From an aerial view, the field of emergency medicine appears quiescent, but up close, the specialty is slowly shifting for the better. These methodical movements come on the heels of a specialty-wide heightened awareness of issues pertaining to race, equity, and justice. Once considered taboo in common working spaces, the discussion is making inroads in normalizing a culture of antiracism.
We must recognize, however, that this inflection point is relative; it is the nadir, not the crest. In fact, our collective vantage point is challenged by the inability to see our own blind spots. Colloquially, blindspotting is when an object, a scenario, or a series of events are viewed from one perspective without considering alternative vantage points. At the root, it's a problem in interpretation. To account for blindspots, a diversity of viewpoints is needed. But to address them requires better training on recognition and a complete audit of our process of interpretation.
We in emergency medicine rely heavily on extensive training to improve the breadth and depth of practice. Emergency physicians in the 1990s recognized the value of point-of-care diagnostic tools, and ultrasound is now a fixture within emergency medical education and a distinguished ACGME fellowship. Similarly, clinicians developed simulation in response to the need for greater exposure to complex emergency cases and uncommon clinical scenarios. Fast-forward, Sim-based learning is inextricably linked to our specialty.
Continuing medical education credit is granted to clinicians who attend national conferences and training seminars on every nuanced facet of our specialty; it is how we gauge commitment to adult learning. Yet there is no structured training around antiracism, equity, and social justice. These are our greatest blind spots.
Within those pockets, there are glimmers of hope, particularly in the form of implicit bias training. This usually consists of modules that explore common scenarios where ethnic, gender, identity, and ability-related biases emerge. The Implicit Association Test, a response-latency tool that reveals hidden biases, has grown in popularity, and serves as an adjunct to implicit bias training. (Project Implicit. Harvard University. https://bit.ly/3c2Uszt.) Many health care entities require this form of training, but there are effectors of racism that do not fit perfectly into the silo of implicit bias. Perhaps these areas have an equally significant or greater influence on our specialty and the way we practice emergency medicine.
A Critical Understanding
The term microaggressions was coined more than 50 years ago and has become increasingly relevant in modern society. Microaggressions are “indirect expressions of prejudice that contribute to the maintenance of existing power structures.” (JAMA Surg. 2019;154:868.) Plainly, these are the nuanced assaults, insults, and invalidations that occur on a daily basis and target marginalized groups, women and ethnic minorities in particular. (JAMA Surg. 2019;154:868.)
Racial microaggressions in medicine fly beneath the radar. Common reported examples include Black physicians being mistaken for non-physicians by patients, or consultants addressing lower-ranking non-Black clinicians before Black clinicians of equal or higher rank in the same workspace. These slights and snubs calcify institutional racism, and they have a dose-response traumatic effect on the target. As one study alluded, intent and impact must be teased apart. (PM R. 2019;11:1004; https://bit.ly/3izR15A.) Therein lies an opportunity for increased optics and focused training.
Loosely defined, privilege is an unearned societal advantage; this can be due to age, gender, geography, or socioeconomic status. But when we look across racial/ethnic lines, a different story unfolds. (The Washington Post. Jan. 26, 2016; https://wapo.st/35CYBJh.) Peggy Macintosh, PhD, first wrote about white privilege in 1988, describing the multitude of assets afforded by navigating the world in white skin. (https://bit.ly/3kjgO2p.) Given that the overwhelming majority of physicians are white, this grade of privilege proliferates in medicine. It's the ability, for example, to walk into a patient room and reflexively be identified as the doctor. It's the luxury to drive home from a late-night shift without fear of being stopped (or killed) by the police. But it is also the subconscious understanding that every building entered infinitely reflects the medical achievements of white dominant culture like two mirrors facing each other.
As one article noted, “to understand the negative implications of white privilege requires a broader understanding of its effect on those who do not possess it.” (Ann Fam Med. 2018;16:197; https://bit.ly/33qRMI0.) Knowing this, we have a formidable substrate for training that deconstructs privilege.
Like implicit bias, microaggressions and privilege are constant reminders of power and hierarchy within the medical system. They also exponentiate the effects of systemic racism. Naturally, the next major step toward antiracism within emergency medicine involves comprehensive training on these overlooked areas.
As emergency physicians, we place special value on perspective. We listen intently to EMTs as they share bystander reports, and then engage families to corroborate and clarify details of an event. We elevate the concerns of our nursing staff when they share additional information about our patients with us. We fraternize with experts of other specialties to glean insight on their scope of practice. The bottom line: See as many angles as possible and allow them to inform clinical judgment.
Under this premise, emergency physicians are uniquely tooled to weave overlooked knowledge into practice. In ignoring the need for extended training on the nuanced areas of racism, we are actively blindspotting, leaving the integrity of our specialty open to interpretation.
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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 past articles athttps://bit.ly/DiversityMatters-EMN.