How medical education can help fight racism

During his physician residency training about 15 years ago, Dr. Chris Colbert doesn’t recall health equity ever being acknowledged or discussed.

“There was just African American residency (training) and the thought that this wasn’t right,” said Colbert, who is African American and serves as assistant emergency medicine residency director and director of health disparities at the University of Illinois College of Medicine. “But we didn’t feel like we were in a place where we could say that out loud.”

That sentiment has permeated medical education for generations, and many experts contend that’s part of the reason cultural and racial inequities persist in a nation that is growing more diverse. 

“I think for a lot of organizations … they’ve just been able to check a box and then keep going” when it came to cultural competency training, said Dr. James Hildreth, president and CEO of Meharry Medical College, one of three historically Black U.S. medical schools.

Unless medical education moves beyond that mentality, clinicians are likely to continue ignoring the effect of their implicit or unconscious biases on their decisionmaking, which has resulted in:

Perpetuation of assumptions that reinforce racist and culturally insensitive stereotypes, such as the notion that Black patients have a higher pain tolerance than whites, leading to misdiagnosed pain assessments that result in Black patients being less likely to receive pain medication. Or when medical book publisher Pearson in 2017 came under scrutiny for such passages as “Arabs may not request pain medicine but instead thank Allah for pain if it is the result of a healing medical procedure,” in its textbook, Nursing: A Concept-Based Approach to Learning.

Lack of investigation into the root causes for the disparities. Take breast cancer—Black women are 41% more likely to die from the disease than white women despite having a slightly lower incidence rate. And while breast cancer incidence rates are higher among Black women than white women under age 45, leading organizations, including the U.S. Preventive Services Task Force, call for routine mammogram screening once every two years for all women between the ages of 50 and 74 at average risk for the disease.

Less intervention, as the Joint Commission points out that non-white patients receive fewer cardiovascular interventions and fewer kidney transplants. Black men are less likely to receive chemotherapy and radiation therapy for prostate cancer and more likely to have testicle(s) removed.

Patients of color are more likely to be blamed for being too passive about their healthcare and less engaged in shared decisionmaking.

“There’s a lot to be said about what’s being put in front of our learners starting in undergrad but especially in medical school,” said Dr. Nanette Lacuesta, director of the Physician Diversity Scholars Program at OhioHealth in Columbus. “There’s a lot of discussion about making sure that the images that are put in front of our students have different cultural considerations woven in.”

To address those disparities, OhioHealth has focused on increasing the number of clinicians from underrepresented communities as well as providing cultural sensitivity training.

“It helps if you’re an African American physician, but a Caucasian physician needs to understand that too,” said Dr. Mysheika Williams Roberts, Columbus’ health commissioner and a program mentor for the past 10 years.

The system has partnered with three local medical schools to pair medical students from underrepresented communities with a mentor who can guide professional development and be a sponsor for up to four years. The hope is that graduates will eventually match into OhioHealth residency programs. Now in its 10th year, the Physician Diversity Scholars Program has been completed by 63 students; 17 have been matched to either residency or fellowship training at OhioHealth and six have become staff members.

“We have a pretty good return on our investment,” Lacuesta said.

But that business case isn’t translating across the industry or down to medical education. During the 2018-19 school year, 6.2% of the nation’s more than 25,000 medical school graduates were African American, according to figures from the Association of American Medical Colleges, relatively the same proportion who graduated from medical schools in 2002.

A sizable portion of Black doctors come from historically Black colleges and universities. Of the 12,219 Black graduates from all medical schools from 2009 to 2019, 14.3% were from HBCUs.

“As the nation gets older and browner and darker and more colorful, it’s going to be even more of a problem to make sure that we have the kind of healthcare providers who reflect our population,” Hildreth said.

Black people account for 22% of all coronavirus deaths, according to the most recent data from the Centers for Disease Control and Prevention. That disparity has underscored a racial healthcare gap that can’t be ignored. And it has spurred academic leaders from historically Black medical schools to advocate for a targeted response from federal lawmakers, one that they say would have a lasting impact.

Hildreth in May testified before Congress, asking for $5 billion over the next five years to help historically Black medical schools address the impact COVID-19 has had on people of color.

The money would help Meharry, Morehouse, Howard and Charles Drew University of Medicine and Science in Los Angeles form a consortium to lead contact tracing and testing efforts within marginalized communities. Evidence has shown less testing and contact tracing occurring in ethnic and racial minority communities compared with predominantly white communities, resulting in fewer tests being administered and less COVID-19 surveillance in minority neighborhoods.

But the consortium’s role would go beyond just responding to the pandemic. Hildreth said much of the funding would go toward the schools’ efforts to address the structural barriers to better health within those communities.

“It changes conversations dramatically when there is a person of color sitting at those tables,” he added.

Developing physician leaders of color has been the primary objective of a diversity program started in 2019 at UCI School of Medicine in California. The Leadership Education to Advance Diversity-African, Black and Caribbean, or LEAD-ABC, is the first four-year program in the country specifically designed to recruit and train medical students to become physicians that will target reducing healthcare disparities in Black communities and other underserved areas.

Evidence has shown a health benefit for minority patients who are treated by minority physicians.

A recent study published in the Proceedings of the National Academies of Sciences of the United States of America found Black newborns were more than three times as likely to survive childbirth if they received care from Black doctors compared with white physicians.

Dr. Peter Pronovost, chief quality and clinical transformation officer at University Hospitals health system in Cleveland, said such evidence should compel healthcare organizations when possible to do more to offer patients of color opportunities to receive care from clinicians who share similar ethnicities.

“Unfortunately we don’t have enough Black physicians to always provide that, but it could be engaging a community health worker who looks like them who’s trusted,” Pronovost said.

Like at Meharry, the hope with the UCI program is that the focus on producing more clinicians of color to serve minority communities will improve the health of those patients and help establish greater bonds of trust in the medical field.

“There are just these assumptions about African Americans that they abuse drugs and that they’re lazier that reflects in the kind of care that they’re given overall,” said Dr. Carol Major, director of UCI’s LEAD-ABC program. “We need to teach students and physicians-in-training to stop making these assumptions about a specific population based on the color of their skin.”

While Lacuesta from OhioHealth acknowledges challenges remain, she’s said more schools have recognized the importance of addressing such issues around race and bias. She attributes some of that to the role the Affordable Care Act played in establishing targets for providers to reduce health inequities in access and outcomes.

“Our world is changing, and people are realizing that structural racism is causing a bigger part in the health inequities not only among our patients but also in our learners,” Lacuesta said.