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Diversity Matters

Diversity Matters

John Lewis's Legacy Extends into the ED

Brown, Italo M. MD, MPH

doi: 10.1097/01.EEM.0000719108.78039.e2
    John Lewis, race
    John Lewis, race:
    Rep. John Lewis at a voting rights march in Boston in 2005.

    Once mere buzzwords, the principles of diversity, equity, and inclusion (DEI) have become drivers of institution-wide accountability. Now hospitals, health care organizations, and academic medical centers are being appraised by their commitment to DEI efforts and antiracism.

    Oversight of DEI efforts lands squarely on the shoulders of EM departmental leadership. These strategic plans are a hybrid of data analysis and subcommittee recommendations in most cases. Despite this groundwork, a lingering concern among most physician groups is whether well-meaning plans will convert into action or fall on the cutting-room floor.

    Broad implementation requires a major shift in departmental culture; perhaps this pivot is the greatest obstacle that leaders in emergency medicine will encounter. And given the specialty-wide newly adopted stance of antiracism and the prioritization of DEI, a dynamic struggle seems imminent.

    When it comes to enduring struggles in the name of equality, leaders within our specialty can glean insight from the lived experience of the late Rep. John Lewis. A prominent civil rights activist, Rep. Lewis was best known for his integral roles in the Selma to Montgomery marches (Bloody Sunday) and the historic March on Washington.

    Over the course of his service career, he fought for equality and championed human rights for all ethnicities, and his dedication to the pursuit of equity garnered respect and support from peers regardless of race or affiliation. Rep. Lewis died of complications of pancreatic cancer in July, but his legacy lives on. In fact, we can see corollaries between Rep. Lewis' philosophies and our own, specifically the interpretation of good and necessary trouble.

    Good Trouble

    As emergency physicians, we interpret risk as a form of trouble. Risk is a cardinal feature of our craft, and is embedded within every ED shift. When a patient rapidly declines, for example, we make a blink-of-an-eye decision to gain central access and deliver medications or blood products to help stabilize him. In cases of respiratory distress with a great risk of decompensation, we take control of the airway to optimize ventilatory support.

    Every single procedure in our field, regardless of difficulty, has an associated risk that we must weigh carefully. We rely on our training and gestalt to evaluate the pros and cons of each circumstance quickly. Then we take decisive action to best help the patient. We are, in so many words, groomed to be calculated risk-takers.

    This risk savviness is even more pronounced beyond the bedside. Each of us has encountered a consultant with divergent views on patient management and reached an impasse. Every emergency physician has had to advocate aggressively for a patient to be admitted when the hospitalist or attending on the service thought otherwise. These microaggressions are omnipresent in academic and community medicine. We consider it a victory whenever the care of the patient supersedes these microaggressions. We call it patient advocacy; John Lewis would have called it “good trouble.”

    The same premise can be attributed to social practices within the emergency department. It is good trouble when a provider advocates for his undomiciled patient instead of pushing for a quick discharge. It is also good trouble when a care team engages multiple services to coordinate care for an uninsured patient. Likewise when a resident asks for translation services to gather accurate information from a non-English-speaking patient. It is good trouble when an attending emphasizes that staff members honor a patient's desire to be referred to as he, she, or they. And whenever we call out colleagues for operating with implicit biases known to worsen health outcomes for racial ethnic minorities, that is good trouble.

    Honorable and Necessary

    From John Lewis's lived experience, we learn that seeking good trouble is honorable and a necessary currency in championing equity. EM leaders have informal training in risk assessment, and they habitually push the appropriate margins to better care. Adapting this mindset prevents us from overlooking opportunities to improve the internal blind spots of our departments. But even more importantly, it gives others the courage to practice similarly, lowering the threshold for culture change among EM faculty, colleagues, and staff.

    John Lewis once stated, “Our struggle is not the struggle of a day, a week, a month, or a year. It is the struggle of a lifetime. Never ever be afraid to make some noise and get into good trouble, necessary trouble.”

    His immortal words are poignant and timely, particularly for leaders in emergency medicine, in this discussion of leadership. Reprogramming the current culture of exclusivity, homogeneity, and prejudice (conscious or unconscious) will be a process with many dimensions; by engaging in this completely, it may feel like one is asking for trouble. But this is good trouble. Moreover, this is necessary to improve the culture of emergency medicine and the outcomes of our diverse patient populations. Do not be fearful; be steadfast.

    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 at

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