Address Structural Racism First!

Drs Jabbarpour and Westfall have provided an excellent commentary on the importance of the future family medicine workforce in addressing racial inequalities by promoting diversity and inclusion in residency training.¹ We agree with many of the recommendations suggested by the authors. Individual, intentional education on diversity, equity, and inclusion (DEI) issues is a good starting point. We encourage leaders to use this education to produce meaningful changes. However, in order to progress, academic family medicine leaders must deliberately dismantle structural racism, which is embedded in culture, practices, and policies of academic medical institutions²; otherwise, our diversity and inclusion efforts are rendered futile. This differs from the traditional approach where institutions have often sought out diversity without first implementing equitable policies and practices.

Structural racism is not only evident in residency recruiting processes but also part of how underrepresented in medicine (URIM) residents are treated once they join residency programs. Underrepresented minority residents have been the target of bias and discrimination in patient interactions as well as from fellow residents, attendings, program leadership, and other health care team members.³ URIM residents’ experiences and opinions need to be understood and valued. They should be equitably evaluated, and they should not be subject to the minority taxes that are commonplace in academic medicine.⁴

Leaders, educators, trainees, and staff must be involved in the work, altering policies to ensure that changes become permanent. Dr Foster and her coauthors in the article “Dear White People” provide meaningful solutions to address these inequities.⁵ Among them: exploring individual biases, uprooting them, dismantling them, taking on the responsibility of learning about the roots of structural racism, and actively educating others about this history. White privilege can also be used to increase equity and eliminate structural racism by channeling this influence into critically examining and abolishing racist structures, practices, embedded norms, and values that sustain inequities.⁶

An additional step to dismantling systemic racism lies in rigorous policy review and revision. Leaders can recognize that “every system is perfectly designed to get the results it gets.”⁷ Therefore, if we are not satisfied with the diversity of our profession, we must admit that our systems are perpetuating that lack of diversity. We then can examine the systems of hiring, admissions, or residency recruitment and make modifications to ensure that we are recruiting a diverse workforce. At least two residency programs have taken this approach, and the changes in policy have resulted in increased compositional diversity.^8,9

The recommendations by Dr Foster and colleagues in addition to our collective resolve can encourage many in our field looking to make sustainable collaborative change in their institutions, with the goals of addressing racial inequities, eliminating structural racism, and ensuring our institutions are truly inclusive environments where those we recruit and care for can thrive.