The United States is a country of rich ethnic and cultural diversity, which, although a strength in many regards, makes health disparities readily apparent. According to the 2020 Census data, the population of the United States is 75.8 percent white, 18.9 percent Hispanic, and 13.6 percent Black/African American.¹ However, when comparing the current physician workforce, the 2022 Physician Specialty Data Report recorded nearly 64 percent of physicians as white, 20.6 percent Asian, only 6.9 percent Hispanic/Latino and only 5.7 percent Black/African American.² It is a growing belief, backed by evidence, that patients have better health outcomes when the physician workforce reflects the complexity and diversity of the patient population.³ One recent study to assess the association between mortality rates in the U.S. and Black representation among primary care physicians found that greater Black workforce representation was associated with higher life expectancy and was inversely associated with all-cause Black mortality.³ Therefore, to better serve our diverse patient population, the field of medicine has been taking innovative and comprehensive steps on improving physician diversity, including pipeline programs, community outreach, and efforts to retain and advance faculty from underrepresented minorities.

Despite these efforts, medical students and residents from underrepresented minorities still face myriad obstacles when navigating their training, from macroaggressions such as overt racism to more subtle microaggressions such as being mistaken by a patient or colleague for a nurse or service worker. These types of encounters increase burnout and compassion fatigue and contribute to minority physicians leaving medicine altogether.^4-6 Experiencing mistreatment and discrimination by patients, families, and visitors has significant occupational and personal implications. Discrimination negatively impacts career satisfaction, career advancement, and job turnover.^4-6 Studies have showed that up to 62 percent of minority medical students note that microaggressions encountered at work lead to feelings of burnout while 40 percent of physicians who have experienced discrimination considered changing careers.^4,5 Hence, acknowledging and discussing implicit bias, structural racism, and discrimination within the house of medicine is crucial.⁷

Addressing such a vast issue is multifaceted

One proposed solution is incorporating diversity, equity, and inclusion (DEI) education into residency training—and faculty training. DEI encompasses everything from fostering and recruiting medical students from diverse backgrounds, to learning about how implicit biases and research biases affect patient care, to teaching physicians how to recognize and address macro- and microaggressions in the workplace. For example, why are myocardial infarctions in women often underdiagnosed? The answer includes the fact that many studies regarding cardiovascular disease and myocardial infarctions primarily recruited men as subjects, creating an unintentional bias.⁸ Biases like this have been enshrined in medical textbooks for decades—fighting to change such truisms can be challenging.

Moreover, certain states—Florida and Texas in particular—have begun to remove or outright ban DEI from public education. The Texas passed SB17, which curbs the ability of public universities to incorporate DEI initiatives into training, hiring, admission, or education.⁹ In earlier versions of the bill, this would have been enforced to the extreme that if faculty discuss DEI, they will have to take a year without pay for the first offense and will be fired for the second.⁹ Similarly, Florida passed a law called the Individual Freedom Act, commonly known as the Stop Wrongs to Our Kids and Employees (STOP WOKE) Act, which prevents employers—including universities—from promoting DEI in any form.¹⁰ While opponents cite these measures as blatantly racist and sexist, lawmakers in support of these restrictive bills claim that they actually uphold equality because diversity, equity, and inclusion endorses a culture of exclusion for those not considered diverse.

Preventing inequality

Laws and proposals like the ones in Florida and Texas may damage the public education system and threaten to impact DEI in residency training and medical education as well. If DEI is banned from primary school to graduate-level education, our society will create a physician workforce that is less diverse and less well versed in the socioeconomic intricacies affecting our patients. Broader laws attempting to cut off all employers from incorporating DEI would directly impact resident education and negatively affect both patient care and physician well-being.

Currently, there is no Accreditation Council for Graduate Medical Education requirement to include DEI training in resident education, nor is there a recommended standardized curriculum. But, if we hope to preserve and build on a culture of tolerance and diversity, medicine must encode DEI education into residency training. Emergency medicine, long a pioneer and advocate for social justice, is primed to take the lead.

Dr. Görgens is ACEP Now’s 2022–23 resident fellow leading the Resident Voice column.

Dr. Fernandez s a graduate of Northwell Northshore-LIJ emergency medicine residency where he served as chief resident. His passion includes education, DEI, and mentorship. He is born and raised in New York, NY, and will be pursuing his fellowship at Mount Sinai.

References

1. QuickFacts: United States. The United States Census Bureau website. Accessed June 12, 2023.
2. Association of American Medical Colleges. 2022 Physician Specialty Data Report: Executive Summary. Association of American Medical Colleges website. Accessed June 12, 2023.
3. Snyder JE, Upton RD, Hassett TC, Lee H, Nouri Z, Dill M. Black representation in the primary care physician workforce and its association with population life expectancy and mortality rates in the US. JAMA Netw Open. 2023;6(4):e236687.
4. Nunez-Smith M, et al. Health care workplace discrimination and physician turnover. J Natl Med Assoc. 2009;101(12):1274-1282.
5. Chisholm LP, Jackson KR, Davidson HA, Churchwell AL, Fleming AE, Drolet BC. Evaluation of racial microaggressions experienced during medical school training and the effect on medical student education and burnout: A validation study. J Natl Med Assoc. 2021;113(3):310-314.
6. Dyrbye L, et al. Physicians’ experiences with mistreatment and discrimination by patients, families, and visitors and association with burnout. JAMA Network Open. 2022;5(5):e2213080.
7. Landry A, Dark C. Only 6 percent of Med School Grads Are Black—Here’s Why That’s a Major Problem for the U.S. Courier website. Published August 14, 2020. Updated/archived November 23, 2020. Accessed June 12, 2023.
8. Woodward M. Cardiovascular disease and the female disadvantage. Int J Environ Res Public Health. 2019;16(7):1165.
9. Creighton B, et al. Senate Bill Number 17, 88th Texas Legislature Regular Session. Texas Legislature website. Published March 10, 2023. Updated May 29, 2023. Accessed June 12, 2023.
10. Bell, et al. CS/HB7 (2022). Florida House of Representatives website. Published January 11, 2022. Last Updated April 22, 2022. Accessed June 12, 2023.