transgender, discrimination: Caitlyn Jenner, formerly Bruce Jenner, brought the limelight to transgender issues last year during her transition.FigureFigureFigureFigure“Whatever affects one directly, affects all indirectly.” — Martin Luther King, Jr., letter from a Birmingham Jail, AL, 1963 Transgender patients, because they are more likely to lack adequate health insurance and access to basic medical care, are also more likely to need emergency medical services, but their fear of discrimination and prior negative experiences also make them more likely to avoid seeking care. One study reported these poor experiences as high as 21 percent for all emergency department encounters for the transgender community in Ontario, Canada. (Ann Emerg Med 2014;63[6]:713.) The authors attributed bad encounters to health providers' lack of experience with transgender patients and insulting behavior. These issues place transgender patients at risk from inadequate emergency care, and merits the need for emergency departments to place heavier emphasis on improving the experience of transgender patients. Transgender individuals, those whose gender identity differs from their sex, is a subgroup of the gender nonconforming community, individuals who do not follow other people's ideas or stereotypes about their looks and behaviors based on their sex. Transgender topics have been covered more in the news and on social media in recent years, and efforts to destigmatize the transgender community have been supported by research suggesting that genetic variations, hormones, and brain structures were causes of disharmony between gender identity and phenotypic sex. (Gynecol Endocrinol 2004;19[6]:301.) This research also suggests that gender identity is not a dichotomous male or female designation, and argues that it may be a trait that lies along a spectrum. Society's use of physical characteristics to define gender identity can lead to emotional distress for those who disagree with this definition. For some individuals, this distress leads to gender dysphoria, a new DSM-V term aimed at eliminating the stigma attached to the former term, gender identity disorder. The psychiatric and medical conditions associated with the transgender community are just as important to understand as the conditions associated with other minority populations. This population also has a higher rate of suicide, potentially related to their higher rate of anxiety and depression. Unfortunately, these patients are also more likely to be victims of hate crimes, sexual/physical assault, and intimate partner violence. (Ann Emerg Med 2015;66[4]:417.) All of this information means transgender patients are more likely to need emergency medical services. Building Trust The first step toward improving the transgender patient's experience is to educate emergency physicians and staff on issues pertaining to their health. Studies have shown that a barrier to providing adequate care is physicians' lack of knowledge on specific gender nonconforming medical issues. That study from Ontario, Canada, reported that 54 percent of transgender patients had to educate their physicians on transgender issues. This void in knowledge can dismantle the patient's trust in health care. Emergency departments can remedy this by including gender nonconforming topics in their cultural competency curriculum, such as paying attention to laws surrounding single-sex bathrooms, health insurance, and spousal rights and how they may influence patient encounters. Emergency departments can also consider recruiting and hiring physicians and staff from the lesbian, gay, bisexual, transgender, and queer (LGTBQ) community to show the gender nonconforming population their commitment to diversity and inclusion. These efforts should also address prehospital care and be supported by the greater hospital administration, working toward creating a safe space to treat transgender individuals and discuss social and medical issues affecting these patients. Improving the emergency department encounter for the transgender community will not be an easy task. Some embrace the conversations and changes, but others may not fully engage in the movement due to personal beliefs. There will also be resistance because the rights of the transgender community are wrapped up in national and state legislation, which may limit the changes an emergency department can make. Regardless of the personal convictions of emergency physicians and government regulations, emergency departments must address the factors that lead to poor patient experiences among transgender patients. Ignoring the deficits in emergency health care delivery to transgender patients will only set a precedent to ignore deficits in care for other at-risk minority groups. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].

gender bias, equality: gender bias, equalityFigureFigureFigureFigureFigureWomen have been playing second fiddle to men for ages, but why is this still the case in 2017? Why are women still undervalued in today's society? It is well known that women in various well-appointed positions still earn less than men in comparable positions. Female physicians on average earned close to $20,000 less than male physicians as of 2015, according to a study that compared the salary information of public employees in 24 medical schools. (JAMA Intern Med 2016;176[9]:1294.) This is the number the researchers got, even after adjusting for age, tally of published papers, years of experience, and specialty type. The wage difference averaged $50,000 without the adjustment. Why is there still such a lag in bridging this gap? Why are women still mistaken for nurses while their male counterparts (who may or may not be a nurse) are believed to be physicians even though both are dressed in professional attire? Some say a reason for this discrepancy may be that women have been underrepresented in medicine, but the data do not seem to support this. A 2016 American Association of Medical Colleges (AAMC) report showed that more than 46 percent of all medical school graduates since 2012 have been women, a rate that has remained steady. (http://bit.ly/2ngMRWe.) One cannot help recognizing the role that gender bias plays in instances where the archaic perception is not to view a woman in a leadership role. Overwhelming evidence shows that the number of women in the workforce with college and graduate degrees has continued to climb and, in some cases, has surpassed that of men. The U.S. Census Bureau reported that women make up 50 percent of the overall working population, but only 26 percent of the science, technology, engineering, and mathematics (STEM) workers are women. (“Disparities in STEM Employment by Sex, Race, and Hispanic Origin,” Sept. 13, 2016; http://bit.ly/2ngNv66.) The AAMC's 2015 State of Physician Workforce Data Book reported that 33.3 percent of physicians actively practicing in the United States were women. (http://bit.ly/2ngUOKY.) Another AAMC report showed that women represented 47 percent of medical students, 46 percent of residents, 38 percent of full-time faculty, 21 percent of full professors, and 15 percent of department chairs. (http://bit.ly/2ngNeAf.) Perhaps our society is suspended in the past, in which doctors were nearly always older, white men in lab coats. With this image posited as the norm, female physicians simply don't “look” the part. STEM fields have typically been dominated by men, so it is critical to encourage young girls to pursue these careers. Having a diverse group of people involved in science leads to discoveries that would have been missed without women at the table. The recently released movie and book, Hidden Figures, embodies female mathematicians, engineers, and computer scientists, and shows how they were instrumental in the success of countless NASA missions. Other less notable female heroes of science who made remarkable discoveries included the astronomer Caroline Herschel, who was the first to discover a comet, and Rosalind Franklin, who was the first to produce an x-ray image of DNA that eventually led Watson and Crick to the discovery of the double-helix DNA structure. A New Reconstruction Skilled professional women often find themselves having to prove their aptitude to their colleagues, superiors, and subordinates, a burden that professional men seldom face. Data now support that men and women practice medicine differently, and that female physicians may even have more favorable patient outcomes despite the roadblocks they face. Tsugawa, et al., found that the 30-day mortality and readmission rates of elderly patients cared for by female internists were lower compared with those cared for by their male counterparts. (JAMA Intern Med 2017;177[2]:206.) This may be because women tend to be better listeners and communicators than men, and they tend to involve patients more in discharge planning. Measures can be taken to address gender inequality issues. First, we must understand and acknowledge that the problem exists before an attempt is made to address it. We should also recognize some of the strides that have been made to curb this inequity and make suggestions for change. Legislation in place addresses equal opportunity employment as it pertains to gender discrimination, but this law does not address the implicit biases that exist. It may necessitate legislative reconstruction to address wage transparency, rewarding those who report discriminatory practices, providing safe and anonymous ways to report wage discrimination, incentivizing entry for women into STEM fields, and providing equality in family care leave. Women are typically given a finite amount of time off for maternity leave; this should also be the case for men to lessen the load of childrearing on women. Secondly, resources should be allocated to encourage women to pursue careers in STEM. A way to garner interest among women would be to increase recruitment efforts starting in grade school. Former Surgeon General Joycelyn Elders, MD, said, “You can't be what you can't see.” It is no wonder that girls are not pursuing STEM careers when impressionable children are constantly bombarded via television, the Internet, and social media with images of men in high-powered roles and women in more supportive roles and with messages of women being valued more for their physical appearance than their intellectual capabilities. One way to begin to combat this is by making efforts to invest in students' exposure to these fields by recruiting female role models who work in STEM fields to engage students and inspire young girls and women to pursue these careers. Achieving gender equality in medicine and other fields should be a collaborative effort, not one-sided. Progress benefits everyone, and it starts with a seed that has to be nourished and nurtured like many great ideas, or it will die a slow and meaningless death. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].

tolerance: toleranceFigureOn the eve of our country's success in defeating the British in the Revolutionary War of 1775, one of our greatest founding fathers, Alexander Hamilton, took the high road and articulated a vision of tolerance, which was highly unpopular at the time. The public was calling for British citizens to be expelled from the United States or dispatched violently, and Hamilton urged that they be treated fairly and justly in accordance with the principles of the newly founded country. “As a revolutionary veteran, I had too deep a share in the common exertions of this revolution to be willing to see its fruits blasted by the violence of the rash or unprincipled men, without at least protesting against their designs,” he wrote. Hamilton railed against the baleful precedent that would be set if the legislature exiled an entire category of people without hearings or trials. If that happened, he warned, “No man can be safe, nor know when he may be the innocent victim of a prevailing faction.” Alexander Hamilton, a true genius whose vision for a representative democracy has spanned centuries, had the foresight to realize the benefits of having a diverse nation. Long before others could even fathom the concept, he advocated for tolerance in a nation that had fought for liberty and freedom from oppression. The recent events in Charlottesville, VA, only serve as a palpable reminder of how far we have drifted from our nation's founding principles. The very tyrannical oppressive forces from which we struggled to be liberated are now being condoned to be re-implemented on others. We of such feeble minds and short-term memories. Perhaps a mere five minutes reviewing the history books may serve as a revival of our inner good conscience. Truly everyone must realize that in such an environment, no particular group, class, or race is safe, and this type of demagoguery and aggression has to be emphatically denounced. Speaking Out Martin Niemöller, a clergyman who defied Hitler and was sent to a concentration camp, wrote a well-known poem that captures what can happen when citizens remain bystanders and do not speak out against hatred and stand up for their neighbors and friends: “First they came for the Socialists, and I did not speak out— Because I was not a Socialist. “Then they came for the Trade Unionists, and I did not speak out— Because I was not a Trade Unionist. “Then they came for the Jews, and I did not speak out— Because I was not a Jew. “Then they came for me—and there was no one left to speak for me.” This has happened countless times the world over: Nazi Germany, Khmer Rouge Cambodia, Rwanda, and more. Let us make sure that the United States does not venture down this dark and atrocious path. We need strong principled leaders who are willing and capable of denouncing destructive rhetoric and setting a high moral plane for our nation, not idly hiding behind the veil of their selfish interests. Tolerance Matters Tolerance, diversity in its entirety, empathy, respect for self and others, caring enough to stand up for noble causes, all of which goes against our core selfish inertia are what we are being tasked with in this century. Noble qualities we all strive for from the moment we are awake till we lie asleep again. Though we all fall short in executing these basic core qualities daily, that should not equate to surrendering our efforts. We are humans and doomed to fail at perfection, but we can get pretty darn close if we keep trying. As my residency program director once said to me, “I want you to train hard like it's the real deal so when the real battle arrives, it doesn't stand a chance against you.” Diversity and tolerance still matter. They are part of the core principles on which this country was founded. Ron Chernow in his biography Alexander Hamilton quotes Hamilton from his brilliant post-war piece: “The world has its eye upon America. The noble struggle we have made in the cause of liberty has occasioned a kind of revolution in human sentiment.” Mr. Chernow added: “If America acted wisely...it had a historic opportunity to refute the skeptics of democracy and to doom despots around the world.” (Penguin, 2005.) We are once again at that crossroad, and the world is watching.

FigureFigureFigureFigureFigureFigureThe #BlackLivesMatter movement arose almost three years ago on social media, prompted by what many saw as law enforcement's unfair and biased handling of blacks. Substantial evidence also shows parallels of biased treatment within health care, limiting access and quality of care because of racial, ethnic, and cultural backgrounds. We understand the problem better, but the notion of disparate care is not new. The Institute of Medicine recognized in 2003 that racial and ethnic minorities with few exceptions had higher rates of morbidity and mortality than non-minorities. Disparate care was seen when racial and ethnic groups were compared independent of sociocultural influence or inadequate income. Blacks and Latinos, for instance, were less likely to receive appropriate cardiac medications (thrombolytics, aspirin, and beta blockers) or to undergo coronary artery bypass surgery even when accounting for insurance status, income, age, comorbidities, and symptom expression. (Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Washington, D.C.: National Academies Press; 2003.) The National Quality Strategy, Healthy People 2020, and the U.S. Department of Health and Human Services aimed to improve the delivery of care by focusing on disparate access and quality. The Affordable Care Act also set new standards for data collection of race, ethnicity, primary language, sex, and disability in population health studies. Addressing disparate care can improve the overall quality of care for all, which in turn would improve health care spending. (Int J Health Serv 2011;41[2]:231.) These strategies have been effective in collecting data and setting objectives to close gaps in care across groups, but they have overlooked the root of the differential treatment. The system has numerous faults, but implicit bias is often cited as a major impeding factor to the delivery of care. Recognize Biases Implicit bias — attitudes and stereotypes that affect our understanding, actions, and decisions in an unconscious manner — have been widely demonstrated within health care. (J Gen Intern Med 2013;28[11]:1504.) One study examining 91 emergency medicine residents showed steady assessments of implicit racial bias that were moderately pro-white and anti-black. This bias was stronger for physicians working in an overcrowded ED. (Acad Emerg Med 2016;23[3]:297.) A cross-sectional survey of 154 providers showed agreement with negative American-Indian stereotypes 22-32 percent of the time and an overall implicit preference to white adults and children. Providers saw American-Indian children as more challenging and less compliant when the proportion of these children seen in the ED increased. (Medical Care 2016;54[6]:562.) The provider's implicit bias negatively affects patient care. Black and Latino patients are less likely to receive analgesia even when correcting for confounders, such as financial status. (J Emerg Nurs 2006;32[3]:219; Acad Emergency Med 2006;13[2]:140; JAMA 1993;269[12]:1537.) One study using clinical vignettes found that pediatricians with a higher degree of implicit pro-white bias were less likely to provide opioid analgesics to blacks. (Am J Public Health 2012;102[5]:988.) Internal medicine and emergency medicine residents who showed greater pro-white bias were significantly less likely to recommend thrombolysis for myocardial infarction in black patients. (J Gen Intern Med 2007;22[9]:1231.) The provider's implicit bias may also shape how a patient perceives his care. Stereotype threat — environmental or interpersonal cues that signal to an individual a risk of judgment or mistreatment based on personal characteristics — has been shown to reduce working memory capacity and cognitive performance, both of which affect information processing and treatment adherence. It also negatively affects performance expectations and effort: Patients are less likely to follow up if they perceive that providers don't expect them to do so. (Du Bois Rev 2011;8[1]:199.) Stereotype threat also influences effective communication and disclosure: Feedback is more likely to be discounted and patients are more likely to be disengaged. Long-term experiences of stereotype threat may even lead to disidentification, which allows the individual to dissociate himself more often from the domains within which he may experience the threat. This may partly contribute to a widely held belief by racial and ethnic minorities that health promotions (exercise and healthy foods) are “white” behaviors. (J Gen Intern Med 2010;25[S2]:S169.) Addressing Provider Bias Ryn, et al., note that empathy and other skills enhance patient interaction and reduce the influence of bias. (Du Bois Rev 2011;8[1]:199.) Exhibiting a greater interest in another person's welfare correlates with positive clinical encounters and lower likelihood of bias. It has positive effects on patient satisfaction, self-efficacy, perception of control, emotional distress, adherence, and health outcomes. (J Gen Intern Med 2007;22[6]:882.) Studies suggest that physicians with good emotion regulation skills who typically begin patient encounters with an overall positive mood are less likely to characterize patients by their racial, ethnic, or cultural backgrounds and more likely to view them by their individual attributes. (Psychol Sci 2005;16[11]:875.) They are also more likely to view themselves as being part of a larger group, fostering greater inclusiveness. (Pers Soc Psychol Bull 1995;21[8]:856; J Pers Soc Psychol 1998;75[1]:109.) A sincere desire to have a meaningful intergroup exchange may actually negatively affect the interaction. Studies show that whites who want to behave in an unprejudiced way may have increased anxiety and heightened levels of arousal during intergroup interaction. This may influence communication and judgment, and nonverbal expressions of anxiety could be misperceived and interpreted as prejudice. This can be lessened by increasing the provider's intergroup exchange. Institutional Bias Physicians can recognize and make certain behavioral adjustments to correct for potential bias, but changing these behaviors is less likely in institutions that may reinforce them. Ryn, et al., discuss adaptations to be considered at the institutional level (Du Bois Rev 2011;8[1]:199): Adjust research standards to improve equity in care: The push to include more descriptors in studies (race, cultural background, sexual orientation) has helped spotlight disparate care. Recognizing disparities improves health outcomes in those populations by encouraging innovative strategies to target feedback and encourage accountability. (Perm J 2009;13[4]:34; Qual Manag Health Care 2009;18[2]:84.) Reduce stressors in the workplace: High noise levels, poor feedback, and inadequate training, staffing, and supervision all challenge one's cognitive load, and when cognitive capacity is taxed, memory tends to bias toward information consistent with stereotypes, making it more difficult to override automatic assumptions. (Med Decis Making 2010;30[2]:246.) Emergency departments are inherently high-stress environments, but leaders must still strive toward an optimal workplace for their physicians and ancillary staff. Improve cultural climate and recruitment: This involves policies and practices that convey an institution's desire to diversify and eliminate discrimination. Racial diversity in the organizational hierarchy has reduced intergroup prejudice, and increased intergroup contact reduces intergroup anxiety during clinical encounters. Patients who witness diversity in their health care establishment also have shown lesser degrees of stereotype threat. (J Pers Soc Psychol 2008;94[4]:615; Du Bois Rev 2011;8[1]:199.) Bias is not just about one's race, ethnic background, or culture. It is about sexual orientation, gender, age, weight, and so many other categories by which people classify others. The benefits of committing oneself and one's institution to being better at addressing implicit bias is substantiated across wider domains of health care delivery. The physician's duty is to serve society and to improve the quality of care for all, and we cannot do this without first understanding how we introduce bias into our clinical decisions. Implicit Bias in Health Care Non-white patients receive fewer cardiovascular interventions and fewer renal transplants. Black women are more likely to die after being diagnosed with breast cancer. Non-white patients are less likely to be prescribed pain medications. Black men are less likely to receive chemotherapy and radiation therapy for prostate cancer and more likely to have testicles removed. Patients of color are more likely to be blamed for being too passive about their health care. Source: “Implicit Bias in Health Care,” The Joint Commission, April 2016, Issue 23; http://bit.ly/2dcY0iw.