The Time Is Now: Racism and the Responsibility of Emergency Medicine to Be Antiracist.

The COVID-19 pandemic has shed light on the ongoing pandemic of racial injustice. In the context of these twin pandemics, emergency medicine organizations are declaring that "Racism is a Public Health Crisis." Accordingly, we are challenging emergency clinicians to respond to this emergency and commit to being antiracist. This courageous journey begins with naming racism and continues with actions addressing the intersection of racism and social determinants of health that result in health inequities. Therefore, we present a social-ecological framework that structures the intentional actions that emergency medicine must implement at the individual, organizational, community, and policy levels to actively respond to this emergency and be antiracist.

The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: Where are we now?

BACKGROUND: Despite identified inequities and disparities in lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) health, past studies have shown little or no education at the medical school or residency level for emergency physicians. With increased focus on health inequities and disparities, we sought to reexamine the status of sexual and gender minority health education in U.S. emergency medicine (EM) residencies. OBJECTIVES: Our primary objective was to determine how many EM residencies offer education on LGBTQ+ health. Secondary objectives included the number of actual versus preferred hours of LGBTQ+ training, identification of barriers to providing education, and correlation of education with program demographics. Finally, we compared our current data with past results of our 2013 study. METHODS: The initial survey that sought to examine LGBTQ+ training in 2013 was used and sent in 2020 via email to EM programs accredited by the American Council for Graduate Medical Education who had at least one full class of residents in 2019. Reminder emails and a reminder post on the Council of Residency Directors in Emergency Medicine listserv were used to increase participation. RESULTS: A total of 229 programs were eligible, with a 49.3% response rate (113/229). The majority (75%) offered education content on LGBTQ+ health, for a median (IQR) of 2 (1-3) hours and a range of 0 to 22 hours. Respondents preferred more hours of education than offered (median desired hours = 4, IQR = 2-5 hours; p < 0.001). The largest barrier identified was lack of time in curriculum (63%). The majority of programs had known LGBTQ+ faculty and residents. Inclusion and amount of education hours positively correlated with presence of LGBTQ+ faculty or residents; university- and county-based programs were more likely to deliver education content than private groups (p = 0.03). Awareness of known LGBTQ+ residents but not faculty differed by region, but there was no significant difference in actual or preferred content by region. CONCLUSION: The majority of respondents offer education in sexual and gender minority health, although there remains a gap between actual and preferred hours. This is a notable increase from 26% of responding programs providing education in 2013. Several barriers still exist, and the content, impact, and completeness of education remain areas for further study.

Overcoming barriers to promotion for women and underrepresented in medicine faculty in academic emergency medicine.

Equity in the promotion of women and underrepresented minorities (URiM) is essential for the advancement of academic emergency medicine and the specialty as a whole. Forward-thinking healthcare organizations can best position themselves to optimally care for an increasingly diverse patient population and mentor trainees by championing increased diversity in senior faculty ranks, leadership, and governance roles. This article explores several potential solutions to addressing inequities that hinder the advancement of women and URiM faculty. It is intended to complement the recently approved American College of Emergency Physicians (ACEP) policy statement aimed at overcoming barriers to promotion of women and URiM faculty in academic emergency medicine. This policy statement was jointly released and supported by the Society for Academic Emergency Medicine (SAEM), American Academy of Emergency Medicine (AAEM), and the Association of Academic Chairs of Emergency Medicine (AACEM).

A Model Partnership: Mentoring Underrepresented Students in Medicine (URiM) in Emergency Medicine.

INTRODUCTION: Creating a racially and ethnically diverse workforce remains a challenge for medical specialties, including emergency medicine (EM). One area to examine is a partnership between a predominantly white institution (PWI) with a historically black college and university (HBCU) to determine whether this partnership would increase the number of underrepresented in medicine (URiM) in EM who are from a HBCU. METHODS: Twenty years ago Emory Department of Emergency Medicine began its collaboration with Morehouse School of Medicine (MSM) to provide guidance to MSM students who were interested in EM. Since its inception, our engagement and intervention has evolved over time to include mentorship and guidance from the EM clerkship director, program director, and key faculty. RESULTS: Since the beginning of the MSM-Emory EM partnership, 115 MSM students have completed an EM clerkship at Emory. Seventy-two of those students (62.6%) have successfully matched into an EM residency program. Of those who matched into EM, 22 (32%) have joined the Emory EM residency program with the remaining 50 students matching at 40 other EM programs across the nation. CONCLUSION: Based on our experience and outcomes with the Emory-MSM partnership, we are confident that a partnership with an HBCU school without an EM residency should be considered by residency programs to increase the number of URiM students in EM, which could perhaps translate to other specialties.

Advancing Diversity and Inclusion: An Organized Approach Through a Medical Specialty Academy.

BACKGROUND: The benefits of a diverse workforce in medicine have been previously described. While the population of the United States has become increasingly diverse, this has not occurred in the physician workforce. In academic medicine, underrepresented in medicine (URiM) faculty are less likely to be promoted or retained in academic institutions. Studies suggest that mentorship and engagement increase the likelihood of development, retention, and promotion. However, it is not clear what form of mentorship creates these changes. The Academy for Diversity and Inclusion in Emergency Medicine (ADIEM), an academy within the Society for Academic Emergency Medicine, is a group focused on advancing diversity and inclusion as well as promoting the development of its URiM students, residents, and faculty. The Academy serves many of the functions of a mentoring program. We assessed whether active involvement in ADIEM led to increased publications, promotion, or leadership advancement in the areas of diversity, equity, and inclusion. METHODS: We performed a survey of ADIEM members to determine if career development and productivity, defined as written scholarly products, presentations, and mentorship in the area of diversity, equity, and inclusion was enhanced by the establishment of the academy. To determine whether there were significant changes in academic accomplishments after the formation of ADIEM, two groups, ADIEM leaders and ADIEM nonleader members, were examined. RESULTS: Thirteen ADIEM leaders and 14 ADIEM nonleader members completed the survey. Academic productivity in the area of diversity, equity, and inclusion increased significantly among ADIEM leaders when compared to ADIEM nonleader members after the founding of ADIEM. In particular, in the ADIEM leader group, there were significant increases in manuscript publications (1.31 ± 1.6 to 5.5 ± 7.96, p = 0.12), didactic presentations (3.85 ± 7.36 to 23.46 ± 44.52, p < 0.01), grand rounds presentations (0.83 ± 1.75 to 8.6 ± 10.71, p < 0.05), and student/resident mentees (6.46 ± 9.36 to 25 ± 30.41, p = 0.02). CONCLUSION: The formation of a specialized academy within a national medical society has advanced academic accomplishments in diversity, equity, and inclusion in emergency medicine among ADIEM leadership. Involvement of URiM and lesbian, gay, bisexual, and transgender faculty in the academy fostered faculty development, mentoring, and educational scholarship.

Attitudes, Behavior, and Comfort of Emergency Medicine Residents in Caring for LGBT Patients: What Do We Know?

BACKGROUND: Although lesbian, gay, bisexual, and transgender (LGBT) patients are ubiquitous in emergency medicine (EM), little education is provided to EM physicians on LGBT health care needs and disparities. There is also limited information on EM physician behavior, comfort, and attitudes toward LGBT patients. The objective of this study was to assess EM residents behavior, comfort, and attitudes in LGBT health. METHODS: An anonymous survey link was sent to EM programs via the Council of Residency Director listserv. The primary outcome of the 24-item descriptive survey was the self-reported comfort levels and self-reported practice in LGBT health care. Secondary outcomes included individual comfort toward LGBT colleagues and patients who are LGBT, and the frequency of colleagues making discriminatory statements toward LGBT patients and staff in the emergency department setting. Associations between personal and program demographics and survey responses were also examined. RESULTS: There were 319 responses The majority of respondents were male (63.4%), Caucasian (69.1%), and heterosexual (92.4%). A sizeable minority of respondents felt histories and physical examinations were more challenging for lesbian, gay, or bisexual patients (24.6%) and more so for transgender patients (42.6%). Most residents do not ask patients to identify sexual orientation when presenting with abdominal or genital complaints (63%). Discriminatory LGBT comments were reported from both fellow residents (16.6%) and faculty (10%). A total of 2.5% of respondents were uncomfortable with other LGBT physicians, and 6% did not agree that LGBT patients deserve the same quality care as others. CONCLUSION: A number of residents find caring for LGBT patients more challenging than heterosexual patients. Even with professed comfort with LGBT health care, most residents report taking incomplete sexual histories that may affect patient care. Attitudes toward LGBT patients are mainly, but not completely, positive in this cohort.

Current Status of Gender and Racial/Ethnic Disparities Among Academic Emergency Medicine Physicians.

OBJECTIVE: A 2010 survey identified disparities in salaries by gender and underrepresented minorities (URM). With an increase in the emergency medicine (EM) workforce since, we aimed to 1) describe the current status of academic EM workforce by gender, race, and rank and 2) evaluate if disparities still exist in salary or rank by gender. METHODS: Information on demographics, rank, clinical commitment, and base and total annual salary for full-time faculty members in U.S. academic emergency departments were collected in 2015 via the Academy of Administrators in Academic Emergency Medicine (AAAEM) Salary Survey. Multiple linear regression was used to compare salary by gender while controlling for confounders. RESULTS: Response rate was 47% (47/101), yielding data on 1,371 full-time faculty: 33% women, 78% white, 4% black, 5% Asian, 3% Asian Indian, 4% other, and 7% unknown race. Comparing white race to nonwhite, 62% versus 69% were instructor/assistant, 23% versus 20% were associate, and 15% versus 10% were full professors. Comparing women to men, 74% versus 59% were instructor/assistant, 19% versus 24% were associate, and 7% versus 17% were full professors. Of 113 chair/vice-chair positions, only 15% were women, and 18% were nonwhite. Women were more often fellowship trained (37% vs. 31%), less often core faculty (59% vs. 64%), with fewer administrative roles (47% vs. 57%; all p < 0.05) but worked similar clinical hours (mean ± SD = 1,069 ± 371 hours vs. 1,051 ± 393 hours). Mean overall salary was $278,631 (SD ± $68,003). The mean (±SD) salary of women was $19,418 (±$3,736) less than men (p < 0.001), even after adjusting for race, region, rank, years of experience, clinical hours, core faculty status, administrative roles, board certification, and fellowship training. CONCLUSIONS: In 2015, disparities in salary and rank persist among full-time U.S. academic EM faculty. There were gender and URM disparities in rank and leadership positions. Women earned less than men regardless of rank, clinical hours, or training. Future efforts should focus on evaluating salary data by race and developing systemwide practices to eliminate disparities.

Racial and ethnic disparities in the emergency department: a public health perspective.

This article discusses racial and ethnic disparities from a public health perspective, specifically why they threaten to impede the efforts to improve the nation's health. The authors (1) provide background information, including a review of the Institute of Medicine report on health care disparities; (2) describe the racial and ethnic compositions of the individuals in the emergency department setting from the perspective of both the patient and health care provider; (3) discuss the most prevalent disease presentations to the emergency department that are likely to have racial and ethnic disparities; and (4) give conclusions and general recommendations on how to address disparities in emergency health care.

The use of standardized patients within a procedural competency model to teach death disclosure.

OBJECTIVE: To design, implement, and evaluate a multi-dimensional, interdisciplinary, educational training module that enables residents to deliver an effective and empathic death disclosure in the emergency setting. The Accreditation Council for Graduate Medical Education (ACGME) "Toolbox of Assessment Methods" to assess competency was adopted as the foundation of this project. METHODS: Sixteen emergency medicine residents, eight postgraduate year 1 (PGY-1) and eight PGY-2, underwent a one-day training and evaluation exercise. The exercise consisted of: 1) a large-group didactic session, 2) a small-group didactic session, and 3) two standardized patient (SP) examinations. Changes in comfort levels, training helpfulness, and competency were measured. Inter-rater agreement between evaluators was examined. RESULTS: Trainees reported improvement in comfort levels and high levels of satisfaction regarding the helpfulness of the training. Good interrater agreement was obtained regarding resident competency to perform a death disclosure between the faculty and SP evaluators [kappa 0.61; 95% confidence interval (95% CI) = 0.33 to 0.88]. However, overall agreement among raters was poor (kappa 0.16; standard error = 0.26). This poor agreement reflected a lack of agreement between resident and SP evaluators (kappa 0.08; 95% CI = 0.16 to 0.33) and resident and faculty evaluators (kappa -0.02; 95% CI = 0.30 to 0.26). CONCLUSIONS: This project used the ACGME "Toolbox of Assessment Methods" to evaluate the competency of emergency medicine trainees to perform an effective and empathic death disclosure. The finding of inconsistent competency assessments by resident self-evaluators compared with those assessments made by faculty and standardized patients have important implications in future curricular design.

The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: what do we know?

BACKGROUND: The Institute of Medicine, The Joint Commission, and the U.S. Department of Health and Human Services all have recently highlighted the need for cultural competency and provider education on lesbian, gay, bisexual, and transgender (LGBT) health. Forty percent of LGBT patients cite lack of provider education as a barrier to care. Only a few hours of medical school curriculum are devoted to LGBT education, and little is known about LGBT graduate medical education. OBJECTIVES: The objective of this study was to perform a needs assessment to determine to what degree LGBT health is taught in emergency medicine (EM) residency programs and to determine whether program demographics affect inclusion of LGBT health topics. METHODS: An anonymous survey link was sent to EM residency program directors (PDs) via the Council of Emergency Medicine Residency Directors listserv. The 12-item descriptive survey asked the number of actual and desired hours of instruction on LGBT health in the past year. Perceived barriers to LGBT health education and program demographics were also sought. RESULTS: There were 124 responses to the survey out of a potential response from 160 programs (response rate of 78%). Twenty-six percent of the respondents reported that they have ever presented a specific LGBT lecture, and 33% have incorporated topics affecting LGBT health in the didactic curriculum. EM programs presented anywhere from 0 to 8 hours on LGBT health, averaging 45 minutes of instruction in the past year (median = 0 minutes, interquartile range [IQR] = 0 to 60 minutes), and PDs support inclusion of anywhere from 0 to 10 hours of dedicated time to LGBT health, with an average of 2.2 hours (median = 2 hours, IQR = 1 to 3.5 hours) recommended. The majority of respondents have LGBT faculty (64.2%) and residents (56.2%) in their programs. The presence of LGBT faculty and previous LGBT education were associated with a greater number of desired hours on LGBT health. CONCLUSIONS: The majority of EM residency programs have not presented curricula specific to LGBT health, although PDs desire inclusion of these topics. Further curriculum development is needed to better serve LGBT patients.

Does stage of change predict improved intimate partner violence outcomes following an emergency department intervention?

OBJECTIVES: The objective was to assess the effect of an emergency department (ED)-based computer screening and referral intervention on the safety-seeking behaviors of female intimate partner violence (IPV) victims at differing stages of change. The study also aimed to determine which personal and behavioral characteristics were associated with a positive change in safety-seeking behavior. The hypothesis was that women who were in contemplation or action stages of change would be more likely to endorse safety behaviors during follow-up. METHODS: This was a prospective cohort study of female IPV victims at three urban EDs, using a computer kiosk to deliver targeted education about IPV to provide referrals to local resources. All noncritically ill adult English-speaking women triaged to the ED waiting room during study hours were eligible to participate. Women were screened for IPV using the validated Universal Violence Prevention Screening Protocol (UVPSP), and all IPV-positive women further responded to validated questionnaires for alcohol and drug abuse, depression, and IPV severity. The women were assigned a baseline stage of change using the University of Rhode Island Change Assessment (URICA) scale for readiness to change their IPV behaviors. Study participants were contacted at 1 week and 3 months to assess a variety of predetermined safety behaviors to prevent further IPV during that period. Descriptive analyses were performed to determine if stage of change at enrollment and a variety of specific sociodemographic characteristics were associated with taking protective action during follow-up. RESULTS: A total of 1,474 women were screened for IPV; 154 (10.4%) disclosed IPV and completed the full survey. Approximately half (47.4%) of the IPV victims were in the precontemplation stage of change, and 50.0% were in the contemplation stage. A total of 110 women returned at 1 week of follow-up (71.4%), and 63 (40.9%) women returned for the 3-month follow-up. Fifty-five percent of those who returned at 1 week and 73% of those who returned at 3 months took protective action against further IPV. Stage of change at enrollment was not significantly associated with taking protective action during follow-up. There was no association between demographic characteristics and taking protective action at 1 week or 3 months. CONCLUSIONS: Emergency department-based kiosk screening and health information delivery is a feasible method of health information dissemination for women experiencing IPV and was associated with a high proportion of study participants taking protective action. Stage of change was not associated with actual IPV protective measures.

Diversity in emergency medicine education: expanding the horizon.

An emergency medicine (EM)-based curriculum on diversity, inclusion, and cultural competency can also serve as a mechanism to introduce topics on health care disparities. Although the objectives of such curricula and the potential benefits to EM trainees are apparent, there are relatively few resources available for EM program directors to use to develop these specialized curricula. The object of this article is to 1) broadly discuss the current state of curricula of diversity, inclusion, and cultural competency in EM training programs; 2) identify tools and disseminate strategies to embed issues of disparities in health care in the creation of the curriculum; and 3) provide resources for program directors to develop their own curricula. A group of EM program directors with an interest in cultural competency distributed a preworkshop survey through the Council of Emergency Medicine Residency Directors (CORD) e-mail list to EM program directors to assess the current state of diversity and cultural competency training in EM programs. Approximately 50 members attended a workshop during the 2011 CORD Academic Assembly as part of the Best Practices track, where the results of the survey were disseminated and discussed. In addition to the objectives listed above, the presenters reviewed the literature regarding the rationale for a cultural competency curriculum and its relationship to addressing health care disparities, the relationship to unconscious physician bias, and the Tool for Assessing Cultural Competence Training (TACCT) model for curriculum development.

Standardized Patients to Teach Medical Students about Intimate Partner Violence.

OBJECTIVE: To use 360-degree evaluations within an Observed Structured Clinical Examination (OSCE) to assess medical student comfort level and communication skills with intimate partner violence (IPV) patients. METHODS: We assessed a cohort of fourth year medical students' performance using an IPV standardized patient (SP) encounter in an OSCE. Blinded pre- and post-tests determined the students' knowledge and comfort level with core IPV assessment. Students, SPs and investigators completed a 360-degree evaluation that focused on each student's communication and competency skills. We computed frequencies, means and correlations. RESULTS: Forty-one students participated in the SP exercise during three separate evaluation periods. Results noted insignificant increase in students' comfort level pre-test (2.7) and post-test (2.9). Although 88% of students screened for IPV and 98% asked about the injury, only 39% asked about verbal abuse, 17% asked if the patient had a safety plan, and 13% communicated to the patient that IPV is illegal. Using Likert scoring on the competency and overall evaluation (1, very poor and 5, very good), the mean score for each evaluator was 4.1 (competency) and 3.7 (overall). The correlations between trainee comfort level and the specific competencies of patient care, communication skill and professionalism were positive and significant (p<0.05). CONCLUSION: Students felt somewhat comfortable caring for patients with IPV. OSCEs with SPs can be used to assess student competencies in caring for patients with IPV.

Promoting diversity in emergency medicine: summary recommendations from the 2008 Council of Emergency Medicine Residency Directors (CORD) Academic Assembly Diversity Workgroup.

Although the U.S. population continues to become more diverse, ethnic and racial health care disparities persist. The benefits of a diverse medical workforce have been well described, but the percentage of emergency medicine (EM) residents from underrepresented groups (URGs) is small and has not significantly increased over the past 10 years. The Council of Emergency Medicine Resident Directors (CORD) requested that a panel of CORD members review the current state of ethnic and racial diversity in EM training programs. The objective of the discussion was to develop strategies to help EM residency programs examine and improve diversity in their respective institutions. Specific recommendations focus on URG applicant selection and recruitment strategies, cultural competence curriculum development, involvement of URG faculty, and the availability of institutional and national resources to improve and maintain diversity in EM training programs.