Recruitment and Retention

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, Equity, and Inclusion (DEI): values that inspire institutional cultural changes and policies to further justice, fairness, and improved experiences of all individuals within and around the institution.

Recruitment: the process of seeking out, identifying, screening, interviewing, selecting, and hiring for a job position.

Retention: the act of an employer to keep individuals employed long term (or during the duration of a residency program), in which employees choose to stay with the employer over leaving for external positions, other residency programs, or alternate careers.

Underrepresented in Medicine (URiM): racial and ethnic populations whose representation in the medical field is lower than their proportion of the general population, as defined by the Association of American Medical Colleges (AAMC). In addition, there are other groups such as LGBTQ+, persons with disabilities, and religious minorities, among others, that may be considered underrepresented in medicine.¹

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 is helpful to recognize.

Pipeline Recruitment: a process to increase the pool of qualified candidates available over time, making future positions easier to fill.

Pathway Recruitment: a term that is generally preferred to "pipeline recruitment," as it places more emphasis on individual agency and non-traditional paths to achieve a goal.

Emergency Medicine DEI Pathway Recruitment: increasing the pool of qualified diverse individuals in emergency medicine (EM), starting with efforts to recruit URiM students to higher education and the medical field.

DEI Critical Mass: having a sufficient number of URiM individuals to positively impact a departmental culture around DEI and create change.²

Diversity Snowball Effect: the ability of a program/department with a DEI critical mass to successfully attract diverse applicants.

Minority Tax: the DEI-related responsibilities placed on URiM individuals that are often uncompensated and in addition to standard job expectations.

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.

For a 1-minute presentation: present your department's diversity statistics on a slide, bringing attention to potential areas of growth through comparing your program to other programs, to the field of EM, and to your patient population. You can ask leaders in other programs for diversity statistics of their department, or see if the information is posted on their website. The AAMC has racial and ethnic data for EM residency programs. For patient population statistics, check the U.S. Census Bureau website. Utilize disparities as a call to action for increasing diversity within your department.

For a 10-minute presentation: after demonstrating potential areas of growth (above), present the benefits of diversifying your workforce. Start by mentioning racial-ethnic health disparities, then discuss the advantages of diverse ideas and backgrounds in innovation. Present evidence supporting improved care with patient-provider cultural, ethnic, and language congruence. If time allows, include quotations from patients, other departments, and learners (residents and students) commenting on your program's culture surrounding DEI. See here for a sample presentation template.

For a 30-minute presentation: following discussion about the benefits of increasing physician diversity (above), review strategies presented in the articles below. Focus on either resident or faculty recruitment. Allow for at least five minutes of large group discussion regarding institutional barriers and ideas for implementation.

Resident Recruitment

Highland EM has published their methods for successfully increasing their residency diversity to better represent the general population. Discuss adopting the strategies below to implement in your own program.³

• No USMLE cutoff: step scores are not associated with resident success, and are not used in determining interview offers or rank list position.
• Increased weight of gestalt score: certain personal characteristics such as leadership, overcoming adversity, and commitment to underserved populations were weighed more highly.
• Diversity committee and buy in: encourage participation from as many faculty and residents to improve commitment to DEI missions.
• Diversity applicant week: allow URiM applicants to interview on days where they can have more interaction with URiM residents and faculty.

Gallegos M, et al. outlined recommendations for holistic review of residency applications to promote DEI. Present these strategies to your group and discuss the experiences and attributes your program values in an applicant.⁴ Selection criteria should:

• Be broad, linked to program mission and goals, and promote diversity as essential to excellence.
• Include experience and attributes as well as academic performance.
• Assess applicants in light of their unique backgrounds and with the intent of creating a richly diverse interview and selection pool as well as residency class.
• Be applied equitably across the entire candidate pool.
• Be supported by performance data that show experiences or characteristics are linked to that individual's likelihood of success.

Programs should consider each applicant's potential contribution to the program and the field of medicine, allowing them the flexibility to weigh and balance the range of criteria needed in a class to achieve their institutional mission and goals.

Race and ethnicity may be considered as factors when making admission-related decisions aligned with mission-related educational interests and goals associated with program diversity, and when considered as a broader mix of factors, which may include personal attributes, experiential factors, demographics, or other considerations (as permitted by federal law).

• This recommendation was published prior to the Supreme Court ruling against affirmative action. You may instead consider including a holistic review criterion for "shared lived experiences" with your patient population, which may be interpreted more broadly.

Faculty Recruitment

Peek M, et al. evaluated the faculty diversity of 82 U.S. medical schools and conducted interviews with the most diverse schools to determine their strategies for recruiting and retaining URiM faculty. You can include these methods in your presentation and discuss strengths and areas of improvement of your department.⁵

• Utilization of human capital and social relationships: proactively seeking out potential applicants through interpersonal connections is more effective than simply advertising "URiM candidates are encouraged to apply." Mentorship at all levels (medical student, resident, junior faculty, senior faculty) was important in recruitment and retention as well.
• Institutional support through resources: URiM faculty are more likely to stay at an institution where they are successful and feel supported. This may come in the forms of a strong recruitment package, opportunities and funding for job development, ability to pursue diverse tasks, and generally supportive environments.
  

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.

URiM physicians face numerous barriers in the path to becoming EM attendings. Departments must be dedicated to recruiting and supporting URiM physicians to ensure success. In turn, increased physician diversity will contribute to a reduction of disparities faced by underserved populations.

Pathway Recruitment

Potential URiM residents and faculty are lost at every stage of education and training, from elementary school through residency and early career development. Barr et al. found that URiM undergraduate students at Stanford were disproportionately likely to abandon premedical studies after taking chemistry classes.⁶ Freeman et al. found that URiM students perceived multiple barriers to becoming a physician, including a lack of personal, family, and institutional resources, lack of mentorship and advising, and family and economic challenges that prevent them from devoting as much time to their studies as their peers.⁷ Jones et al. described how there is an achievement gap that begins in preschool and persists throughout undergraduate education and medical school.⁸ Structural racism may play a large part in this achievement gap, as demonstrated by an assessment of social factors that impact Medical College Admission Test (MCAT) scores.⁹ In addition, many studies have demonstrated bias in clerkship grades, letters of recommendation, and the medical student performance evaluation (MSPE) when describing women and URiM students compared to white male students.¹⁰ For instance, when comparing URiM students and white students with the same core clerkship grades, reviewers described white students with more positive superlatives in their clerkship narrative comments.¹¹ These factors can make URiM students appear less competitive for residency and can affect their choices of which specialty and programs to apply to. However, with support, URiM residents are able to thrive and improve patient care. Garrick et al. found that American Board of Emergency Medicine (ABEM) oral and written boards rates for both URiM and non-URiM graduates were comparable to the national average.³ One medical institution found no difference between intern clinical assessment scores between URiM and non-URiM residents.¹² URiM residents are also more likely to practice with underserved and uninsured patients, and their patients endorse improved communication and satisfaction regarding their care.¹³ These factors are why best practices in DEI recruitment recommend early outreach and moving away from over-reliance on standardized testing for medical school and residency selection.

Faculty and Resident Burnout and the Minority Tax

Challenges persist for residents and early faculty. Studies have shown that residents of color and female residents experience racial and gender bias from patients and family members and nurses, as well as other physicians during their residency and that these experiences can lead to higher rates of burnout.^14-15 The experience of bias, decreased access to mentorship leads, and the minority tax of taking on uncompensated work in DEI initiatives, all inhibit success for URiM students, residents, and faculty.¹⁶

Diversity Critical Mass and the Diversity Snowball Effect

Such barriers can be overcome by dedicated efforts outlined in this curriculum. For instance, the Highland Hospital EM program increased their percentage of URiM residents from 12% to 27% using a comprehensive set of initiatives described above.³ It should be noted these initiatives included opportunities for URiM applicants to spend time with each other and with URiM residents and faculty, as well as changes in the approach to application review. Students were more likely to apply to specialties with higher percentages of physicians from their racial and ethnic group.¹⁷ The diversity snowball effect means that having a diverse group of residents and faculty assists with recruitment of diverse residents and faculty because it helps provide mentorship and peer support.

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.

The data below has been selected from U.S.-based studies to support proposals for departmental DEI recruitment and retention efforts. While there are various definitions of diversity, improved racial/ethnic diversity is often a primary goal of DEI efforts. Thus, racial/ethnic diversity and health disparities are the focus of these statistics. You are encouraged to seek relevant statistics regarding other protected groups (LGBTQ+, persons with disabilities, religious minorities, low income/first-generation college students, persons with non-English language preference, etc.) based on your departmental needs.

Racial/Ethnic Health Disparities

Decades of research has demonstrated racial and ethnic minorities experiencing differential treatment, poorer health outcomes, and higher mortality compared to white patients. This is due to a variety of factors including low socioeconomic status, lack of insurance, lack of access to health care, food deserts, discrimination, and structural racism. Below are a few examples of such disparities in the United States.

• The average lifespan of Black and American Indian/Alaska Native persons is 11 and 6 years (respectively) shorter than the average White person.¹⁸
• In a national cross-sectional cohort, Black children with appendicitis were less frequently given pain medication and opioids compared to White children.¹⁹ Hispanic and Black children were also less likely to undergo diagnostic imaging than White children across 44 emergency departments (EDs) in the U.S. from 2016-2019.²⁰ For children with appendicitis, this leads to delayed diagnosis and increased risk of complications such as perforation.²¹
• Meta-analyses of adult ED patients found that those who were Black or Hispanic received less pain medications than White patients.²² Black adults were also observed to undergo less imaging than White and Asian patients across various EDs from 2005-2014.²³
• Patients living in predominantly Black and Hispanic zip codes are less likely to receive a transcatheter or surgical aortic valve replacement for aortic stenosis, even after controlling for socioeconomic factors and comorbidities.²⁴ Hispanic, Native American/Alaskan Native, and Black patients are 1.5 to 2.3 times more likely than White patients to die from diabetes-related complications.²⁵
• There are many significant racial/ethnic disparities in cancer incidence, severity of disease, and mortality. Prostate, lung, colorectal, pancreatic, and gastric cancers have higher incidence and mortality among the Black population. For cancers that predominantly affect White individuals (e.g. leukemia and breast cancer), the mortality rates remain higher among Black, Hispanic, and American Indian/Alaska Native patients.²⁶
• In Louisiana during the COVID-19 pandemic, Black patients with COVID-19 were disproportionately more likely to be hospitalized than White patients.²⁷
• Non-elderly Hispanic, Black, American Indian/Alaska Native, and Native Hawaiian/Pacific Islanders are more likely to be uninsured than Whites.²⁸

Benefits of a Diverse Physician Workforce

There is a growing body of research evaluating the benefits of a diverse workforce, and fewer studies that specifically examine diversity in the healthcare field. Most studies focus on racial/ethnic and cisgender diversity. Further research should be undertaken to evaluate the impact of increased representation of other minority groups (e.g. LGBTQ+ individuals, persons with disabilities, and religious minorities).

• Numerous studies have found that more diverse organizations in and out of the medical field have improved performance and outcomes across a variety of metrics.^29-31
• Medical students who come from underserved communities are more likely to work with similarly underserved populations after residency.³²
• One study of Black men in Oakland found that those with Black primary care physicians were more likely to engage in preventative care interventions than if they had a White physician.³³
• Black infants suffer a significantly higher mortality rate at birth than White infants. This difference was shown to be substantially reduced when a Black infant was delivered by a Black physician vs. a non-Black physician in a retrospective study of Floridian newborns from 1992-2015.³⁴
• Some studies report higher satisfaction and improved communication in clinical encounters when treated by physicians who share the same race/ethnicity.^35-36
• Medical student body diversity has been found to improve the educational experience of all students. In a study of over 100 medical schools, White students from more diverse programs reported a higher commitment to working with underserved, minority populations.³⁷

Lack of Racial/Ethnic Diversity in the EM Workforce

The graph below depicts the racial and ethnic makeup of emergency residents, attendings, and academic faculty compared to the U.S. general population and medical student enrollees. Findings include:^38-42

• White EM residents, attendings, and academic faculty are overrepresented when compared to the general population and medical student enrollees.
• Asians are overrepresented among medical school enrollees, however are less likely to enter the field of EM.
• Hispanic and Black representation in medicine progressively diminishes with entry to the medical field and pursuit of an EM career. Hispanic and Black EM academic faculty are the most underrepresented. Combined, these groups comprise less than one in twelve EM academic faculty despite representing one-third of the U.S. general population.

Images and graphical representations can clarify concepts and enhance interest. Please cite the sources of these images appropriately if you use them in your presentation, found below. 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.

Here is an example Google Slides presentation on the importance of recruiting diverse individuals to your department. You are welcome to copy the presentation for your own use.

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 (i.e. a white facilitator presenting on antiracism or minority tax), and this section may address some of those tensions.

Departments may be hesitant to implement DEI recruitment and retention strategies due to a variety of barriers.

• Minority Tax and Lack of Leadership: DEI initiatives are often spearheaded by URiM individuals as they are often the most impacted. This can place an unfair expectation on the few URiM individuals in a program to take on extra DEI-related work ("minority tax"), thus reducing their productivity in other projects. This may prevent achievement of academic milestones such as publication and promotion, further exacerbating lack of diversity in academic medicine leadership. Some URiM individuals may elect to spend their time in non-DEI pursuits like most of their non-URiM colleagues. However these individuals may be unfairly perceived as not performing their expected DEI-related duties by their peers.¹⁶
• Prioritizing Other Values: departmental leaders may have other priorities they would like to focus on over DEI. In a resource-limited environment, it may be difficult to advocate for prioritization of DEI initiatives such as recruitment and retention. Thus, it is crucial to educate leaders on the evidence supporting the institutional benefits of a diverse workforce.⁴³
• Time and Resources: given the points above, there may be few persons interested in leading DEI recruitment and retention initiatives, limiting their scope and potential for success. In addition, if DEI is not prioritized by a department, other programming is likely to receive more support and resources.⁴³
• Politicizing of DEI: there has been a recent increase in bans of DEI and social justice initiatives.⁴⁴ Many of these groups also favor patriarchy at the expense of women and gender minorities. Policies have been passed banning DEI-related education and initiatives in several states (predominantly in the southeastern U.S.).⁴⁵ Some organizations have removed DEI mission statements and eliminated DEI leadership roles and offices. Additionally, in June 2023 the Supreme Court rejected affirmative action in higher education on the grounds that race-conscious admissions were unconstitutional.⁴⁶ This may further impact the ability of under-resourced URiM students to pursue medical education. Despite these recent movements and rulings, race-conscious hiring in medicine continues to play an important role in advancing DEI and improving patient care. Awareness of these positions is crucial in combating misconceptions and continuing to promote departmental DEI recruitment and retention efforts. One method of addressing these arguments is to reference the benefits of a diverse physician workforce (use data listed above).

This section may be useful to hospital ethics committees who want to increase their DEI awareness as part of monthly meetings, or to other groups who are interested in the ethical underpinnings of the topic.

Efforts to recruit URiM individuals to EM programs and departments have been driven by a desire to further DEI and improve the experiences of all individuals in a department, including patients. As noted in the Quantitative Analysis section, this can be supported by various studies examining the impact of a diverse workforce on work culture. In addition, other studies have noted the positive impact of URiM physicians on patient care. By uplifting individuals who have faced structural barriers in the field of medicine, EM programs can further promote equity in the workforce and in patient outcomes. However, programs may come across opposition in doing so and should also consider the following when responding to pushback.

The censorship of DEI may be considered to be in violation of several ethical principles. First, the prohibition of DEI roles and initiatives infringes upon the autonomy of departments to determine the needs of their institution and patient population. Proponents of DEI censorship also attempt to distort the ethical principles of beneficence and justice to support their policies. However, further examination reveals the contradictory nature of these arguments. For instance, the purpose of beneficence is to prevent "direct and imminent harm" and to limit threats. These are inappropriate justifications for banning DEI efforts, which are geared at improving outcomes and reducing health disparities. In addition, some may argue that justice indicates equal treatment of all individuals. However, such arguments fail to address the concepts of distributive justice and the difference principle, which provides justification of unequal distribution that results in reduced inequalities for the most disadvantaged individuals.⁴⁷ DEI initiatives are attempts to address such structural inequities.

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.

The field of emergency medicine, and medicine as a whole, continues to improve with respect to physician diversity. By focusing on pathway programs, recruitment, and retention of diverse residents and faculty, your department can create impactful change that will benefit all stakeholders. Below are some opportunities to promote cultural change and improve outcomes for your department and patient population:

• Create a pathway program within your community to encourage local URiM students to pursue medicine.
• Start affinity groups for URiM trainees and attendings in your department to encourage mentorship and community.
• Implement departmental quality improvement projects to address health disparities faced by minority pateints.
• Publish a study demonstrating successful implementation of strategies for recruitment and retention of diverse EM trainees and faculty.
• Publish the impact of hiring diverse individuals on your departmental administrative and clinical outcomes.

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 are the barriers to recruiting and retaining URiM residents and faculty that have been encountered in your emergency department (ED)? What strategies have you used to overcome those barriers? What seems to have been most helpful in your setting?
2. Performative diversity, equity, and inclusion initiatives often convey an outward commitment to DEI but lack action or policy change designed to disrupt the status quo and move towards a more equitable state. Have you experienced performative DEI when it comes to recruiting diverse faculty, residents, or students? How did it show up? How is performative DEI hurtful to the goal of recruiting and retaining a diverse workforce? What strategies might you suggest to address performative DEI when it is identified?
3. A holistic review of candidates is one strategy for recruiting a more diverse group of EM clinicians. Has your group implemented holistic review, and what does that look like in your setting? How helpful has holistic review been to your group in terms of your ability to recruit underrepresented folks to your team? What challenges have you encountered in implementing holistic review and how have you addressed those?

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

1. URiM physicians are less likely to pursue emergency medicine or obtain academic faculty positions. Increasing physician diversity is critical to addressing health disparities.
2. Departmental URiM recruitment efforts must go hand-in-hand with cultural changes that will encourage retention and promotion of URiM hires.
3. Arguments against DEI recruitment and retention can be combated with data regarding racial/ethnic health disparities and benefits of a diverse physician workforce.

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

A current priority of the U.S. Surgeon General is to operationalize diversity, equity, inclusion, and accessibility (DEIA) norms, policies, and programs. "In inclusive workplace cultures, all workers - including those from diverse racial and socioeconomic backgrounds - feel safe to be authentic and express their feelings. This depends on a culture of trust where all coworkers welcome and value each other's unique perspectives. When diversity is celebrated as a source of strength, workers experience less stress and anxiety as bias and prejudice is not tolerated. Employers can prioritize DEIA norms by putting relevant policies and programs in place. Inclusive leadership is vital for fostering diversity among teams and is required to support a work environment where all team members feel valued and represented."⁴⁹

Below are Emergency Medicine-specific resources for this topic.

Pre-Interview Preparedness Best Practice Recommendations from the CORD Guide for Resident Recruitment⁴

1. Define clear and prioritized goals for diversity-related residency recruitment.
2. Assess program readiness to implement diversity-related recruitment and support URiM trainees that match.
3. Mitigate bias through inclusion of bias training and predetermined scoring rubrics for screening, interviews, and ranking.
4. Create DEI committees to inform and steer diversity-related recruitment.
5. Ensure representation of URiM faculty in the screening, interview, and selection process but avoid tasking URiM faculty with too much during the recruitment cycle.
6. Begin recruitment of URiM applicants early through directed and expanded efforts such as enrichment, outreach, and pathway programming.
7. Collaborate with minority student groups in early mentorship and advisory programs for URiM applicants.

Invitation and Interview Strategies from the CORD Guide for Resident Recruitment⁴

1. Apply an equity lens to each step of the recruitment process to expose existing bias and allow for correction.
2. Holistic review should be applied equitably across all applicants.
3. Identify characteristics for holistic review that align with a program's mission, vision, and values.
4. Avoid screening applicants solely on standardized examination scores or grades.
5. Standardize the structure of interviews in terms of logistics and questions asked.
6. Ensure URiM faculty visibility and allow networking during the interview process or through structured asynchronous opportunities to engage with DEI topics.
7. Partner with Historically Black Colleges and Universities (HBCUs) and neighboring EM residency programs to help further promote diversity within the specialty.

Post-Interview Best Practice Recommendations from the CORD Guide for Resident Recruitment⁴

1. Select diverse members for the rank committee.
2. Conduct the rank meeting in a safe, private space with collaborative discussion.
3. Inform committee members about the characteristics identified as valuable to the program before the ranking process.
4. Ensure ranking is done based on scores from the predefined rubrics for screening and interviewing.
5. Offer second look visits (onsite or virtually) to network with URiM faculty and discuss DEI within the program.
6. Define clear expectations for follow-up and designate a point person for communication.

Recruitment Strategies from the CORD Guide for Faculty Recruitment⁴⁸

1. The institutional and departmental mission statements should include an explicit commitment to diversity, equity, and inclusion.
2. Institutions and departments should make focused efforts to expand the candidate pool with diverse candidates.
3. Departmental and institutional recruitment committees should include diverse membership.
4. Institutions should incentivize all stakeholders and increase accountability for diversity efforts.
5. Departments and institutions should engage in inclusive marketing and targeted recruitment of URiM candidates.
6. Institutions should consider recruitment packages and debt reduction programs for URiMs and ensure equitable salaries.
7. Interview committees should use a holistic review of applications and consider faculty ambassadors.
8. Interviewers should undergo implicit bias training.

Retention Strategies from the CORD Guide for Faculty Recruitment⁴⁸

1. Establish a culture of inclusivity. This should include cultural competency and bias training, as well as initiatives to identify and address discrimination.
2. Avoid overusing URiM faculty for administrative and mentoring positions and ensure that URiM faculty are properly supported and recognized for their contributions.
3. Create institutional diversity leadership positions, such as a Chief Diversity Officer or Assistant/Associate Dean of Diversity, that are backed by institutional support.
4. Ensure URiM faculty are promoted appropriately and evaluate for biases in the promotion and tenure process.
5. Create faculty development programs specifically focused on URiM faculty.
6. Pair URiM faculty with both URiM and non-URiM mentors. Leaders should sponsor qualified URiM faculty for opportunities.
7. Promote and support engagement with national organizations.

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

Pathway programs dedicated to mentoring minority pre-medical students:

• MiMentor⁵⁰
• Tour for Diversity in Medicine⁵¹
• Mentoring in Medicine⁵²

Medical student organizations that connect minority medical students and empower them to become leaders and advocates for underserved populations:

• The Latino Medical Student Association⁵³
• Student National Medical Association⁵⁴
• Asian Pacific American Medical Student Association⁵⁵
• Association of Native American Medical Students⁵⁶
• Building the Next Generation of Academic Physicians⁵⁷

Organizations focused on supporting URiM attendings and eliminating health disparities faced by their communities:

• National Hispanic Medical Association⁵⁸
• National Medical Association⁵⁹

Departmental or institution-wide affinity groups may improve a sense of belonging and offer support for URiM individuals. Your department may also participate in local community outreach pathway programs with underserved students. This could be as simple as presenting at a local high school's career day, or establishing a formal mentorship program with undergraduates.

1. What are some barriers URiM individuals face while on the path to academic emergency medicine?
2. How can physician diversity improve patient care?
3. What are some resources you can use to inform your departments' efforts in DEI recruitment and retention?

1. Lack of resources (including financial and institutional support), limited mentorship, reduced exposure/promotion opportunities, discrimination/bias, and the minority tax, to name a few.
2. Diverse ideas have been found to improve institutional performance outcomes across various fields, including healthcare. In addition, URiM physicians are more likely to work with underserved populations. Additionally, a shared culture or language improves communication and patient satisfaction.
3. This curriculum, the CORD guides to resident and faculty recruitment, literature published by programs such as Highland Emergency Medicine, established pathway programs, and national organizations supporting URiM medical students and physicians.^1,2,48

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 presentation closing.

How will you commit to taking action towards changing the way that your team approaches recruitment and retention of a diverse EM workforce? Will you raise the topic at a faculty meeting? Develop a set of standardized questions relating to DEI for your group to use during interviews? Craft a departmental statement of commitment to DEI? Develop a mentoring program for underrepresented students, residents, or faculty? The possibilities are endless to leave a lasting impact!

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

1. Underrepresented in Medicine. Association of American Medical Colleges.
2. Kaplan SE, et al. Challenges in Recruiting, Retaining, and Promoting Racially and Ethnically Diverse Faculty. J Natl Med Assoc. 2017 Apr 21.
3. Garrick JF, et al. 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 Mar 20.
4. Gallegos M, et al. 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. West J Emerg Med. 2022 May 10.
5. Peek ME, et al. "URM Candidates Are Encouraged to Apply:" A National Study to Identify Effective Strategies to Enhance Racial and Ethnic Faculty Diversity in Academic Departments of Medicine. Acad Med. 2013 Mar.
6. Barr DA, et al. The Leaky Pipeline: Factors Associated with Early Decline in Interest in Premedical Studies Among Underrepresented Minority Undergraduate Students. Acad Med. 2008 May.
7. Freeman BK, et al. Understanding the Leaky Pipeline: Perceived Barriers to Pursuing a Career in Medicine or Dentistry Among Underrepresented in Medicine Undergraduate Students. Acad Med. 2016 Jul.
8. Jones AC, et al. Admissions is Not Enough: The Racial Achievement Gap in Medical Education. Acad Med. 2021 Feb 1.
9.  Lucey CR, Aaron S. The Consequences of Structural Racism on MCAT Scores and Medical School Applications: The Past is Prologue. Academic Medicine. 2020 Mar.
10.  Ross DA, et al. Differences in Words Used to Describe Racial and Gender Groups in Medical Student Performance Evaluations. PLoS One. 2017 Aug 9.
11.  Lee KB, et al. Cultural Competency in Medical Education: Demographic Differences Associated with Medical Student Communication Styles and Clinical Clerkship Feedback. J Natl Med Assoc. 2009 Feb.
12. Lypson ML, et al. Evidence for Increasing Diversity in Graduate Medical Education: The Competence of Underrepresented Minority Residents Measured by an Intern Objective Structured Clinical Examination. J Grad Med Educ. 2010 Sep.
13. Smith SG, et al. Pipeline Programs in the Health Professions, Part 1: Preserving Diversity and Reducing Health Disparities. J Natl Med Assoc. 2009 Sep.
14. Dyrbye L, et al. Association of Racial Bias Without Burnout Among Resident Physicians. JAMA Netw Open. 2019 Jul 26.
15. Nunez-Smith M, et al. Race/Ethnicity and Workplace Discrimination: Results of a National Survey of Physicians. J Gen Intern Med. 2009 Nov.
16. Rodriguez JE, et al. Addressing Disparities in Academic Medicine: What of the Minority Tax? BMC Med Educ. 2015.
17. Nunez-Smith M, et al. Health Care Workplace Discrimination and Physician Turnover. J Natl Med Assoc. 2009 Dec.
18. Ndugga N, et al. Key Data on Health and Health Care by Race and Ethnicity. Kaiser Family Foundation. 2024 Jun 11.
19. Goyal MK, et al. Racial Disparities in Pain Management of Children with Appendicitis in Emergency Departments. JAMA Pediatr. 2015 Nov.
20. Marin JR, et al. Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children's Hospitals, 2016-2019. JAMA Netw Open. 2021 Jan 4.
21. Goyal MK, et al. Racial and Ethnic Disparities in the Delayed Diagnosis of Appendicitis Among Children. Acad Emerg Med. 2021 Sep.
22. Lee P, et al. Racial and Ethnic Disparities in the Management of Acute Pain in US Emergency Departments: Meta-Analysis and Systematic Review. Am J Emerg Med. 2019 Sep.
23. Schrager JD, et al. Racial and Ethnic Differences in Diagnostic Imaging Utilization During Adult Emergency Department Visits in the United States, 2005-2014. J Am Coll Radiol. 2019 Aug.
24. Nathan AS, et al. Racial, Ethnic, and Socioeconomic Disparities in Access to Transcatheter Aortic Valve Replacement Within Major Metropolitan Areas. JAMA Cardiol. 2022 Feb 1.
25. Spanakis EK, Golden SH. Race/Ethnic Difference in Diabetes and Diabetic Complications. Curr Diab Rep. 2013 Dec.
26. Zavala VA, et al. Cancer Health Disparities in Racial/Ethnic Minorities in the United States. Br J Cancer. 2021 Jan.
27. Price-Haywood EG, et al. Hospitalization and Mortality Among Black Patients and White Patients with COVID-19. N ENgl J Med. 2020 Jun 25.
28. Hill L, et al. Health Coverage by Race and Ethnicity, 2010-2022. Kaiser Family Foundation. 2024 Jan 11.
29. LaVeist TA, Pierre G. Integrating the 3Ds: Social Determinants, Health Disparities, and Healthcare Workforce Diversity. Public Health Rep. 2014 Jan.
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