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Diversity Matters

Diversity Matters

Racism: The Elephant in the ED

Brown, Italo M. MD, MPH

doi: 10.1097/01.EEM.0000695544.26503.64

    Difficult conversations are an occupational hazard in emergency medicine. We accept that they are part and parcel of the specialty and invite the discomfort, for better or for worse.

    When radiology calls characterizing a new lesion, we assume the responsibility of sharing those findings with our patients and factor in the gravity of the discussion. We show our compassion by standing with families who practice different religions from ours as they pray over a declining loved one. We deliver the heart-wrenching news of fetal demise to an expectant mother with complete cognizance of the emotions we may trigger. And we explain to the weary son or daughter that their ill parent unfortunately did not survive despite our best efforts, and we remain in their presence for the fallout.

    We anticipate these circumstances and conjure our prior training to navigate them confidently. Our tone, posture, and gestures—the entire gamut of verbal and nonverbal cues—are rehearsed down to a science. We make a preemptive decision as emergency physicians to lean into discomfort even when it is to our own detriment. When it comes to racism, racial inequality, social injustice, and the various ways that each affects our specialty, however, we yield.

    This has historically been perceived as a volatile dialogue, and it is often driven to the outskirts of emergency medicine to remain unaddressed. But for whose comfort, or more importantly, for whose benefit? This dialogue aligns with evidence-based practice. We know the downstream effects of explicit and implicit biases. We are familiar with the multitude of studies that demonstrates worse health outcomes for Black men and women in comparison with their white counterparts. (The New York Times. Jan. 13, 2020;

    We understand the literature on the mismanagement of pain symptoms (Pain Med. 2012;13[2]:150;, mistriaging of Black patients (Medicine. 2016;95[14]:e3191;, and preferential prehospital services. (JAMA Netw Open. 2019;2[9]:e1910816; The evidence of racial health disparities continues to mount as COVID-19 decimates communities of color across the United States. From a societal vantage point, and more finely within the practice of emergency medicine, the discussion of race, racism, and inequality has become unavoidable. Yet we continue to deprioritize it. These topics are difficult to broach for a few reasons.

    Emergency medicine is not as racially diverse as we think. Black men and women comprise about 13 percent of the U.S. population and are among the highest utilizers of emergency department services (of note, this is due to the greater likelihood of underinsurance or lack of primary care). (Int J Health Serv. 2018;48[2]:267.) Black people comprise roughly five percent of all U.S. physicians, however. (AAMC. Fig. 18. July 1, 2019; The nature of our work supports the illusion that our field is diverse (i.e., service to marginalized communities, interaction across all ethnicities and socioeconomic statuses). Yet the disparity among providers indicates otherwise. Without adequate representation, conversations about racism are chronically placed on the back burner.

    This challenges the culture of medicine at a foundational level. We struggle as physicians to acknowledge that racism is woven into the fabric of medical education. Our understanding of BMI, for instance, is based on the body types of white men. The beliefs that Black patients possess thicker skin and have higher thresholds for pain are a direct result of the eugenics movement of the 1920s, but medical students and residents expressed similar false beliefs as recently as 2016. (PNAS. 2016;113[16]:4296; The principle of nonmaleficence in medical ethics was formed to combat inhumane research practices; historically, Black people are overrepresented among subjects. (The New York Times. Jan. 13, 2020; These along with other prejudices subconsciously shape the lens through which we view our patients and our peers. Moreover, we would be forced to admit that our training is inherently biased.

    Cognizance will warrant action. Emergency physicians identify life-threatening causes of illness and infirmity. If racism is identified as a root cause of mortality for Black men and women, there will also be an obligation to address it. Emergency physicians are wired to think downstream and to advance care. In that vein, our awareness of racism is a one-way valve; we wouldn't just be encouraged to act, but rather, it would be a call to action. Our pragmatism would extend this action beyond an academic or thought exercise. In fact, it would drive us to change behaviors at all levels.

    We are risk-averse when it comes to difficult conversations on racism, racial inequality, and social injustice. It is as though we fear disturbing the comfortable equilibrium established across the field, but these conversations are essential to the evolution of our specialty. Emergency medicine is unique because we do not get to hand-select our patients. By definition (and by mandate), we accept every creed, color, and character. Those who present to an emergency department are entitled to optimal care by the team that receives them. In eschewing dialogue on the racial prejudices and biases that frame our reality as physicians, however, we have failed to deliver the full dimension of optimal.

    We chose to care for patients at the fringes of society and operate at the intersection of critical social issues. Not only is engaging in this conversation in our best interest, but there is a clear, data-supported value proposition—the vast improvement in health outcomes for Black men and women. We should strive to be thought leaders in this space, from acknowledging our own racial biases and improving the systems that are subject to bias to supporting legislation and policies that seek to lessen the impact of these systemic inequities.

    If we truly wish to advance the specialty, we need to figure out how to tackle racism internally and externally. Yes, it will likely be wrought with discomfort, awkward moments, debate, and an inevitable struggle for common ground. Fortunately, we have our 10,000 hours of practice and preparation to fall back on. If we treat the difficult conversation of racism with the same gravity as the unsettling news we deliver within the ED, then maybe it becomes a priority. Maybe we won't have to act like there's an elephant in the emergency department.

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    Dr. Brownis an emergency physician and an assistant professor in social emergency medicine at Stanford Hospital. He is also the chief impact officer of T.R.A.P. Medicine, a barbershop-based wellness initiative that leverages the cultural capital of barbershops to address the physical and emotional health of Black men and boys. He also served with the ABC News Medical Unit, and has contributed health equity and wellness pieces to The New York Times, USA Today, GQ, and The Root. Follow him on Twitter@gr8vision. Read his articles at

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