Her patient had suffered multiple strokes, and Denise Connor, MD, urged him to take blood-thinning medication. But he repeatedly declined, says Connor, an internal medicine doctor at the San Francisco VA Medical Center.
The patient, a Black man in his late 60s, was attuned to a history of racism in medicine that includes such abuses as the Tuskegee syphilis study. “I remember him saying something like, ‘You’re all just experimenting on me,’” she notes.
And he was certainly not her only patient with such fears.
Looking back, Connor, who is also an associate professor of medicine at the University of California, San Francisco, (UCSF) Medical School, wishes she’d better understood how to help. “I wish I’d known more about how to talk with patients about the discrimination in health care that they and their communities have experienced,” she says. “If I did, I believe I could have opened up conversations that would have led to very different outcomes for their health.”
The need for physicians who understand health inequities and the impact of societal factors like racism has grown acutely clear in the last year, experts say, particularly in light of the murder of George Floyd by police and the disparate impact of COVID-19 on Black and Brown communities.
Hispanic people have been twice as likely as White non-Hispanic people to contract the coronavirus, and Black communities have suffered twice the death rate. Even before the pandemic, 14% of Black people had poor or fair health compared with 8% of non-Hispanic White people. For American Indians and Alaska Natives, that proportion was 17%.
“A growing number of schools are working more intentionally to become anti-racist, either by creating new courses or expanding or threading new experiences into existing curricula.”
Lisa Howley, PhD
AAMC senior director of strategic initiatives and partnerships
Increasingly, leaders in academic medicine are rejecting the educational status quo. A passing mention or optional course on these issues is not enough, they say. Instead, they are weaving content and experiences throughout their curricula to significantly boost awareness of social inequities and structural drivers of health.
“In 2018, only 40% of medical schools reported teaching about racial disparities,” notes Lisa Howley, PhD, AAMC senior director of strategic initiatives and partnerships. “Fortunately, a growing number of schools are working more intentionally to become anti-racist, either by creating new courses or expanding or threading new experiences into existing curricula.”
Natasha Dass, a fourth-year student at the University of Texas at Austin Dell Medical School, is among the learners helping to overhaul curricula.
“It’s crucial that we make changes to ensure that students can’t go through medical school without having their biases challenged,” she says. “It’s amazing that my school is now saying that all future physicians need to understand issues of equity and inclusion.”
A desperate need
The social determinants of health matter — a lot. In fact, experts say that societal factors like access to healthy food and safe housing influence 80% of health outcomes while medical care makes up just 20%. Education about the imbalanced effects of such factors on groups that have been marginalized matters, too. For example, including a curriculum on minority communities increased students’ intentions to serve in those communities, according to a study of 49 U.S. medical schools.
Certainly, most medical school curricula address some health equity issues — whether around race, gender, immigration status, or other concerns — and several have been working for a while to strengthen their efforts. But experts say that a deeply meaningful focus on such topics is too often lacking.
“Schools have made progress in both their required and elective courses,” says Howley. “But they haven’t yet fully tackled the magnitude of the need.”
The demand for more and better education often comes straight from students.
At Boston University School of Medicine, after students expressed concern over curricular shortcomings, the school’s medical education committee approved their request in 2019 for an in-depth analysis of race-related content. A review of gender and sexual identity topics was already underway.
Kaye-Alese Green, a third-year Boston University student involved in the anti-racism project, explains that it was a massive undertaking that spanned 13 months. In fact, dozens of students pored over hundreds of pages: every syllabus, lecture slide, course document, and practice exam question. The result was a 137-page report released in June. Now, the school is rolling out major educational updates beginning this year and continuing for several more.
One of the key issues concerning leaders at Boston University and elsewhere is the conflation of race with biology. “Being Black is not a risk factor for disease,” says Green. “Instead, it’s a risk marker of structural forces that cause disparities like access to healthy food. Race by itself does not cause disease.”
“We’re saying you can’t be a bystander, you can’t just be passive. You need to actively work to disrupt the systems that continue to marginalize and oppress people. That’s really powerful.”
Student at the University of Texas at Austin Dell Medical School
At Dell Med, students served on a team tasked with crafting the school’s eighth educational competency — a fundamental graduation goal — created to focus on health equity. Officially added in January, it spans more than a dozen skills, including the ability to recognize one’s own biases.
But Dass, who served on the work group, most appreciates the competency’s final element: taking intentional disruptive action.
“I’m proud that we’re saying it’s not enough to understand the root causes of disparities,” she notes. “We’re saying you can’t be a bystander, you can’t just be passive. You need to actively work to disrupt the systems that continue to marginalize and oppress people. That’s really powerful.”
Putting equity front and center
To really work, health equity education must be a central, driving theme, experts say.
“Understanding the social context of health has to be a foundational skill,” explains Aditee Narayan, MD, MPH, Duke University School of Medicine associate dean for curricular affairs. “It’s the lens through which we want students to see every patient encounter.”
That’s why social determinants are a key element in the school’s new “Patient First” curriculum. The overhaul involves getting to know patients starting on day one — a rarity among medical schools — and learning about their cultural and social needs together with their medical ones.
At several schools, efforts involve a focus on training faculty. Boston University recently installed a diversity and inclusion fellow, who will help faculty revise content and offer sessions on such topics as how to be an ally in the face of microaggressions. In addition, the school’s required self-assessments now ask faculty to describe changes related to the anti-racism report, such as using more diverse images of patients and providers in their course slides.
As they work to reform curricula, educators note that the gold standard is integrating health equity into every course and clinic.
“If we say, ‘This is your month to think about disparities, but we’re not going to talk about them at other times,’ that’s not very effective,” says Connor. “It also has unintended consequences. It ‘others’ these topics and marginalizes them.” At UCSF, Connor is now directing a three-year effort to expand existing content into the school’s new longitudinal anti-oppression curriculum.
How will issues of race and equity show up? OB/GYN courses will explain that some information stems from experiments conducted on enslaved people without anesthesia, for example. Cardiology courses will note that Black patients have been offered catheterization less often than White patients. Clinical clerkships will teach that you need to inquire about social determinants when taking a patient’s history.
“Understanding the social context of health has to be a foundational skill. It’s the lens through which we want students to see every patient encounter.”
Aditee Narayan, MD, MPH
Duke University School of Medicine associate dean for curricular affairs
At Duke, integration efforts have meant the creation of a new, umbrella approach that’s launching with this year’s class. The goal is to seamlessly weave together biomedical, clinical, and social factors on any given topic.
“We don’t think it’s enough for students to learn about asthma and then, ‘Oh yeah, later on, let’s learn about related social issues,’” says Narayan. “As they’re learning about symptoms like shortness of breath, they also need to know that a patient may be living in an environment that’s heavy with pollution and that pollution is more present in vulnerable communities.”
Educators note that focusing heavily on equity issues is not without its detractors. “The pushback is, ‘Don’t students need more time to focus on medical knowledge?’” says Beth Nelson, MD, associate dean of undergraduate medical education at Dell Med.
“Our argument is that this also is part of your medical knowledge. If you don't understand the context of the patient in front of you, you're unlikely to help them enough."
The physician of the future
If health equity leaders succeed, they say the physician of the future will look very different.
For one, a provider will know how to avoid contributing to biased care — even inadvertently. That might mean something as simple as the wording used in a patient’s chart, says Connor.
“We have a one-liner summary. You could write, ‘54-year-old homeless woman abusing drugs,’ or you could write, ‘54-year-old woman with substance use disorder who is experiencing homelessness,’ she explains. “Dehumanizing language can activate stereotypes that negatively affect a patient’s care. If you’re the next doctor reading the chart, you may have a much narrower view of how seriously to take a patient’s concerns.”
In addition, future doctors will likely better understand their local communities and know how to connect patients with necessary resources.
Dell Med, for example, has students working with patients during hospital discharge to ask about any health-related social needs. Students will then connect patients with services and follow up later to ensure that their needs are met. At UCSF, community connections are so central that patients will be part of the team helping to develop the school’s new anti-oppression curriculum.
Hierarchies also will be slashed, some hope.
To Connor, anti-oppression education begins with treating students as valued partners — who will then treat their patients with similar respect. “When you leave medical school, are you ready to partner with your patient, or are you used to a rigid hierarchy in which the doctor is the expert and they’re going to dictate what to do?” she asks.
Kenyon Railey, MD, who created and directs Duke’s inaugural course on health disparities and cultural determinants of health, hopes future graduates will see patients through a vastly expanded lens.
“We’re trying to teach students a new paradigm, which is that although other skills matter, your ability to be present matters most,” he says. “Have we considered the unique context our patients live in? Do we know who they love? Do we know about their work lives? Do we consider the broader systems around them? I like to say that our course isn’t about patients. It’s about people.”