential disparities that may not be apparent through traditional measurements of quality and address racism and other forms of bias that patients experience during their ED course.¹⁵ This level of integration of health equity into all functions of a department requires consistent leadership, complemented by financial support and academic rigor seen in other spaces in the practice of medicine.

RESEARCH

Emergency medicine must continue to identify evidence‐based interventions to improve diversity, equity, and inclusion. Areas of need include greater understanding of the practices, policies, and interventions that can enhance diversity recruitment. Work by Sungar et al.⁴ highlighting the impact of holistic review on diversity recruitment provides an exemplary model for all residency programs looking for an evidence‐based intervention to improve resident diversity. Furthermore, the specialty must rigorously examine the climate of inclusion within the training environment and how this climate may influence the retention of diverse emergency medicine residents, faculty, and community practitioners. An innovative study by Landry et al.¹⁵ shines a critical light on the prevalence of microaggressions in emergency medicine. Future work should also explore the physical and mental effects of microaggressions, which have been shown to have a deleterious psychological impact on medical students.¹⁶ Last, emergency medicine should continue to investigate the benefits of a diverse workforce. Abreu et al.¹ present a remarkable study demonstrating that Black and Hispanic/LatinX medical students applying to emergency medicine are significantly more likely than their White peers to report an intention to practice in a medically underserved area. These findings support prior literature in primary care showing that physicians of color are more likely to provide medical care for patients without insurance or insured through Medicaid.¹⁷

CONCLUSION

The ED serves as the safety net of health care and therefore should lead medicine in addressing health equity. Medical education must be a cornerstone of these sustained changes so as to produce the next generation of physicians who are trained in how to address the whole spectrum of a patient from their physical care to social needs as well as the public health of the communities they come from. Academic medicine must be the architect of the plans of building better, more equitable health care systems.

Landry A, Boatright D, Smith TY. Call to action in academic emergency medicine: Going beyond the appreciation of diversity, equity, and inclusion to true practice. AEM Educ Train. 2021;5(Suppl. 1):S7–S9. 10.1002/aet2.10671