Editorial, Diversity and Inclusion, Advancement of EM

A Perspective on Diversity From the Outside in Emergency Medicine Training

A word that carries as many definitions as emotions it engenders. Sometimes used as a pejorative; sometimes as a compliment, it has often been the central word in controversies in a variety of issues — perhaps because it draws on raw emotions related to affirmative action, racism, civil rights for gay people, immigration, and other ongoing political and social concerns. Or, perhaps it is its role that often confuses us. Should diversity be a consequential state of being, or should it be a goal to be obtained? Regardless of its definition, diversity has meaning in all situations.

Having spent the past six years living abroad and surviving the very emotional Match process as an international medical graduate (IMG), I've done a lot of reflection regarding the importance of diversity in emergency medicine. With the experience now behind me, I feel there are still gains to be made toward promoting workplace diversity, particularly with regard to the role of IMGs in our field.

Like many other North Americans, I chose to attend medical school overseas. There are numerous reasons others make the same choice, including family or religious heritage, cost, the opportunity to live abroad and work in a different culture and health system, and, for some, because it is so darn hard to get into schools in the United States and Canada. Many students don't have the time, money, or patience to take the MCAT over and over again and apply year after year. As for me, I was working in Paris and thoroughly enjoying living abroad when I made the decision to study medicine at Trinity College, Dublin.

Trinity is well known globally, with famous alumni having coined the names of many major disease processes: Abraham Colles (Colles' fracture), Robert Smith (Smith fracture), William Stokes (Cheyne-Stokes respiration; Stokes-Adams syndrome), and Robert Graves (Graves' disease).

Ireland boasts a well-funded government-run health system, where every citizen has basic coverage and most have a reliable primary care physician to navigate their health and preventive treatments. Medical outcomes, including infant mortality, life expectancy, and maternal mortality, are among the best in the world and their health care costs (as a percent of GDP and per capita) are much lower than in the U.S.

Although I enjoyed my time spent in Europe, I, like many others, wanted to come back home to the States for residency. Our country is fortunate to have expedited specialist training compared to most other places, where residency programs are a minimum of five years following at least three general “house officer” years after medical school. As one of only three Americans in my class at Trinity, I knew I would be a unique applicant but that I would have some “informing” to do about the format of my Irish coursework, transcripts, and clinical training when submitting my ERAS application. However, I did not expect the significant role the “unknown” factor would play in nearly every interview.

It can be surprising how many biases there are against IMGs (for both U.S. and non-U.S. citizens) in the Match process, particularly in the more competitive specialties like emergency medicine. In the recent Match, only 1.8% of new EM residents were IMGs — a very small percentage compared to other specialties: 42.7% in internal medicine, 16.7% in family medicine, and 7.5% in pediatrics.1 In 2013, emergency medicine had the lowest rate (28%) of U.S. IMG applicants getting their preferred specialty, compared to the overall rate of 48% (by contrast, anesthesiology had 59%).2 A majority of programs will not consider interviewing IMGs, regardless of work experience, volunteer activity, references, or academic credentials. It is intriguing to read on programs' websites about their curricula boasting international electives and global EM, yet those same pages state they have never had IMGs in their programs. It seems that — despite the diverse applicant pool of countries and programs from which IMGs hail — in some places and programs, there is a general assumption that all IMGs are the same and somehow subpar choices as residents.

This may be due to emergency medicine being a younger specialty, meaning IMGs do not have the same established credibility as they do in other specialties. Coupled with EM being increasingly competitive — even for U.S. seniors — IMGs just do not have a strong presence. Similar to other minority groups that traditionally have not had as large a role in medicine or EM, IMGs may seem “different,” but likely have unique perspectives and experiences to bring to the table.

America is a melting pot of different races, cultures, and nationalities, founded by immigrants on the principles of self-reliance, hard work, and innovation. And yet for residency there can be a great deal of reluctance to hire someone whose path was a bit outside the conventional.

My experience with the Match is what you might call an “aha moment.” his is why people have been fighting to institute diversity in the workplace. As long as people from different backgrounds are not included, the default bias is that they are less desirable, less strong, and less valued. I was crushed when I heard feedback from one program coordinator after my interview: “Bree, people really liked you; one interviewer even wrote you were made for their program. However, unfortunately, we just don't know about the Irish training, so we can't rank you.” Here it was clear as day: discrimination was still quite present in the workforce, despite the gains society has made.

To some degree, we all prefer the familiar; the “known commodity.” Generally, we enjoy working with others who are like us, and often we are reluctant to trust what is new and different. Preferences and biases are human and come from many influences, including our upbringing and values, our experiences in the world, and our interactions with others from backgrounds similar and dissimilar to our own. But the emergency department is a different kind of workplace. As physicians, we need to put aside those preferences and biases and be as objective as possible. We deal with patients of all ages and from every cultural, economic, and religious persuasion. We have to be open to change and different ways of doing things. This had already been introduced to many of us in medical school through cultural competency classes. There is already recognition that regardless of where we end up practicing, with the current global economy we all will be treating patients from cultures and backgrounds different than our own.

While accepting that patients may be different than us, an ongoing challenge in medicine is incorporating cultural competence toward our physician colleagues. There are IMG physicians throughout the United States in all medical specialties. It fits with Thomas Friedman's notion of a global economy that he presented in The World is Flat and it is a good thing for our country. Many IMG doctors apply to the U.S. Match having at least one year (if not many more) of valuable practical clinical experience — often while working with dramatically fewer clinical resources. Some have completed entire medical residencies in their own countries before starting over again at the bottom rung in the U.S.

I have visited many programs that accept students from Saudi Arabia into their residencies as a part of an agreement with the Saudi Arabian Cultural Ministry. Program directors often sing praises of these residents, who are frequently among the hardest working and well trained in their residency classes. U.S. residents commonly say how enriching it is having the Saudi residents in their programs —not only for the diversity they bring, but also because (despite different cultures and geographic origins) there are actually many similarities between young, tired, and hardworking residents. Perhaps if we worked regularly with more physicians from culturally diverse backgrounds we would not need those culture competency classes in medical school. Life and experience alone would serve as our instruction.

Being able to finally come home to join an emergency medicine residency program has been truly amazing. Despite the difficulties, there has been tremendous mentorship from EM faculty from around the country and support from fellow applicants and other residents. Most of these people have been overwhelmingly positive and interested in learning about my unique Irish experience.

Each year, EM is getting increasingly more competitive, even for U.S. seniors, and it is a difficult argument to make that more spots should go to IMGs, or to any other underrepresented group, for the sake of   diversity. But perhaps we should challenge ourselves as a specialty to put aside preferences and biases during the application process and consider every applicant as an individual. No two applicants are the same. Every candidate has unique qualities and perspectives to bring to our workforce based on their backgrounds and training. By promoting unique perspectives and valuing diverse training experiences, we are going to improve the practice of emergency medicine.

Diversity in the physician pool not only helps us more accurately reflect the globalization of our patient population, but it also helps us see that while cultural differences do exist, our similarities are what will stand out in the end.

Many students don't have the time, money, or patience to take the MCAT over and over again and apply year after year.


  1. Results and Data 2014 Main Residency Match. April 2014. Table 12. Page 32. National Resident Matching Program Web site. Available at  www.nrmp.org/wp-content/uploads/2014/04/Main-Match-Results-and-Data-2014.pdf. Accessed November 1, 2014.
  2. Charting Outcomes in the Match. International Medical Graduates. Characteristics of Applicants Who Matched to Their Preferred Specialty in the 2013 Main Residency Match. Charting Outcomes in the Match for IMGs, 2014. 1st edition. January 2014. Page 4. National Resident Matching Program Web site. Available at  www.ecfmg.org/resources/NRMP-ECFMG-Charting-Outcomes-in-the-Match-International-Medical-Graduates-2014.pdf. Accessed November 1, 2014.