The United States is entrenched in two pandemics, one driven by a novel viral pathogen and the other by centuries of systemic and structural racism. Ironically, the emergency department serves as a point of convergence in this syndemic. As our specialty embraces its distinction as an essential workforce, expectations are growing for the next wave of emergency medicine specialists to possess skillsets beyond their clinical knowledge.
Incoming emergency physicians will need to be culturally competent, aware of implicit biases, and equipped with a health equity lens and a compass for social justice. We expect emergency medicine to meet the complete medical needs of an ethnically diverse patient population, but as we demand more from our specialty and from medical education as a whole, a deeper concern arises: How do we ensure diversity of trainees in the time of a pandemic?
The primary and secondary effects of novel coronavirus impose considerable stress on the medical education system. (“Residency Match 2021: How COVID-19 Is Forcing Major Adjustments,” AMA. May 27, 2020; https://bit.ly/3fsEejT.) In response, institutions have adopted virtual curricula and remote classrooms, indirectly making traditional bedside learning opportunities a commodity. This poses unique problems for hands-on specialties like emergency medicine.
The pathway into emergency medicine is rather formulaic: bridge strong USMLE Step scores with exemplary performance in core clerkships, add a litany of recommendations from clerkship directors of accredited emergency medicine programs across the country, and court a coveted residency interview. But newly-minted, institutional COVID-19 policies and precautions will displace medical students from emergency medicine clerkship experiences and further complicate the traditional routes of obtaining the highly-regarded standardized letters of evaluation (SLOEs).
Residency interview season will take on a completely new look accented by virtual interview sessions. (JAMA. 2020;324:29; https://bit.ly/32tUmhJ.) These are in the interest of safety for the student body, but these decisions amplify known pain points within academic emergency medicine, particularly the dearth of ethnic minorities practicing within our specialty. Much like COVID-19 exacerbated known ethnic health disparities, there is a strong possibility that it will also widen the gap between candidates described as underrepresented in medicine (UiM) as well as non-UiM candidates.
For context, consider the National Resident Matching Program (NRMP) data. (May 2020; https://bit.ly/2ZpPoR2.) About 4000 candidates applied for PGY-1 emergency medicine slots in 2019 (2488 total positions distributed among roughly 250 emergency medicine residencies across the United States). Seven percent and 9.5 percent in that applicant pool identified as Black and Latinx, respectively. (Association of American Medical Colleges. 2019; https://bit.ly/2ZqgRSw.)
Unfortunately, an ethnic breakdown of the 2019 match data is not available to the public. The best-case scenario—a 100 percent UiM match rate—translates into 170 Black and 232 Latinx (new) PGY-1 emergency medicine residents. Not only is this disproportionate to the number of ethnically-diverse patients who present to U.S. emergency departments, it hints at the systemic barriers that UiM candidates encounter in the pursuit of emergency medicine.
Similar to the social determinants of health, structural determinants of academic success exist that disproportionately affect racially marginalized groups in medical education. UiM students often feel excluded by their peers, the educational and clinical faculty, and the administration. Underrepresented groups are also prone to inequitable access to mentorship, reliable information, and shadowing opportunities. These elements heavily influence a candidate's chances of matriculating into emergency medicine.
One of the major areas of concern is candidate advocacy; that is, the championing of UiM candidates by academic emergency medicine faculty members. UiM medical students are more likely to come from institutions that do not have an established emergency medicine clerkship, and as such, there is a dependence on visiting clerkship opportunities to gain exposure, find mentors, and earn the support of advocates. Due to the coronavirus pandemic, many visiting clerkships in emergency medicine have been canceled. Without an in-house accredited EM clerkship experience, the odds of obtaining a legitimate letter of recommendation are substantially decreased, placing an uneven burden on UiM candidates.
A second major concern is implicit bias. Within the field, the in-person interview serves as a litmus test of the best fit with a particular program. Virtual interviews are equally as subjective, but the literature demonstrates that virtual interviews are highly susceptible to implicit biases. (Medscape. June 23, 2020; https://wb.md/3iYIGZY.) UiM candidates are less likely to receive objective review, making the virtual interview a vehicle for further marginalization.
To put this in plain terms, the current structure is primed to benefit candidates who are at institutions with robust academic emergency medicine programs, well-established mentorship channels, sufficient exposure to the field, and adequate resources for interview support. COVID-19 has once again teased apart the fundamental differences between the haves and the have-nots. Instead of health outcomes, however, a diverse workforce representing the populations that seek emergency care most commonly is at stake.
Academic emergency medicine programs must be sensitive to the amplified burden UiM candidates face this residency application season. Our specialty associations are cognizant of this inequity and have initiated the hunt for solutions. The Coalition on Physician Accountability released a consensus statement in May about the residency application process and provided recommendations to ensure equity among 2020-2021 emergency medicine candidates. (AAEM/RSA, ACEP, ACOEP/RSO, CDEM, CORD, EMRA, SAEM/RAMS. https://bit.ly/2YtMrx9.)
The American Medical Association released a statement in early July with explicit recommendations to protect UiM students and residents during COVID-19. (July 6, 2020; https://bit.ly/38VIRk4.) These statements offer clarity, but it is difficult to tell if the needle has moved forward in eliminating the structural determinants of success that disproportionately affect UiM students pursuing careers in academic emergency medicine. The perfect solution may be an unrealistic expectation at this time, but a bridge over troubled water is a well-warranted request.
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 past articles athttps://bit.ly/DiversityMatters-EMN.