In It Together for the Long Run

Striving for health equity and overcoming the effects of racism and bias in medical education are central to the mission of STFM. To our knowledge this is the first column cowritten by the incoming, current, and immediate past presidents of STFM and the chief executive officer of STFM. We are writing together to acknowledge the importance of this work, to explore what this means for our organization, and to prompt reflection and response.

We also write from a place of deep personal conviction:

I’m aware that my lack of meaningful exposure to other cultures, races, and ethnic groups while growing up limits my understanding of minority perspectives. I have to be intentional to overcome this lack of experience and be mindful of my own blind spots.

My Asian-American immigrant story is one of hard work and perseverance, but also must not ignore the privilege of educated parents and voluntary emigration that ultimately contributed to the “model minority” myth. Asians are not an underrepresented minority in medicine, but they are underrepresented in race and social justice work. It is my responsibility to contribute, represent, and lead.

As an immigrant to this country, I was shaped by the experience of trying to adjust to a new culture as a third grader, not speaking the language. As a white man I struggle to find ways to move beyond the guilt of privilege and serve as an effective ally.

As a black man who has been blessed with a wonderfully wide swath of life experiences of which not all have been wonderful, my brother Beat has no need to feel guilt for either who he is or who his parents are. We are born into station and status outside our doing; who we are is borne out through our decisions and actions no matter the context of our birth. Extend mercy, do justice to and for the weak, lonely, oppressed, and needy whoever they are: this is part of the call to health equity.

Overt and implicit biases contribute to health inequities by affecting medical education, clinical care, and medical decision making. Underrepresented in medicine (URM) is defined by the Association of American Medical Colleges as those racial and ethnic groups that are underrepresented in the medical profession relative to their number in the general population (https://www.aamc.org/initiatives/urm). URM patients are more likely to have more difficulty accessing care, experience suboptimal care, and suffer negatively from social determinants of health. As a result, health outcomes are often significantly worse for underrepresented minorities.1,2 While efforts are being made to draw attention to the devastating effects of overt and implicit bias, much work remains to be done.3

The physician and faculty workforce does not reflect the demographics of our communities.4 The total number of black male physicians in the workforce has remained unchanged since the 1970s while the relative percentage has decreased.5 Disparities like this may serve to amplify the implicit biases we have in how we mentor, how we grade, and how we recruit.

In her president’s column in 2016, Melly Goodell, MD, asked the provocative question: “Are we doing enough to promote diversity?”6 While it is difficult to know what exactly is enough, we are proud to say that STFM has continued to increase its commitment to addressing health inequities.

Some of the recent efforts are named below. More details about these efforts are on the STFM website (http://www.stfm.org/Resources/ResourcesforResidencyPrograms/HealthEquityActivitiesandResources).

All three presidents have committed to making health equity a major focus of their terms. Presentations at our conferences on how to recognize and address health equity have increased significantly. At the 2018 annual conference were: plenaries that address allyship, social determinants of health, health equity, and moral obligations of citizenship; a preconference on equity and diversity; 15 sessions on diversity; nine sessions on racism; eight sessions on social justice; and seven sessions on inequity. All other STFM conferences in 2018 and 2019 will also have a major focus on health inequity. STFM journals (Family Medicine and PRiMER) are increasingly publishing articles on diversity and inclusion; there have been 10 articles and five president’s columns addressing these topics in the last year. This current issue of Family Medicine is entirely focused on racism and health equity. The STFM Foundation recently launched an Underrepresented in Medicine Initiative, which is focused on a fund-raising campaign and training a more diverse workforce.

STFM is collaborating with the other organizations of academic family medicine through the Council of Academic Medicine (CAFM) Leadership Development Initiative to increase the URM and female diversity in leadership across academic family medicine. The Minority and Multicultural Health Collaborative is one of STFM’s largest and most active collaboratives, keeping us focused on emerging issues related to URM health equity in education.

This partial list of recent activities is significant and should make us proud—proud enough to be energized, but not proud enough to be satisfied. Given the persistent grave health inequities that continue to plague us, STFM remains committed to advancing education and advocacy activities that help move American health care toward greater equity for marginalized populations.

Disparity and inequity will always be with us. We will, therefore, need to be consistently persistent and vigilant as the faces and realities of health equity evolve over time. If we are to succeed in the long run, we need to commit being all in for the long run. Being all in has important implications:

1. These efforts must be intentional and should make us uncomfortable. These efforts will require resources. We have to make this work a high priority and not give up because the work is hard.
   • What are the efforts that allow us to fulfill our mission and most effectively use our talents to improve health equity?
2. Current efforts often focus on raising awareness of the problem but are sometimes less successful at helping us find solutions. Such efforts can leave us feeling ambivalent, dissatisfied, or even guilty without clear ideas on what to do next.
   • How do we most effectively support our community of educators to develop and be part of solutions?
   • What are the bystander skills that we can train in our conferences and with our online resources? How do we create a stronger community of allies?
3. We do not yet have good measures to assess whether we are moving in the right direction. Counting sessions and programs is a good beginning but not adequate in the long run. On the other hand, it is not helpful to set measures that are so lofty that we cannot achieve them with our resources. We have an effective program assessment process. But we need to define the right metrics
   • How will we define SMART (smart, measurable, achievable, relevant, time-bound) metrics to evaluate and track progress in our work towards health equity?
4. What is the level of commitment to achieve health equity? We, your three STFM presidents, board of directors, CEO, and staff, are committed to this journey. We hope you are as well and will participate in efforts to address the three questions above as STFM endeavors to be part of the solutions to enhancing health equity.