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Chapter 14: Building on Values: Justice, Equity, Diversity, and Inclusion (JEDI)

The title of this chapter is borrowed from the (Romanow) Report of the Royal Commission on the Future of Healthcare in Canada, written over 20 years ago. [1] As we move forward in the redesign of emergency care, we must continue to ensure that we keep our core values in mind. The Canadian Charter of Rights and Freedoms, founded on the concept of a just society, [2] states that “every individual . . . has the right to equal benefit without discrimination based on race, national or ethnic origin, colour, religion, sex, age, or mental or physical disability.” [3] Yet, we witness daily examples where this standard is not met.


Health equity is defined as “the state in which everyone has the opportunity to attain their full health potential, and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances.” [4] The causes of health inequity do not begin or end with the health system, but with the social determinants of health that impede some groups from having access to the resources and opportunities others enjoy.


As respected members of society, physicians can and should be powerful advocates for social justice to ensure healthy living conditions for all. Most urgently, however, it is incumbent on us to tackle the systemic discrimination that persists within our own health system. This chapter will outline some of the ways we can do so, with a focus on ED staffing, leadership, and care of marginalized populations. It is important to note that the implications of JEDI go far beyond this brief overview; JEDI should inform all aspects of emergency care planning and be considered in relation to all sections of this report.


Many diverse and marginalized populations do not feel safe accessing care in the ED, often sensing that they are not heard and their needs are not addressed. [5,6,7,8,9] The scourge of anti-Indigenous racism has contributed to tragic deaths like those of Brian Sinclair [10] and Joyce Echaquan. [11] Healthcare is also plagued by additional types of racism, as well as ageism, ableism, sexism, homophobia, transphobia, and other forms of discrimination. An important part of the solution is to ensure the diversity of Canada’s population is reflected in its healthcare system. [12, 13] Representation matters; it has profound impacts on how people view and use the system, trust providers, and adhere to healthcare recommendations that affect patient outcomes. [14,15,16] Despite small advances in this area, significant disparities continue to exist among physicians with respect to representation, level of advancement, and salaries by gender, age, and race/ethnicity. [17,18,19] Research demonstrates increasing harassment, sexual assault, hiring bias and pay inequity among women and racialized minorities, even when accounting for education, academic rank, geographic training, clinical hours worked, years of experience, and administrative roles. [17,12,20,21] The effects are further increased if someone identifies as being part of more than one equity-deserving group. [12] Just a few years ago, an Ontario ED was discovered to not have hired a female physician for 16 years, despite women making up over 40% of ED residents. [22] Hospitals and healthcare systems must ensure that they employ diverse hiring panels, mandate training to mitigate bias and regularly review staff makeup to evaluate whether it represents the population it serves. [23]


The lack of diversity is even greater within leadership positions, where racialized individuals are considerably lacking. Without diversity, teams miss key perspectives to guide decision-making and engender mistrust in underrepresented communities. Diverse leadership may be more likely to promote culturally sensitive care and foster a culture of anti-racism among staff and is thought to also improve patient experiences and outcomes. [12]


In addition to diversifying leadership and workforce, efforts should also be made to educate healthcare staff on the impacts of discrimination in medicine and incorporate JEDI into medical education (24). It’s essential that all healthcare staff are trained to provide culturally-safe care to the diverse populations we serve. [25,26] A diverse workforce with proper training in JEDI has the potential to decrease treatment disparity, increase cultural sensitivity, and inform policymaking to facilitate change. [27] 

Several other JEDI-promoting initiatives should be adopted as we move forward:


Enhance Inclusivity

Some easy-to-implement changes to enhance inclusivity within the ED include posting non-discrimination policies, using visuals that promote diversity, offering population-specific resources, and creating “all-gender” bathrooms. [28]  


Collect More Data

It is essential to properly capture ED patients’ gender identity. [26] In order to better understand the community that the ED serves, efforts should be made to collect expanded sociodemographic data, particularly race and ethnicity. Barriers to care, such as transportation, food insecurity and housing, also need to be gathered. [26,29,30,31,16] Data must be leveraged to ensure we understand our patients’ diversity, address the right problems, and evaluate our change processes.


Equitable Technology

It’s important to ensure that the adoption of new digital technologies—especially those delivered privately—doesn’t increase health disparities by providing care only to those who can afford the technology or have the cultural comfort and health literacy to use it. [32,33,34,35,36] Care should also be taken when implementing AI-based technology, to ensure biases are not further amplified.


Diverse Voices of Patients

As we look ahead, the patient voice, including diverse perspectives, must inform ED co-design and policy development, fulfilling the dictum nothing about us without us. [37,29]


Impact of Stress on Provider Bias

Finally, we note the synergy between the promotion of JEDI and the overall aims of this report. As the safety net for Canadians, the ED is the primary locus of care many patients whose health is affected by adverse social and economic conditions. Lacking access to care through other means, they are disproportionately impacted as the quality of ED care drops. [38] The stress of working in an understaffed, overstretched ED can impair a provider’s decision-making, increasing the chance that racial and other biases will pollute clinical judgement that further exacerbates differences in care between populations. All measures required to create a functional system of emergency care, as discussed in other chapters, are also crucial to the pursuit of JEDI.


In addition to the recommendations below, we encourage you to read the excellent submission by the CAEP Health Equity Subcommittee (Appendix 2).


Recommendations for Building on Values: Justice, Equity, Diversity, and Inclusion

(JEDI) in Emergency Medicine

  1. Emergency care programs (ECPs) should promote diversity within leadership and among healthcare staff, to better understand and care for the communities they serve.

  2. ECPs should foster patient and community engagement from marginalized groups in clinical service planning and delivery.

  3. All ECP staff must undergo formal training to better understand the different cultures and populations they serve.

  4. ECPs should expand the collection and utilization of sociodemographic data to better evaluate and address JEDI within their programs. There should be public reporting of key operational outcomes that impact marginalized and oppressed populations.

  5. Academic departments of emergency medicine should contribute to the understanding and amelioration of inequities in emergency care delivery by supporting JEDI-focused research and multidisciplinary special interest groups (SIGs).

  6. JEDI must be a paramount consideration as digital health is incorporated into Canada’s healthcare system.


References

  1. Government of Canada PS and PC. Building on values: the future of health care in Canada: final report / Roy J. Romanow, Commissioner. : CP32-85/2002E-IN – Government of Canada Publications – Canada.ca [Internet]. 2002 [cited 2023 Jun 29]. Available from: https://publications.gc.ca/site/eng/237274/publication.html

  2. Just society. In: Wikipedia [Internet]. 2023 [cited 2023 Jun 29]. Available from: https://en.wikipedia.org/w/index.php?title=Just_society&oldid=1149571975

  3. The Canadian Charter of Rights and Freedoms [Internet]. [cited 2023 Jun 29]. Available from: https://www.justice.gc.ca/eng/csj-sjc/rfc-dlc/ccrf-ccdl/

  4. Ramirez LKB, Baker EA, Metzler M. Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health: (540452013-001) [Internet]. 2008 [cited 2023 Jun 29]. Available from: http://doi.apa.org/get-pe-doi.cfm?doi=10.1037/e540452013-001

  5. Understanding and Ameliorating Medical Mistrust Among Black Americans [Internet]. 2021 [cited 2023 Jun 29]. Available from: https://www.commonwealthfund.org/publications/newsletter-article/2021/jan/medical-mistrust-among-black-americans

  6. Canada H. Certain Circumstances Issues in Equity and Responsiveness in Access to Health Care in Canada [Internet]. 2003 [cited 2023 Jun 29]. Available from: https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-accessibility/certain-circumstances-issues-equity-responsiveness.html

  7. CBC · DBG·. CBC. 2015 [cited 2023 Jun 29]. Ageism still rampant in health care | CBC Radio. Available from: https://www.cbc.ca/radio/whitecoat/blog/ageism-still-rampant-in-health-care-1.3139864

  8. Canada PHA of. Infographic: Inequalities in mental illness hospitalization in Canada [Internet]. 2019 [cited 2023 Jun 29]. Available from: https://www.canada.ca/en/public-health/services/publications/science-research-data/inequalities-mental-illness-hospitalization-infographic.html

  9. Kim PJ. Social Determinants of Health Inequities in Indigenous Canadians Through a Life Course Approach to Colonialism and the Residential School System. Health Equity. 2019 Jul 25;3(1):378–81.

  10. Ignored to death: Brian Sinclair’s death caused by racism, inquest inadequate, group says | CBC News [Internet]. [cited 2023 Aug 14]. Available from: https://www.cbc.ca/news/canada/manitoba/winnipeg-brian-sinclair-report-1.4295996

  11. News · AN· C. CBC. 2021 [cited 2023 Aug 14]. Racism, prejudice contributed to Joyce Echaquan’s death in hospital, Quebec coroner’s inquiry concludes | CBC News. Available from: https://www.cbc.ca/news/canada/montreal/joyce-echaquan-systemic-racism-quebec-government-1.6196038

  12. Sergeant A, Saha S, Lalwani A, Sergeant A, McNair A, Larrazabal E, et al. Diversity among health care leaders in Canada: a cross-sectional study of perceived gender and race. CMAJ Can Med Assoc J J Assoc Medicale Can. 2022 Mar 14;194(10):E371–7.

  13. Canadian Medical Association [Internet]. [cited 2023 Jun 29]. Addressing gender equity and diversity in Canada’s medical profession: A review. Available from: https://www.cma.ca/physician-wellness-hub/resources/equity-and-diversity-medicine/addressing-gender-equity-and

  14. Togioka BM, Duvivier D, Young E. Diversity and Discrimination in Healthcare. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Jun 29]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK568721/

  15. Cohen JJ, Gabriel BA, Terrell C. The case for diversity in the health care workforce. Health Aff Proj Hope. 2002;21(5):90–102.

  16. Kalich A, Heinemann L, Ghahari S. A Scoping Review of Immigrant Experience of Health Care Access Barriers in Canada. J Immigr Minor Health. 2016 Jun;18(3):697–709.

  17. Madsen TE, Linden JA, Rounds K, Hsieh YH, Lopez BL, Boatright D, et al. Current Status of Gender and Racial/Ethnic Disparities Among Academic Emergency Medicine Physicians. Acad Emerg Med Off J Soc Acad Emerg Med. 2017 Oct;24(10):1182–92.

  18. Sheppard G, Pham C, Nowacki A, Bischoff T, Snider C. Towards gender equity in emergency medicine: a position statement from the CAEP Women in Emergency Medicine committee. CJEM. 2021 Jul;23(4):455–9.

  19. Canada E and SD. Discussion guide on ageism in Canada [Internet]. 2022 [cited 2023 Jun 29]. Available from: https://www.canada.ca/en/employment-social-development/corporate/seniors/forum/consultation-ageism/discussion-guide.html

  20. What’s Holding Women in Medicine Back from Leadership [Internet]. [cited 2023 Jun 29]. Available from: https://hbr.org/2018/06/whats-holding-women-in-medicine-back-from-leadership#

  21. Marco CA, Geiderman JM, Schears RM, Derse AR. Emergency Medicine in the #MeToo Era. Acad Emerg Med Off J Soc Acad Emerg Med. 2019 Nov;26(11):1245–54.

  22. Ontario emergency room chief who hired no women for 16 years resigns amid discrimination probe – The Globe and Mail [Internet]. [cited 2023 Jun 29]. Available from: https://www.theglobeandmail.com/canada/investigations/article-ontario-emergency-room-chief-who-hired-no-women-for-16-years-resigns/

  23. Kuhn GJ, Abbuhl SB, Clem KJ, Society for Academic Emergency Medicine (SAEM) Taskforce for Women in Academic Emergency Medicine. Recommendations from the Society for Academic Emergency Medicine (SAEM) Taskforce on women in academic emergency medicine. Acad Emerg Med Off J Soc Acad Emerg Med. 2008 Aug;15(8):762–7.

  24. Barnabe C, Osei-Tutu K, Maniate JM, Razack S, Wong BM, Thoma B, et al. Equity, diversity, inclusion, and social justice in CanMEDS 2025. Can Med Educ J. 2023 Mar 21;14(1):27–32.

  25. Williams DR, Rucker TD. Understanding and Addressing Racial Disparities in Health Care. Health Care Financ Rev. 2000;21(4):75–90.

  26. Leeies M, Grunau B, Askin N, Fesehaye L, Kornelsen J, McColl T, et al. Equity‐relevant sociodemographic variable collection in emergency medicine: A systematic review, qualitative evidence synthesis, and recommendations for practice. Acad Emerg Med. 2022;

  27. Nair L, Adetayo OA. Cultural Competence and Ethnic Diversity in Healthcare. Plast Reconstr Surg Glob Open. 2019 May 16;7(5):e2219.

  28. pdf [Internet]. [cited 2023 Jun 29]. Available from: https://rnao.ca/sites/rnao-ca/files/bpg/2SLGBTQI_BPG_June_2021.pdf

  29. Pinto AD. Can a Focus on Equity, Diversity and Inclusion Transform Health Services Research. Heal Pap. 2022 Apr;20(3):53–60.

  30. Deb S, Sud M, Wijeysundera HC. If You Can’t Measure It, You Can’t Improve It: Data Collection and Standards in the Evaluation of Racial and Ethnic Disparities in Cardiovascular Disease. Can J Cardiol. 2023 May 11;S0828-282X(23)00386-0.

  31. Fraze T, Lewis VA, Rodriguez HP, Fisher ES. Housing, Transportation, And Food: How ACOs Seek to Improve Population Health By Addressing Nonmedical Needs Of Patients. Health Aff Proj Hope. 2016 Nov 1;35(11):2109–15.

  32. News · DBG· C. CBC. 2020 [cited 2023 Jun 29]. The health cost of being poor | CBC Radio. Available from: https://www.cbc.ca/radio/whitecoat/the-health-cost-of-being-poor-1.5449683

  33. Affleck E. Inequity in Digital Health Planning in Canada. Healthc Pap. 2022 Apr;20(4):37–43.

  34. Koehle H, Kronk C, Lee YJ. Digital Health Equity: Addressing Power, Usability, and Trust to Strengthen Health Systems. Yearb Med Inform. 2022 Dec 4;31(1):20–32.

  35. Miller A, News · BS· C. CBC. 2022 [cited 2023 Jun 29]. Would more privatization in Canadian health care solve the current crisis? | CBC News. Available from: https://www.cbc.ca/news/health/canada-healthcare-privatization-debate-second-opinion-1.6554073

  36. Challenges and opportunities for primary care and health equity in the age of technology – Healthy Debate [Internet]. [cited 2023 Jun 29]. Available from: https://healthydebate.ca/2023/05/topic/challenges-opportunities-primary-care-technology/

  37. Lee TH, McGlynn EA, Safran DG. A Framework for Increasing Trust Between Patients and the Organizations That Care for Them. JAMA. 2019 Feb 12;321(6):539–40.

  38. Harrell IB. Emergency Departments and Care for Marginalized Populations. [cited 2023 Jun 29]; Available from: https://digitalcommons.odu.edu/humanities_etds/17/

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