15 minute read
Diversity and Inclusion Belonging: The Missing Piece for Our Learners
Belonging: The Missing Piece for Our Learners
By Joel Moll, MD; Michelle Lall, MD, MHS and Sheryl L. Heron, MD, MPH for SAEM's Academy for Diversity & Inclusion in Emergency Medicine
The United States continues to become more diverse in areas of race, ethnicity, sexual orientation, and gender identity; however, within emergency medicine, this diversity is not always reflected. Data shows that the demographics of current and future emergency physicians continues to lag behind that of the patients we serve (Table 1). Public data does not readily exist for representation in emergency medicine of lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) colleagues, either in our current work force or those in training. Some older studies suggest that in general, LGBTQ+ individuals may be less likely to choose professional careers such as medicine and within medicine may be more likely to choose primary care due to concerns with acceptance. With the focus on gender and racial inequities in the past year many programs have intensified efforts to recruit a more diverse residency class.
Focusing on demographic numbers is one way to measure progress and success, but it is not enough. As your residents who matched in emergency medicine (EM) and your EM bound students arrive to your departments this summer, the question is, do they feel like they belong? Underrepresented individuals often suffer from imposter syndrome, an internalized sense of not belonging or deserving their success or achievement, which can be devastating to growth and development. Some, such as those in the LGBTQ+ community, may also feel like they must conceal who they fundamentally are in order to have a successful career in medicine or in residency. Much energy and effort may be siphoned away during this formative time to simply deny or hide who they fundamentally are, leading to isolation. However, a recent article in Harvard Business Review questioned this phenomenon of imposter syndrome notably as it pertains to women and women of color aptly stating that imposter syndrome puts the blame on individuals, without accounting for the historical and cultural contexts that are foundational to how it manifests in both women of color and white women. The impact of systemic racism, classism, xenophobia, and other biases was not a part of the scientific literature when the concept of imposter syndrome was developed. The authors posit that rather than aiming our attention at fixing women at work, we should focus on fixing the places where women work. This is certainly applicable to all minoritized and disadvantaged groups. Programs can and should be deliberate and dedicated to creating a sense of belonging, not just opportunity, in EM training. Medicine is a social profession, and a sense of belonging is critical to feeling safe and developing emotional connections and well-being during a challenging time in training. Without belonging, isolation and imposter feelings can easily interfere with training, performance, emotion, and even physical health. Fundamentally, our residents and students need to be well to learn. Equally, our faculty and staff from marginalized groups must also feel a sense of belonging to effectively teach. Individual identities are complex, multifaceted, and unique. Assumptions by societal majorities should not be made regarding any aspect of an individual’s identity or needs. There are many new and current resources focused on creating a sense of belonging in the learning and work environments. Below are some recurring suggestions that will hopefully help create a sense of belonging for everyone in your department.
State and reinforce diversity, equity, and inclusion as a value.
Commitment to this concept should be broad and visible. Your mission statement and specific aims should reflect the environment you have or which you have a desire to create. The statement should be provided not only to the Accreditation Council for Graduate Medical Education (ACGME) and your graduate medical education office, but to every person in your department. You should remind your learners, faculty, and staff of this statement when you recruit, onboard, and develop your residents throughout their training. Actions should mirror words to create an environment of safety and belonging.
Table 1: Demographics of EM residents, faculty, and US population
Demographic EM Residents2 Active EM Physicians2 U.S. Population3
Female 34.9% 28% 50.8% Black 3.9% 4.5% 13.4% Latino 4.9% 5.3% 18.5% LGBTQ+ Unknown Unknown Estimated 5.6% (C ) continued on Page 16
Your actions should demonstrate your inclusion.
Before an applicant or incoming resident considers your program, review and, if needed, revise your departmental policies and procedures to ensure they are inclusive. In addition, you must be knowledgeable of your institutional policies as they relate to discrimination and harassment. An institutional nondiscrimination policy that excludes certain groups does not show inclusion nor welcome the learner. Lack of supportive benefits, such as same-sex domestic partner benefits, may lead to a learner feeling excluded, devalued, and disconnected. Studies have shown that approximately one-third of program directors in EM are not aware of if their institutional policies protect LGBTQ+ individuals from discrimination.
Words matter. Majority and heteronormative assumptions are ubiquitous: asking a man about his wife, or a woman about her husband occurs daily. The process of visibly identifying one’s sexual orientation (coming out) is a very emotional and potentially negative and isolating experience depending on the individual’s circumstance. By making assumptions and not using inclusive language, the learner may feel pressured to have to “come out” by repeatedly correcting you or choosing not to correct the assumption and hiding a fundamental part of who they are. One study shows that half of LGBTQ+ individuals in the workplace “come out” on a weekly basis due to such assumptions. Use neutral terms such as “partner” or “spouse” instead of assumptions fueled by implicit bias. Certain words and phrases may be unintentionally hurtful. Sexual or gender “preference” can indicate that you believe their identity is a choice, despite no credible studies that reflect and support that assumption. Use neutral terms that let learners identify as they choose so everyone feels like they belong. Understand the value of using the correct pronouns to address your residents who are nonbinary.
Social events may be an indicator of a real or potential chasm in your community. Take note as to whether or not everyone is included in these events, feels comfortable attending, welcome to bring a partner, and participates in common social conversations. Leaving people who are not in the majority out of conversations about their holidays with their significant other can be a subtle but noticeable slight to that person. Leadership can facilitate inclusion and a sense of belonging by pulling these individuals into these types of conversations. Also, be careful not to celebrate only the holidays and/ or observances that are important to you. Be inclusive in your messaging; your learners will appreciate that what is important to them is also important to you.
Confront microaggressions. Due to our implicit biases, microaggressions will happen even under the best of circumstances and with the best of intentions. That does not make them acceptable, but it does give us an opportunity to educate others and correct their behavior. Having scripts as aids for responding to microaggressions is an important investment in those who are the most likely to suffer from them — and it helps leaders respond professionally while at the same time sending the message that this behavior is not accepted nor tolerated. Microaggressions should not be ignored, and both education and intervention should occur by departmental leadership, residency program, and/or institution. The burden for addressing microaggressions, and worse, should not be on the victim but should be on every member of the faculty and every leader in the department and/or institution.
Stop using the word “fit”. Nothing typifies your implicit bias by judging a candidate or individual as a “fit” for your program. For most of us a good “fit” is someone similar to ourselves and who is affected by our own biases, both positive and negative. Programs should seek to be welcoming and create belonging for all. Individual applicants or learners should assess the program’s fit for their educational goals, not the other way around.
Recognize and acknowledge areas for improvement.
No program is unaffected by implicit and explicit bias. While a program may have an exemplary record of creating an environment of belonging for racial and ethnic minorities, it may still have few women and/or members of the LGBTQ+ community. This is an opportunity to learn how to improve your community and assess what overt and subtle factors may be adversely impacting your learners. We should not be offended when areas for improvement arise, rather we should embrace the criticism and
acknowledge the blind spots with intentionality to improve and create a culture and climate reflective of our values. A deep and ongoing reflection on trends and results in areas of diversity, equity, and inclusion is essential as part of an annual program evaluation. Creating a sense of belonging is a journey not a destination.
Visibility matters.
Leaders must be visible and set an example for others to follow. This starts with the program director and clerkship director but should include all department leaders. Visible support and community involvement are great opportunities to demonstrate your values and build belonging.
As previously mentioned, ask your residents before they arrive what are their pronouns. Avoid asking about “preferred” pronouns as this can cause unintentional offense. Provide your residents with badge buddies that identify their pronouns to each other, colleagues, and patients.
Consider placing pronouns on your websites and/or shared rosters. Although most of your residents will likely use binary pronouns, consideration of pronouns creates and demonstrates an inclusive environment. Fairly or not, prospective and current learners will judge your values based on your website and the images displayed on it. Use visibility to your advantage not to your detriment. Avoid tokenism. Some feel that the quickest way to inclusion is a singular focus on an underrepresented faculty or learner. This not only creates an extra burden or minority tax for that person, if not truly developed and valued, it can also undermine their significance and worth. All members of the community should be considered and developed to their potential in a way that is consistent, purposeful, and in line with the value of diversity, equity, and inclusion in the EM program.
Educate your team.
Many education regulatory agencies, including the ACGME and Liaison Committee on Medical Education (LCME), require a focus and educational curriculum on disparities and inequities in health care. Education of your entire department meets many of these requirements and demonstrates the value that educational and department leaders place on addressing inequities in medicine. Inequities and disparities should address all vulnerable groups in emergency medicine whether it be by race, ethnicity, gender, gender identity, sexual orientation, religion, need for accommodation, or many other areas. In many locations, specific groups may require additional attention based on patient demographics to provide culturally appropriate and sensitive care.
Part of education and leadership is learning where your unintentional offenses may have occurred. Apologizing for an unintended microaggression or unintended bias demonstrates your commitment to inclusion of all learners, colleagues, and importantly your patients.
Be an advocate and an ally for your residents and students.
Although it may seem at times that your learners have no difficulty advocating for themselves, this is clearly not true for many, especially with more sensitive topics or situations. Creating an environment of belonging requires that you step up and advocate for them when they cannot or are uncomfortable doing so for themselves. Being inclusive, open, and sharing your own vulnerability helps residents and learners feel supported, valued, and — importantly — like they belong.
Look for opportunities to support organizations and events that celebrate the diversity of humanity and your learners. Participating in organizations that advise underrepresented groups, such as the Student National Medical Association, National Medical Association, Latino Medical Association, Latino Medical Student Association, National Hispanic Medical Association, American Medical Women’s Association, or LGBTQ+ and other medical organizations sends a powerful message and helps you achieve your vision and goal of true belonging.
ABOUT THE AUTHORS
Dr. Moll is an associate professor and residency program director in the department of emergency medicine, Virginia Commonwealth University School of Medicine and program director of the medical education fellowship.
Dr. Lall is an associate professor in the department of emergency medicine at Emory University School of Medicine and Emory’s inaugural director of wellness, equity, diversity, and inclusion. She is a member of the SAEM Board of Directors.
Dr. Heron is professor and vice-chair of faculty equity, engagement and empowerment, department of emergency medicine, Emory University School of Medicine; associate dean for community engagement, equity and inclusion; and the associate director for education and training, Injury Prevention Research Center at Emory (IPRCE).
A Clarion Call for a Race-Aware Approach to Medical Education
By Monica Saxena, MD, JD and Mariame Fofana, MD on behalf of SAEM’s Academy for Diversity & Inclusion in Emergency Medicine
Last December, as she lay in bed connected to an oxygen tank, Dr. Susan Moore, a Black medical doctor infected with COVID-19, called out the racism she experienced as a COVID-19 patient.
In a Facebook video that went viral, Dr. Moore detailed her repeated difficulties to have her doctors acknowledge and treat her pain and shortness of breath despite cat scans showing the worsening progression of her disease. She begged her doctor to complete the course of the antiviral treatment that had been started, and her doctor refused.
“He said, ‘ah, you don’t need it.
You aren’t even short of breath.’
I said, ‘Yes, I am.’ And then he went on to say, ‘you don’t qualify.’ “I must have (qualified), because I got two treatments. Then he further stated, ‘you should just go home right now.’” Dr. Moore did go home, and less than 12 hours later, she was readmitted to the hospital. She later died of complications from the COVID-19 virus. Dr. Moore’s death gained national attention, with racial justice advocates calling for change. As emergency medicine physicians and women of color, we agree that Dr. Moore’s death was a tragedy, as are the deaths of the more than half a million Americans — a disproportionate number of whom are Black and Latinx. This latter fact gives us pause and asks us to reflect on the more significant lessons of Dr. Moore’s death for our profession. Ultimately, we see Dr. Moore’s death as a clarion call to reform medical education and incorporate antiracism into the training of doctors. The incorporation of education on racial disparities in medical school remains uneven. As recently as 2019, the national governing organization of medical schools, the American Association of Medical Colleges, noted “there is a lack of standardized, fully integrated racial disparity education in medical school curricula. This gap fails to train our young doctors to best treat their patients fully; thus, we propose a three-pronged approach to incorporating racial inequity/bias into medical training. First, teach doctors about the social determinants of health responsible for
both COVID-19 deaths and the racial disparities in the presentation of the disease. Collectively, Black Americans have a higher rate of hypertension, diabetes, and cardiovascular disease than non-hispanic whites. These conditions are directly linked to the worse outcomes, including death, of COVID-19 among Black Americans. These racial disparities are linked to social determinants of health, including access to primary care doctors, health literacy, and nutrition, which result from higher rates of poverty in communities of color.
Second, teach medical students that diseases present differently in people of color. For example, there remains a dearth of information on how dermatologic conditions present in people with brown and black skin, leading to a delay of diagnosis that can be deadly, such as skin cancer. This race-aware approach also applies to chronic diseases such as kidney disease, where the current standard in medicine is to overestimate the kidney function of Blacks, though this hasn’t been validated by physiology. As noted in a 2020 study published in the New England Journal of Medicine, the result could be a delay in diagnosis of compromised kidney function, which in turn could lead to advanced progression of disease requiring dialysis.
Finally, recognize that medical education does not exist in a vacuum and that the realities of the world affect how future doctors will treat their future patients. As students enter medical school, they bring with them ingrained societal racism, which can be detrimental to their future patients. Studies have shown that as many as half of surveyed medical students and residents believed that there were biological differences in how Black and white patients experienced pain. These differences suggested that Blacks had a higher pain threshold than whites. These racially biased beliefs play out in practice as doctors unknowingly undertreat or even mistreat their patients. As Dr. Moore noted, “This is how Black people get killed.”
Teaching our physician trainees about race is essential for clinical practice and the future health of our nation. Dr. Moore‘s story, and the racial disparities brought to light by the COVID-19 pandemic, is a flashpoint for the medical profession to start talking about race in medical training. ABOUT THE AUTHORS
Dr. Saxena is a clinical educator and ultrasound fellow at Stanford University Department of Emergency Medicine. She holds an AB from Smith College, a JD from the University of Michigan, and an MD from Wayne State University. @MonicaRSaxena Dr. Fofana is a second-year resident at Stanford University Department of Emergency Medicine. She holds a BS from Seton Hall University and an MD from Meharry Medical College. @DrMariameFo
About ADIEM
The Academy for Diversity & Inclusion in Emergency Medicine (ADIEM) works towards the realization of our common goals of diversifying the physician workforce at all levels, eliminating disparities in health care and outcomes, and insuring that all emergency physicians are delivering culturally competent care. Joining ADIEM is free! Just log into your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”
