Diversity in Emergency Medicine: Are We Supporting a Career Interest in Emergency Medicine for Everyone?

Emergency physician personnel crisis: a survey on attitudes of new generations in Slovenia

BACKGROUND

Emergency departments globally are overburdened, and emergency medicine residency is losing popularity among students and physicians. This raises concerns about the collapse of a life-saving system. Our goal was to identify the key workforce reasoning and question medical staff employment behavior.

METHODS

This was a prospective cross-sectional study. In December 2022, medical students and pre-residency doctors in Slovenia were invited to complete a web-based questionnaire. The data were analyzed using T-test, chi-square test, Mann‒Whitney-Wilcoxon tests, and principal component analysis. Open-ended questions were hand-categorized.

RESULTS

There were 686 participatns who clicked on the first page and 436 of those finished the survey. 4% of participants gave a clear positive response, while 11% responded positively regarding their decision to pursue emergency medicine residency. The popularity of emergency medicine decreases significantly among recent medical school graduates upon their initial employment. People who choose emergency medicine are less concerned about its complexity and pressure compared to others. Most respondents preferred 12-hour shift lengths. The preferred base salary range for residents was I$ 3623-4529, and for specialists, it was I$ 5435-6341. The sample's primary personal priorities are achieving a satisfactory work-life balance, earning respect from colleagues, and engaging in academic activities. Factors that attract individuals to choose emergency medicine include high hourly wages, establishment of standards and norms, and reduced working hours.

CONCLUSIONS

Our findings indicate that enhancing compensation, establishing achievable standards and norms, facilitating a beneficial work-life equilibrium, providing assistance with initial property acquisition, stimulating participation in deficit residency programs, fostering collegiality among peers, restricting the duration of shifts, and enabling pension accrual may be imperative in attracting more individuals to pursue emergency medicine residency.

Understanding clerkship experiences in emergency medicine and their potential influence on specialty selection: A qualitative study

Objectives

The specialty of emergency medicine (EM) is experiencing a significant decrease in student interest. In addition, women are historically underrepresented within the specialty at all levels of training and practice. We sought to understand how clinical experiences and perceptions of EM influence specialty selection by medical students, particularly women.

Methods

Using a constructivist grounded theory approach, we analyzed semistructured interviews with senior medical students who considered EM as a specialty. We used purposive sampling to recruit from diverse learning environments and represent a variety of experiences. Participants reflected on their specialty selection process and experiences in EM including their perceived acceptance in the work environment.

Results

Twenty-five medical students from 11 geographically diverse schools participated. A total of 68% (17/25) identified as women. The majority (21/25, 84%) planned on applying to EM residency. We identified four major themes: (1) distressing interpersonal interactions with patients and the ED care team negatively affect students; (2) EM culture includes behaviors that are perceived as exclusionary; (3) beliefs about the attributes of an ideal EM physician and the specialty itself have a gendered nature; and (4) ease of access to mentors, representation, and early exposure to EM environment increased interest in specialty.

Conclusions

Our participants express that EM causes challenges for students to accept the norms of behavior in the field, which is an essential element in joining a group and professional identity formation. In addition, we raise concern that gendered perceptions and language may send exclusionary environmental cues that may negatively impact recruitment of a diverse physician workforce.

Call to action: equity, diversity, and inclusion in emergency medicine resident physician selection

OBJECTIVES

This call to action seeks to improve emergency care in Canada for equity-deserving communities, enabled by equitable representation among emergency physicians nationally. Specifically, this work describes current resident selection processes and makes recommendations to enhance the equity, diversity, and inclusion (EDI) of resident physician selection in Canadian emergency medicine (EM) residency programs.

METHODS

A diverse panel of EM residency program directors, attending and resident physicians, medical students, and community representatives met monthly from September 2021 to May 2022 via videoconference to coordinate a scoping literature review, two surveys, and structured interviews. This work informed the development of recommendations for incorporating EDI into Canadian EM resident physician selection. At the 2022 Canadian Association of Emergency Physicians (CAEP) Academic Symposium, these recommendations were presented to symposium attendees composed of national EM community leaders, members, and learners. Attendees were divided into small working groups to discuss the recommendations and address three conversation-facilitating questions.

RESULTS

Symposium feedback informed a final set of eight recommendations to promote EDI practices during the resident selection process that address recruitment, retention, mitigating inequities and biases, and education. Each recommendation is accompanied by specific, actionable sub-items to guide programs toward a more equitable selection process. The small working groups also described perceived barriers to the implementation of these recommendations and outlined strategies for success that are incorporated into the recommendations.

CONCLUSION

We call on Canadian EM training programs to implement these eight recommendations to strengthen EDI practices in EM resident physician selection and, in doing so, help to improve the care that patients from equity-deserving groups receive in Canada's emergency departments (EDs).

Strategies for recruiting underrepresented in medicine and sexual and gender minority students to emergency medicine

Background

Despite having well-described benefits, diversifying the physician workforce has been an ongoing challenge. Within emergency medicine (EM), multiple professional organizations have identified expanding diversity and inclusion as top priorities. The following is a description of an interactive session held at the SAEM annual meeting addressing recruitment strategies for underrepresented in medicine (URiM) and sexual and gender minority (SGM) students into EM.

Methods

During the session, the authors provided an overview of the current state of diversity in EM. In the small-group portion of the session, a facilitator helped characterize the challenges programs face in recruiting URiM and SGM students. These challenges were described during three distinct phases of the recruitment process: (1) preinterview, (2) interview day, and (3) postinterview.

Results

Our facilitated small-group session allowed for discussing the challenges faced by various programs in recruiting a diverse group of trainees. Common challenges in the preinterview and interview day included messaging and visibility as well as funding and support. Postinterview challenges included communication and the ranking process. Through this exercise, we were able to collaboratively share ideas on tangible solutions that programs may use to overcome their specific challenges.

Conclusions

Given the importance of intentionality in diversifying the physician workforce, the authors describe successful strategies implemented within one residency program and those shared by session participants to overcome recruitment challenges.

Interest in Serving the Underserved: Role of Race, Gender, and Medical Specialty Plans

Introduction

Medical students often express their plans to care for medically underserved populations, but little is known about how this interest remains during medical school (MS). This study examined how self-reported interest in working with medically underserved communities may change during MS training based on several student characteristics.

Methods

A secondary data analysis of all student records in the Electronic Residency Application Service (ERAS) from 2005 to 2010 is presented. Predictors included gender, under-represented in medicine (URiM) status, age, academic metrics, career interest, and medical specialty choice. Outcomes included interest in caring for medically underserved populations when entering MS, graduating MS, and graduating MS controlling for entering interest.

Results

The total population included 6890 student records (49.5% women and 18.2% URiM). Women had a higher likelihood of being interested in practicing in underserved communities when entering and graduating MS (odds ratio [OR] 1.55, 95% confidence interval [CI] 1.37-1.77; OR 1.24, 95% CI 1.09-1.40). For all outcomes, URiM students had a higher likelihood of planning on a career with underserved populations compared with their non-URiM peers. Compared with Emergency Medicine, Internal Medicine/Pediatrics and Family Medicine had a higher likelihood of plans to work with underserved populations upon entering, graduating, and at graduation controlling for entering interest.

Discussion

Gender, race, and specialty choice all had meaningful associations with a student's plans on practice in an underserved community. This study's findings can help support efforts to improve MS diversity nationally and drive study on cultural effects embedded within medical specialty identity.

[Nuclear Medicine Physicians: A threatened species?]

Einleitung Die demografische Entwicklung in Deutschland führt zu einem ärztlichen Nachwuchsmangel. Ziel dieser Arbeit ist es, aus den von der Bundesärztekammer (BÄK) veröffentlichten Ärztestatistiken der letzten 25 Jahre die Entwicklung und den aktuellen demografischen Status der Nuklearmedizin in Deutschland darzustellen und deren Konsequenzen aufzuzeigen.

Materialien und Methoden Die seit 1996 von der BÄK jährlich veröffentlichten Zahlen der ärztlichen Versorgung in Deutschland wurden systematisch im Hinblick auf die Altersentwicklung und die Geschlechterverteilung in den Fächern Nuklearmedizin, Radiologie und Strahlentherapie zusammengefasst und mit einer deskriptiven Statistik ausgewertet.

Ergebnisse Die Anzahl der berufstätigen Fachärzt*innen hat sich von 1996–2021 in der Nuklearmedizin um 114% erhöht mit einer deutlichen Verschiebung der Altersstruktur in die älteren Altersgruppen: 2021 lag der Anteil der Ärzt*innen unter 40 Jahren bei 13,0% in der Nuklearmedizin und bei 21,0% in der Radiologie und derjenige Anteil über 60 Jahren bei 27,1% in der Nuklearmedizin und bei 22,3% in der Radiologie. Der Anteil an Frauen lag im Jahr 2021 in der Medizin insgesamt bei 48,5%, in der Nuklearmedizin, Radiologie und Strahlentherapie bei 34,4%, 37,1% bzw. 48,0%.

Schlussfolgerungen Die Fachärzt*innen in der Nuklearmedizin sind 2021 deutlich älter als diejenigen in der Strahlentherapie und Radiologie, und der Anteil von Frauen ist unterdurchschnittlich. Wenn die Nuklearmedizin als eigenständiges Fach ihrer klinischen Verantwortung gerecht werden will und eigenständig bestehen bleiben möchte, müssen die Bemühungen vor allem um den weiblichen medizinischen Nachwuchs in der nuklearmedizinischen Gemeinschaft eine maximale Priorität bekommen.

Diversity of the physician workforce: Specialty choice decisions during medical school

Background

Despite efforts to increase the overall diversity of the medical student body, some medical specialties have a less diverse applicant pool based on both gender and race than would be expected based on medical graduate demographics.

Objectives

To identify whether women and Underrepresented in Medicine (URiM) medical students have baseline differences in their career interests or if their career plans change more during medical school when compared to men and non-URIM students.

Methods

Secondary data analyses of all medical students who applied through ERAS from 2005–2010 was conducted. Binary logistic regression models with the response being a planned career in one of four medical specialties (internal medicine, pediatrics, OB/GYN, and general surgery/surgical specialties) at medical school entry and graduation. Regression models included demographics, student attitudes, debt, academic metrics, and medical school experiences.

Results

Comparatively, women were less likely to be interested in internal medicine and surgery and more interested in pediatrics and OB/GYN at matriculation. URiM students expressed more interest in OB/GYN and surgery when starting medical school. At graduation, women were less likely to plan for internal medicine and surgery and were more interested in pursuing OB/GYN and pediatrics. URiM students were more likely to plan for a career in internal medicine and less likely to choose pediatrics.

Conclusions

From matriculation to graduation, women have relatively stable preferences regarding planned medical specialties. In contrast, URiM students’ specialty plans shifted over time among the four specialties, with variation in preferences occurring between matriculation and graduation.

Characteristics of medical students interested in emergency medicine with intention to practice in underserved areas

OBJECTIVES

Emergency departments serve a wide variety of racial, ethnic, socioeconomic, and gender backgrounds. It is currently unknown what characteristics of students who express interest in emergency medicine (EM) are associated with a simultaneous desire to work in medically underserved areas. We hypothesize that those who are underrepresented in medicine, are female, learn another language, and have more student debt will be more likely to practice in a medically underserved area.

METHODS

Data from the National Board of Medical Examiners, Association of American Medical Colleges (AAMC) Student Record System, and the AAMC Graduation Questionnaire were collected on a national cohort of 92,013 U.S. medical students who matriculated from 2007 through 2012. Extracted variables included planned practice area, intention to practice in underserved areas, race/ethnicity, sex, medical school experiences, age at matriculation, debt at graduation, and first-attempt USMLE Step 1 score.

RESULTS

EM-intending students who identified as female, non-Hispanic Black/African American, or Latinx/Hispanic; had a larger debt at graduation; had experiences with health education in the community; had global health experience; and had learned more than one language were more likely to report an intention to practice in underserved areas.

CONCLUSION

With the increasing importance of physician diversity to match those of the community being served, this study identifies factors associated with a desire of EM students to work in underserved areas. Medical schools and EM residencies may wish to consider these factors in their admissions process.

Untold stories: Emergency medicine residents' experiences caring for diverse patient populations

OBJECTIVES

The Accreditation Council for Graduate Medical Education expects specialties to teach and assess proficiency in culturally competent care. However, little guidance has emerged to achieve these goals. Clinical training within socioeconomically disparate settings may provide an experiential learning opportunity. We sought to qualitatively explore resident experiences working in the generic clinical learning environments (i.e., exposure to socioeconomically diverse patients across different training sites) and how it shapes cultural competency-related skill development.

METHODS

Residents were recruited from emergency medicine (EM) programs. We used purposeful sampling across all postgraduate years and elicited experiences related to working at the different sites related to cultural identity, frustrating patient encounters, vulnerable populations, and development of health disparities/social determinants of health knowledge. Individual structured interviews were conducted via phone between May and December 2016. Interviews were audiotaped, transcribed, anonymized, and analyzed using systematic and iterative coding methods.

RESULTS

Twenty-four interviews revealed three main themes. EM residents' experiences caring for patients across sites shaped their understanding of: (1) potential patient attributes that affected the clinical encounter, (2) difficulties in building rapport had adverse effect on the clinical evaluation, and (3) residency program and training experiences shaped their clinical preparedness and willingness to work in underserved areas.

CONCLUSION

Assessing the impact disparate clinical setting exposures have on trainees' preparedness to care for socioeconomically diverse patients can provide valuable insight for medical educators into barriers and facilitators to delivering optimal learning and patient care. Participants provided a breadth of stories illuminating their real-world consciousness and competency with meeting the needs of diverse populations and their access to varied educational outlets to grapple with the disparities they observed. More research is needed to uncover effective strategies to help residents thrive and feel more prepared to care for diverse populations.

Factors influencing emergency medicine residency choice: Diversity, community, and recruitment red flags

BACKGROUND

Emergency medicine (EM) applicants consider many factors when selecting residency programs. Prior studies have demonstrated that applicants consider geography as well as modifiable/nonmodifiable program factors. Less attention, however, has been paid to underrepresented groups. Additionally, the prevalence and characteristics of "red flags," or factors that may lead an applicant to lower a program's rank or not rank it at all, remain unknown in EM. Our objective was to describe the factors that influence current EM-bound medical students' residency selection focusing on underrepresented applicants and red flags encountered during the recruitment process.

METHODS

We conducted a mixed-methods survey study of EM-bound graduates from U.S. medical schools in the 2020 application cycle. Quantitative analysis included descriptive statistics, measures of central tendency, 95% confidence intervals (CIs), nonparametric tests for ordinal data, and logistic regression. For the qualitative portion of the study, two independent reviewers performed a thematic analysis of the red flag free-text responses. Discrepancies were addressed via consensus with third-party oversight.

RESULTS

Our survey response rate was 49%, and most applicants considered both geographic and program factors. Underrepresented applicants prioritized program diversity, program commitment to the underserved, neighborhood/community, and patient population. Of all respondents, 71% reported red flags. Women had a significantly higher odds of encountering red flags (odds ratio = 1.64, 95% CI = 1.25 to 2.18). Red flags included seven key themes: violations of regulatory standards, program characteristics, interview day experience, program culture, interpersonal interactions, lack of fit, and quality of life; subthemes included lack of diversity and racism.

CONCLUSIONS

Modifiable/nonmodifiable program factors and geography continue to influence EM-bound applicants' residency choices. Underrepresented applicants place a higher value on diversity, community, and patients served. Residency programs should consider modifiable factors and self-assess for red flags to successfully recruit the next generation of EM physicians.

A mandatory Emergency Medicine clerkship influences students' career choices in a developing system

BACKGROUND

Attracting medical students for a front-line specialty, Emergency Medicine, is challenging in many countries. The available literature is scarce and bounded to the mature emergency care and education systems. In the countries where emergency medicine is a new specialty and has different contextual needs, the perception of the students and their career interest in emergency medicine specialty is an unanswered question.

OBJECTIVE

We aimed to study the effects of a mandatory Emergency Medicine (EM) clerkship on students' perceptions and their future career choice to be emergency physicians.

METHODS

A voluntary de-identified survey was prospectively collected before and after the EM clerkship to capture students' perceptions in four domains (EM clerkship, EM physicians, EM patients, and EM specialty as a career choice). The survey included 24 statements having five-point Likert scale for each statement. Non-parametric Wilcoxon signed rank test was used for statistical analysis.

RESULTS

Sixty-seven students responded to both surveys (response rate of 85%). Students' perceptions have significantly improved on the EM physicians, and their job after attending the clerkship (p < 0.001). They found EM a respected (p = 0.038), flexible (p < 0.001), secure (p < 0.001), satisfying, and prestigious (p = 0.006) job. They found EM physicians compassionate (p < 0.011), have adequate patient contact (p < 0.045) and control on their time (0.004). Choosing EM as a future career has significantly increased after clerkship (p < 0.001).

CONCLUSIONS

Our mandatory EM clerkship significantly improved students' perceptions on EM specialty as a future career choice. A well-structured and mandatory EM clerkship can attract more students to be trained in the EM.

Medical students attitudes toward and intention to work with the underserved: a systematic review and meta-analysis

BACKGROUND

Experts in the field of medical education emphasized the need for curricula that improve students' attitudes toward the underserved. However, some studies have shown that medical education tends to worsen these attitudes in students. We aimed at systematically reviewing the literature assessing the change in medical students' attitudes toward the underserved and intention to work with the underserved throughout medical education, the sociodemographic and educational factors associated with favorable medical student attitudes toward and/or intention to work with the underserved and the effectiveness of educational interventions to improve medical student attitudes toward and/or intention to work with the underserved.

METHOD

We conducted a systematic review on MEDLINE, Scopus, and Web of Science databases. Three investigators independently conducted the electronic search. We assessed the change in medical students attitudes toward the underserved by computing a weighted mean effect size of studies reporting scores from validated scales. The research team performed a meta-analysis for the sociodemographic and educational factors associated with medical students attitudes toward and/or intention to work with the underserved.

RESULTS

Fifty-five articles met the inclusion criteria, including a total of 109,647 medical students. The average response rate was 73.2%. Most of the studies were performed in the USA (n = 45). We observed a significant decline of medical students attitudes toward the underserved throughout medical education, in both US and non-US studies. A moderate effect size was observed between the first and fourth years (d = 0.51). Higher favorable medical students attitudes toward or intention to work with the underserved were significantly associated with female gender, being from an underserved community or ethnic minority, exposure to the underserved during medical education and intent to practice in primary care. Regarding educational interventions, the effectiveness of experiential community-based learning and curricula dedicated to social accountability showed the most positive outcome.

CONCLUSIONS

Medical students attitudes toward the underserved decline throughout medical education. Educational interventions dedicated to improving the attitudes or intentions of medical students show encouraging but mixed results. The generalizability of our results is impeded by the high number of studies from the global-North included in the review.