DEI in EM from a Mission to Results: A Student Perspective

Josué M. Rodríguez, MS-III, Emory University School of Medicine
EMRA MSC Southeast Regional Coordinator 2023-2024

Kristina Pagano, MS-II, FIU Herbert Wertheim College of Medicine
EMRA MSC Southeast Regional Representative II 2023-2024

Samantha J. Jacobson, OMS-II, Edward Via College of Osteopathic Medicine-Louisiana
EMRA MSC Southcentral Regional Representative 2023-2024

Allie Kukla, OMS-III, Edward Via College of Osteopathic Medicine-Carolinas
EMRA MSC Southeast Regional Representative I 2023-2024

Diversity, Equity, and Inclusion (DEI) are foundational values for most emergency medicine institutions. However, most educators and learners would agree that much work still needs to be done. What prevents the field of Emergency Medicine from truly welcoming all? Where do students fit into this picture?

What is DEI? The EMRA Diversity and Inclusion Committee defines three main objectives.

1. To promote and support diversity and inclusion for medical students and EM physicians-in-training on the basis of gender, race, ethnicity, sexual identity, sexual orientation, age, socioeconomic status, religion, culture, disability, spirituality, and other characteristics; through education, collaboration, advocacy, and research.
2. To promote increased diversity and inclusion of individuals underrepresented in emergency medicine to better match our patient population through promotion of pipeline, mentorship, and career development programs.
3. To promote equal access to quality healthcare and the elimination of disparities in treatment and outcomes through resident education and research.

These objectives provide three tangible and measurable aims essential to improving DEI. They define a concrete categorization of the groups subject to historical inequity, a quantifiable outcome, and a proposal for an evidence-based mechanism for change.

Diversity is a fundamental tool for emergency medicine since patient backgrounds can be just as diverse as the pathology. Therefore, having a diverse ED staff that can respond in culturally appropriate and sensitive ways is indispensable. Not only is increasing diversity a powerful tool for addressing health disparities, but it also addresses logistical problems within the ED. For example, having a multilingual workforce can address the perceived increased time and labor of utilizing professional interpretation services¹. Furthermore, interactions with non-English speaking patients in the absence of bilingual physicians result in increased cost, decreased compliance with follow-up, and reduced patient satisfaction². Maximizing the potential of a diverse workforce is crucial in healthcare, particularly in busy emergency departments.

Medical education has taken considerable strides in addressing the lack of minority representation. For example, for the past four years, women have made up the majority of newly enrolled students. However, we still see that women only make up 40% of emergency medicine residents.³ Other groups have made minimal improvements. Black or African American comprised 10% of matriculants in 2022-23, up from 9.5% in 2020-21. Sadly, matriculation in groups like American Indians or Alaska Natives has decreased in the past year⁴. Furthermore, groups such as those with physical disabilities rarely get accounted for and are commonly left out of important conversations.

The road to medical school is often steep. Systemic racism significantly impacts the everyday life of medical students who are underrepresented in medicine (URiM). Unfortunately, it is common for underrepresented medical students to be the subject of microaggressions by patients, peers, and physicians. Lack of diversity within faculty also dramatically impacts students' success. Many URiM students go weeks or months without seeing faculty that share their background. Mentorship remains scarce, and URiM students and faculty carry the increased burden of tokenism.

Diversity, equity, and inclusion are topics of interest for the upcoming generation of physicians—the plethora of student-led initiatives around the nation, such as pipeline mentoring programs⁵, evidence this. Furthermore, students today seek to attend programs that have tangible commitments to DEI, become key pillars in healthcare advocacy, and make significant contributions to the body of evidence surrounding social determinants of health. Medical education at all levels is reaping the benefits of recent increased attention to DEI. However, what does the future look like? How can programs continue the progress?

The answer to historical inequalities lies in the upcoming generations of providers; therefore, medical students should be part of the answer. As active, passionate, and enthusiastic leaders, young learners must play a central role in all efforts to improve and advance diversity. From medical schools to residency programs, initiatives aimed at ameliorating systemic inequalities must tap into the wealth of knowledge and experiences medical students provide.

Successful involvement of young learners in pivotal conversations requires intentionality and commitment. The mere presence of students in strategic planning committees does not equate to active and sincere student engagement. The goal of student representation should be to harness their tremendous potential, and students require a safe space free of hierarchical power dynamics to do so. In other words, organizations must guarantee and safeguard an honest and unprejudiced environment to maximize learners' proficiency in DEI. Attempts to include students without prioritizing open and safe communication are futile.

To truly address healthcare inequalities, we must take a multi-sectoral approach. Undoubtedly, medical institutions carry the onus of addressing systemic racism and inequities. Yet, young learners can continue to contribute positively in multiple ways. This does not equate with making URiM students responsible for addressing historical problems. Such an approach reinforces negative and detrimental experiences for minorities. Nonetheless, many students are intrinsically motivated to tackle these issues.

What are ways you can become involved in enhancing DEI at your medical school?

Ways to address DEI as medical students are expansive; avenues for change range from acting within your program to advocacy work at the national level.

Locally, URiM students can strive to participate in the admissions processes within their school, thereby alleviating implicit biases that admission committees may hold. Even those who do not identify as URiM can significantly contribute by staying informed on the impact of racism and discrimination on admission decisions⁶. Increasing representation in medical schools can consequently improve both the diversity in emergency medicine and the equity of patient care. Furthermore, learners can continue advocating for DEI in their curriculums. Knowledge and practices learned throughout training will translate into care and treatment provided by all future physicians.

Research shows that DEI workshops during orientation, as well as longitudinal threads, are highly effective at introducing concepts and frameworks⁷. When addressing DEI within your program's curriculum, it is crucial to receive feedback from colleagues to understand pitfalls and areas for improvement.

For students interested in emergency medicine, emergency medicine interest groups can enhance DEI by involving emergency physicians of diverse backgrounds, hosting panels that allow these physicians to discuss their experiences, and developing mentoring programs. EMIGs can directly impact the number of URiM applicants in EM through their efforts to increase awareness of biases and improve the support readily available to URiM students.

Other means to enhance DEI are through action on social media and by participating in advocacy work at a regional and national level. Examples of advocacy can range from activity on Twitter to participating in the American Medical Association's resolution writing. The Medical Student Section Open Forum is a powerful and effective means for students' resolution ideas to be identified and acknowledged. Furthermore, the Emergency Medicine Residents' Association (EMRA) provides tangible support by taking action on various policies of interest within the EMRA community.

The field of emergency medicine today inherently demands a diverse workforce that can harness the potential of all to provide the best care for whoever walks through the door. To do so, we must employ a holistic approach to diversity, equity, and inclusion centered around junior learners, their experiences, knowledge, and passions.

References:

¹Ramirez D, Engel KG, Tang TS. Language interpreter utilization in the emergency department setting: a clinical review. J Health Care Poor Underserved. 2008 May;19(2):352-62. doi: 10.1353/hpu.0.0019. PMID: 18469408.

²Hampers LC, McNulty JE. Professional Interpreters and Bilingual Physicians in a Pediatric Emergency Department: Effect on Resource Utilization. Arch Pediatr Adolesc Med. 2002;156(11):1108–1113. doi:10.1001/archpedi.156.11.1108

³Number of active residents, by type of medical school, GME specialty, and gender. AAMC. (n.d.). Retrieved March 8, 2023, from https://www.aamc.org/data-reports/students-residents/interactive-data/report-residents/2022/table-b3-number-active-residents-type-medical-school-gme-specialty-and-gender

⁴ Diversity increases at medical schools in 2022. AAMC. (2022, December 13). Retrieved March 8, 2023, from https://www.aamc.org/news-insights/press-releases/diversity-increases-medical-schools-2022

⁵Clayborne EP, Martin DR, Goett RR, Chandrasekaran EB, McGreevy J. Diversity pipelines: The rationale to recruit and support minority physicians. J Am Coll Emerg Physicians Open. 2021 Jan 2;2(1):e12343. doi: 10.1002/emp2.12343. PMID: 33532751; PMCID: PMC7823093.

⁶ Davis DLF, Tran-Taylor D, Imbert E, Wong JO, Chou CL. Start the Way You Want to Finish: An Intensive Diversity, Equity, Inclusion Orientation Curriculum in Undergraduate Medical Education. J Med Educ Curric Dev. 2021 Mar 17;8:23821205211000352. doi: 10.1177/23821205211000352. PMID: 33796793; PMCID: PMC7975489.

⁷Boatright D, London M, Soriano AJ, et al. Strategies and Best Practices to Improve Diversity, Equity, and Inclusion Among US Graduate Medical Education Programs. JAMA Netw Open. 2023;6(2):e2255110. doi:10.1001/jamanetworkopen.2022.55110