228 Sex and Racial Visual Representation in Emergency Medicine Textbooks: A Call to Action to Dismantle the Hidden Curriculum Against Diversity in Medicine

Abstract

Study Objective: Medical educators acknowledge that in addition to the formal didactics and training, informal training occurs through a hidden curriculum. As the hidden curriculum shapes the values held by medical students and professionalism, we must consider how this perpetuates and reinforces the existence of implicit biases in medical education. One possible way is through the selection of images used in formal instruction. This study aimed to examine the demographic representation of sex and race among images in one commonly used in the education of emergency medicine residents. We performed a cross- sectional study of the racial and sex representation of figures in Rosen’s Emergency Medicine: Concepts and Clinical Practice, 9th Edition. All images were downloaded and screened for further inclusion by two reviewers, with disagreements resolved by a third reviewer. Images were excluded if they did not include humans or visualized skin (eg, posterior pharynx, eyeball, radiographic images). We developed and piloted a data extraction tool to identify and categorize images. Two reviewers independently reviewed each image and assessed the type of image (photo or illustration), sex of the individual in the image (male, female, or indeterminate), race of the individual in image (Caucasian, non-Caucasian, or indeterminate), and role of the individual in the image (clinician, patient, both roles, indeterminate). A third reviewer resolved any disagreements. Differences were characterized using contingency table analysis; significance levels were determined by chi-square statistic. The sample proportions for sex, race and role were compared to the population proportions using binomial tests. 95% Confidence Intervals were calculated for all statistics. Data was analyzed using SAS, version 9.4. We identified 1,185 total images, of which 377 images met inclusion criteria. Race was able to be estimated in 327 (87%) cases, with Caucasians comprising 74.8% (95% CI 70.4% to 79.2%; p<0.001). Sex was able to be estimated in 149 (40%) cases, with males comprising 69.1% (95% CI 61.7% to 76.6%; p<0.001) of images. In this preliminary evaluation of a key textbook in EM, there is a male sex and Caucasion race predominance in visual representation. Deliberate diverse representation in the selection of textbook images may positively counteract implicit bias, realign the hidden curriculum towards diversity in medicine, improve patient care, and accurately depict the natural variation in appearance of diseases and conditions.