I was on a shift in the ED when a white colleague mentioned that she wanted to be more intentional about including Black and Brown skin tones in her lecture slides. “Great!” I thought—until she asked me if she could take pictures of different parts of my body to use in her lecture.
We all make mistakes despite our best intentions on the individual path to anti-oppression. Course work and training sessions on implicit bias and microaggression cannot fully prepare us for daily interactions. The work is done as we navigate with different people and through various situations and experiences. It is important to remain humble and be open to listening deeply when these learning moments happen.
Deep listening creates space to exercise empathy and curiosity to understand the impact of our actions and words better. We each have a responsibility to become aware of the strengths and limitations that shape the lens with which we view the world. Contextualizing the intersectionality of our many identities and past life experiences within our own biases is helpful because we can take conscious actions to mitigate the effects of bias in patient care delivery and interpersonal interactions once we are aware of our biases.
This is a daily practice that does not stop with the completion of an implicit bias assessment or an institutional DEI training module. The real work begins when we start to exercise this awareness in everyday interpersonal interactions. It's important that we practice these skills as much as we practice clinical procedures like intubations and central line placement.
I declined the photo shoot, of course, and let my colleague know that asking to take pictures of my body was inappropriate and was a direct microaggression, and this created space to discuss the impact of this interaction.
Walking the Anti-Oppressive Path
The journey toward becoming anti-oppressive, and specifically antiracist, is constant, nonlinear, and nonbinary. This is different from the linear educational and professional journey of emergency medicine or its subspecialties. After completing the curriculum, passing the exam, and successfully performing required procedures, an emergency physician is considered an expert. There is a binary nature to this path that designates an EP as board certified or non-board certified, a subspecialist or non-subspecialist.
The journey toward becoming anti-oppressive, in stark contrast, is multifaceted with overlapping work occurring on individual, interpersonal, institutional, and structural levels. (Acad Emerg Med. 2022;29:1383; https://bit.ly/3GnByEm.) A common misconception is that there is a set endpoint and that completing a DEI course, reading an antiracist book, or leading an implicit bias training session will check the box of being antiracist and anti-oppressive.
The larger concept is that this work is continuous and requires individual actions, institutional policies, and a shift in internal beliefs and overall workplace culture that consistently strives to create a space where individuals are safe and can thrive as their authentic selves.
Many opportunities are available for ongoing examination and improvements when we look at our practices within our departments. These can include the language used to discuss patients with colleagues or the words that we type into the electronic health record to represent patients. They also include the policies used for promotion and compensation and the methods used for recruitment, retention, and mentorship.
The reality is that the journey is humbling and demanding, but the result yields a positive return for all parties. The real value of this continuous and explorative process is creating a culture and work environment where all members of the community feel safe, heard, and cared for and where colleagues are able to show up authentically while being appropriately valued and supported for their work.
Consider another example: An academic-affiliated ED wanted to analyze the impact of a new attending-only shift. The ED purposefully assigned more junior faculty to this shift to acclimate them to the ED. These shifts became some of the most strenuous as ED volumes increased. The analysis revealed that more faculty of color had been assigned to this shift and they disproportionally carried the clinical burden because the majority of faculty of color were junior faculty.
The departmental and institutional paths toward anti-oppression are rooted in examining policies, compensation plans, and recruitment and retention methods for inequities based on race, ethnicity, gender, sexual orientation, and ability. The department must be committed to taking action by rewriting policies and restructuring compensation and recruitment methods. Polices and plans must change if their impact perpetuates racist or oppressive inequities, regardless of their initial intent.
The onus for recruiting a diverse workforce lies with the department and institution prioritizing efforts that align with this goal. Department leadership must broaden recruitment efforts to include medical associations that cater to highly qualified EPs from groups that have been historically excluded. Some of these include the National Medical Association, the National Hispanic Medical Association, the Association of American Indian Physicians, and Health Professionals Advancing LGBTQ Equality, to name a few.
A holistic review process should be utilized to more accurately appreciate the distance traveled along an applicant's career journey, such as being the first in a family to graduate from college. A department investing in more robust recruitment must have a plan for retention to mitigate the isolation and lack of support that many underrepresented EPs experience. Departments should also continuously assess the impact of policies, pay structures, shift allocation, clinical buy-down, and total compensation. The results of these analyses should be widely available to current and future employees.
The shift assignment of junior faculty I mentioned was subsequently changed to allow for equity across all providers. The shift allocation was not intentionally targeting faculty of color, but it perpetuated racial inequities in shift distribution.
The journey toward becoming anti-oppressive and antiracist requires a complete team approach deeply rooted in the culture of the ED with all hands on deck. The work cannot rely solely on the few EPs from racial and ethnic groups that have been historically excluded in medicine and who hold DEI leadership roles. The principles of anti-oppression should be upheld at every level of an organization, throughout its recruitment, retention, promotion, clinical policies, and overall culture. The health of our communities, the well-being of the physician workforce, and the longevity of medical education depend on this important work to eliminate systems of oppression within all aspects of health care.
Dr. Knightis the director of faculty experience at Zuckerberg San Francisco General Hospital and Trauma Center, the associate chair of diversity and inclusion in the department of emergency medicine, and an emergency medicine diversity, equity, and inclusion endowed professor at the University of California, San Francisco. Follow her on Twitter@StarrKnightMD.