11 minute read
Diversity, Equity, and Inclusion in EM Research: A Call to Action
By Angela Lumba-Brown, MD; David Fernandez, MD; and Nancy S. Kwon, MD, MPA, on behalf of the SAEM Research Committee and SAEM Equity & Inclusion Committee
Diversity, equity, and inclusion (DEI) are cornerstones of the mission of emergency medicine. Similarly, emergency medicine research requires thoughtful and deliberate focus on DEI to impact meaningful change and advance our field. While specific DEI definitions vary in wording, we example the American Association of Colleges and Universities definitions here and offer the SAEM DEI Resource Library and Academy for Diversity and Inclusion in Emergency Medicine (ADIEM) for further information on SAEM’s mission to impact DEI in emergency medicine.
Scientific literature across many disciplines in medicine, including emergency medicine, repeatedly demonstrates the prevalence of inequities in patient diagnosis, management, and treatment. Health care inequities span widespread topics including wait times, admission, rates, presentations for various disease states and injuries, pain treatment, mental and health support. In one well-known study from the New England Journal of Medicine, black women were
TERM DEFINITION
DIVERSITY Individual differences, group and social differences, historically underrepresented populations, and cultural, political, religious, or other affiliation. EQUITY Creation of opportunities for historically underrepresented populations to have equal access to and participate in programs that can close the achievement gaps INCLUSION Active, intentional, and ongoing engagement with diversity in ways that increase awareness, content knowledge, cognitive sophistication, and empathic understanding of the complex ways individuals interact within systems and institutions
significantly less likely to be referred for a cardiac catheterization than white men. More recently, multiple studies demonstrate the immense race and ethnic inequities that occurred during the Covid-19 pandemic and the impact on health outcomes. These are just a couple examples of health care inequities that occur secondary to race, ethnicity, and sex, and many other unrepresented groups.
The imminent need for DEI focus in research is not limited to topical disease-based approaches; a constant commitment to examining representation of physicians and health care personnel in emergency medicine is also important. The specialty will not address health inequity if we overlook DEI in the health care teams that care for our patients. Although this area of research continues to expand, further research is needed specifically in emergency medicine. The gender gap is a prime example of inequity in emergency medicine that has received recent scientific attention. In a study comparing male vs. female faculty evaluations of emergency medicine residents, males and females received similar evaluations at the start of residency, but males received higher milestone attainment than females throughout residency.
Scientific examinations of disparities in DEI is incredibly important, but research is not effective without implementation of positive change. Christopher Johnson, a board member at the Nonprofit Leadership Center, writes that “diversity, equity and inclusion” represents the nonnegotiable pillars on which strong cultures must be built.” He highlights eight beliefs of leaders who authentically embrace diversity, equity and inclusion: 1. Diversity, equity, and inclusion are everyone’s responsibility. 2. No marginalized population is more important than another. 3. One person’s life experience doesn’t discredit another’s; we have a responsibility to see people through each lens. 4. Words do matter. 5. Actions mean more than words.
6. Embracing allies is important. 7. Change starts by meeting people where they are. 8. There is no finish line.
Taking his conceptual framework into mind, what actions have emergency medicine and SAEM taken to address DEI in research and beyond? The SAEM22 Consensus Conference on May 10, 2022 in New Orleans is titled “Diversity, Equity, and Inclusion: Developing a Research Agenda for Addressing Racism in Emergency Medicine.” The goals of this conference are “to support the development of a consensus-driven research agenda, research collaboration network, and dissemination plan for evidence-based practices related to the care of health disparity populations in emergency care settings.” The goals of this conference are both patient- and physician-centered and include 1) clarifying knowledge gaps and prioritizing research questions to improve community health and develop best practices; 2) developing research agendas, disseminating innovations, and addressing research priorities with key stakeholders; 3) Creating resident/ faculty programs to enhance recruitment, retention, and advancement of diverse groups. SAEM has many new (and enduring) DEI initiatives, including the work of the Equity and Inclusion Committee and the Academy for Diversity and Inclusion in Emergency Medicine (ADIEM). The Equity and Inclusion Committee was founded in 2020 following the recommendation of the 2019 SAEM Diversity, Equity, and Inclusion Task Force, chaired by SAEM’s new president, Dr. Angela Mills.
ADIEM provides grant funding to support research that examines 1) the state of DEI in the field; 2) evaluates interventions to improve DEI; and/ or 3) studies disparities in health care outcomes among underrepresented or marginalized groups. The Academy for Women in Academic Emergency Medicine (AWAEM) also supports research in DEI and provides research awards to investigators who wish to address a research question in line with its core ideology. This core ideology includes (but is not limited to): 1) enhancing the recruitment, promotion, and retention of women in academic emergency medicine throughout their careers; 2) identifying gender gaps and organizational practices that hamper the advancement of women emergency medicine practitioners and researchers; and 3) advancing research that leads to an understanding of the role that sex and gender play in emergency patient care.
A first step to effect change in emergency medicine is to support clinician-scientists and further funding streams that advance research and implementation efforts in DEI realms. Awareness and transparency of gaps are supported by data publication. Along these lines, promoting the diversity of our researchers and research disseminators (scientific journal reviewers and editors) is also key.
Studies evaluating the data on the diversity of emergency medicine researchers it is limited. In a study from the American College of Emergency Physicians (ACEP) reporting on the diversity of research awardees and barriers that researchers face, gender was perceived as one of the largest barriers to success. In data from an academic emergency medicine program, only one woman was awarded the Faculty Teacher of the Year Award and the Resident Teacher of the Year award in over 17 years. Examining such trends and bringing forth implicit biases is a data-driven step to highlight change that must occur. Investigators from this program are in the process of researching the gender disparity of similar awards across multiple programs to provide more data on implicit bias, and a call to action that such data should promote change. It is time to take ownership over what needs to be fixed.
As SAEM continues to embrace a constant commitment to DEI and research, our emergency medicine programs across the country must do the same, and many have. SAEM members, the SAEM Board of Directors, SAEM Equity and Inclusion Committee, ADIEM, AWAEM, and beyond are voicing this need and their continuing strong commitment at their own institutions and among national organizations. As stated above, “diversity, equity, and inclusion are everyone’s responsibility” and research in this area is just one way to take responsibility, make data transparent, and promote positive change.
ABOUT THE AUTHORS
Dr. Lumba-Brown is an associate vice chair and associate professor of emergency medicine at Stanford University School of Medicine. She is a member of the SAEM Bylaws Committee and AWAEM Research Committee. She also sits on the Centers for Disease Control and Prevention’s Board of Scientific Counselors. Her research examines of sex-based differences, disparities in care, and subtype classification of traumatic brain injury.
Dr. Fernandez is a resident physician PGY-2 at Northwell Northshore-LIJ in NYC, NY and oversees the Diversity, Equity, and Inclusion Resident Subgroup committee. Dr. Fernandez completed his undergraduate career in the city of Boston and attended medical school at New York Medical College. He is passionate about DEI, mentorship, teaching, and patient care.
Dr. Kwon is the vice chair of emergency medicine at Long Island Jewish Medical Center which is part of Northwell Health. She has been an active member of SAEM as part of the Faculty Development, Research, and Equity and Inclusion committees, and is presently a member of the SAEM Nominating Committee. Her areas of interest and research include faculty development and mentorship, diversity, equity and inclusion, and the implementation of programs to support vulnerable patient populations.
On-Shift Leadership: Teaching Beyond the “Hidden Curriculum”
By Michael Zdradzinski, MD; Stephen Sanders, MD; Caroline Molins, MD; and Nicole Prendergast, MD, on behalf of the SAEM Education Committee
As emergency physicians, we play many roles on-shift. We care for patients; we educate patients, families, nurses, and learners; and we assist with departmental flow and coordinate with specialists. Central to all these activities, however, is leadership. An effective emergency physician is a leader for the department, orchestrating its ebbs and flows, and navigating difficult interpersonal situations. Despite the importance of leadership to physicians’ clinical success, it is seldom given time in packed residency conference curricula; therefore, it tends to exist as part of the “hidden curriculum” of residency training. Working in the emergency department (ED) throughout the COVID-19 pandemic has underscored the importance of specific aspects of leadership. With prolonged wait times, high volumes, and staffing challenges,
“An effective emergency physician is a leader for the department, orchestrating its ebbs and flows, and navigating difficult interpersonal situations.” the pandemic has highlighted the need for physicians to demonstrate empathy, professionalism, and effective communication skills. Given this need, we suggest that residencies develop a curriculum to discuss on-shift
leadership skills. Such a curriculum can facilitate resident development in many ways. Beyond highlighting important characteristics of good leaders, like clinical competence, confidence in oneself, and the ability to make critical decisions quickly, a curriculum can help trainees to envision themselves as leaders and to understand that others view them as leaders.
The literature identifies several themes that contribute to high-quality clinical leadership: team management, vision, communication skills, and personal attributes. Leadership topics can also be conceptualized in either a team-based model (i.e., resuscitation management) or a more individualized model (such as managing a difficult patient interaction with nursing staff). To teach these important concepts, we suggest a yearly workshop or integrated longitudinal curriculum tailored to each residency class.
For Interns
For interns, resuscitation leadership provides a good introduction to the broader concepts, as this topic is often of interest while they begin to care for critically ill patients. The discussion should include best practices, including closedloop communication, clear assignment of responsibilities, soliciting feedback from staff, and debriefing. Simulation or case-based learning can also be applied to encourage practice of these key skills. The session can progress to a review of common leadership styles and their relative benefits and drawbacks. Through group discussion, learners should be encouraged to anticipate challenges they may encounter as they progress into more supervisory roles.
For PGY-2 and PGY-3 Residents
For the middle resident workshop, we suggest delving further into different leadership styles (such directive, empowering, transformational, transactional, laissez-faire), and encouraging residents to identify the strengths and weaknesses of each. These learners can be asked to reflect on their developing leadership styles, discuss challenges they have faced, and identify areas for improvement as they progress in seniority.
For Senior Residents
The graduating senior resident workshop can provide an opportunity for the learners to reflect on their leadership journey throughout training, anticipate new challenges as early attendings, plan for potential administrative leadership opportunities, and consider the need for ongoing self-assessment and growth as attendings.
When we implemented a similar workshop series, the residents expressed appreciation for the curriculum, noting that they have become more deliberate in developing their leadership styles. If you are interested in developing such a curriculum, the graphic lists some resources available to assist.
On-shift leadership is a crucial topic for residents to learn. Beyond the immediate need for these skills in the pandemic environment, emergency physicians who have trained in these techniques will be better equipped to lead both their departments and communities.
ABOUT THE AUTHORS
Dr. Zdradzinski, is an assistant professor in the Department of Emergency Medicine at the Emory University School of Medicine. He serves as the director of postgraduate education and is the assistant director of the Medical Education Fellowship for the department.
Dr. Sanders is an assistant professor in the Department of Emergency Medicine at Emory University School of Medicine.
Dr. Prendergast is a PGY-4 and chief resident in the Department of Emergency Medicine at Stanford University
Dr. Molins is an assistant professor in the Department of Emergency Medicine at Loma Linda School of Medicine and clinical assistant professor at University of Central Florida College of Medicine and Florida State University School of Medicine.
