Care Disparities and Diversity in Emergency Medicine

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Health Care Disparities and Diversity in Emergency Medicine

Lisa Moreno-Walton, Christian Arbelaez

Key Points

• The U.S. population is changing rapidly and becoming more diverse.

• Improving access to care for racial and ethnic minorities has not proved effective in ameliorating disparities in health care.

• A diverse workforce that mirrors the patient population is a key and important step toward reducing health care disparities.

• Cultural competency helps health care providers understand how to approach patients from different backgrounds by improving communication and building trust in the doctor-patient relationship.

• Cultural competency is as important as clinical competency to successful practice of emergency medicine.

Introduction

As the globalization of trade, technology, investment, and migration create a more diverse U.S. population, we are increasingly becoming aware of disparities in economics, health care, and human rights. Our nation was founded on the concept that “all men are created equal,”¹ and equal treatment and equal access are the goals toward which we strive. Nowhere else in medicine is the commitment to equality as obvious as it is in our emergency departments (EDs), where the sole criteria for moving to the front of the line is severity of illness. Other specialties now restrict the days and hours during which they are available to patients and tell their patients at hospital discharge to go the ED if they have any problems or concerns. Fewer private physicians are welcoming indigent patients into their practices. Changes in the economy have resulted in a significant increase in the percentage of uninsured.² Only the ED provides medical care 24 hours a day, 365 days a year for every patient with any chief complaint. As advocates for our patients, emergency physicians (EPs) are at the forefront of the promotion of diversity and elimination of disparities in health care not just at home but throughout the world as well.

An awareness of the history of disparities in access to quality health care (Table 1), the benefits of clinical research (Table 2), and medical education and emergency medicine (EM) practice (Box 1) will create a contextual framework within which the reader can appreciate all that has been accomplished, as well as the tasks that remain, as we work toward the ideals of diversity and cultural competency.

Table 1 History of Health Care Disparities

1619-1865	Contaminated drinking water led to frequent outbreaks of cholera, typhoid, hepatitis, malaria, and yellow fever and the transmission of intestinal parasites among slaves.³ Slaves develop a system of care involving indigenous herb root doctors and midwives.⁴
1824	The Bureau of Indian Affairs is established and provides limited health care to Native Americans on reservations.⁵
1852	The first hospital for the care of Negroes is opened (Jackson Street Hospital, Augusta, Georgia).⁶
1862	The only government-funded hospital for Negroes, Freedmen’s Hospital in Washington, DC, is established.⁷
1948	Executive Order 9981 mandates the integration of Veterans Administration hospitals.⁸
1955	The Indian Health Service is commissioned.⁹
1965	The Johnson administration announces that federal Medicaid and Medicare payments will be denied to segregated hospitals.¹⁰
1990	A metaanalysis of 485 articles confirms that migrant health care is confined almost exclusively to charity migrant clinics and virtually nothing is known about the health status of the workers.¹¹
2004	At every age, blacks have higher blood pressure than nonblacks do.¹²
2005	A total of 16.5% of American Indians, 10.4% of Hispanics, and 6.6% of whites are diabetic.¹³
2006	African Americans are more likely to die of coronary artery disease than whites are. They and Hispanics are less likely to be offered bypass or angioplasty. Blacks have worse cancer survival rates, are more likely to undergo amputation for complications of diabetes, and are less likely to be referred for transplantation evaluation than whites are. Hispanics and Native Americans are least likely to be offered cholesterol management services.¹⁴
2009	Of all patients in whom human immunodeficiency virus infection was diagnosed this year, 52% are black.¹⁵
2010	Twenty percent of the population lives in rural areas, where only 9% of physicians practice.¹⁶

Table 2 History of Disparities in Research

Nazi human experimentation: 1938-1945	Josef Mengele, MD, was one of the notorious physicians who performed burning, boiling, freezing, beating, hanging, and poisoning experiments on human prisoners of war who were predominantly racial and ethnic minorities in Europe.¹⁷
Tuskegee Study of Untreated Syphilis in the Negro Male: 1932-1972—Taliaferro Clark, MD	The U.S. Public Health Service conducted a study of the natural course of syphilis in black males, often not informing them of their diagnosis and deliberately preventing them from seeking and obtaining treatment when penicillin became widely available.¹⁸
Willowbrook: 1963-66	Saul Krugman, PhD, studied the effects of gamma globulin on hepatitis by deliberately infecting mentally handicapped children with the virus.¹⁹
Nuremberg Code: 1948	This code arose from the trials of Nazis for crimes against humanity; it addressed consent by and protection of subjects of human research.²⁰
Declaration of practice, Helsinki: 1964	The World Medical Association established good clinical practices in human research (standards revised in 1975, 1983, 1989, 1996, 2000, 2002, 2004, and 2008).²¹
Belmont Report: 1979	This report established boundaries between practice and research and basic ethical principles of human research.²²

Box 1 History of Disparities in Medical Education

• 1783: Dr. James Durham, a former slave, becomes the first African American physician. He sets up practice in New Orleans after an apprenticeship training.

• 1837: Dr. James McCune Smith is the first African American to obtain an MD degree. He has to go to the University of Glasgow to do so. He sets up practice in New York City.

• 1847: Dr. David J. Peck is the first African American to graduate from a U.S. medical school (Rush Medical College).

• 1849: Two African American men receive MD degrees from Bowdoin College, Maine.

• 1850: Thirteen African American doctors are practicing: 9 in New York City and 4 in New Orleans.

• 1857: Dr. Elizabeth Blackwell becomes the first woman to graduate from a U.S. medical school and founds the New York Infirmary for Women and Children.

• 1864: Dr. Rebecca Lee Crumpler, a former nurse, becomes the first African American woman to earn a medical degree in the United States.²³

• 1867: Dr. Blackwell founds the Women’s Medical College of Pennsylvania

• 1868 and 1876: Eight black medical schools were established; only two are still open: Meharry, Tennessee (1876), and Howard, Washington DC (1868).

• 1889: Dr. Susan La Flesche Picotte is the first American Indian woman to earn an MD degree; she receives it from the Women’s Medical College of Pennsylvania.

• 1890: There are 909 African American doctors, as compared with 1734 in 1900 and 4500 in 1960.

• 1891: Dr. Daniel Hale Williams opens the first black-owned hospital (Provident Hospital in Chicago).

• 1905: Being denied membership in “mainstream” medical associations, Dr. Williams establishes the National Medical Association.

• 2009: Dr. Marcus L. Martin is appointed Vice President of the University of Virginia after holding the posts of Chairman, Department of Emergency Medicine, and Assistant Dean of the School of Medicine. Dr. Martin is the first African American President of the Society for Academic Emergency Medicine and the first African American President of the Council of Emergency Medicine Residency Directors.

History of Health Care Disparities in the United States

The word disparity, simply defined, implies the lack of parity or the “state of being dissimilar or unequal.”²⁴ America, historically referred to as “the melting pot,” is a nation whose culture is based on dissimilarity but, ostensibly, on equality. The “melting pot” concept implies that disparities melt away as the nation comes to embody a mixture of qualities from the cultures of all people who live in the United States,²⁵ thus giving rise to the equality envisioned by the framers of our Constitution. However, no republic in recorded history has ever been able to embody the equality on which it is theoretically based, and the United States is no exception. The words of the Bill of Rights, “all men are created equal,” were rather promptly contradicted by our Constitution’s Three-Fifths Compromise and Enumeration Clause.²⁶ Parity in representation was not granted to African Americans until the 15th Amendment was passed in 1870, and women were denied suffrage until passage of the 19th Amendment in 1920. Our policies continue to reflect the wish to achieve equality within the realities of our imperfect history.

Disparity in access to care is as old as America itself. Typically, plantation slaves lived in quarters where contaminated drinking water led to frequent outbreaks of cholera, typhoid, and hepatitis and facilitated the transmission of intestinal parasites. Food scraps and human excrement in stagnant water bred the mosquitoes that transmitted malaria and yellow fever.³ Slave owners usually performed the services of leaching and blistering and administered home medications, with a physician being sent for only as a last resort. Slaves came to distrust the care rendered by owners and overseers and developed their own system of care involving herb root doctors and midwives.⁴ It was not until 1852 that hospital care became available to slaves, when the Jackson Street Hospital was founded in Augusta, Georgia, by a white physician, Dr. Henry Fraser Campbell of the University of Georgia School of Medicine. In 1862, Freedmen’s Hospital in Washington, DC, became the only government-funded hospital for Negroes.⁷ Hospitals remained segregated until Executive Order 9981, which mandated the integration of Veterans Administration hospitals, was signed by President Truman in 1948,⁸ and the administration of President Johnson forced integration in 1965 by denying federal Medicaid and Medicare dollars to segregated hospitals.¹⁰

Access to care for members of American Indian tribes was even more restricted. The Bureau of Indian Affairs, established in 1824 by then Secretary of War John C. Calhoun, provided limited health care to the original Americans who had been segregated to reservations. The scope of care was improved when the Indian Health Service was commissioned in 1955,⁹ and access to all hospital care was afforded under the 1965 Medicare and Medicaid legislation.

As recently as 1990, a metaanalysis of 485 articles confirmed that migrant health care was confined almost exclusively to charity migrant clinics, with virtually nothing being known about the health status of the workers.¹¹ Today, lack of access to care plagues America’s rural areas, where 20% of our citizens are served by only 9% of our physicians. Economic recession and loss of employment have resulted in a decreased number of insured patients to support a rural medical practice.¹⁶

History of Disparity in Research

With the advent of antibiotics, vaccines, and other drugs to treat human ailments, the findings of basic science became applicable to the medical care of human patients, and with this came the advent of clinical research. The scientific method was applied to medicine as physician-scientists sought to understand the processes of disease and the best ways to treat them. Clinical research proceeded without regulation, and despite the fact that most scientists conducted their work with the good of their patients as the highest goal, several experiments overtly violated human decency and human rights. The most barbaric of all human experimentation was that conducted in the Nazi death camps during World War II (see Table 2). These experiments were, in fact, so unthinkable that physicians and the public saw this as an aberration and did not believe that doctors could ever violate human rights in any other circumstances. However, in 1963, Saul Krugman of the New York University School of Medicine infected severely mentally retarded children at the state-supported Willowbrook School with live hepatitis B virus, both orally and by injection, to test the effect of gamma globulin on progression of the disease (see Table 2). Dr. Krugman had obtained written consent by mail from the mothers of his subjects, but the consent was woefully inadequate in explaining that the children would be deliberately infected with virus. When the Tuskegee experiments were brought to national attention by Jean Heller of the Associated Press in 1972,²⁷ there was a public outcry against experimentation conducted by the U.S. Public Health Service with tax dollars that violated the rights of U.S. citizens. Both Dr. Krugman and Dr. Taliaferro Clark (the principal investigator on the Tuskegee experiment) justified their actions by stating that these were merely “studies in nature” following the natural course of a human disease.²⁸

History of Disparity in Medical Education

Box 1 chronicles the remarkable history of the education of women physicians and physicians of color in a nation that for more than a century made no formal provision for the education of nonwhites and then chose to relegate them to segregated schools with inferior textbooks and equipment. Not only were African Americans pioneers in the advancement of their own education, but their contribution to advancement in many fields of medicine is also significant. Several suggested readings and links are listed at the end of this chapter for readers who wish to learn more.

Despite the progress that has been made, barriers and biases continue to impede the progress of those underrepresented in medicine (URM) and women who choose to enter the field of medicine. An important study in the Journal of the National Medical Association reported that women believed that the specialties they were encouraged to pursue were affected by their gender and that they were often mistaken for nonphysicians. URM students noted that a lack of same-race role models had a negative impact on their medical school experience, and they overwhelmingly reported feeling the need to be “twice as good” to be treated as equal to white students.²⁹

Diversity and Cultural Competency

Introduction

Racial and ethnic health care disparity has been an issue in the forefront of medicine at the national level since the Institute of Medicine (IOM) report in 2003 highlighted the significant differences in health care experienced by patients and described important ways to address them through diversity and cultural competency.

Definitions

The definition of some important terms, broadly and more specifically as they relate to EM, will help provide a common understanding and language for the reader. According to the Webster dictionary, culture is defined as “the customary beliefs, social forms, and material traits of a racial, religious, or social group; also: the characteristic features of everyday existence shared by people in a place.…”²⁴ When individuals from the general population come into contact with the health care system, they bring with them their culture and all that it encompasses: their beliefs, values, identity, and links to the community.

According to the IOM report in 2003, the committee defined disparities as “racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention.”³⁰

When people from different cultures and backgrounds come together, diversity is achieved. As defined by the Merriam-Webster dictionary, diversity is the “inclusion of different types of people in a group or organization.” According to the 2010 U.S. census, there are currently more than 300 million Americans: 65.1% white, 15.8% Hispanic, 12.9% black, 4.6% Asian, and 1.2% American Indian or Alaskan Native.³¹ Recognizing how the changing patient demographics in the United States should be reflected in the physician workforce, the Association of American Medical Colleges (AAMC) Executive Council in 2003 adopted a definition of URM as “those racial and ethnic populations that are under-represented in the medical profession relative to their numbers in the general population.” Before this, the AAMC used the term “under-represented minority,” which specifically targeted African Americans, Mexican Americans, Native Americans, and mainland Puerto Ricans. A much broader definition of diversity includes racial and ethnic, socioeconomic, sexual orientation, religion, disability, age, language, and geographic diversity.⁶

The Office of Minority Health (OMH) defines cultural and linguistic competence as “a set of congruent behaviors, attitudes and policies that come together in a system, agency or among professionals that enables effective work in cross-cultural situations.”³²

Tools for Cultural Competency

The educational concepts for cultural competency are centered around the provider gaining the knowledge, attitude, and skills necessary to elicit patients’ explanatory model of their illness and incorporating it into the medical decision-making process. The skills that lead to this competence are not so different from those that we envision when we think of the ideal humane, compassionate, and caring physician. In the end, this concept helps create a framework that allows the health care provider, with a general approach to any patient from any cultural background, to navigate the cross-cultural experience. In effect, this leads to greater understanding of the patient’s perspective and social context. An important conceptual model recently published by the Agency for Healthcare Research and Quality titled “Can Culture Competency Reduce Racial and Ethnic Health Disparities? A Review and Conceptual Model” describes how integrating nine major cultural competency techniques could potentially improve the ability of physicians and health care systems to deliver appropriate services to diverse populations ³³:

1. Interpreter services

2. Recruitment and retention policies

3. Training

4. Coordination with traditional healers

5. Use of community health workers

6. Culturally competent health promotions

7. Inclusion of family and community members

8. Immersion into another culture

9. Administrative and organizational accommodations

In 2002 the OMH published a practical guide to implement standards for culturally and linguistically appropriate services in health care, and various models and educational programs have been published and are available for health care providers to use.³² Over the course of time there has been an evolution in the education and assessment of cultural competency in undergraduate and graduate medical education. The Liaison Committee on Medical Education has codified the following criteria: “Students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments.”³⁴

Similarly, the Accreditation Council for Graduate Medical Education (ACGME) has defined its competency standards within two of the six core competencies, patient care and interpersonal communication skills.³⁵ Numerous other professional organizations have published similar statements promoting cultural competence, including the American Medical Association, the AAMC, the American Association of Medical Students, the American Academy of Nursing, the American Nurses Association, and the American Association of Colleges of Nursing.

Institute of Medicine Committee and Sullivan Commission National Reports

The IOM was charged by Congress with the evaluation of racial and ethnic disparities in health care. The authors published their landmark report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare” in 2003.³⁰ They concluded that “Racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factors, such as patients’ insurance status and income, were controlled.” It is important to note that the committees focused specifically on disparities in health care and not on health outcomes. The authors outlined two important strategies to help reduce disparities: workforce diversity and cultural competency. The benefits of racial and ethnic diversity among health care professionals include providers who are more likely to serve minority and underserved communities, greater levels of professional satisfaction, and report of a better educational experience among students. In 2004, the IOM committee and the Sullivan Commission completed their work and issued the following reports, respectively: “In the Nation’s Compelling Interest: Ensuring Diversity in the Healthcare Workforce” and “The Missing Persons: Minorities in the Health Professions.” The Sullivan Alliance, composed of former members of the IOM committee and the Sullivan Commission, aimed to transform the health professions by providing a comprehensive framework that included a total of 62 recommendations from both reports for the health care professions and major organizations.

Association of American Medical Colleges

The AAMC has led several efforts targeted at the critical steps referenced by the IOM and Sullivan Alliance. In the 2010 publication “Diversity of the Physician Workforce: Facts and Figures,” the authors reported that between 1978 and 2008, 75% of all medical school graduates practicing medicine were white and that blacks or African Americans, American Indians or Alaska Natives, and Hispanics or Latinos accounted for a combined 12.3% of the U.S. physician workforce. Also worth noting is that over the last 30 years there has been a narrowing of the gender gap, except within the black or African American groups, where in contrast to all other groups, the percentage of women physicians has been greater than that of men. The report identified the U.S. medical schools that historically graduate the greatest number of minority medical students and produce a significant proportion of the minority applicant pool for residency programs. Howard, Meharry, and the University of Illinois have graduated the most black or African American physicians. Oklahoma, North Dakota, and the University of Washington have graduated the greatest number of American Indian and Alaska Native physicians. The Universities of Puerto Rico, Caribe, and Ponce have been the greatest producers of Hispanic or Latino physicians.

Recognizing the challenges and barriers faced by medical schools and academic medical centers in implementing these recommendations, the AAMC has published several road maps to help with these roadblocks. The “Roadmap to Diversity: Key Legal and Educational Policy Foundations for Medical Schools,” the “Roadmap to Diversity: Integrating Holistic Review Practices into Medical School Admission Processes,” and the “What You Don’t Know: The Science of Unconscious Bias and What To Do About It in the Search and Recruitment Process” highlight some of the legal, practical, and subtle barriers, as well as the different levels of commitment required throughout the organization.

Equally important to organizational challenges are the obstacles encountered by individual providers who are susceptible to unconscious bias occurring at the bedside. With this in mind, the AAMC also developed TACCT, a Tool for Assessing Cultural Competence Training, which provides a framework for designing, implementing, and integrating an effective cultural competency educational program.³⁶ The TACCT is a self-administered assessment tool that can be used to examine all components of the curriculum, including problem-based learning, to identify strengths and weaknesses within the program’s educational curriculum. In addition, the ACGME’s Toolbox of Assessment Methods is an excellent resource that includes a description of 13 assessment methods and references to articles in which more complete and in-depth information can be found. The design, implementation, and assessment of effective cultural competency curricula must be flexible, be tailored to the institution, maximize the existing resources, and be linked to a data collection component to measure and monitor for success.

Increasing the diversity of students in U.S. medical schools and ensuring that current physicians are trained to be culturally competent have been cited as key strategies for addressing health care disparities and preparing health care systems for the challenges of the new century. This is especially true for EM because it serves as the hospital’s main entry point, as well as frequently a safety net, for a diverse patient population.

Moving Toward Parity in Health Care

Even though access to care has improved remarkably for racial minorities over the past 2 centuries, it is important to realize that they “are disproportionately affected by multiple barriers to care: financial, linguistic, cultural, logistical, organizational, institutional and systemic. Disturbingly, providing disadvantaged populations with adequate access to care may not be sufficient to eliminate racial/ethnic disparities in health.”³⁷ In the Health Disparities and Inequities Report of 2011 by the Centers for Disease Control and Prevention, minority groups were overrepresented in every diagnostic category monitored except suicide and drug-induced death, where whites prevailed.³⁸ Development of cultural competence through the use of tools such as TACCT and the ACGME’s Toolbox of Assessment Methods is an important way for individual physicians to improve outcomes for their patients. However, a systems approach must be used to ameliorate the disparities in disease incidence and outcome that are seen across all levels of health care in the United States. In 2005, the Robert Woods Johnson Foundation launched “Finding Answers: Disparities Research for Change.” This program seeks to identify, evaluate, and disseminate specific interventions that will reduce racial and ethnic disparities in both the care and the outcomes of patients with the specific target diseases of depression, cardiovascular disease, and diabetes. Breast cancer has since been added to this program. Information on specific interventions is available online.³⁹ Another valuable resource for using the systems approach to amelioration of health care disparities is the series titled “Health Affairs: At the Intersection of Health, Health Care and Policy.” This series contains such titles as “Left Out: Immigrants’ Access to Health Care and Insurance” and “Interventions to Reduce Racial and Ethnic Disparities in Health Care.”⁴⁰

Moving Toward Justice in Research

History documents that although man’s humanity toward his fellows has always been inspirational, even in the direst of circumstances, man’s inhumanity toward his fellows has been appalling, even in the best of circumstances. Following the Allied victory in World War II, the Nuremberg War Crimes Trials included proceedings to develop a code of ethics addressing the issue of consent in human experimentation. The Nuremberg Code was established in 1948 and stated that “The voluntary consent of the human subject is absolutely essential.”⁴¹ Concern for human rights has remained in the forefront of world consciousness since that time. In 1964, the World Medical Association chose to address this issue at a meeting of the organization in Finland. The Declaration of Helsinki was established to guide medical doctors in biomedical research involving human subjects. It governs international research ethics. It was revised in 1975, 1983, 1989, 1996, 2000, 2002, 2004, and 2008 and is the basis for the good clinical practices used today.

Issues addressed in the Declaration of Helsinki include the following:

• Research on humans should be based on results from laboratory and animal experimentation.

• Research protocols should be reviewed by an independent committee before initiation.

• Informed consent from research participants is necessary.

• Research should be conducted by medically or scientifically qualified individuals.

• Risks should not exceed benefits.⁴²

When particularly shocking acts of injustice and abuse occurred in Tuskegee and at Willowbrook despite the codes of ethics established at Nuremberg and Helsinki, the U.S. government charged the Department of Health, Education and Welfare with developing standards for protecting subjects of human research. Three fundamental ethical principles were put forth in their report:

1. Respect for persons: Protecting the autonomy of all people, treating them with courtesy and respect, and providing for informed consent. Researchers must be truthful and conduct no deception

2. Beneficence: The philosophy of “Do no harm” while maximizing benefits for the research project and minimizing risks to research subjects

3. Justice: Ensuring that reasonable, nonexploitive, and well-considered procedures are administered fairly—fair distribution of costs and benefits to potential research participants—and equally ⁴³

In the United States, the Belmont Report remains the standard by which institutional review boards (IRBs) ensure that subjects of human research are treated with respect for persons, beneficence, and justice. The report states that “Injustice arises from social, racial, sexual, and cultural biases institutionalized in society. Thus, even if individual researchers are treating their research subjects fairly, and even if IRBs are taking care to assure that subjects are selected fairly within a particular institution, unjust patterns may nevertheless appear in the overall distribution of the burdens and benefits of research.”⁴⁴ Equal opportunity to benefit from research has come under scrutiny recently. Theoretically, diseases that predominantly affect racial and ethnic minorities and low socioeconomic groups should have the same opportunity to be studied as diseases predominantly affecting males and whites. Over the past decade, however, there has been concern regarding the lack of inclusion of women as subjects of research⁴⁵ and inadequate inclusion of blacks and Hispanics in human immunodeficiency virus research.⁴⁶ Because trauma is predominantly a disease of racial and ethnic minorities, the poor, and the undereducated and because these populations are regarded as vulnerable by IRBs, there are significant barriers to conducting trauma research. Several EM researchers have questioned whether there exist vulnerable populations in conditions in which acute loss of decisional capacity makes all patients equally vulnerable.⁴⁷ Others question whether the standard informed consent process, refused more often by black than by white patients, may not introduce bias into research studies by underrepresenting disease among minority patients.⁴⁸ Because EM research is predominantly conducted by EP-scientists, our specialty must continue to take the lead in ensuring that all patients have equal access to the benefits of research while they are equally respected and protected from potential abuse.

Moving Toward Diversity in Medical Education and Practice of Emergency Medicine

Increasing the diversity of the medical student population and ensuring that physicians are trained to be culturally competent have been cited as key strategies in addressing health care disparities. The concept of concordance,⁴⁹ or phenomena by which patients prefer physicians who mirror their own cultural and ethnic backgrounds, values, and communication styles and express more satisfaction when cared for by doctors of their own race, emerges as another convincing factor in favor of increasing diversity of the physician workforce. Yet despite increasing evidence of the benefits of physician diversity, we have been slow to change. In 2004, 6.6% of U.S. medical students were Latino and 7.3% were African American. Today, although 16% of the U.S. population is Latino and 13% is African American, only 7.9% of medical students are Latino and 7.1% are African American.⁵⁰ In 1963, Dr. W. Montegue Cobb, in discussing the reasons for the dearth of Negro physicians in the country, cited the inferior quality of education offered to many African Americans, inadequate financial resources, and “failure to become oriented toward medicine and its exacting requirements early enough.”⁵¹ It is unfortunate that almost 50 years later, these continue to be the reasons for the dearth of URM physicians in this country. The National Medical Association and the National Hispanic Medical Association continue to take the lead in nurturing URM high school and college students to consider medicine as a career and to nurture residents toward success. The Diversity Interest Group of the Society for Academic Emergency Medicine (SAEM)⁵² provides virtual and real-time advisement and support to minority students interested in EM, especially those at schools of medicine without an academic department of EM or an EM residency program. Our organization is available to students of color at their Emergency Medicine Interest Group meetings, and we attend the student sections of annual meetings of the National Medical Association and National Hispanic Medical Association. Mentoring in Medicine (MIM),⁵³ an organization started by EPs at Montefiore Medical Center in the Bronx, New York, provides a pipeline program beginning at the elementary school level to encourage URM children in their desire to become health care professionals and to facilitate this desire through mentoring, tutoring, and linkage to resources. Ten graduates of the MIM program were accepted to medical school for the 2011-2012 academic year, and in the 2010-2011 academic year, 21 of the 24 MIM applicants to health professional programs were accepted, most with financial packages.⁵⁴

Current Scope of the Problem in Emergency Medicine

Despite this national mandate, the face of medicine, including EM, has been slow to change and reflect the evolving patient demographics. Between 1978 and 2008, the AAMC reported a workforce totaling 471,409 physicians.⁶ Of all medical school graduates practicing medicine, 75% were white, whereas African Americans, American Indians and Alaska Natives, and Hispanics or Latinos accounted for a combined 12.3% of the U.S. physician workforce. This is in stark contrast to the 30% URM composition of the general population in the United States. Similarly, the specialty of EM in 2008 had a total of 25,516 practicing physicians with a breakdown by race and ethnicity of 78% white (20,016) and 12% minority groups (1474 African American, 1365 Hispanic or Latino, and 156 American Indian).⁵⁵ In comparison to the survey conducted in 1997 by the SAEM Task Force on Women and Minorities, there has been some progress. With a 76% response rate by EM full-time faculty at 105 EM residency programs, minority faculty represented 9% of those surveyed (4% African American, 2% Puerto Rican, 2% Native American, and 1% Mexican American).⁵⁶

Additional problems are presented by the very nature of EM practice. We care for the most disadvantaged and vulnerable racial and ethnic minority populations. The fast-paced and unpredictable clinical setting of the ED has numerous challenges that may lead to disparities in care, including time constraints, limited information, and inadequate resources. The ED health care team must establish rapport quickly and gain a sense of trust from the patient and family. Patients who are acutely ill, sometimes with a language barrier, represent some of the most challenging patients for emergency providers and are at the highest risk for suffering from unconscious bias, disparities in care, and worse outcomes.

According to the IOM and Sullivan Alliance reports, the specialty of EM should adopt the two broad strategies recommended to help reduce racial and ethnic health care disparities by proactively recruiting a diverse workforce and training students, residents, fellows, and faculty in cultural competency.