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Transcript: Racism Under the Microscope

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David Skorton, MD: Welcome to “Beyond the White Coat.” I’m David Skorton, president and CEO of the Association of American Medical Colleges. As we launch into this new year, it’s worth taking stock of the current state of racism in medicine. We’ve known for a long time that systemic racism influences the social determinants of health — affecting, quite literally, who in this country survives and who suffers. People who live in poorer neighborhoods often receive lower quality and less care from health care providers. And long-standing discrimination against all marginalized communities has created dramatic health inequities. To guide us as we move forward, let’s take a look back at some of the conversations we had about these very thorny and persistent issues this past season on “Beyond the White Coat.” 

At the beginning of this season, and amidst much racial unrest in our country, I spoke with Lonnie Bunch the third, the 14th secretary of the Smithsonian Institution, about how the history of racism in medical education, clinical care, and research has impacted academic medicine’s relationship with the Black community. 

We started to explore what can be done to regain trust and become allies and partners in their health and wellness. 

Let’s listen in for a moment to the discussion we had back in September about what’s different about this particular moment in history and what we may have learned from the past. Here’s a brief clip from our first “Beyond the White Coat” episode of season two. 

[Audio excerpt from “Beyond the White Coat,” season 2, episode 1] 

David Skorton, MD: With the amplified conversations on race and racism in America, is the shift that we are seeing across the country in the American mindset today any different from the shift that took place after Congressman John Lewis helped lead the Civil Rights protesters across the Edmund Pettus Bridge in 1965? Is there anything new under the sun? 

Lonnie Bunch: I think it’s first important to recognize that we’ve been in this place before. We’ve been in moments where Black bodies were broken. We’ve had moments where people have said that’s wrong and they’ve protested in the streets. What’s different now, however, though is — I think, first of all, because of social media, you begin to see that this is not just a localized activity but a national and international activity. 

You’re also seeing something that gives me great comfort — which is, traditionally when African Americans struggle for fairness, they have allies, but it’s mainly an African American movement. Here, you see a greater diversity of people owning this, because I think one of the great challenges and where I’m optimistic about this moment is, traditionally these are issues that say, “How do we improve the status of African Americans?” Today, you’re hearing people say, “How do we improve the status of Americans?” — because if we do this, this is something that we all have to own. So that gives me a bit of hope. 

David Skorton, MD: So, this pandemic obviously has laid bare the tremendous, maddening inequalities in the health and health care of African Americans. As you mentioned, it didn’t start with the pandemic by any means; it was generations and generations and generations. But it certainly has been laid bare and shown in bold relief. What are some of the historical factors that have led to these kind of disparities, and how did African American patients fare during earlier pandemics — for example, the Spanish flu in 1918? 

Lonnie Bunch: Well, what you really have historically is the health of African Americans has always been undervalued. In some ways during the period of slavery, African Americans were worked excessively; there was limited health care to them, a lot of it tended to come out of traditional health care coming back from Africa. What you also have is then a racism that says some of the diseases that Blacks succumb to were because they were inherently inferior, because their bodies were different. So that even when medical science could have improved a lot of African Americans, they didn’t. 

And what you see then is, not only is there the lack of treatment for African Americans, but African Americans then become used. They are used in test cases, they are experimented on. In essence, their worth is seen as, “How do they improve the White community?” 

So, in a way, what we have is the lack of historic treatment on many of the illnesses that African Americans have. So then when diseases hit, whether it’s tuberculosis in New York in the 19th century, whether it’s the Spanish flu in the early 20th century, African Americans are both weakened because they’ve had a history of not having fair health care. But also, they’re the last to be paid attention to in these moments. So, they got the tail end of the treatment and they ended up having larger number of losses than others. 

And so what I think we see is that hundreds of years of neglect, hundreds of years of not prioritizing Black health care has led us to the moment where we are now where, when we look at the numbers of African Americans who die or Latinos who are dying versus other communities, the only answer is it’s because we didn’t care enough as a country to invest in their health. 

[End audio excerpt from “Beyond the White Coat,” season 2, episode 1] 

David Skorton, MD: Powerful words by Secretary Bunch indeed. It’s so important that we revisit our history and continue to reflect and learn from these lessons.  

In this next episode, my colleague Dr. Malika Fair, AAMC senior director of health equity partnerships and programs, spoke with four experts in academic medicine to explore how academic medicine can move toward more equitable care for all and to dive deeper into how we prepare and train the physicians of tomorrow to be allies for everyone. She heard some interesting insights from all four experts, including Dr. Laura Guidry-Grimes, an assistant professor in medical humanities and bioethics; Dr. Brian Gittens, a vice chancellor of diversity, equity, and inclusion — both from the University of Arkansas for Medical Sciences — and Dr. Carol Major, an obstetrician and co-founder of Leadership Education to Advance Diversity–African, Black and Caribbean; and Dr. Charles Vega, a professor of family medicine who also directs a program on medical education for the Latino community — both from the University of California, Irvine [UCI], School of Medicine.  

Their conversation provides an interesting look at how we can structure our curricula so that topics like these are addressed prominently and head-on, so that tomorrow’s medical providers have a solid foundation for achieving equity, diversity, inclusion — and anti-racism.  

Let’s listen in to a portion of their conversation. 

[Audio excerpt from “Beyond the White Coat,” season 2, episode 4] 

Malika Fair, MD, MPH: Can any of you talk about what education and training is needed for all students to address racism and other forms of oppression? 

Charles Vega, MD: I love the concept of creating anti-discrimination, anti-racism curriculum and building it proactively and creating frameworks, and the real challenge is to try to, one, evaluate how it's doing. And so, I think that there's a lot of value that we haven't paid as much attention to in evaluating how our learners are performing in these areas, and we've developed some models using objective-structured clinical exams to really look at that here at UCI. While we want, I think, good networks and institutions that we can rely on that support these efforts over time so they don't just go away in the next academic year or when something else new is flying in front of us, but they also have to be able to shift. Because culture is constantly changing and shifting, and the priorities and the needs of our communities are changing as well, so it has to be baked into those institutions that they have some flexibility as well. And I think that will help us respond to new challenges. As we've seen in 2020, those new challenges can be severe and really require everything we've got. 

Laura Guidry-Grimes, PhD: I think part of what the curricular development should be looking at is the ways in which patients and families and health care professionals can be multiply marginalized, right? The point about intersectionality and how someone's experience of racism can be interlocked with experiences of sexism, or heterosexism, or ableism. And so, looking at different forms of oppression through that kind of lens, and then what our trainees' responsibility was — their role in that. And I think part of the challenge is to train students to consider the implications of complicity and complacency. Many of our students think that racism has — and other forms of oppression has — nothing to do with them or their future medical practice, or they think that racism is a problem for our politicians and activists to address and not them. And I think there are two sort of big learning barriers here. One is a rejection of anything that makes them uncomfortable, and another is distancing themselves from how they are morally implicated by systemic issues like racism and other forms of oppression. 

So, we have to create spaces that teach students how to live with discomfort, which is a big task, right? None of us likes to be uncomfortable, but I think it's one of the biggest learning points of 2020, in a way, is learning how to be uncomfortable and have those kinds of really difficult conversations with each other and to have that introspection. The topic of racism and racial privilege should be making students uncomfortable, and they should embrace that discomfort as an opportunity to be humble and to learn. And we have to emphasize the moral role that they have if they are silent and if they're passive on this issue. So, to reinforce a lot of the points of my co-panelists here as far as being actively anti-racist, being actively involved in combating bias in health care. And if they are passive, those are choices, and they do reflect on moral character. 

And so, having the concept of everyday racism — the empirical work on everyday racism and other forms of oppression, as well as intersectionality — be part of ongoing curricular efforts, instead of one-off events where students can opt out of learning and being uncomfortable, I think is really important. 

[End audio excerpt from “Beyond the White Coat,” season 2, episode 4] 

David Skorton, MD: Those are especially important points — about living with discomfort, about intersectionality, and about how complex the multiple layers of racism and other forms of oppression really are. Clearly, there’s a lot more work ahead of us. 

But what I take away most from listening to these conversations is that we always have the ability to evolve and change. We can always introduce new ways of working with and supporting each other.  

For that reason, I passed the mic to my colleague Geoffrey Young, AAMC senior director of student affairs and programs, for the third episode of this season to talk with a fourth-year medical student at Yale School of Medicine. Geoff spoke with Max Jordan Nguemeni Tiako about his experience as a learner and as an advocate for racial equity and equality in medical education and health care. Let’s listen to a bit of their conversation. 

[Audio excerpt from “Beyond the White Coat,” season 2, episode 3] 

Geoffrey Young, PhD: So, as our nation really begins to talk about and have conversations about anti-racism and how it needs to be addressed in the academic medicine community, how do you think you and your colleagues, medical school colleagues more specifically, can address that distrust to help promote a better relationship with communities of color? 

Max Jordan Nguemeni Tiako: That's a hard question, man. I don't even know where to start. I mean, I don't think people are equipped. Medical mistrust is like a deep, deep issue and I think there are many reasons why, right? Like, and it can start at, like, the small level of the patient encounter. Where, like, providers can be — can literally treat their patients better, right? 

There's evidence that, for instance, like, physicians who are not Black, like especially physicians who are White use, like, fewer words and have like, more or, like, less open body language when they are treating Black patients and there's this sort of, like, feedback — feedback loop in the communication between, you know, patient and provider, such that, you know, if I'm noticing that you're not using a lot of words when you are speaking to me or that your body language isn't so positive, then you're making me, like, feel some type of way about this clinical encounter. I'm sort of like — close off myself. Or, yeah, in clinical encounters, it's like a small way to sort of, like, get at whether or not people trust the institution. 

But I think on a larger scale, how do you treat Black people, right, like at an institution — like quite literally? And by that, I don't necessarily mean just in the clinical encounter. A lot of these hospitals in academic medical centers are anchor institutions in their communities, right? So, like, I go to Yale. Yale University and Yale New Haven Hospital are like the two largest employers you have in Connecticut. 

So beyond patient encounters, how do you treat Black people over there? How do you treat the Black people that you employ, right? Because we talk, right, like Black folks will tell you, “Oh yeah, that place is racist” and like, that's based on perhaps how somebody got treated at work and that also translates into how people are — what, like, people's attitude or, like, the physician towards the place might be when they show up for clinical care, right, knowing that you don't treat your Black employees right. Like, how am I supposed to believe that you're going to treat me right as a patient if you don't do your employees right, right?  

So, I think that's something that is, like, critically missing in this conversation of, like, anti-racism and health care. It's especially when I think about it. So, most Black people who work in the hospital are not physicians, right? But this conversation of anti-racism has sort of — of like, focus on, “Oh, we need more Black doctors” — nah, nah, nah, which we do, yes, but, like, I don't think that that is, like, the most — that is not the most anti-racism that a medical center can do, right? 

Hospitals hire the majority of low-wage health care workers who are disproportionately Black and Hispanic, right? Many of them Black women, many of them who live in poverty, especially if they have children and, for instance, are, like, insured on their Medicaid, right? How come if you work for a big … if you work for a hospital, how come you're not insured under the same insurance plan as the other people who work in the hospital, right? 

So, I think there is far more anti-racism to be done than paying lip service to the, you know, the project of diversifying medicine as a profession. You don't even need — I mean, we need Black doctors obviously, but, like, you don't need more Black doctors for hospitals to start paying their Black employees better, you know what I mean? 

[End audio excerpt from “Beyond the White Coat,” season 2, episode 3] 

David Skorton, MD: What a compelling message — I think the academic medicine community is very lucky to have future doctors in the making like Max. Those are all valid points, and we should take Max’s perspective seriously as we look for ways our medical institutions can do better for all. 

Let’s move on to another topic. In the second episode of this season of “Beyond the White Coat,” I spoke with my colleague Dr. David Acosta, the AAMC’s chief diversity and inclusion officer, about the history of structural racism in U.S. medical education and how that history informs today’s learning environment. 

Dr. Acosta also shared more about our association’s history and role in the segregation of medical education. 

Both Dr. Acosta and I feel it is so important that each of us look in the mirror and hold ourselves accountable, recognizing our own role in working toward social justice. We need to do even more to become diverse, equitable, inclusive, and anti-racist — not just as individuals and as an organization, but as the entire academic medicine community and in society at large. 

And that starts with acknowledging our past and telling the full story. Let’s listen in to how Dr. Acosta and I spoke about that back in October on “Beyond the White Coat.” 

[Audio excerpt from “Beyond the White Coat,” season 2, episode 2] 

David Skorton, MD: So, as we both know, the AAMC has a long-standing commitment to promoting diversity in medicine, but this wasn't always the case, even with our association. And share with the listeners: What was the AAMC's role in the history of segregation and medical education? And then, you know, move forward in time and tell us, what's the AAMC doing now to make progress in this absolutely critical area, please. Give us the history, give us the current status, if you would. 

David Acosta, MD: Sure. And when I arrived at the AAMC, you know, this history I really didn't know, but it was there clearly to see in our resource center that keeps archives, you know, dating way back as far as we can go, about some of the things that have transpired at the AAMC. So, again, as we all know — listeners may not know this, but the AAMC was founded in 1876, and at that time, the membership was limited to predominantly White institutions. And these institutions also restricted medical school admissions to women, Jews, and other people of color, as well. Well, the history goes that, in 1949, the National Medical Association petitioned the AAMC to issue a policy statement that said, essentially, that medical schools be open to all, without discrimination related to ancestry or religion. And the AAMC's executive counsel response, at that time, was to maintain that it “never interfered with admission policies of any of its member colleges.” 

And so, they declined to take a stand against segregation at that time, and discrimination in medical schools. And it wasn't until 1968 that the AAMC — and this also included the AMA — joined to endorse the supposition that all medical schools should accept, as a goal, their expansion of their enrollments, and commit fully to ensuring that African Americans and all minority students had equal and meaningful access to medical schools. And again, in 1968, again, it was the result of the Civil Rights Act that was passed in 1964, and also, the Brown versus Education back in 1954, that really put the pressure on, I think, the AAMC, but also the AMA, as well, at the same time. So that was 1968, and in 1969, the AAMC established its first Office of Minority Affairs, but came under the student affairs division that was there at the time. And it really wasn't until 20 years later that the AAMC hired their first vice president, a physician, to lead diversity work. 

And that was Dr. Herbert Nickens, a name that we all know, and he created the Division for Minority Health Education and Prevention, at that time. But then, fast-forward almost another 20 years, and it wasn't until 2007 that our past president, Dr. Darrell Kirch, publicly acknowledged this history. And that was after receiving a letter from an emeritus professor at Harvard University to inform him of the past that the AAMC had. So, at that time, President Darrell Kirch expressed the association's deep regret, for the first time, for the decision of the past, and took responsibility for the association's inaction. So, as you say David, as I fast-forward to today as, you know, how have we — if I ask the question, “Well, how did we try to repair our past?” 

You know, today, the AAMC, as you have mentioned, is very committed to equity, diversity, and inclusion. Not only do we have a chief diversity officer, but we also have three senior directors and 16 staff that focus on workforce development, they focus on the learning and workplace environment, on becoming anti-racist, diverse, and equitable and inclusive. We also have a portfolio that addresses population health, health equity, social determinants of health, and even racism. You know, we're interconnected, now, with all facets of medical schools, teaching hospitals, from student affairs to research to health care affairs, and assist in any way that we can along DEI matters that we can help with. And that includes also offering DEI education and training, where DEI matters. 

David Skorton, MD: Well, thanks, Dr. Acosta, that's a very interesting and sobering review of the history of our own association, and an upbeat review of where we are going. And please permit me to say, to everyone listening, that you yourself have been such a big, big part in moving us along in the direction we're going. You're quick to thank and comment on everybody else, but you've really been an extraordinarily effective leader, not only nationally but in this association, and I want to thank you for that.  

[End audio excerpt from “Beyond the White Coat,” season 2, episode 2] 

David Skorton, MD: That was a tough moment, and there’s no doubt in my mind that there’s more work to be done. In addition to holding ourselves accountable, we need to be intentional in our actions. And that is exactly what we’re doing at the AAMC in several key areas. We’ve released our Framework for Addressing and Eliminating Racism at the AAMC and Beyond and have already taken a number of related actions, including renaming one of our awards that had been named after someone whose racist and sexist ideas we no longer wish to associate with. 

And that’s just a start. But I’m very hopeful that the hard work of our colleagues in academic medicine and the ongoing conversations we’re having will continue to lead us down a path of progress, especially for the next generation, which is so important for our future.  

Academic medicine has already shown it has what it takes to lead the way forward. Your spectacular response to this year’s unthinkable conditions gives me great hope. At every step, academic medicine has defined the front lines of the pandemic. You have shown this nation, your communities, and your patients the very best amid conditions that were the very worst. 

You have done this in the context of COVID-19. And I also believe academic medicine has the collective energy, ingenuity, and innovation to make a difference in other ways, too, including the ever-present challenges of systemic racism in our institutions, our communities, and in our everyday lives. It’s even more urgent today that we make steady and significant progress on this set of issues.  

Thank you for going on this journey with us on the past season of “Beyond the White Coat.” Now, let’s translate these conversations into tangible next steps within our institutions and beyond. Let’s lead the way forward. Now is our time to act. Thank you. 

[End of audio] 

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