The analogy of a fish swimming in water with no idea what water is describes an experience I have frequently had with colleagues in emergency medicine. Twenty years ago, I beat my head against a wall sharing with fellow residents and faculty that implicit bias and prejudice were adversely affecting the health outcomes of our patients. In the words of my mostly white male colleagues, they just didn't see it. To them, I simply had a chip on my shoulder.
When it came time for senior grand rounds presentations, I proposed the topic of racial dissonance and miscommunication leading to poor clinical decision-making and health inequity. My program director said no one on the faculty had any expertise in that area, and our department chair said, “I don't think anyone here knows what you're talking about.” Several residents shared a conviction that affirmative action was no longer needed because we were serving a largely poor African-American community on the south side of Chicago and “doing these people a favor.” One white peer said I should feel fortunate as an African-American to be there. After all, there were now two of us in the program.
My mentors pejoratively suggested I look into a master's in public health, but my black peer and I leaned toward pursuing a master's in business administration, believing we might have more impact as business leaders than as health justice policy advocates.
Twenty years later, the situation in that residency has improved as a result of diversity and inclusion efforts; there is presently a senior black mentor in leadership, and half of the residents in the program are women. Unfortunately, the vast majority of training programs are still swimming in the water of white hegemony; even when managing to achieve diversity, they still struggle with inclusion. Diversity is not inclusion.
My first job as a newly boarded EP was as the associate medical director for a contract management group (CMG) at a Catholic hospital serving a largely Latino community on Chicago's west side. It was gratifying to be the one bilingual physician on staff. The community welcomed me, inviting me to advocate for their interests. The hospital public relations coordinator asked me to record public service announcements on health and safety for our local Telemundo/Univision affiliate.
Meanwhile, I tried to balance meeting benchmarks (already the sole index for increasing revenue) against support for patients struggling against the real determinants of health: social and economic constraints. Cultural competence was not a company priority, even though inclusion was clearly on the hospital's agenda. Any emphasis on community advocacy seemed superfluous to my medical director, who I considered an ally until he made clear he was not interested in how health disparities affected the revenue cycle.
Eventually, the hospital's identity transformed its mission and its market. It became a designated stroke center and tertiary care referral center, shifting its mission to healing ministry rather than serving the local community. The contract group is now long gone, but they still have no blacks or Latinos in senior leadership roles, though they do have an Asian-American vice president. Inclusion seems a threat to some and possibly irrelevant to those not serving minority communities.
With this lesson learned, I moved to a Latino community, in part because I reasoned it would not be made a marginalized market. Here lies one of the greatest hypocrisies and formidable challenges to understanding diversity and inclusion: Latin American society in southern Florida is more vested in white hegemony than Anglo culture is in America. I thought my childhood experience with racist Cuban Americans-in-exile would be different, tempered by my professional credentials, but Cubans on those hospital staffs routinely expressed the racist view that blacks, particularly American ones, are inherently inferior to whites.
I commonly interrupted conversations in the physician lounge peppered with loud references to a black presidential candidate they called “the monkey.” This toxic and deplorable behavior is entrenched in the culture. (Recently, a black student movement at the University of Miami was set off by the increased frequency of white students using the n-word and monkey emojis and calling for the enslavement of blacks, all despite the university establishing a diversity task force the year before to combat bigotry.)
It was around this time that I moved to a North Miami Beach hospital serving a black community. There I met David Farcy, MD, the president of the American Academy of Emergency Medicine and the chairman of emergency medicine at Mount Sinai Medical Center in Miami Beach, and several other forward-thinking physicians who were becoming increasingly active in the Florida Chapter of the American Academy of Emergency Medicine (FLAAEM) and the National Medical Association in part to call attention to health equity, professionalism, and ethics in emergency medicine practice. A culturally diverse group of professional friends and I put together a TV show called Connections to speak about unity in the minority melting pot of our community, but it was nowhere near enough to put a dent in the inertia of divisiveness.
Minority presence does not equal diversity or impede hostility in the workplace. I set out to acquire the language of the C-suite with a health care MBA and a goal to promote a new model prioritizing health creation and curbing wasteful expenditure on catastrophic care. Everyone knew health disparities lead to a lack of care for chronic disease and the unequal allocation of power and resources. A significant part of the $4 trillion misspent in this country every year could be addressed by funding relatively simple preventive measures. My classmates and I came up with proposals for strategic corporate philanthropic efforts for community-based health care academies and clinics, education for local labor pools, and career paths into training. We researched how clinical documentation systems could be used to help patients save money and limit health expenditures. Of course, this doesn't fit current business models or strategies focused on the next quarter.
It ultimately dawned on us that we could not reinvent the wheel if we wanted to be included in the current health care business structure. Even in meetings set up by a small consulting group I joined later, we never met black people in leadership to champion novel strategies. Being open to diversity does not guarantee it, and health equity requires powerful leaders. I headed north to pursue an interest in policy and advocacy, finally accepting that that might be a better path to health justice. What better area for that than Washington, DC?
I took part in AAEM's Policy and Advocacy Congressional elective while awaiting credentialing at a hospital where I accepted a position as a medical director at a small hospital in a rural farming community. The welcome can best be summed up this way for anyone familiar with the movie Blazing Saddles: I was the new Sheriff Bart. Shortly after I started, two scribes and a unit clerk told me they heard one EP repeatedly make racist remarks about me. I met with him, and he emphatically denied it. I notified our regional director about the issue, and the response was that nothing could be done.
I decided this company was not worth any more of my time and energy. I was active in the National Medical Association, and a colleague suggested I consider the Howard University College of Medicine. I have been practicing there as an associate professor for emergency medicine ever since. There was initially enthusiasm for collaborative work on social justice at Howard, but then the contract was taken over by a CMG.
Diversity and inclusion require integrity and commitment. Last summer while attending emergency medicine lectures at the National Medical Association Scientific Assembly, I ran into the AAEM's president-elect, Lisa Moreno-Walton, MD, who invited me to join the AAEM's Diversity and Inclusion Committee and to speak at the Scientific Assembly. The enthusiasm around diversity and inclusion in most organizations is fueled by avoiding lawsuits and meeting compliance and workplace safety measures but not at AAEM. And many diversity and inclusion initiatives and officers are not taken as seriously as other leaders, but AAEM disproved that. Even my limited involvement there has already been immensely rewarding.
At my first AAEM Scientific Assembly about 20 years ago, I felt isolated and alone as one of a handful of black EPs wandering aimlessly from one lecture to the next. Last year I wandered about expecting that same experience, but the response was more often a positive greeting or suggestion to connect and collaborate. I even came across a young black physician who said he had been wandering around the conference not knowing where to go. “You just made my week,” he said. “Thank you for helping me feel part of this.”