Invited Commentary
Equity, Diversity, and Inclusion
September 24, 2024
The Glass Ceiling—Racial Disparities Among Emergency Medicine Chief Residents
Alden M. Landry, Italo Brown
JAMA Netw Open. 2024;7(9):e2432606. doi:10.1001/jamanetworkopen.2024.32606
The role of a chief resident extends beyond a mere title; it is a gateway to opportunities and a stepping stone to leadership roles in both academic and community emergency medicine (EM) settings. Within the department, a chief resident signals to faculty and trainees that the title-bearer is clinically excellent, organized, thorough, and well-respected. It is often considered an unspoken metric for fellowship trainee positions, medical directorships, and other leadership-oriented roles. Although this title denotes increased academic responsibilities, it is also tethered to social capital capable of launching a successful career in EM.
However, this coveted position may not be equally accessible to all. Data from Tsai et al1 suggest that women underrepresented in medicine (URIM; a category that included residents identified as Black, Hispanic, American Indian or Alaskan Native, and Native Hawaiian or Other Pacific Islander) were least likely to be selected for chief promotion, and 50% as likely to be selected for chief resident compared with White men. This is corroborated by other studies demonstrating that URIM physicians, particularly Black women, are less likely to occupy executive leadership roles (commonly referred to as the “c-suite”) or departmental leadership roles (ie, department chair, vice chair, program director).2,3 This disparity systematically distances URIM physicians from career trajectories that could lead to significant social and economic capital.
Some consider facets such as individual popularity, likability, and on-shift performance to be driving forces in the selection process for chief residents. Although the selection criteria are thought to be objective, there is an inherent subjectivity to nomination, ranking, and voting. This perception may provide insight into the true state of department and residency culture in the US. Furthermore, it raises the question: Are the requirements for becoming a chief intrinsically and structurally biased? If so, this could suggest that the standards and requirements for these roles may need to be reevaluated to ensure fairness and inclusivity.
Chief residents have line of sight to both residency and departmental operations. As a function of proximity and open communication, chiefs can build close relationships with faculty and administration during this formative year. Under their tutelage, significant growth occurs and produces enduring mentorship and sponsorship threads; this serves as an inflection point in career trajectory. The overlay of mentorship and sponsorship, or the lack thereof, can widen the opportunity gap in professional development.
The downstream implications of this disparity in representation are profound. Some programs select their fellows from the pool of chief residents, and some groups and departments only hire chief residents. The skill set development that chief residents undergo is attractive to employers and directly translates into administrative and leadership roles in EM. Thus, the lack of URIM physicians in these roles can limit their career advancement opportunities.
One counterargument has been the floor effect; in other words, the selection pool of URIM residents is inherently low, which contributes to the scarcity of URIM chief residents. However, the recruitment of URIM physicians partly hinges on representation at leadership levels; among those ranks are chief residents. Fewer URIM chiefs can translate to fewer persons with voting privileges advocating on behalf of URIM applicants. For active URIM residents, it reinforces the notion of a glass ceiling—that is, a systemic barrier of access to leadership roles within medicine and health care.
As health care has pivoted toward precision medicine, monitoring outcomes, and cost-savings models, value has been placed on leadership that can influence these factors. And although not explicitly stated, chief residents are in this leadership pipeline—which makes the selection process even more critical. To date, there are no studies that link the presence (or absence) of URIM chiefs to health outcomes. However, for the most vulnerable populations concordance literature does reflect improved clinical outcomes, greater adherence, reduced utilization, and lower health care expenditures (all metrics of interest) when clinicians come from URIM backgrounds.4 Despite the seemingly natural alignment in goals, a dearth of URIM chiefs exists, as evidenced by this study.
Tsai et al1 underscores the value of continued implicit bias and microaggression training. It also highlights a significant area of ignorance in the recruitment, advancement, and sponsorship of URIM physicians in leadership roles within the EM workforce. Furthermore, it indirectly elevates a dialogue about the connection between leadership and equitable health outcomes. These dynamics impact health outcomes for diverse patients and represent a branching point where intervention can be targeted.5
Association of American Medical Colleges and American Medical Association both support diversity, equity, and inclusion (DEI) in medicine; American College of Emergency Physicians, American Academy of Emergency Medicine, Society for Academic Emergency Medicine, and Emergency Medicine Residents’ Association all support DEI within emergency medicine.5,6 Unfortunately, there is also an overarching, concerted effort to dismantle DEI initiatives. Some irony lies in the fact that many of the targets have been Black women newly hired in leadership roles, despite its benefit being skewed toward White women.7 This article provides additional evidence for why these efforts are both necessary and urgent.
The underrepresentation of URIM physicians in leadership roles, such as chief residents, is a pressing issue that needs to be addressed. It is crucial for the medical community to recognize this disparity and take proactive steps to ensure equal opportunities for all, regardless of their race, ethnicity, and gender. This will not only enrich the diversity of leadership in emergency medicine but also enhance the quality of patient care and health outcomes.
