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Special Report

Special Report

Building a Diverse Emergency Medicine

Shaw, Gina

doi: 10.1097/01.EEM.0000657624.32588.6c
    Figure
    Figure:
    emergency medicine, diversity, equality

    Like many other medical specialties, emergency medicine has a diversity problem. Women, minorities, and LGBTQ+ individuals are not represented on emergency department staffs, in departmental leadership, and of other top positions in the field, such as on the boards and review panels of peer-reviewed journals, at anywhere near the rates they are represented in the population.

    Consider just a few figures:

    • Blacks, Hispanics/Latinos, American Indians, Pacific Islanders, Alaska Natives, and Native Hawaiians make up 33 percent of the U.S. population. But only 9.9 percent of emergency physicians identified as underrepresented minorities in 2013 (4.5% black, 4.8% Hispanic/Latino, and 0.6% American Indian/Alaska Native). That's roughly the same as in the physician population as a whole. (Ann Emerg Med. 2019;73[6]:639.)
    • Underrepresented minorities comprise 17 percent of all medical residents but 14 percent of emergency medicine residents. (J Emerg Med. 2013;45[1]:100.)
    • Among active emergency medicine residents in 2018-2019, 35.5 percent were women and 64.5 percent were men, according to data from the Association of American Medical Colleges. Here, emergency medicine also compares unfavorably with most other medical specialties (particularly the primary care specialties), with just a few exceptions, such as orthopedic surgery and neurosurgery. (AAMC. Sept 5, 2019; http://bit.ly/35X5EJk.)
    • Only one percent of active ACEP members are black; 1.5 percent are Hispanic. Women make up only 25 percent of active ACEP members. (Ann Emerg Med. 2017;69[6]:714.)
    • Only 20 percent of the deputy editors for Annals of Emergency Medicine in 2018 were women. Women also comprised just 24 percent of the Annals editorial board, 28 percent of Annals original research authors, and 31 percent of Annals core reviewers. (Ann Emerg Med. 2019;74[6]:736.)
    • No studies could be found about the prevalence of LGBTQ+ individuals in emergency medicine residencies or the workforce, but research suggests that sexual and gender minorities do not receive culturally competent care in emergency departments. A 2018 survey of emergency medicine programs found that a sizeable minority of respondents felt histories and physical examinations were more challenging for lesbian, gay, and bisexual patients (24.6%) and even more so for transgender patients (42.6%). Discriminatory LGBT comments were reported from fellow residents (16.6%) and faculty (10%).

    Still White and Male

    “Emergency medicine is still a predominantly white and male field, and that's just among the trainees,” said Dowin Boatright, MD, an assistant professor of emergency medicine at Yale School of Medicine and a leader in the Society for Academic Emergency Medicine's Academy for Diversity and Inclusion in Emergency Medicine (ADIEM). “Among leadership—the chairs of departments, the full professors, and so on—it is even more overwhelmingly white and male. Women and underrepresented minorities make less than their counterparts in the field and are less likely to get promoted, adjusting for a variety of factors.”

    A 2017 study of the academic emergency medicine workforce found that 15 percent of white non-Hispanic faculty were full professors, compared with just 10 percent of underrepresented minorities and other faculty, and only 18 percent of 113 chair and vice-chair positions were filled by nonwhite faculty. (Acad Emerg Med. 2017;24[10]:1182; http://bit.ly/2tW1ILw.) The same study also found significant salary disparities by gender.

    “The fact that the situation hasn't changed in so long is startling to me, especially as national demographics have changed,” Dr. Boatright said. “I think it speaks to the fact that as a field we have not historically recognized the importance of diversity. There may have been statements saying it's important, but until recently, there have been no real national initiatives to make change. I think we have to start asking ourselves about the climate and the culture of the field. With studies showing, for example, that women and minorities are less likely to be promoted, that calls on us to question if we have an environment that supports diversity, even when physicians from these groups do choose to enter emergency medicine.”

    John Burkhardt, MD, PhD, an assistant professor of emergency medicine and learning health science at the University of Michigan, whose research focuses on reevaluating medical education policy to increase fairness, equity, and health care disparities, said he thinks there are structural and social barriers. “How can we be more successful in recruiting students who weren't initially interested in emergency medicine to come to the field? Do women, students of color, and LGBTQ+ students see role models in emergency medicine? We aren't as diverse as some other specialties, so do people feel welcome to the party?

    “If you go to emergency medicine interest groups and most of the students and faculty are straight white men, you may not see that as the place for you,” he said. “We may also be ‘cooling people out’—driving underrepresented students away from emergency medicine even when they enter medical school with an interest in it. Findings from my dissertation research (http://bit.ly/30jz2bi) suggest that the issue is a combination of these factors.”

    Making Changes

    Efforts to change this environment require action by organizations leading the field as well as individual institutions. Over the past several years, the American College of Emergency Physicians (ACEP) and Society for Academic Emergency Medicine (SAEM) have created initiatives specifically focused on diversity, inclusion, and equity. ACEP's Section on Diversity Inclusion and Health Equity (DIHE) was inaugurated at the 2018 Scientific Assembly at a meeting of more than 85 participants, while SAEM's Academy for Diversity and Inclusion in Emergency Medicine (ADIEM), founded in 2012, now has nearly 400 members.

    Both groups focus significant attention on mentoring. DIHE aims to offer a variety of mentoring opportunities including training recommendations, career planning, and education, research, and leadership development. ADIEM is now restructuring its mentoring program to create a more systematic and formal program.

    “We also have a speakers team featuring people who are doing research or are highly engaged in work on diversity, equity, and inclusion as it relates to emergency medicine, and provide programmatic content for the SAEM annual meeting,” said ADIEM President Marquita Norman Hicks, MD, a professor of emergency medicine at Wake Forest Baptist Medical Center in North Carolina.

    ADIEM also sponsors a scholarship for the Association of Academic Chairs of Emergency Medicine's (AACEM) Chair Development Program (CDP), covering full tuition and a travel stipend for participation in the CDP by a rising leader who represents the ADIEM mission. The organization also maintains a list of emergency medicine residencies who have developed visiting scholarship programs for rising fourth-year medical students interested in emergency medicine to work in their departments as a subinternship year. (http://bit.ly/2ssTD0w.)

    “We feel that increasing the pipeline will ultimately lead to improvements in workforce diversity in the future, which will ultimately lead to improvements in health equity,” said Ava Pierce, MD, an associate professor of emergency medicine at UT Southwestern Medical Center in Dallas. “Research shows that physicians from underrepresented minority communities are more likely to practice in those communities.”

    Dr. Hicks said this is essential to patient care. “Patients need to see providers who have similarities with them,” she said. “It is also critical to medical education. You can't be what you can't see. If we have students who can't envision themselves as emergency physicians because they never see physicians in the field who are like them, how do we expect to improve the pipeline? Representation matters.”

    More Women

    Annals of Emergency Medicine has also announced that it will redouble efforts to improve diversity among its authors, reviewers, and editors. Editor-in-chief Michael Callaham, MD, the founding chair of the department of emergency medicine at the University of California, San Francisco, focused on the paucity of women in the journal's ranks in an editorial this past December. “We will explore possible ways to encourage and support women as first or last authors, as well as ask more women to write editorials or other invited publications,” he wrote.

    “We should make sure high-performing reviewers (especially women) are aware of the fact that the pathway to editorship begins with a strong profile as a peer reviewer,” Dr. Callaham continued. “We have also placed a special priority on finding strong female candidates for more senior editor positions because that is where the deficit is greatest; recently, we have filled a deputy editor position with a very experienced female editor. We will expand this process whenever possible.” (Ann Emerg Med. 2019;74[6]:736; http://bit.ly/2Tn9NDJ.)

    Dr. Callaham, in an interview with EMN, described plans to take similar action for underrepresented minorities in the journal. “We have only a smattering of minority physicians on our editorial board at present,” he said. “Among the reviewers, it's a bit more, but again, nothing like their proportion in the population. ... [T]his issue will be among those at the top of the diversity agenda.”

    Model Program

    Perhaps nowhere has more progress been made at individual institutions than at Highland Hospital in Oakland, CA, part of the Alameda Health System. “When I arrived at Highland 17 years ago, I was the only emergency faculty member from an underrepresented background and one of only two women on a faculty of 15,” said emergency physician Jocelyn Freeman Garrick, MD, who directs the Alameda County Health Pipeline Partnership, a consortium of community organizations addressing health disparities by diversifying the health workforce.

    “Among the residents, we did a little better on gender—about 30 percent were women—but only two of 40 residents were from underrepresented minority backgrounds,” she said. “And this is in Oakland, one of the most diverse cities in the country. Our faculty and our residents did not reflect our patient population.”

    Dr. Garrick and Berenice Perez, MD, then the chief resident and now the medical director of Highland Emergency Medicine, were determined to put diversity and equity front and center on the agenda. “The ranking process for the residency match takes about half the year, and whenever we had meetings to discuss it, we would ask, ‘What are we doing to address diversity?’” Dr. Garrick said.

    “It took a few years and a lot of these conversations to really get the buy-in to change what we considered to be important in the residency application process,” she continued. “Honestly, I think some of our faculty at the time felt that if a resident of color had lower USMLE scores or didn't go to a top 10 school, they might not give top 10 output. But after we made the changes and the underrepresented minority numbers in our residency started to increase, they saw that the quality of the residents didn't go down.”

    A Good Example

    Today, 27 percent of emergency medicine residents at Highland are underrepresented minorities, and more than half are women. “We have people from a diverse array of backgrounds, but we still get the top residents in terms of academics, extracurriculars, and social involvement,” Dr. Garrick said. “They're superstars. The word on the street is that the Highland culture is an inclusive environment, so every underrepresented minority student who aspires to go into emergency medicine applies to our program. Last year, 90 percent of Latinx students who wanted to pursue emergency medicine applied to Highland.”

    Other programs will have to try to follow Highland's example: The Accreditation Council for Graduate Medical Education (ACGME), which in 2019 named its first Chief Diversity and Inclusion Officer, has adopted new Common Program Requirements that mandate “a focus on recruitment and retention of a diverse and inclusive workforce.”

    Dr. Garrick advises other emergency medicine programs to take a holistic approach to improving the diversity of their residencies and faculty. “It impacts and helps the entire program, so it shouldn't be one person's task and certainly not the one person of color,” she said. “It's a collective. Chairs, program directors, attendings, residents, everyone needs to be involved and put their arms around it.”

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    Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.

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