Equity, Diversity, and Inclusion (EDI): Let’s Move from Pamphlet to Practice

Kristen Mathias is an Internal Medicine Resident at the University of Chicago. She can be reached at Kristen.Mathias@uchospitals.edu. Daniel Cabrera is a faculty member in the University of Washington Department of Medicine and contributed to this article.

The medical field has an Equity, Diversity, and Inclusion (EDI) problem that is far from subtle. I have noticed it throughout every stage of my training. In my premedical courses, it was a silent force that caused less than a handful of people in the room to be Black. During clinical rotations, it was a nagging voice in my head, asking if my surgery attending was taking me more seriously than my stellar transgender classmate. Most recently, the problem resurfaced during one of my first rotations as a senior resident. One of my medical students, a Black woman, walked in one morning looking defeated. Ten minutes prior, a nurse had walked in while pre-rounding on a patient and asked the student if she was there to take out the trash.

Nearly every institution professes a commitment to the ideals of EDI, touting them on websites and in trainings, and medicine is no different. Despite our widespread adoption of these ideals, there remains a gap in their successful implementation.  In 2018, only 10% of practicing physicians in the United States were Hispanic/Latinx, Black, or African American. Furthermore, the number of Black or African American male medical school applicants and students has decreased in the last 30 years. In 2018, nearly 1 out of 4 medical students reported being the subject of sexist remarks and/or names, and a 2017 study revealed that admission committees harbor unconscious biases against homosexual individuals. These sobering statistics likely underestimate the scope of medicine’s EDI problem, as many challenges faced by individuals underrepresented in medicine go unnoticed and undocumented.

We need to rethink our approach. What if we were to treat medicine’s EDI problem the way we treat other problems that occur in the clinical setting?  Let us imagine a hospital has experienced several adverse events after the incorrect deliveries of medications to patients with the same name. To address this issue, the institution would likely use a quality improvement framework. A root cause analysis would be conducted to determine the systemic issues that allowed the errors to occur. After hearing perspectives from pharmacists, nurses, and physicians, certain processes would be implemented to improve outcomes and the success of these processes would be measured. Systems that worked would be integrated into practice, and systems that did not would be revised.

I challenge us to apply these same principles when thinking about EDI within our own workspaces. It is crucial that we introspect at a personal and institutional level about the biases and systems that undermine the success of individuals underrepresented in medicine.  We must listen to the perspectives of these individuals, learn about the challenges they face, and clearly communicate these challenges to institutional leadership. Finally, we must create actionable ideas to improve EDI, implement the ideas into practice, and measure the success of these endeavors. Endeavors that improve EDI should be integrated into institutions. Endeavors that do not should be adjusted or even abandoned.

I propose three simple measures that can instill the above principles. First, all students, trainees, and faculty should undergo training about allyship and implicit bias. Administrators that oversee recruitment should receive special instruction on how to screen applications and interview applicants in ways that minimize prejudice. Second, every institution should create an online interface that underrepresented minorities can use to report specific hardships they have faced within their institution. This forum could be used to educate others about common implicit biases, microaggressions, and barriers faced by underrepresented minorities in medicine, or in any field where it is implemented. We could even use data from such a tool to inform policy changes that address the specific EDI deficiencies of an institution. Finally, institutions must create dedicated task forces to ameliorate specific issues within EDI.  By researching and targeting individual issues, concise and clear-cut policies can be created to address institution-specific issues with EDI.  The success of these policies can be subsequently measured and integrated into clinical practice if they achieve their goals.

As we work on creating institutions that embody EDI, it is essential to consider events outside of medicine that undermine these values. Medicine has a longstanding tradition of keeping clinical practice separate from discussions about society and politics. But how can we genuinely profess a commitment to inclusivity without acknowledging the disproportionate burden of disease put on low-resource communities due to inequitable access to healthcare?  How can we write mission statements about equity without acknowledging the countless Black lives that have been lost to police brutality and structural racism? I urge us all to consider the inequities that shape the fabric of our society and reflect upon how we can try to dismantle them. EDI cannot exist within institutions if it does not exist outside of it.

It is clear that the medical field is far from fully exemplifying EDI. We have, however, made some progress towards this goal. As of 2019, women represent the majority of medical school students. There is also a small increase in the amount of medical school matriculants who are from underrepresented backgrounds. Advocacy in medicine is also becoming more common, with groups such as the American Medical Association and the American College of Physicians organizing around issues ranging from access to healthcare to gun violence. Achieving EDI is not an easy or swift task however, it is long overdue. I am hopeful that by increasing awareness of EDI issues, the field of medicine will bridge this disparity through action and eventually, sustainable change. Let’s all make an effort to move from pamphlet to practice.