The Time Is Now

The STFM Foundation Board of Trustees appreciates the opportunity to comment on the theme of racism curricula and diversity recruitment, in recognition of our initiative to increase underrepresented in medicine faculty in family medicine. We launched the Underrepresented in Medicine (URM) Campaign at the 2018 STFM Annual Spring Conference with the goal of advancing the presence, voice, and scholarship of URM faculty, residents, and students. The URM initiative goals are increasing the number of URM students and residents choosing academic family medicine, retaining URM faculty in family medicine, and expanding community URM family physician engagement in educational roles. Our work will build on robust STFM programs and collaboration with established organizations that have aligned aims. As we move forward, our attention will be focused on mentoring and leadership development, scholarship to define the best approaches to this work, and opportunities at every step of the path to becoming a successful family medicine educator.

We, the board members of the STFM Foundation, are a diverse group. We identify as:

• black, brown, yellow, and white;
• at different stages of self-reflection on our own privileges and multifaceted identities;
• individuals working to confront our biases and striving to overcome them; and
• at different times victims, witnesses, and perpetrators of microaggressions.

Our ability to listen, learn, and grow together as a leadership body has strengthened our work on the URM Campaign.

We are particularly grateful for the work of the authors of this special issue of Family Medicine.

In the late 1980s, one of us offered a workshop titled “Teaching About Racism: One White Girl’s Approach.” This was well before the Institute of Medicine published Unequal Treatment,1 and was just as Secretary of Health and Human Services Margaret Heckler was developing the Task Force on Black and Minority Health in the Reagan Administration. At that time, there was little research regarding health disparities by race, little discussion about diversity in the workforce, and not much attention paid to the gulf between patients and clinicians of different backgrounds. Thus, the workshop worked toward a basic understanding of race as a social construct, explored different types of racism (conscious and unconscious, individual and institutional) and the potential for unconscious bias, even in well-meaning people, to contribute to racial disparities.

Now, more than 25 years later, health care and health status disparities by race are well documented in the literature and individual provider contributions to those disparities are accepted as integral. The presence of implicit bias is settled science and, as the 2014 Kirwan Report notes,

Sometimes the behavioral research leads us to completely change how we think about an issue. For example, many of our antidiscrimination policies focus on finding the bad apples who are explicitly prejudiced. In fact, the most pernicious discrimination is implicit, subtle, and nearly universal.2

As we move forward together to address inequities in health care delivery, health professional training, and our daily interactions, our focus must continue to be on the intrapersonal level, reaching into our own unconscious and mindfully monitoring our behaviors. Over time, creating habits based in debiasing strategies can change one level of racism that Camara Jones, MD, PhD, describes as “personally mediated” racism.3

Nonetheless, the shackles of racism exist not only at the individual level. The United States has a deep structural burden of division by race, exacerbated by the involvement of class, geography, education, and other social determinants, that ultimately leads to the disparate access to becoming a family physician. We aspire to increased diversity as a key strategy to improve the health of our country. The STFM presidents in 2016 and 2017 have each written columns on the subject.4,5 Family Medicine has published more articles on racism in the last 3 years, but one must go back as far as June 2001 for another concentrated production. That issue includes still-relevant articles on the use of race in the clinical presentation,6 the relative lack of success of women and URM faculty in academic family medicine,7 racism in the examination room,8 and Former President Denise Rodgers, MD’s, column “Celebrating Diversity/Eliminating Disparities.”9

In this special issue, we see evidence of both the progress made and the intransigent nature of racism. Two honest essays10,11 illuminate the realities of living in a racist society and the continuum of microaggressions to overt discrimination levelled from patients. These occurrences have not changed, and the question of how to continue to combat racism at every level remains the challenge. How does an individual consistently demonstrate the courage and commitment to walk into a room, never knowing what response will meet them? How does one show compassion and curiosity in the face of hate? Racism curricula need a very specific module to address this. Curricula alone, however, are far from enough. Additionally, institutional policies must demonstrate unequivocal support for the learner and clinician as well as every member of the health care team, as none are immune. These policies should offer a specific, actionable guide for working through complex, multilayered interactions.

In that spirit, we encourage you to look back and read two essays from recent issues of Family Medicine, “Meeting Jim Crow,”12 and “An Unforgettable Case.”13

Fortunately, there is cause for optimism. Two articles14,15 in this issue demonstrate the benefit of simple, intentional efforts to increase diversity at two residency programs. These efforts are a call to all of us to look carefully at our residency recruitment and selection procedures. Application and selection processes are frequently at risk for structural and intrapersonal bias.16 As many programs are experiencing a deluge of applications, it can be tempting to use exclusionary guidelines that look at quantifiable attributes (USMLE scores, honor society membership, etc). Nevertheless, most of these single markers of student success are encumbered by structural forms of racism.17 Standardized tests, subjective grading, and the variable quality of student advising and mentoring can all contribute to differential access. Then also discrimination in the selection process can be compounded by interviews that are uninformed about the risk of implicit bias.18 It is encouraging to note that by bringing an antiracism awareness to every step, both programs were quickly able to change their resident composition regarding race. While we may eventually face the competition for a limited pool of applicants of color, we must consider opportunities to address this at every step of the path.

Racism curricula have forged ahead in this area. In this issue, an innovative multidepartmental educational series is described that uses an antioppression framework to empower health care workers to function as allies in addressing bias.19 Inventive features of this program include supporting participants from knowledge development and introspection, to skills building. In addition, the program was delivered to multiple professionals, including physicians, nurses, midwives, researchers, and administrative staff. Results show the positive response of increased confidence in addressing bias in health care. As a community of educators, we are moving from discussions about cultural humility to the skills necessary to address behaviors grounded in unconscious bias. Similar training will be invaluable for academic health centers seeking to address diversity and inclusion. Earlier this year, Tanya White-Davis, PsyD, et al reported in Family Medicine on a rich toolbox of resources that can be used to create specific educational experiences on bias, racism, oppression, and responses for faculty members.20 STFM and family medicine educators are well positioned to offer antiracism resources and strategies.

We, the STFM Foundation Board of Trustees, are committed to being a catalyst in providing opportunities for URM in family medicine. This theme issue of Family Medicine also encourages members of our community to identify overt bias, unconscious or not, and respond effectively as allies against racism. It is incumbent upon each of us, our programs, departments, and organizations, to review the policies and procedures that reinforce structural barriers to inclusion. An antiracist awareness must be brought to the design and implementation of curricula and interventions at every level of physician education and patient care. We are at a time of new ideas and clarity. The time is now to address the personal and institutional racism that derails the careers of URM candidates seeking careers as physicians and faculty. We thank you for your support and ask you to join us in our work. Finally, we invite you to learn about the structural forms of racism, take a stand as an ally in the face of microaggressions and support the STFM Foundation with a gift of any size. This can be done online at http://www.stfm.org/Foundation/Donate.