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Diversity & Inclusion Recruiting, Engaging, and Retaining Diverse Faculty in EM: A Call to Action
Recruiting, Engaging, and Retaining Diverse Faculty in EM: A Call to Action
By Tabia Santos, MD; Annabella Salvador MD; and Nancy Kwon MD on behalf of the SAEM Equity and Inclusion Committee and Faculty Development Committee
Health care disparities are a national issue, and disparities in health outcomes have been widely studied. There is overwhelming evidence to support the existence of persistent gaps in health care and the need to find solutions to these inequalities, including diversifying the medical workforce.
When reviewing health outcome measures, historically marginalized communities have lagged white populations. When the patientprovider relationship is hampered by mistrust, satisfaction with health care services decreases and correlates with worse health outcomes (e.g., lack in medication adherence and patient follow-up visits). Consequently, the Joint Commission is addressing these disparities as a quality and patient safety imperative. Emergency medicine has long been a critical gateway and safety net for patients with poor access to health care services. The emergency department (ED) is a clinical setting where patients should have equal health care regardless of their race, ethnicity, gender and/or ability to pay; yet health inequity runs rampant even in this setting.
Diversity in the health care workforce has been proven to improve the inequalities of health care outcomes, yet the medical workforce does not represent the diversity of the populations and communities that they serve. While there have been improvements in the representation numbers for some groups, such as women, significant imbalances remain. Multiple studies have shown that increasing the number of physicians that come from underrepresented communities improves overall quality of care, especially for patients that come from similar communities. However, physicians from traditionally marginalized communities remain underrepresented in medicine despite national efforts to increase diversity in the health care workforce.
Although Hispanic, Black, and Native Americans represent roughly one-third of the United States (U.S.) population, physicians from these three racial and ethnic groups comprise only 5.8%, 5.0%, and 0.3% of the physician workforce, respectively — a proportion that has not changed substantially over the last three decades.
The dearth and attrition of underrepresented health care providers begins in higher education, and more specifically during undergraduate medical education. Many schools of health professions struggle to recruit and support underrepresented-in-medicine (URM) students. Despite 50 years of increases in outreach and enrichment initiatives, admission, and financial changes, and using specific admission targets, the racial and ethnic composition of the physician workforce has not changed substantially over the last two decades. According to the AAMC Diversity in Medicine: Facts and Figures 2019 Executive Summary, despite the fact that women have surpassed men in applying to medical school, the growth of Black or African American applicants, and graduates lags behind other groups. As a specialty, emergency medicine (EM) is not faring any better in its diversity efforts. Residency training is the next step after medical school for the physician workforce, so increasing diversity at the residency level has a direct impact on the diversity of practicing physicians. On the other hand, implicit bias and discrimination during medical school, residency, and beyond, has harmful effects resulting in inadequate workplace support and isolation.
Professional development and growth are impeded for URM physicians when there is a lack of diversity and in environments where implicit bias and microaggressions prevail. This may be a contributing factor to why only a small number of Black physicians choose to remain on faculty at academic medical institutions.
The Accreditation Council for Graduate Medical Education (ACGME) has developed requirements related to diversity, equity, and inclusion, including requirements pertaining to recruitment and retention of a diverse and inclusive workforce. Medical schools, residency programs, and academic institutions and health systems must determine their own strategies to achieve this goal. Improving the diversity, equity, and inclusion of our emergency medicine workforce requires a multiprong and longitudinal strategy and commitment.
Fortunately, examples of best practices do exist in literature and in programs across the country. The American Association of Medical Colleges (AAMC) is one of the national organizations that is working to “develop strategic initiatives to cultivate a diverse and culturally prepared workforce, advance inclusion, …and enhance engagement.” The AAMC has published a document titled “Equity, Diversity, and Inclusion Cluster: Portfolios, Initiatives, and Programs 2022” and in included in this initiative is the Workforce Diversity Portfolio which has as its mission “to be a catalyst for the development of a diverse, culturally responsive healthcare workforce prepared to address societal health needs.” Some of the aims of the initiative include to: • “Develop programs and initiatives that attract, and support racial and ethnic minority faculty and leaders to thrive in academic medicine” • “Create and lead programs that improve access to information and resources for students who are underrepresented in the health professions”
The Society for Academic Emergency Medicine has also made a commitment to diversity, equity, and inclusion (DEI). The SAEM Equity and Inclusion Committee is currently in its third year and doing a great deal of work, including building a multifaceted DEI educational curriculum. Furthermore, all of SAEM’s Committees have as a goal identifying, developing, and mentoring future leaders with an eye toward increasing the diversity of leadership on committees, sub-committees, and projects. In addition, one goal of the SAEM Equity and Inclusion Committee is to increase diversity and inclusion in academic emergency medicine through the implementation of a strategic longitudinal plan.
The Council of Residency Directors (CORD) recently published a paper on best practices for faculty recruitment, retention, and representation. These best practices include creating recruitment committees composed of members who are committed to diversity, encouraging accountability by tracking diversity metrics, and incentivizing staff for participation in diversity and inclusion
DIVERSITY & INCLUSION
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activities. Other best practices identified by the authors include employing an inclusive marketing strategy and targeted recruitment, utilizing a holistic process for reviewing candidates, standardizing the interview process, appointing URM faculty ambassadors to connect with applicants, and requiring interviewers to participate in implicit bias training. However, when recruiting faculty with an attention to diversity, it is important to acknowledge that the burden of responsibility is often disproportionally placed on underrepresented faculty. This is known as the “minority tax”; it is a major source of inequity in academic medicine and hindrance to professional advancement in academia. This “tax” burden comes at a professional cost for URM faculty as these types of responsibilities can syphon time away from career-advancing activities, seldom count toward scholarship, and frequently go unrecognized, unrewarded, and uncompensated. As Christopher Johnson, a board member from the Nonprofit Leadership Center
says: “diversity, equity, and inclusion are everyone’s responsibility.” Retention and engagement strategies are just as important as recruitment strategies. According to the CORD article establishing a culture of inclusivity is a chief way to retain and engage recruited residents. Some suggested methods for establishing an inclusive culture include: • Providing organization-wide implicit bias training • Supporting staff who encounter discrimination • Scheduling ongoing, facilitated discussions and dialogue on race and racism • Appointing diversity leaders such as a
Chief Diversity Officer • Establishing a DEI council to create the climate of diversity, equity, and inclusion for the workforce and patients • Ensuring academic development opportunities for URM faculty • Promoting and URM faculty • Supplying memberships in national organizations to allow for networking and relationship-building opportunities • Implementing faculty development programs that target URM faculty • Encouraging local mentorship and sponsorship or URM faculty by both
URM and non-URM faculty
The paucity of diversity in academic medicine is a national crisis that needs to be addressed through constant commitment, effort, and attention. In the literature, program directors have cited the lack of URM applicants as the most significant barrier to recruitment. This scarcity of applicants needs to be addressed at all levels, from middle school to medical school. If we do not expose URM students to the medical professions, and provide programs to provide mentorship, guidance, and skills at earlier stages, there will be no pathway to medical school. We need to change current processes in order to improve upon this for the future.
For instance, when it comes to MCAT scores, there is increasing support for reviewing candidates holistically rather than placing so much weight on MCAT scores. Some institutions have implemented programs to assist candidates with the MCATs. The Indiana University School of Medicine, for example, reported improvements in MCAT scores for URM students who had enrolled in a program to improve testtaking skills on the MCAT.
The literature suggests that the diversity of faculty and residents should reflect the diversity of the patient population, otherwise health equity will never be achieved. Some of the best practices to achieve this goal are highlighted above, but these efforts entail a dedicated, coordinated, and honest approach that is owned by all. This is a call to action to embed racial justice and advance health equity to reform our medical workforce for the future.
ABOUT THE AUTHORS
Dr. Salvador-Kelly is Northwell Health’s senior vice president of medical affairs, deputy chief medical officer, and associate professor of emergency medicine for the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. She leads medical affairs throughout Northwell Health, including credentialing, policies, and procedures, and curating talented physicians and team members. She is also responsible for standardizing pharmacologic/therapeutic interventions and procedural products across the entire clinical enterprise.
Dr. Santos is a PGY-2 resident physician at Northwell Northshore-LIJ in NYC, NY and one of the leaders of the Diversity, Equity, and Inclusion Resident Subgroup Committee.
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.
