Diversity Snowball Effect

Starting with a common understanding of key words, phrases, and potentially misunderstood related terms in DEI discussions helps ensure that all participants feel informed and welcome to participate in the discussion. Some terms have multiple definitions provided to help highlight nuances in the definitions.

Diversity: Refers to the identities we carry. There are many kinds of diversity, based on race, gender, sexual orientation, class, age, country of origin, education, religion, geography, physical or cognitive abilities, or other characteristics. Valuing diversity means recognizing differences between people, acknowledging that these differences are a valued asset, and striving for diverse representation as a critical step towards equity. (1)

Snowball Effect: A situation in which one action or event causes many other similar actions or events (2)

Diversity Snowball Effect: A situation where individuals of certain identity groups see others within those groups thriving in a certain environment (program, organization, workplace, etc). This subsequently attracts a critical mass of high-performers. (3)

Minoritized: Groups that are different in race, religious creed, nation of origin, sexuality, gender, or other identity and as a result of social constructs have less power or representation compared to other members or groups in society (4) 

Marginalized: Process experienced by those under- or unemployed or in poverty, unable to participate economically or socially in society, including the labor market, who thereby suffer material as well as social deprivation. (1)

Underrepresented in Medicine (URiM): those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population. (5)

This section highlights the definitions of other words that may be used in discussion of this topic. Sometimes these words can be used interchangeably with the terms defined above, and sometimes they may have been used interchangeably historically, but have distinct meanings in DEI conversations that it is helpful to recognize.

Equity: Refers to fairness and justice and is distinguished from equality. While equality means providing the same to all, equity requires recognizing that we do not all start from the same place because power is unevenly distributed. The process is ongoing, requiring us to identify and overcome uneven distribution of power as well as intentional and unintentional barriers arising from bias or structural root causes. (1)

Inclusion: Refers to how our defining identities are accepted in the circles that we navigate. Belonging evolves from inclusion; it refers to the extent to which individuals feel they can be authentic selves and can fully participate in all aspects of their lives. Inclusion is a state of being valued, respected and supported. At the same time, inclusion is the process of creating a working culture and environment that recognizes, appreciates, and effectively utilizes the talents, skills and perspectives of every employee; uses employee skills to achieve the agency’s objectives and mission; connects each employee to the organization; and encourages collaboration, flexibility and fairness. In total, inclusion is a set of behaviors (culture) that encourages employees to feel valued for their unique qualities and experience a sense of belonging. (1)

Justice: Describes a future state where the root causes (e.g., racism, sexism, class oppression) of inequity have been dismantled and barriers have been removed. It is an achievable goal that requires the sustained focus, investment, and energy of leaders and communities working together, holding each other accountable to redesign structures, policies, and practices to deliver the highest quality and safest possible conditions that allows for everyone to reach their highest potential. (1)

As many users may have varying amounts of time to present this material, the authors have recommended which resources they would use with different timeframes for the presentation.

1 minute

1. Context and Background: Facilitator uses powerpoint slide to briefly introduce the concept of the snowball effect and the importance of intentionality around DEI recruitment

10 minute

1. Context and Background: Facilitator explains relevant definitions and briefly reviews the PRESS model
2. Role Playing Scenario: Facilitator leads the group in brainstorming interventions they can implement today at their program that would result in lasting change tomorrow

30 minute

1. Context and Background: facilitator explains relevant definitions and briefly reviews the PRESS model
2. Group Engagement Activity: Facilitator introduces the following:
   1. Review one journal article, we recommend:
      1. Garrick JF, Perez B, Anaebere TC, Craine P, Lyons C, Lee T. The Diversity Snowball Effect: The Quest to Increase Diversity in Emergency Medicine: A Case Study of Highland's Emergency Medicine Residency Program. Ann Emerg Med.2019;73(6):639-647
   2. 5 minute video clip -Diversity, Inclusion, and Equity in Emergency Medicine Research, Education, and Clinical Practice (ADIEM Sponsored) (3:16-8:33)
3. Role Playing Scenario: Facilitator leads the group in brainstorming interventions they can implement today at their program that would result in lasting change tomorrow

This section provides an overview of this topic so that an educator who is not deeply familiar with it can understand the basic concepts in enough detail to introduce and facilitate a discussion on the topic. This introduction covers the importance of this topic as well as relevant historical background.

It is well known that the field of medicine, including emergency medicine, lacks diversity. (7) When compared to the diversity of the US, emergency medicine physicians are substantially less diverse in every measured domain including race, ethnicity, gender, and LGBTQ+ identities. (8) Diversifying the health profession is essential, as it has been proposed as a means of decreasing health disparities. Incorporating diverse backgrounds brings a range of viewpoints and life experiences into an organization. There is evidence to suggest that patients achieve better outcomes from individuals of concordant backgrounds. (9) Furthermore, without a diverse range of identities an organization will find it challenging to attain equity or inclusion.

Some differences in representation can be partially attributed to systemic issues such as the large-scale disenfranchisement of minoritized groups resulting in fewer educational opportunities which ultimately contributed to less diversity in medical schools. One notable example of systematic disenfranchisement resulted from the Flexner Report. In 1910, Abraham Flexner published a report which transformed medical education by centering the advancement of scientific knowledge as the ethos of the physician and categorized medical schools based on observational factors. (10) The transformation of academic medicine to incorporate the principles detailed in Flexner’s report was largely supported by the Rockfeller and Carnegie Foundations. (10) His report ultimately resulted in the closing of one third of all medication institutions, including 5 of the 7 institutions serving Black people. (10,11) It intentionally excluded certain identities, such is Black Americans and women, from the practice of medicine ultimately imbedding racial and sexual descrimination into the field. (10,11) More than 100 years later, academic medicine is still seeking to create a more equitable distribution of racial and ethnic groups in medicine. (12)

The lack of representation of disenfranchised populations ultimately makes the path to medicine increasingly difficult to navigate due to a paucity of mentors. However, much can and should be done to promote diversity within emergency medicine. Addressing the lack of diversity will take creative problem solving and societal buy-in. Within emergency medicine, taking those first steps toward addressing disparities can seem daunting. The notion that diversity begets diversity and lack of diversity begets lack of diversity implies that it may be seemingly impossible to change representation in medicine. (13) However, research has shown that over time, institutions and organizations can transform. 

The diversity snowball effect introduces the concept of a positive feedback loop when creating a more diverse, equitable, and inclusive organizational culture. When an organization implements good faith efforts toward creating a diverse and inclusive environment, individuals from marginalized backgrounds see this as a place where they will be supported, drawing them to the program. (3) Such actions can range from creating visiting clerkships for students from backgrounds underrepresented in medicine (URiM), to integrating DEI topics into educational curricula, and incorporating DEI contributions into promotion and tenure requirements. With time, the snowball builds and more individuals embrace the importance of sustaining DEI efforts. The initial actions may be difficult as they may require dedicated funding from already stretched budgets and training in uncomfortable topics. However, once a critical mass is achieved, further advancing DEI efforts becomes less challenging as they are weaved into the departmental culture. While the ultimate goal may take years or decades to achieve, the diversity snowball effect posits that small actions today can have a lasting, sustained, and powerful impact tomorrow.

Starting this change is vital to emergency medicine departments as research indicates that student and resident attitudes toward program diversity are evolving. Recent literature consistently reports the importance of changing systems and cultures to recruit and retain diverse students, residents, and faculty. (14) Specifically, with regards to residency selection, there is a growing trend highlighting the importance of both geographic location diversity and institutional staff diversity amongst applicants to US residency programs. (15) Residents from underrepresented backgrounds have expressed challenges in residency, including experiencing microaggressions, overcoming tokenism and being seen as an ambassador for their race and culture. These challenges cause difficulty in creating a positive professional identity. (16) Faculty, such as female physicians, face disparities in salary and leadership promotion. (17) These experiences led to the creation of best practices for faculty recruitment, retention, and representation. (14) The success of a program may ultimately depend on its ability to attract competitive candidates, create a healthy environment for residents, and cultivate faculty talent. 

Healthcare organizations, including academic emergency medicine programs, have struggled with overcoming deeply ingrained conscious and unconscious factors when attempting to create culture change. Several best practices have been published in the EM literature on what departments should do. (14) To understand how these interventions can be implemented, we refer to the work published in the business literature. Robert Livingston’s PRESS model incorporates problem awareness, root-cause analysis, empathy, strategy, and sacrifice to promote racial equity in the workplace. (18) Put plainly, the greatest need to achieve the diversity snowball effect (where diversity begets diversity) is to assess one’s current state of diversity and set a path forward. Livingston’s PRESS model can be readily applied to a healthcare system seeking to create a meaningful impetus to start a diversity snowball. 

• Problem Awareness: Understanding the current state of an organization is critical to setting goals. Surveying the current environment allows a department to determine needs and define priorities. While a mission statement may act as a compass to provide a general direction, it requires a sense of knowing where one is and where one wants to go to be useful. Problem awareness begins with data collection to understand the current demographics of an organization and its leadership. It may also mean understanding the rates of attrition and retention. It will require the buy-in from leadership stakeholders to permit access to potentially sensitive information. Problem awareness may be most challenging in that departments may be unwilling or fearful to openly acknowledge their deficiencies; however, leadership must be brave in recognizing it as a necessary step in initiating a diversity snowball effect. Some tools available to assess the institutionalization of diversity, equity, and inclusion include the AAMC’s Achieving Inclusion Excellence in Academic Medicine: The Foundational Principles of Inclusion Excellence (FPIE) Toolkit and the New England Resource Center for Higher Education (NERCHE) Self-Assessment Rubric for the Institutionalization of Diversity, Equity, and Inclusion in Higher Education. (19,20) Both tools provide rubrics that can help departments and institutions assess at what stage they are in achieving diversity, equity, and inclusion goals and may be available through institutional diversity offices.
• Root-cause analysis: After an organization identifies the problem, they must then ask “why” the problem exists. This step is just as important and potentially difficult as problem awareness. Asking why requires a thoughtful, introspective approach that challenges previous assumptions and deeply ingrained barriers. It is helpful to consider which barriers are at play. Dr. Camara Phyllis-Jones describes three levels of racism: institutionalized, personally-mediated, and internalized. (21) In her article, she defines institutionalized racism as, “differential access to the goods, services, and opportunities of society by race… it is structural, having been codified in our institutions of custom, practice, and law…” A frequently cited example of institutionalized racism in medical education is the use of United States Medical Licensing Examination (USMLE) Step 1 scores as a predictor of clinical skills. (22) USMLE Step 1 scores were shown to not be good predictors of resident clinical performance, however, they were heavily utilized in the resident selection process. (22) The National Board of Medical Examiners (NMBE) re-evaluated the exam’s purpose and impact and transitioned it to pass-fail. (23) In parallel with this transition was the promotion of holistic review, which aims to review the entirety of an applicant and generally de-emphasizes numeric reporting from standardized test exams. (24) This is an example of how systems can both be hurtful (operating on incorrect assumptions and potentially introducing bias) and helpful (removing previous barriers to allow a standard, more fair approach to assessment). A thorough root cause analysis recognizes that both individuals and systems have a complex interplay that can create exclusion, thereby hindering a successful diversity snowball effect.
• Empathy: While objective data collection and analysis of root causes can produce a well-thought-out strategy, buy-in from key stakeholders will ultimately be needed to create change. One way to obtain stakeholder buy-in is by cultivating empathy. There are many ways to stimulate empathy. One such method is to make the invisible visible. Hearing the lived stories of discrimination faced by various groups can help create a better understanding (and hopefully empathy) for the challenges faced by marginalized populations. For example, sharing parents’ stories of breastfeeding and their challenges, such as pumping while on shift, inadequate facilities, or lack of privacy, can help garner empathy for their situation. (25) The problem, without passion, will not drive change. However, once this empathy is cultivated, the equity mindset is put into practice and facilitates the snowball effect for future diversity efforts. 
• Strategy: Now that the problem is understood, the root causes are identified, and there is buy-in from key stakeholders, it is time to develop an intervention. A thoughtful intervention applies the SMART goals acronym: specific, measurable, attainable, relevant, and time-bound. It is equally important to measure your progress. After all, results will speak volumes to your key stakeholders, who are inevitably asked to make an investment in your intervention. Recognizing that there are individual and institutional layers to any barrier, Livingston suggests that actionable and sustainable change requires addressing three categories, personal attitudes, informal cultural norms, and formal institutional policies. There are many examples within emergency medicine training programs that have found success including visiting student clerkships, DEI committees, and formalizing DEI department leadership roles. The implementation of holistic review is another great example. From a personal attitude, there must be a fundamental understanding of the various values in which an individual’s success and contributions can be defined. Cultural norms must be challenged as certain extra-curricular activities may erroneously be seen as predictors of success over other activities. Lastly, institutional policies must allow for the appropriate application of blinding or highlighting of unique attributes - a policy that “color blinds” an application, for example, can have the opposite effect than intended. 
• Sacrifice: It is difficult to imagine a successful intervention that does not require time, money, or both. Stakeholder buy-in is equally important as they must be willing to commit resources and prepared to sacrifice to achieve long-term goals. Those looking for a “free win” are unlikely to find success. Creating a diversity snowball effect requires a long-term commitment to an equity mindset and interventions that are likely to produce dividends well beyond the initial investment. Over time, as an organization develops a culture that prioritizes diversity and promotes a sense of belonging, its reputation will speak for itself. High-quality trainees, faculty, and staff will gravitate to places where they can thrive. 

Overcoming organizational culture to create lasting change may seem daunting. Remember, the diversity snowball effect is a process that will require an ongoing, intentional commitment to achieve a long-term goal. The PRESS model is just one tool that can be used to facilitate this process.

This section highlights the objective data available for this topic, which can be helpful to include to balance qualitative or persuasive analysis or to help define a starting point for discussion.

According to a 2020 AAMC report, 2,885 of the 8,029 (35.9%) active EM residents were female. This study suggests a correlation between female residents, total female leadership, and female chief residents. (13)

On diversity visiting clerkships: “Prior to program implementation, URiM residents represented approximately 13.9% of all residents (95% confidence interval [CI] = 11.5% to 16.3%, p = 0.000). Three years after implementation, there was a significant net increase of 3.6% (95% CI = 1.70% to 5.5%, p = 0.009) URiM residents recruited, resulting in URiM residents representing 17.5% of residents in these nine programs at the end of 3 years.” (26) 

On the “diversity snowball effect:” Compared with the graduating classes of 1990 to 2009 and before the initiative, the proportion of underrepresented minorities in the graduating classes of 2010 to 2021 significantly increased, from 12% to 27% (95% confidence interval [CI] 6% to 24.1%), as did the overall proportion of nonwhite residents, from 24% to 47% (95% CI 11.7% to 33.1%) (3)

Images and graphical representations in presentations can clarify concepts and enhance interest. Please cite the sources of these images appropriately if you use them in your presentation, found in the last section of this page. We purposefully avoided providing complete slide decks in this curriculum, and instead opted to offer easy building blocks for a great personalized presentation regardless of the format.

Role-playing scenarios can enhance investment and participation. Always consider psychological safety when asking participants to engage in any role-playing activity to avoid potential adverse effects. We highly recommend a discussion for each group to agree on ground rules of respectful learning prior to engaging in any role-playing scenarios (embrace ambiguity, commit to learning together, listen actively, create a brave space, suspend judgment, etc.). It is reasonable to review these ground rules prior to each role-playing discussion.

Knowing your department’s structure, please use this time to consider how you create and implement one of the following interventions using the PRESS model. 

Consider, what is your current state vs ideal state. Be sure to consider any perceived barriers and describe possible solutions on how you might overcome them.

• Creating a diversity visiting clerkship
• Creating a DEI Committee
• Increasing community engagement 
• Supporting a URiM student/resident/faculty to minimize isolation

This section should help the facilitator anticipate any questions, naysayers, rebuttals, or other feedback they may encounter when presenting the topic and allow preparation with thoughtful responses. Facilitators may experience concerns about their personal ability to present a specific DEI topic (ie a white facilitator presenting on anti-racism or minority tax), and this section may address some of those tensions.

The perception of a zero-sum game

• This is more of a myth than an actual barrier. Some people hold the viewpoint that implementing diversity strategies will take resources from historically majority populations. In actuality, creating a more supportive environment or improving accessibility for those with a physical disability benefits everyone.
• Recognize that the US population and medical schools are becoming increasingly diverse. Physicians should be representative of the populations they seek to treat. Thus over time, all programs may become diverse. 

The challenge of getting started

• It can seem overwhelming when considering the multitude of items that need to be implemented to change an organization's cultural diversity. Remember, creating a diversity snowball starts with small items that grow over time. Start today with something small. Start with an area you are passionate about where you can use your unique talents and privileges to create change.

Patience and persistence 

• Remember, change takes time. These are serious, long-term goals that may require wide-scale departmental change or the acquisition and incorporation of resources and training that the department currently does not have. Recruiting, for example, happens over a very long time scale. Remind stakeholders that it will require sacrifice to achieve these goals. 
• The first change is often invisible and unmeasurable (the hidden curriculum), but it is a necessary first step. 

Diversity benefits everyone

• Diversity improves team performance, regardless of an individual’s status. There’s even a business argument: 
  1. https://www.mckinsey.com/business-functions/people-and-organizational-performance/our-insights/why-diversity-matters
  2. https://www.mckinsey.com/business-functions/people-and-organizational-performance/our-insights/is-there-a-payoff-from-top-team-diversity
  3. https://www.bcg.com/en-us/publications/2018/how-diverse-leadership-teams-boost-innovation

Avoiding the “minority tax” 

• This refers to the phenomenon whereby the task of creating diversity initiatives falls on a small number of people who are typically minoritized individuals. Promoting diversity is a cause that should be championed by all - they are not solely the responsibility of one group. If an individual chooses to take on DEI efforts, consider creating an incentive structure to value their work (time, pay, recognition, promotion consideration, as examples.)

Avoiding tokenism

• Tokenism is the concept that individuals of a certain background serve as a representative or “minority spokesperson” of their group. This adds additional stress to those individuals as they are isolated.
• It threatens inclusion by identifying individuals as having a separate role (i.e., to serve as the “minority spokesperson”). Additional impacts of tokenism include isolation, the “minority tax”, and reinforcing stereotypes.

Going beyond recruitment ensures retention and success

• A commitment to diversity cannot be a means to an end. Recruiting students, residents, or faculty should be viewed as the beginning of a journey to support the individual and help them thrive.

Sometimes DEI topics can present depressing history and statistics. This section highlights glimmers of hope for the future: exciting projects, areas of study inspired by the topic, or even ironic twists where progress has emerged or may be anticipated in the future.

Get creative and think outside the “EM box.” There are often resources within the institution and community that are able to leverage larger groups. Creating a community of practice outside of your department can spur creativity and collaboration.

A journal club facilitator can access several salient publications on this topic below.  Alternatively, an article can be distributed ahead of a presentation to prompt discussion or to provide a common background of understanding. Descriptions and links to articles are provided.

1. The Diversity Snowball Effect: The Quest to Increase Diversity in Emergency Medicine: A Case Study of Highland's Emergency Medicine Residency Program (3)
   
   
   Garrick JF, Perez B, Anaebere TC, Craine P, Lyons C, Lee T. The Diversity Snowball Effect: The Quest to Increase Diversity in Emergency Medicine: A Case Study of Highland's Emergency Medicine Residency Program. Ann Emerg Med. 2019;73(6):639-647.  doi.org/10.1016/j.annemergmed.2019.01.039
   This is a case study from an EM program that specifically highlights several interventions and its impact on recruiting URiM. This provides a useful roadmap of specific examples taken within an EM program to demonstrate its commitment to diversity. 
   
   
2. Factors influencing emergency medicine residency choice: Diversity, community, and recruitment red flags (27)
   
   
   Weygandt PL, Smylie L, Ordonez E, Jordan J, Chung AS. Factors influencing emergency medicine residency choice: Diversity, community, and recruitment red flags. AEM Educ Train. 2021;5(4):e10638. doi.10.1002/aet2.10638
   
   This is a mixed methods study in understanding the factors that influence emergency medicine residency applicants choice of programs. Specific analysis was conducted with URiM and LGBTQIA+ individuals to understand their unique perspectives and values. 
   
   
3. How to Promote Racial Equity in the Workplace (18)

Livingston R. How to promote racial equity in the Workplace. Harvard Business Review. November 10, 2020. Accessed here: https://hbr.org/2020/09/how-to-promote-racial-equity-in-the-workplace. This article provides a framework to applying any equity intervention in the workplace. This article can be used for programs to identify what change management step they need to address to advance DEI efforts previously implemented but did not meet expectations.

The questions below could start a meaningful discussion in a group of EM physicians on this topic. Consider brainstorming follow-up questions as well.

1. What have you tried to improve diversity at your institution? 
2. What barriers have you encountered in designing diversity efforts? 
3. Who do you turn to when attempting to overcome these barriers? 
4. Consider your circle of influence, how can you have an impact in improving your department's commitment to diversity?

The authors summarize their key points for this topic below. This could be useful to create a presentation closing.

• Every snowball starts small; think of the step you may be able to take today.
• There is no quick fix - interventions take time to create a culture of equity, inclusivity, and diversity 
• Focus on fixing systems, not statistics, and create an enriching environment for diverse people

Meaningful and relevant quotations (appropriately attributed) can be used to enhance presentations on this topic.

"Life is like a snowball. The important thing is finding wet snow and a really long hill.” -Warren E. Buffett

Below are links to Emergency Medicine-specific resources for this topic.

https://pubmed.ncbi.nlm.nih.gov/34099994/

• A helpful review of current state of EM-specific visiting student diversity scholarships

https://snma.org/page/programspipeline

• A resource from SNMA (Student National Medical Association) on available pathway programs

Below are links to educational resources or supportive programs in the community that are working on this topic.

https://www.aamc.org/what-we-do/equity-diversity-inclusion/action-collaborative-black-men-medicine

• Work at AAMC on recruitment and retention

https://www.tandfonline.com/doi/full/10.1080/0142159X.2021.1935832

• Case study and best practices from several medical schools 

https://www.rand.org/pubs/research_reports/RRA1901-1.html

• Environmental scan of literature and community participatory research on the best practices for designing pathway/pipeline programs

https://www.cultureamp.com

• Resource on workforce diversity

https://hbr.org/2020/11/getting-serious-about-diversity-enough-already-with-the-business-case

• An argument that diversity is more than just a “business case”

https://www.umass.edu/employmentequity/what-works-evidence-based-ideas-increase-diversity-equity-and-inclusion-workplace

• Another good workforce diversity resource guide

Below are links to videos that do an excellent job of explaining or discussing this topic. Short clips could be used during a presentation to spark discussion, or links can be assigned as pre-work or sent out for further reflection after a presentation.

Diversity, Inclusion, and Equity in Emergency Medicine Research, Education, and Clinical Practice

• https://www.saem.org/detail-pages/media/diversity-inclusion-and-equity-in-emergency-medicine-research-education-and-clinical-practice-adiem-sponsored-204bd5

ARMED MedEd - The State of Diversity in Medical Education Today

• https://www.youtube.com/watch?v=WawUH_nQdmw 

Possible questions and an answer key are provided below. These can be useful to document effectiveness in learning and knowledge gained but can also be useful to help learners identify that they may not actually know everything about a DEI topic, even if they have participated in presentations on it previously.

1. What does the AAMC “EAM” acronym stand for?
2. T/F: When creating a diversity committee, it is important to have only diverse individuals 
3. T/F: Recruiting a URiM to our program won’t fix the lack of diversity, there’s only so many diverse applicants.
   

Below is a statement that inspires participants to commit to meaningful action related to this topic in their own lives. This could be used to prompt reflection, discussion, or could be used in a presentation closing.

Take a moment to think about one change you can implement in your residency program that will create a more welcoming and inclusive environment for diverse trainees.

All references mentioned in the above sections are cited sequentially here.

1. American Medical Association and Association of American Medical Colleges. (2021) Advancing Health Equity: Guide on Language, Narrative and Concepts. Available at www.ama-assn.org/equity-guide. 
2. (Merriam-Webster) (Definition of Snowball Effect)
3. Garrick JF, Perez B, Anaebere TC, Craine P, Lyons C, Lee T. The Diversity Snowball Effect: The Quest to Increase Diversity in Emergency Medicine: A Case Study of Highland's Emergency Medicine Residency Program. Ann Emerg Med. 2019;73(6):639-647. doi:10.1016/j.annemergmed.2019.01.039 
4. Minority vs. Minoritized: Why The Noun Just Doesn't Cut It. July 13, 2022. Accessed here: https://www.theodysseyonline.com/minority-vs-minoritize 
5. Underrepresented in Medicine Definition. American Association of Medical Colleges. June 2, 2022. Accessed here: https://www.aamc.org/what-we-do/equity-diversity-inclusion/underrepresented-in-medicine 
6. Equity vs. Equality and Other Racial Justice Definitions, Ann Casey Foundation. Retrieved June 2, 2022 from https://www.aecf.org/blog/racial-justice-definitions?gclid=Cj0KCQjwnNyUBhCZARIsAI9AYlG6YmOUBIoJnCopCyzfmSGoCMMQI65vypM9nLeKPRdwyGU87X9z6_EaAmh1EALw_wcB
7. Diversity in Medicine: Facts and Figures 2019. American Association of Medical Colleges. June 2, 2022. Accessed here: https://www.aamc.org/data-reports/workforce/report/diversity-medicine-facts-and-figures-2019 
8. Ehrhardt T, Shepherd A, Kinslow K, McKenney M, Elkbuili A, Diversity and inclusion among U.S. emergency medicine residency programs and practicing physicians: Towards equity in workforce. The American Journal of Emergency Medicine. 2020;46:690-692. doi: https://doi.org/10.1016/j.ajem.2020.08.055 
9. Alsan M, Garrick O, Graziani G. Does Diversity Matter for Health? Experimental Evidence from Oakland. American Economic Review. (2019) 109(12):4071-4111 https://doi.org/10.1257/aer.20181446 
10. Duffy TP. The Flexner Report--100 years later. Yale J Biol Med. 2011;84(3):269-276.
11. Flexner A. Medical Education in the United States and Canada. Washington, DC: Carnegie Foundation for the Advancement of Teaching; 1910. Available at: http://archive.carnegiefoundation.org/publications/pdfs/elibrary/Carnegie_Flexner_Report.pdf 
12. Ordonez E. Opportunity Cost to Advancing Diversity and Inclusion: The Hidden Fees of the Minority Tax. SAEM Pulse. 2020;35(1):20-22.
13. Saak JC, Mannix A, Stilley J, Sampson C. Diversity begets diversity: Factors contributing to emergency medicine residency gender diversity. AEM Education and Training. 2021;5(S1). doi:10.1002/aet2.10676 
14. Davenport D, Alvarez A, Natesan S, Caldwell M T, Gallegos M, Landry A, et al. Faculty Recruitment, Retention, and Representation in Leadership: An Evidence-Based Guide to Best Practices for Diversity, Equity, and Inclusion from the Council of Residency Directors in Emergency Medicine. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health. 2022; 23(1). Retrieved from https://escholarship.org/uc/item/0pt1w95h
15. Dinh JV, Salas E. Prioritization of Diversity During the Residency Match: Trends for a New Workforce. Journal of Graduate Medical Education, 2019;11(3), 319–323. doi: 10.4300/jgme-d-18-00721.1 
16. Osseo-Asare A, Balasuriya L, Huot SJ, et al. Minority Resident Physicians’ Views on the Role of Race/Ethnicity in Their Training Experiences in the Workplace. JAMA Netw Open. 2018;1(5):e182723. doi:10.1001/jamanetworkopen.2018.2723
17. Wiler JL, Wendel SK, Rounds K, McGowan B, Baird J. Salary disparities based on gender in academic emergency medicine leadership. Acad Emerg Med. 2022;29(3):286-293. doi:10.1111/acem.14404 
18. Livingston R. How to promote racial equity in the Workplace. Harvard Business Review. November 10, 2020. Accessed here: https://hbr.org/2020/09/how-to-promote-racial-equity-in-the-workplace. 
19. AAMC FPIE Toolkit: https://store.aamc.org/foundational-principles-of-inclusion-excellence-fpie-toolkit.html
20. NERCHE Website: https://nerche.org
21. Jones C. Levels of Racism: A Theoretic Framework and a Gardener’s Tale. Am J Public Health. 2000;90:1212-1215 
22. Sajadi-Ernazarova, K., Ramoska, E. A, & Saks, M. A. (2020). USMLE Scores Do Not Predict the Clinical Performance of Emergency Medicine Residents. Mediterranean Journal of Emergency Medicine & Acute Care, 1(2). http://dx.doi.org/10.52544/2642-7184(1)2001
23. Barone MA, Filak AT, Johnson D, Skochelak S, Whelan A. Summary report and preliminary recommendations from the Invitational Conference on USMLE Scoring (InCUS). USMLE Updates & Research. March 11, 2019. https://www.usmle.org/sites/default/files/2021-08/incus_summary_report.pdf.
24. Gallegos, M.; Landry, A.; Alvarez, A.; Davenport, D.; Caldwell, M.; Parsons, M., et al. (2022). Holistic Review, Mitigating Bias, and Other Strategies in Residency Recruitment for Diversity, Equity, and Inclusion: An Evidence-based Guide to Best Practices from the Council of Residency Directors in Emergency Medicine. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 23(3). http://dx.doi.org/10.5811/westjem.2022.3.54419 
25. Haas, M., Landry, A., Joshi, N. 2020 Breast Practices: Strategies to Support Lactating Emergency Physicians. Ann Emerg Med. 2020;75:681-690 https://doi.org/10.1016/j.annemergmed.2020.01.012 
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