Diversity Moves to the Center

The overhead operator announced, “Code Blue, cardiac arrest, MICU.” I still remember that day from the end of my intern year some 40 years ago. My pager went off at about the same time as the announcement directing me to the Code Blue. I ran quickly, knowing that even a few seconds could make a critical difference, but I was also hoping that I would not be the first to arrive and have to take charge. I wanted someone more senior and experienced to be there ahead of me. When I reached the patient’s bed, I was not expecting to see a wheelchair tilted at the head of the bed, from which one of the other residents, who I recognized to be paraplegic, was attempting to intubate the patient and run the code. I watched as this resident hoisted himself up on his elbows at the head of the patient, balancing himself precariously in the air. His biceps bulged against the weight of his body. He was holding a laryngoscope in one hand and an endotracheal tube in the other. A crowd of nurses, students, and other residents gathered around the bed, gazing at the heart monitor and at the patient, who was a thin elderly woman with a wrinkled face, thin blue lips, and pale gray lifeless eyes—but mostly, they were staring at this resident.

For a few seconds the resident supported himself with his hands and elbows like a gymnast on the uneven bars. Then he craned his head forward looking into the patient’s mouth, straining to view the vocal cords. I could see the beads of sweat now on his forehead. As I watched, I felt sure that he would fail in his impossible attempt, and I readied myself to take his place. He suddenly nodded that he had a good view and plunged the endotracheal tube into the patient’s throat and down into the trachea. A nurse connected the tube to a ventilation bag as the resident lowered himself back into his wheelchair. He directed me to listen for breath sounds, and I placed my stethoscope on the woman’s chest and confirmed the tube placement. He then shouted out orders for various medications to treat arrhythmias. I listened to the orders and watched as the treatments seemed to work. It was a remarkable and heroic effort.

When the patient stabilized, and the crowd dissipated, I waited and finally introduced myself. The resident was two years ahead of me, ready to graduate. He nodded at me and told me he had seen me in grand rounds although we had never worked together. We discussed the resuscitation and the intubation and he brought up issues about what might have led to the crisis. While I listened and tried to learn from what he was telling me, what I really wanted to ask him was how he had done it—intubated the patient on a bed from his wheelchair. I could not even accomplish the task reliably with my four functioning limbs in the best of circumstances. It seemed miraculous. And I wanted to know more about him, how he had come to be in the wheelchair, and what he had done to succeed in the residency to overcome his disability. But we both had patients to see, and the moment was not right for such personal questions.

It was not until years later that I fully appreciated what this remarkable man had accomplished to complete his training in those days before electric wheelchairs and some 13 years before the passage of the Americans with Disabilities Act. Not only did he have to navigate the hallways, patient doorways, bathrooms, exam rooms, sleep rooms, and parking lots in his wheelchair. He also had to overcome biases about what a proper doctor should look like and act like, what physical and mental abilities would be essential for success, and whether he had them. While few of us probably fit the idealized images of fictional doctors on television in the 1960s—young, blond, earnest Dr. Kildare or the intense surgeon Ben Casey—we also recognized what doctors did not look like; they were not female, black, Hispanic, or disabled. Although much has changed since those days, both in the television and movie portrayals of physicians and in the actual makeup of our physician workforce, many of the biases remain.

Both within and beyond medicine, our society continues to struggle with the meaning and value of diversity. In their Last Page in this issue, Nivet et al¹ present a diversity framework that locates diversity at the core of academic medicine and includes the following areas of human diversity: “socioeconomic status, race, ethnicity, language, nationality, sex, gender identity, sexual orientation, religion, geography, disability, and age, among others.” The authors further note that “diversity embodies inclusiveness, mutual respect, and multiple perspectives, and serves as a catalyst for change resulting in health equity.”

How might we achieve these goals in our educational programs and in the physicians they produce? Could the use of competencies provide guidance? Englander et al² have created a taxonomy that describes eight domains and 58 competencies for the health professions, collated from around the world, that can serve as a basis for what students need to be able to know and do regardless of their backgrounds, identity, or capabilities. Eckstrand et al,³ in their article in this issue, demonstrate how the competency framework can be modified to better define competencies related to care of diverse populations through identifying gaps in current knowledge, attitudes, and skills needed for such care, modifying the competencies with qualifiers, and editing the qualifiers. While Eckstrand et al used this approach to develop competencies associated with lesbian, gay, bisexual, and transgender patients, the approach could also be used for other populations such as disabled, ethnic, or racial minorities, or others identified by Nivet et al in their diversity framework. It might also be possible for health professions to use Englander and colleagues’ competency taxonomy in their admission processes by matching the competencies with the capabilities and likely potential of applicants. This approach could be particularly pertinent to the disabled student.

The language we use to characterize various types of differences has greater influence on our thinking than we sometimes realize. For example, although the use of the term disabled has some utility, it also has the effect of putting people who are very different into the same grouping, and categorizing them as less “abled” than those who are “fully abled,” rather than emphasizing that they are “differently abled.” For example, in the incident I related above, the resident who was in the wheelchair had certain capabilities that were different but effective and valuable. When we label a person as disabled, we may not see the special capabilities that person may have or recognize that person’s unique identity. In this issue of Academic Medicine, Sarmiento et al⁴ describe a medical school program focused on enlarging the understanding of disabilities for first- and second-year students through exposing them to the words and lives of individuals with disabilities. Although the program is mainly focused on helping the students to understand patients with disabilities, I believe it will also help them to appreciate the diversity in their colleagues and teachers.

Unfortunately, many medical schools do not appear to encourage the applications of disabled students, according to Zazove and colleagues’⁵ report in this issue. They reviewed technical standards displayed on U.S. medical school Web sites that describe admission requirements and possible accommodations that could be made for disabilities of hearing, sight, or mobility. Their findings indicate that 61% of medical schools in this country lacked information on the responsibility for providing accommodations. If we are to encourage diversity of the medical student population to include students with disabilities, we need to consider what the essential abilities of a physician are and how accommodations can be made for those with different types of abilities. It may also be time to consider current requirements that assume the need for a physician to function successfully in all core specialties in spite of the recognition that students soon differentiate and develop specialty expertise in areas that may not require the same capabilities.

As we consider the encouragement of a diverse workforce with the ability to care for a diverse patient population, we must also recognize the unique features of diversity. Each category identified by Nivet et al has a history and experience that differs from the others. To fully embrace diversity we must understand those histories and their current manifestations. In this issue, Powers et al⁶ introduce the concept of race-conscious professionalism and its effect on the career paths of African American physicians. The unique history and population needs of the African American community have created the forces that forged the physician identity for African American physicians. Race-conscious professionalism may help explain decisions of many African American physicians to devote their energies to community engagement rather than academic pursuits. Powers et al suggest that if academic health centers developed centers for the research and care of minority populations, they might be able to better support and retain African American physicians in academic medicine. Those authors also note that although mentoring and other resources may provide support for minority physicians considering academic careers, this does not address the internal psychological factors of race-conscious professionalism that are important to many African American physicians.

Also in this issue, Lewis et al⁷ report their attempt to improve satisfaction with mentorship relationships in a controlled study of mentor training and peer support for a largely minority and female cohort of graduate students, fellows, and junior faculty using a self-determination theory framework. They had limited and temporary success in improving the participants’ satisfaction with mentors or the participants’ satisfaction with their own work. Whether the issues raised by Powers et al may have affected the results of this randomized controlled study is not clear but is worth considering.

To improve diversity in the physician workforce will require a multifaceted and creative agenda. For example, in this issue, Tunson et al⁸ describe a pilot program at the Denver Health Residency in Emergency Medicine program (affiliated with the University of Colorado School of Medicine) to improve recruitment of underrepresented minority (URM) applicants. They describe a multiphase program involving scholarships for student externships, paid second-look visits, and engagement of URM faculty. The results, although early, appear promising and suggest that shifting a small amount of resources and a demonstrated institutional commitment can influence the recruitment of URM residency applicants. Improvements in diversity will also be dependent on a deeper understanding of our biases and the role of education in sometimes inadvertently reinforcing biases. Tsai et al⁹ describe a student-led initiative to examine how race was presented in the preclinical curriculum, which may have reinforced biases about connections between biology and race. The students’ efforts led to changes in the curriculum and an enhanced understanding of unconscious bias in medical education.

After reflecting on the evolution of diversity in health care, I reached three conclusions.

• The stories and examples of unique individuals, such the resident I described at the start of this essay, can influence our attitudes and understanding of the value and meaning of diversity. We will continue to need the examples of those remarkable individuals and of medical school admission programs that erase barriers and increase inclusion and acceptance.
• But we also need to create clinical and educational structures that reinforce an empowerment and inclusion environment for diversity. We should not expect every person with a difference to be a superstar to overcome institutional barriers.
• Finally, we cannot take the advances that have occurred for granted, whether in the compliance with technical standards for disabled students or the support and advancement of members of underrepresented groups to the highest leadership levels of academic medicine. There still needs to be a sustained and unwavering commitment to diversity for us to achieve the goals of health equity and health excellence. Political support and legal decisions may change, but the commitments of all of us in academic medical institutions must remain solid. We must do this not only because it is fair and just but also because it offers the best care possible to everyone.

David P. Sklar, MD