We've often noticed our patients' looks of curiosity shift to puzzlement and then to muted excitement when we introduce ourselves as their doctors. As Yale emergency medicine residents from under-represented minority (URM) groups, this happens all too often when caring for people of color or anyone, for that matter. Patients of color sometimes tell us how happy they are to see someone like themselves and how medicine needs to be more diverse. Perhaps we represent something different to each patient, but most see us as a rare source of inspiration within the realm of academics and medicine.
Many are curious to know our path to medicine, and ask for words of wisdom to pass onto their family members. To some, we become their confidante and liaison between their own world and medicine, and we get a sense that these patients are more trusting that we will do what is in their best interest simply because there is an unspoken understanding cultivated in the shared similarity of our cultural background or just a mutual respect and appreciation of shared diversity in this ever more homogenous world.
An innate understanding exists among groups of people of the same racial or ethnic background that often cannot be verbally explained. Physicians of color offer a different approach to research, treatment, cultural competency, beliefs, and experiences different from their colleagues from “in-medicine majority” cultures. As Marcus Martin, MD, put it, “Quality health care depends not only on scientific competence but also on the cultural competence of physicians as well.” (Acad Emerg Med 2000;7:1027.)
It has been more than a decade since The Sullivan Commission's report highlighted important steps toward improving access to health care for underserved populations by increasing diversity among medical students, residents, and faculty. (Missing Persons: Minorities in the Health Professions: The Sullivan Commission, 2004; http://bit.ly/1NqFmVR.) Still much work remains to be done in all three arenas in light of the ever-changing racial and ethnic background of our patient population, especially in emergency medicine.
Recent emphasis on cultural competency has grown in medical school curricula, which is not surprising because, more than ever, educators understand the importance and benefits of cultural diversity in treating patients. Cultural competency often can be more powerful than any prescribed therapy for a known manageable condition like diabetes mellitus or hypertension. We recently saw an elderly man of African descent in the ED who was brought in by his son for fatigue. He was found to have elevated blood pressure with worsening kidney function. He had been seen and prescribed treatment for his longstanding hypertension, but the patient refused to take medications prescribed by his Caucasian physician. Fortunately, the emergency physician in this encounter spoke the same language, and was able to explain the disease process, prompting the patient to embrace the advice given to him by a fellow countrywoman, or “Adanna,” meaning daughter of the father. Despite having just met, they had a connection and trust as if they had known each other for years. How often do we hear stories of providers encountering compliance issues with their patients? How often is it actually a patient's willful noncompliance but rather a patient's mistrust of the caregiver's intentions or culturally incompetent delivery of medical information? We posit that the latter happens more often than we realize or care to acknowledge.
Arthur Brooks, the well-known American social scientist, musician, and president of the American Enterprise Institute, a conservative think tank, got it right when he wrote in the New York Times that human diversity is one of the great intellectual and moral epiphanies of our times. He contended that being around others who are different from ourselves makes us better people and more productive. (The New York Times. 2015 Oct 30. http://nyti.ms/1kiox1l.)
There is consensus that expanding the pool of URMs in health care is a great idea and the right thing to do for many reasons. Diversity reflects positively on our industry, our colleagues, and our nation, and is the moral banner that we hoist around the world as a tolerant, God-fearing nation that loves and welcome everyone into our melting pot of America. It is what has made us great and continues to do so.
But we believe an even more compelling reason to make this a national priority has been highlighted by ACGME and the American College of Emergency Physicians. We owe the racially and ethnically diverse patient populations that we serve on a daily basis in EDs across this country an equally diverse physician pool to deliver and enable the best health outcomes possible. (J Emerg Med 2013;45:100.)
Increasing URMs in the workforce directly improves health care for medically underserved populations, benefiting the entire population at large. (N Engl J Med 1996;334:1305.) This stems from the finding that URMs are more likely to seek, accept, and stay rooted in working environments that have diverse patient populations. Given a choice, patients who are racial or ethnic minorities are more likely to select a provider with a similar racial or ethnic background to their own.
It has a positive and therapeutic effect on the health of patients who have access to racially and ethnically diverse physicians in an ED; it offers hope and progress in a place where people often face the most desperate situations of their lives. We are in the business of healing the whole body, mind, and soul; why not provide such a welcoming and inspiring atmosphere, which adds no cost to the patient or the institution?
How do we increase racial and ethnic diversity in emergency departments and in medicine in general? We acknowledge that a resident's time can be spread thin among numerous tasks, but we recommend the following steps to leverage existing networks and activities already in place in academic settings. Emergency medicine residency programs can take some of the following steps:
- Align EM residency programs with the minority interest groups at its affiliated or local medical school. Groups that support URMS in medicine include the Student National Medical Association, the Latino Medical Student Association, and the Association of Native American Medical Students.
- Recruit at local and national conferences hosted by these minority interest groups, an efficient way to advertise any residency program because of the large target population being captured in a short period of time.
- Participate in pipeline programs that expose URMs to medicine, encouraging greater numbers to pursue medical careers. One of these programs is the Summer Medical and Dental Education Program, a six-week program offered at 12 institutions across the country where undergraduates learn about the basic elements of medicine and dentistry. Emergency medicine residents can give lectures, participate in workshops, and serve as mentors.
- Foster shadowing opportunities for students of color to rotate through the emergency department to give them exposure to medicine and potentially jumpstart an early interest in pursuing a career in emergency medicine.
- During interview season, advertise the EM residency program's respective institution's stance on diversity. This should mention organizations outside the emergency department that focus on minority topics in medicine. This value-added support may be just what some applicants are looking for. Display information on diversity on the residency program website and in the information packets given to applicants on their interview day.
- The Yale EM residency has established a fully funded diversity committee that aims to attract qualified URM applicants by funding a Second-Look Program for carefully selected applicants. We have created a cost analysis matrix to measure our efforts and chart our progress in recruiting.
- Last but not least, we are all in this together. Encouraging residency programs from other specialties to increase their minority recruitment can help build the culture of diversity within an institution.
Just as reproductive diversity is vital to our existence as humans, racial and ethnic diversity among physicians is important to the health of our emergency departments and patients. Racial and ethnic diversity in emergency medicine, often the gateway to other encounters with medicine, is as healthy as any tonic we could prescribe to our patients. Fully embraced, this diversity will lead to the more idealistic world we have long envisioned for ourselves, our children, and our planet. Any efforts in this direction can best be echoed by the famous Neil Armstrong quote: “One small step for medicine, one giant leap for mankind.”
Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, D.C.: National Academies, 2003.
The authors would like to thank Gail D'Onofrio, MD, a professor of emergency medicine and the chair of the department of emergency medicine at Yale.
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