Addressing Racism in Medical Education

Despite efforts to promote health equity over the past 30 years, significant racial and ethnic disparities persist.1 Racial and ethnic minorities continue to be disproportionately affected by disparities in disease.2,3 Structural and personally-mediated racism increasingly emerge as drivers of these inequities as they impact social, economic, and environmental factors, health care delivery, and clinician behavior.4-12

Teaching clinicians about health care inequities has primarily focused on disparity statistics, power analyses, and cultural competence training.13,14 These strategies, however, have proved insufficient to reach health equity, as they address the symptoms while neglecting how racism helps create inequities and do not challenge the institutional and personal behaviors that sustain them.15-18 While teaching health care professionals about racism reduces biases,8,19-23 few curricula for medical education exist.20-23 Therefore, a workshop and toolkit to help medical educators teach and address racism was created and presented at the 2016 Society of Teachers of Family Medicine (STFM) Annual Spring Conference.

Members from the STFM Group on Minority/Multicultural Health organically formed a multiracial, multidisciplinary team to develop a curriculum for educators to address racism as a key social determinant of health. Using transcripts of group electronic discussions, this team identified essential curricular themes (see Table 1) using Jones’ Tripartite Model as a framework for exploring levels of racism (institutional, personally-mediated, and internalized).24 The team created a relationship-based faculty development workshop and accompanying toolkit.

The 90-minute workshop consisted of a didactic presentation on the connections between racism and health inequity, a video vignette developed by the team, small group discussion, large group debrief, and a commitment activity. The toolkit included articles, books, podcasts, videos, websites, and activities which explore racism, implicit bias, privilege, and the intersectionality of identities that could be used in participants’ settings.25 Workshop materials are available at the STFM Resource Library (https://resourcelibrary.stfm.org/search?executeSearch=true&SearchTerm=racism&l=1).

The presentation summarized how discrimination, bias, and racism affect Americans, and the applicability of Jones’ model to poor health outcomes.24 Participants then viewed a 3-minute video depicting an inpatient family medicine team rounding outside the room of a patient presenting with a gunshot wound. A supervising white male physician speaks disparagingly about the patient, presumes he is Latino and a gang member, and simultaneously is condescending to an African American, female intern who is further undermined by a white male senior resident.26

Workshop faculty divided participants into groups of ten and facilitated discussions using standardized questions (Table 2). Participants then shared their discussions in a large group debrief. The educator resource toolkit was then presented. Finally, participants wrote one action they would take to address racism in their home institutions and rated their confidence in following through (Table 3). Participants were instructed to keep and review this commitment in 6 months. An anonymous pre- and postworkshop survey was administered to assess any change in participants’ knowledge and attitudes (Table 4). Faculty facilitators recorded issues discussed in small groups, which were later analyzed by a team member for recurrent themes. This project was classified as exempt by Montefiore Medical Center IRB.

One hundred twenty participants attended this workshop, as determined by count from three facilitators. Demographic information was not collected for workshop participants, but the participants appeared diverse in many respects. The team reviewed facilitators’ notes on small and large group discussions to identify themes. Facilitator notes revealed that small groups began with reactions to the video’s content. Some groups moved to an affective level, while others had cognitive discussions about scenarios and strategies. Some participants expressed feeling dismay, anger, fear, and shame. Various issues were discussed (Table 5), and some participants expressed wanting more time for deeper discussion than time allowed. In the large group debrief, when asked to raise their hands, a majority of participants endorsed feeling discomfort during the small group process. However, many said they were able to “push through it.” Some participants had powerful emotional connections to the content; some became tearful, yet simultaneously expressed finding the experience beneficial. Four notable themes emerged in the large group debriefing (Table 5).

The pre/postsurvey was completed by 72 participants and analyzed in aggregate (Table 4). Results revealed that participants improved their knowledge of the impact of racism on health inequities (Q1, P=0.001) and of strategies to address racism in home institutions (Q2, P=0.001). Participants had higher levels of confidence in making strategies to improve the racial climate in their institutions (Q4, P=0.001) and in teaching learners to reduce racism in patient care (Q5, P=0.001). Finally, participants highly rated their commitment to make personal changes in addressing health disparities (Q3, P=0.01).

This relationship-based workshop and toolkit are early steps in developing an antiracism curriculum in medical education, and demonstrate how providing information and relational context for difficult conversations can engage faculty to consider addressing racism in their educational institutions. Survey results showed that participants felt they had changed or improved their knowledge of how to address these issues.

Participants selected this workshop, and demographic information was not collected, which limits generalizability. Due to underestimating the number of participants, only 80 paper copies of the survey were distributed, and 72 were completed. The survey results may not truly reflect the entire group experience. The lack of a control group calls into question whether attitude changes were attributable solely to information presented in the workshop. Additionally, qualitative information from group discussions were collected via group facilitators, who were presenters and also authors of this study, which may introduce bias.

Health inequities are not inevitable.27 Given the evidence on the role of racial bias in disparate health outcomes, racism must be included in medical education curricula.5,8,13,29 This workshop offers preliminary evidence that educators can benefit from exploring racism in medical education. Training programs should: (1) prepare health professionals to address racism; (2) adhere to the health inequities training requirements of the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education; and (3) develop innovative, impactful, relationship-based curricula that are facilitated with thoughtfulness and respect by well-prepared faculty members. Educating future health care professionals to combat racism is essential in eliminating health inequities.