Diversity and Inclusion in Emergency Medicine

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As our country grows more diverse, tackling health disparities is imperative to improving patient outcomes. After all, human experiences and cultural perspectives intimately shape the interactions our patients have with physicians and the health care system.

Unfortunately, in the U.S., minority groups carry a disparate burden of health mortality and morbidity. For example, African-Americans suffer from early onset and greater severity of hypertension that has led to an 80% higher stroke mortality rate, a 50% higher heart disease mortality rate, and a 320% greater risk of hypertension-related end-stage renal disease when compared to the general population.1,12 Other studies have discovered a significant difference in the likelihood of African-Americans, Hispanics, and Asians receiving coronary artery bypass graft or angioplasty for acute coronary syndromes when compared to Caucasians — even after controlling for primary diagnosis, age, gender, income, insurance, and co-morbidities.2,12

Half of uninsured Americans — many of whom will present to the ED — are from minority groups and are therefore more likely to have no usual source of care.3,12 It is imperative that we recognize how important diversity and inclusion is to our specialty.

What Are the Benefits of Diversity and Inclusion?

Diversity and inclusion can improve learning and work environments, expand access to care, allow for heightened recognition of health inequities, and spur creative solutions to complex issues.

Increasing diversity within medicine could potentially increase access to care, as underrepresented minority physicians are more likely to serve in underserved areas.4,5,12 Furthermore, studies have shown patients like physicians similar to themselves, and that when patients have demographic concordance, they are more satisfied, have more trust in the physician, and greater compliance to treatment.6,12 This was found to be true not only as it pertains to race and ethnicity, but also rural/urban backgrounds and language, and likely translates to other areas of common ground.

Diversity and inclusion boost cultural competence and enhance learning and work environments. People who practice with others from different backgrounds feel more comfortable asking questions and learning about differences.7,8,12 In Blind Spot: Hidden Biases of Good People, psychologists Mahzarin R. Banaji and Anthony G. Greenwald explain how our brains work differently when we feel connection with someone.9,12

EM: Where Do We Come In?

Even within our own specialty, ethnic, racial, and gender diversity is lacking.10 Women represent 25% of emergency physicians and roughly 37% of EM residents and fellows;11 9% of emergency physicians and 14% of residents self-identify as underrepresented minority (URM).10

Diversity will only augment our breadth of knowledge as a group. We can utilize our colleagues’ experiences when treating patients from different backgrounds.12 Since a team-based approach is essential to emergency care, and as we interact daily with a variety of specialists and allied healthcare professionals, cultural competence can only strengthen our care.

On the Front Line

Emergency medicine has stood up among other specialties to champion diversity and inclusion within the house of medicine. Inclusion has been defined as “the active, intentional, and ongoing engagement with diversity; to extract the benefits of diversity.”12 EMRA and ACEP are promulgating inclusion initiatives.

In April 2016, ACEP hosted the first Diversity and Inclusion Summit to promote and facilitate diversity and inclusion and cultural sensitivity. Led by ACEP President-Elect Rebecca Parker, MD, FACEP, emergency physicians from around the country gathered in Dallas, Texas, for a day of facilitated sessions, brainstorming, and sharing of personal experiences. As a trainee, it was heartening to see that so many have done so much to promote diversity both within their institutions and within the specialty as a whole, but the summit also highlighted that much work is yet to be done. For every opportunity and reason to improve diversity in EM, barriers (both real and perceived) were also discussed, and together we considered ways to move past them. Moving forward, ACEP has created a Diversity and Inclusion Expert Panel to serve as subject matter experts, as well as a Diversity and Inclusion Task Force to work on strategies and tactics.

What We Can Do

I challenge all of you to consider how you personally can advocate for diversity and inclusion. Start by taking the Implicit Associations Test to gain insight into your own biases, visit https://implicit.harvard.edu/implicit. Get to know a colleague with a different background. Encourage your program to make diversity a priority. Get involved in EMRA and ACEP initiatives addressing diversity. It is time to move beyond diversity awareness to a conscientious integration of inclusion practices into emergency medicine. No action is too small.

References

  1. Wali RK, Weir MR. Hypertensive cardiovascular disease in African Americans. Curr Hypertens Rep. 1999;1(6):521–8.
  2. Carlisle DM, Leake BD, Shapiro MF. Racial and ethnic differences in the use of invasive cardiac procedures among cardiac patients in Los Angeles County, 1986 through 1988. Am J Public Health. 1995;85(3):352–6.
  3. Lillie-Blanton M, Rushing OE, Ruis S (The Henry J. Kaiser Family Foundation). Key facts: race, ethnicity and medical care. Menlo Park, CA: The Henry J. Kaiser Family Foundation; 2003 Report No.: 6069
  4. Association of American Medical Colleges. Analyzing physician workforce racial and ethnic composition associations: geographic distribution (Part II). Analysis in Brief. 2014 Aug;14(9).
  5. Komaromy M, Grumbach K, Drake M, Vranizan K, Lurie N, Keane D, et al. The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med. 1996;334(20):1305–10.
  6. Street RL, O’Malley KJ, Cooper LA, Haidet P. Understanding concordance in patient physician relationships: personal and ethnic dimensions of shared identity. Ann Fam Med. 2008;6:198–2005.
  7. Milem JF, Chang MJ, Antonio AL. Making diversity work on campus: a research-based perspective. Association of American Colleges and Universities. 2005 [cited 2015 Jan 19]. Available from: https://siher.stanford.edu/AntonioMilemChang_makingdiversitywork.pdf.
  8. Saha S, Guiton G, Wimmers PF, Wilkerson L. Student body racial and ethnic composition and diversity-related outcomes in US medical schools. JAMA. 2008;300(10):1135–45.
  9. Banaji MR. Blindspot: hidden biases of good people. New York, NY: Delacorte Press; 2013.
  10. Landry AM, Stevens J, Kelly SP, Sanchez LD, Fischer J. Under-represented minorities in emergency medicine. Journal of Emergency Medicine. 2013 Jul;45(1):100-04.
  11. http://www.acepnow.com/article/emergency-medicine-workforce-needs-women-physicians
  12. Martin, M.L., Heron, S., Moreno Walton, L., Jones, A.W. (Eds.). Diversity and Inclusion in Quality Patient Care. Springer International, 2016.
Tiffany Jackson, MD

Tiffany Jackson, MD

EMRA Vice-Speaker of the Council, Emergency Medicine Resident, University of Alabama at Birmingham, Birmingham, AL
Tiffany Jackson, MD

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Vidya Eswaran, MD

Vidya Eswaran, MD

Emergency Medicine Resident, Northwestern University, Feinberg School of Medicine, Chicago, IL; @vidyaeswaran
Vidya Eswaran, MD

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