AEM special issue on (in)equity in emergency medicine (2021)

The year of 2020 was a momentous one for the United States. A confluence of purposely designed systems’ outcomes and deep histories of schism converged with a viral mutation to force the topic of (in)justice to reenter mainstream conversation. Not since the Civil Rights Movement has the matter of (in)equity been in the homes of so many U.S. families and the (virtual) offices of so many workplaces. The disproportionate deaths of Indigenous, Black, Asian, and Latinx peoples in relation to Whites is long known in communities of color and is well documented in public health.1-3 The public killing of people of color by authority figures is not novel either.4 The human rights abuses suffered and endured by U.S. persons of color have been cited at least twice by the United Nations.5, 6 Now is another critical moment in the arc of history. Now lies an opportunity to swing the proverbial needle farther from hegemonic trauma and closer to justice. National experts and National Institute of Minority Health and Health Disparities researchers recently published a textbook focused on health disparities science because practitioners and researchers must understand where and how we fall short to achieve the aim of equity in health care provision.7 We in emergency medicine (EM) tout this equity ethos and the Emergency Medical Transfer and Labor Act (EMTALA) holds us to it: Collectively, we (cl)aim to serve those in need, regardless of what they look like, who they vote for, what language they speak, how much money they have, their gender, or any other social factor. The reality is far removed from that vision of optimal emergency health care though. For example, Goyal et al.,8 in “Racial and ethnic disparities in the delayed diagnosis of appendicitis among children,” describe that (in their study sample of 7,298 children with documented appendicitis) Black children are less likely than White children to undergo definitive imaging and are more likely to have a delayed appendicitis diagnosis and perforation. But we in EM do not accept our inadequacies. We fight for our patients; it is a point of pride in our clinical community. In this issue, article authors highlight some ways in which we must fight our own implicit biases, despite our explicitly stated beliefs. Our actions, laid bare in patient outcomes and even in our workforce, tell the truth: We are as flawed as the society that raised and trained us. Sethuraman et al.,9 in “Here to chair: gender differences in the path to leadership,” describe EM’s continued unequal gender representation in positions of leadership. In “Racial and ethnic disparities in emergency department restraint use: a multicenter retrospective analysis,” Carreras Tartak et al.10 again demonstrate that we restrain patients of color more than White patients.11 Such truths are mortifying because they go against our creed. It is not who we expect to see when we look in the mirror, but the people who comprise EM will continue to push boundaries and move beyond the status quo as is our way. We have never let imposed or initial limitations permanently hold us back. It is now commonplace for emergency practitioners to conduct point-of-care ultrasounds with competence.12, 13 We perform rapid sequence intubations and execute procedural sedations, and we do these well.14-16 In this issue of Academic Emergency Medicine we highlight work that pushes our field toward equity. In many of these articles, authors demonstrate ugly truths; we are telling ourselves who we are now. What must continue to define this specialty is our subsequent actions upon collective recognition of deep shortcomings. To help us become the clinicians we want to be, this issue also offers the scaffolding of what EM must do next. The reality of racism, for example, is deeply rooted and foundational to U.S. systems of function.17-19 As such, the solutions to how we can disentangle our emergency health care from the prejudices that mark our clinical efforts are not simple. Implicit bias is a natural by-product of White supremacy and patriarchy, for example. It is entrenched in our behaviors so “awareness” and superficial solutions may be insufficient for course correction. As Congdon et al.20 describe in “Impact of patient race/ethnicity on emergency department management of pediatric gastroenteritis in the setting of a clinical pathway,” clinical guidelines alone may be insufficient to overcome bias. Similarly, Honcoop et al.,21 in “Racial and ethnic disparities in bronchiolitis management in freestanding children's hospitals,” found that guidelines were insufficient to mitigate race- and ethnicity-based disparities in EM care. Still guidelines have value: They are the corrective lenses that help us see more clearly, and they are yardsticks to measure our growth. Trent et al.,22 in “Established evidence-based treatment guidelines help mitigate disparities in quality of emergency care," found that guidelines with accountability measures can mitigate implicit bias-based disparities in our care provision. In “The role of an academic emergency department in advancing equity and justice,” Landry et al.23 offer a conceptual framework for other techniques and solutions EM can employ as generations right the nation's path. And there is more good news: there is the will. This issue had more submissions than we could accept. To us this proves that there are those among us who are willing to look within and name and measure our flaws. There are many emergentologists24 working toward equity, attacking inequity from many angles. While we no longer need to verify that disparity is happening (it is), we do need more information about the ways in which disparities show up clinically and how structurally supported biases impact the lives of various community members. We need to understand the hegemonic disparities and traumas that we and our colleagues endure, as Kaltiso et al.25 point to, in “The impact of racism on emergency health care workers,” not only for the downstream impacts on patients but also because our/colleagues’ lives are inherently valuable. We need more published data on the ways in which Native and Asian people experience race-based health disparities in ED care and the ED-based remedies and capacities for mitigation of larger, structural inequities. In fact, we need much more information about the solutions with sustainable potential and methods of monitoring and evaluating those solutions. This special issue should encourage those already doing this work that we are not alone and our numbers are growing. This issue welcomes others to climb aboard and become even better clinicians. We are among the most important clinicians in the United States: we are the face and frontline of health care in the United States and most in the nation will use the ED at least once in their lifetime. Patients—people—present to us and trust us because they must; with this journal issue, we recommit to being worthy of that trust. There are lessons in these pages for EM and we must learn our lessons, apply the knowledge, and become more trustworthy.