1) Experiences of racism in medicine are ubiquitous | A) Everyone has either witnessed and/or experienced racism directed at themselves, their colleagues, and/or their patients. Some have experienced extensive racism and had little recourse. | “I have so many examples, we would honestly need to interview for weeks or months on end.” “I can say that at all stages of my training I experienced racism.” “One of the attendings … asked me about my visa status...” (from someone who was born and raised in the US) “I frequently got mistaken for [the one other dark-skinned person in the program]” |
B) Outright racism was not uncommon and ranges from use of the “N word,” to assuming a physician was someone on staff with lesser training such as a student, cleaner, transport, nurse, or tech. | “When I was called the N word by a patient, they changed them to another provider, nobody followed up with me” “I dealt a lot with, you know, like ‘ohh, hi, nurse’.” “One of my attendings … would always wear a suit and he was the only black attending that I can recall in the ICU ... A lot of the other attendings would wear scrubs … and when he was asked by one of my co residents... 'why do you always wear suits, including on weekends?', he said 'So that people take me seriously.’” |
C) Racism exists on a spectrum ranging from micro-aggressions (in written word, spoken word, and actions and gestures) to structural and systemic such as policies and social/cultural “norms.” | “I've seen [hospital] managers treat [staff] differently based on race, like having a different standard for certain … tasks.” “I was given far more on-call overnight shifts than [any other interns]... [I also] remember a meeting, it was supposed to be in a meeting for all the intern residents … so we could learn how to do better and [the senior residents] were going to call people out by name but [said] ‘don’t take it personally at all, this is just so that way we can nip some bad habits in the bud.' It was all the upper-level residents and all the interns ... in one small room and they proceeded to spend the next hour saying only things about me, [gives almost all examples of non-medical related things]. It was shocking. [All the other interns’] jaws dropped because it was just so unexpected... it even became just very mean, and I remember ... by the end of it, I started crying, but I was still taking notes ... because I’m trying to be [the] best intern, and I remember I got in trouble for that too because they [said] ‘it’s disrespectful that you’re not making eye contact... even if you’re crying, you still need to look me in the eyes taking notes.’” (from someone who was the first black resident to ever be in the program). “I had an attending who would joke about me being from Africa and [ask] if I swing trees or have pet lions”. |
D) Racism exists in the medical system in multiple forms including but not limited to race-based medicine and calculators to expectations of outcomes based on race to misguided attempts to address racism. | “The structural racism that is inherent in medicine I think is really important to acknowledge as well. Things like different values for GFR for patients with chronic kidney disease [based on race]. That's an example of structural racism, where the system is … saying that a lower GFR is less serious in a [black] patient than in a white patient.” |
E) Racist policies instituted by local, state, or federal government (such as restrictions on use of the words equity and diversity) all the way down to racist clinic policies (such as allowing physicians to not see patients who arrive > 10 min late) exist and contribute to the problem. | “We officially are not allowed to say the word ‘diversity’ anywhere in our documents.... Nothing [with] state funding can have the D word in it". “There are a lot of things [we could do to improve care for our under-represented minority patients, for example], if patients arrive late, you can accommodate [because] you know they obviously have struggles... a lot of the times [they have ] transportation issues or [other barriers] we just don’t know {about].” |
F) Several people discussed discrimination based on other characteristics and the importance of considering intersectionality in such curricula. | One participant recalled an attending saying to the team about a patient “He's obviously gay. That's why he has HIV.” “[A patient} asked me if I was Jewish and [said] they wouldn’t want a Jewish doctor because of whatever various anti-Semitic ideas they had, and I did have [other] encounters with patients who were either neo-Nazi or [part of] the KKK, but there was no specific support structure around that, and I didn’t report it to anybody, I just carried on with my duties as a resident.” |
G) Tokenism was also mentioned, and it was noted that often POC are pushed into equity and anti-racism work when they prefer to focus on other things. When they are interested in doing this work, they are often poorly compensated. | “...the oppressed are usually being put in the position and tokenized to fix the problem on behalf of the oppressing system” "I’ve had promotions announced [and then] people comment that it was smart of my boss to [promote me] because [they could now] ‘check the diversity box.’” |
2) Experience of teaching anti-racism in medicine are variable | A) Multiple participants said they had little to no anti-racism teaching in their own training. Some reported they had it but it was named something else such as “social determinants of health” or “cultural competency.” | “There wasn’t any education provided or any training provided in our curriculum that pertain[ed] to racism.” “I can remember maybe once or twice where there was some discussion within dermatology specifically about different appearances of rashes on darker skin, and that was the extent of it, though. There was absolutely no discussion of racism specifically or (its) its impacts on health.” “My medical school and residency both had lectures and seminars on cultural competency, [but] I can’t remember anything... like an antiracist curriculum at any point.” |
B) The tone for anti-racism teaching is set from the top. System leaders, chairs, faculty/program directors must be an example and set the tone for anti-racism action and teaching. | One participant noted that when patients made racist comments during rounds, “[as a] more a junior person on the team, you always look to your attending or your senior resident ... to see what their reaction is and often [that] sets the tone for the rest of the encounter.” “I really try to model my own style around those [attendings] that I came to respect very highly … to be able to confront the [racism] issues directly.” “[The medical school has a] dean that just focuses on [equity]” |
C) Many respondents reported at least attempting to engage in teaching anti-racism in their current practice. Some had very developed curricula. Some even reported enacting other anti-racism measures such as recruitment/retention efforts, and examination, rebuilding, and reconstructing of activities that previously were perpetrating implicit bias (such as interview selection rubric, orientation activities, and even M&M presentations). | “The ambulatory attending rounds were not infrequently centered around issues of race and implicit bias.” “We received a grant ...to create a virtual reality application intended to teach providers about social determinants of health and Health Equity, which is to say also … about racism... I led a team that created [the] exercise ...[that] dropped the user into [an] … under-resourced neighborhood and has them follow a family through six different scenes [describes each scenario]. [Learners are then] assigned to look for help assets and health risks within the setting.” “There's been a huge effort both at the residency and faculty level in recruiting trainees and faculty who are historically underrepresented in medicine and supporting [them] once they're there” |
D) Some participants reported in their current programs having didactics, interactive sessions, case-based learning poverty simulations, outside consultants, and support groups for URMs. | “Our residency lives within a larger Medical Center that has a robust equity inclusion and diversity [program that] puts on events for the entire Medical Center quite regularly.” “Our organization is also working on training clinicians in cultural humility, which includes some racial components as well as implicit bias [and] micro-aggressions." |
E) Some programs emphasized collaboration with the community and having community representation. | “[We] use evidence-based practices that we’ve weaned from the ... community.” “They oftentimes will have a community or patient representative so that they have a voice [in program planning and design].” |
3) Sustainability considerations for anti-racism curricula should focus on recruitment & retention, resources, and systemic changes | A) Integrate anti-racism outcome measures into credentialing, accreditation, and other metrics needed for individual or program success (such as inclusion of USMLE, MCAT, specialty board exam questions, include as ACGME core competency, and ensure hospital equity scores tied to grant funding). | “There [are] some outcomes ... like testing scores or step scores [where anti-racism knowledge could be tested]" “Measurable outcomes in the population that residents treat, or satisfaction scores.” “Every ACGME accredited program has specific milestones that … are connected to EIDA... I would like to see that happen on a specialty-specific basis. I would like to see that at the ACGME level, it's happening through the clinical learning environment review. Healthcare disparities are there as part of healthcare quality but don't really have teeth behind them. So, to make it an ACGME requirement, to really add in that language in the different core competencies, would be something that could be really powerful.” “I think there should be anti-racist and implicit bias [criteria included in] how medical students are evaluated. … [and] when you apply to medical school, it should be part of the screening... it ought to be as important as all the other things that you screen for.” |
B) Ensure that all lecture topics covered during residency include 1–2 slides on equity. | “Each program has... didactic curriculum that's given at least annually, if not more often.” “...more integrated in every topic, every talk... if we're talking about communication, [we mention] cultural humility. If we're talking about heart failure, [we note] healthcare disparities in this area. So it is really woven into everything that we're doing instead of set aside as its own topic.” “...we provide a PowerPoint slide showing an example of a framework that they can use and that has been really nice and ... so even if they’re talking about OB... or GI, then [disparities or racism] components can be included.” |
C) Ensure dedicated staff with protected and compensated time are in charge of leading the effort, but also ensure buy in and ownership feeling by all. | “[You] not only need funding, but [also] to have a strong commitment.” “Having that ownership and pride from the people higher up is paramount.” “...having a champion, someone in the program who will continue to help lead it and to make sure that it’s integrated year after year into the curriculum.” “This is something that everybody in our educational community has to own.” |
D) Find and ensure ongoing /permanent resources and support are present. Share training opportunities across the system. | “Each program has materials that they use for education, especially in teaching healthcare disparities... those materials are shared among our learning community in graduate medical education across different programs.” “[Hire] someone to specifically look at diversity and inclusion” “Any ways in which you can combine forces, because obviously these concepts are transdisciplinary, so there’s no need for each program to recreate the wheel and there’s power in numbers if multiple programs in the same institution can have a shared curriculum.” “Many of our educational leaders have become trainers as well of those programs. So not only are they receiving the training, but they're providing the training so that there's some built-in model where we have local expertise." |
E) Include equity in program advertising strategies. | ‘[The anti-racism curriculum i]s something that the program advertises and is proud of. It’s hard for it to disappear if they use it as one of their recruitment tools...[For example the recruitment language could be something along the lines of] ‘Among the many benefits of this program, [are that] we have a light call schedule, we are situated in the vibrant city, and we also have a robust curriculum that integrates awareness of antiracism and equity inclusion and diversity.’” |
F) Ensure URM are recruited, supported, and promoted to leadership positions. Provide extra mentoring and support for URM, create a safe space. | “... this training pathway is very complicated and what you have to do, to get into medical school, to get into residency, to be successful, [is difficult]. The training is not easy, and having somebody who can coach you through [all of this] is essential... [providing this] kind of mentorship connections at much earlier stages [is necessary].” “...it’s not just limited to finding someone who was previously not going to get in or get selected and bringing [that person into your program] ... [this can’t undo] the decades or centuries of suppression … it is more likely that people from those groups are going to have struggles and those struggles need to be supported as well. So we had systems for making sure we provide [support].” |
G) Include staff from across the system and integrate efforts when possible. Include ethics departments in planning if possible. | “[Looking at] how a bioethics department across the hospital system would be able to effectively address issues of healthcare and equities specifically.” |
H) Promote STEM in local communities to encourage kids from URM groups to be interested in medicine. | “[Encourage staff to support elementary and high school] students from historically under-represented minorities in STEM [programs].” “A lot of our pipeline development is … starting from elementary school with some really dedicated physicians who are going out and doing and mentorship and an outreach.” |
I) Consider additional training tracks for residents and/or faculty who want to be change leaders. | “One of the structural things that is currently being done... is to make sure that when we are looking at hiring ()? program directors, assistant program directors, or core faculty, that we are thinking about diversity, and if we don't have representation from groups historically underrepresented in medicine, then we're probably not trying hard enough to sponsor and mentor faculty members to aspire to those roles." “[An equity fellowship supporting an annual] cohort of 30 to 40 fellows and residents from all across different departments [who participate longitudinally to learn about equity].” “... support mentorship that is provided to meet (?) the needs of trainees who are underrepresented in medicine.” |
J) Change mindset from “We are doing this to help URM,” to “We are doing this to make us all better.” | “We [are] moving away from [saying] ‘let's bring in trainees [from] under representative minorities for diversity’s sake, to ‘it makes us a better program, a better healthcare system, because there is just so much added benefit to having our workforce represent the communities that we're serving and to have diverse viewpoints...’” |
K) Continuous quality improvement efforts. | “[Another important] piece of this of course was the quality improvement piece where we tried to actualize an intervention to try and reduce disparities.” "A lot of our programs have residents who are either working on disparities research or doing disparities quality improvement projects.” “Continually having an evaluation of the actual curriculum [is] paramount.” |
| L) Create equitable ‘scoring rubrics’ for resident selection. | “When we were looking at our process, we realized that there were a lot of issues … [for example] when we asked our current residents [what sorts of questions they were asked in interviews, we found] a lot of applicants and residents were picked or ranked highly [based on] having more similar hobbies as opposed to clinical skills or life experiences that were important … Now we [use elements of] our program mission and values [in] deciding what to score ... for example [skills related to] clinical medicine, social medicine, and community medicine, aspects of resilience and distance traveled and connection to our program and that is how we formulated our scoring sheet [for] who gets [invited] for an interview. Then when it comes to the interview process, we’ve implemented structured interviews [based on] certain aspects of our program that we care strongly about, for example, experiences or interest in addressing racial health disparities, [or serving] our urban underserved population.” |
4) Tools for curriculum building are abundant if you know where to find them | A) Books & Podcasts. Have residents present on a topic they learned about. | “Medical Apartheid”, “How to be an anti-racist", “Henreitta Lax” “So You Want to Talk About Race” “And there’s a lot of different podcasts and articles on how to unpack white privilege [etc.]” “[Have residents review] podcasts, print media, videos, [etc., and then assign them to give] their own presentation [to faculty and co-residents on a topic they choose in anti-racism or disparities].” |
B) Problem and case-based learning (e.g., Cases that demonstrate things like roots of health care disparities or unfair consequences/discipline for similar actions in white residents vs. URM) | “[Have residents watch and evaluate residents in two videos] where the first a white male [who] showed up a little bit late [his first] day [and his seniors] make a joke about [it and he is] given the benefit of the doubt, [but then compare it to a black resident experience who also shows up late but] do[es]n’t receive any benefit of the doubt [and is seriously reprimanded].” |
C) Online simulations and other tools | “A poverty simulation ... on[line] that you can walk through, and you you have X amount dollars, and you have to make decisions [about feeding your kids vs taking medications etc].” “Urban mapping” “We have an anti-racism self-study curriculum” |
D) Speakers/Pre-recorded lectures/Paid consultants who are URM | “There’s a bunch of [URM] people that they own their own [consultant] companies [that can support anti-racism work]” “Sandra Kim” “Stella Safo” “Ijeoma Oluo” |
E) Speakers from the community or community medicine rotation | “We .. had.. patients talk to us about their experience with racism in the hospital setting... they [shared] their perspective, what they go through when they walk in the door of the hospital [and it was eye opening].” “We have a community medicine rotation, which our 2nd and 3rd years also participate in.” |
F) Shadow other staff in clinic/hospital | “Integrate residents into working with our chaplaincy service [and have them work] with our transitional care team to try to understand the barriers that our patients face." |
G) Didactics | “Invite speakers [to] provide some perspectives about racism.” |
| H) Colleagues share their own experiences | “Having small groups [where] people just like you ... [including] leaders [can openly] discuss … experiences [during] residency, [including those involving] racism, or homophobia, [etc.,] ... getting people's personal perspective... allow[ing] people to be comfortable, [especially for some white residents/students who] might be sheltered … it might open their eyes [or allow them to realize] colleagues … have experienced all these horrible things .... I think would be really useful because in in a sense... talking about personal experiences [will help people understand] … then you won't have those people who [say] ‘racism doesn't exist’ or ‘it doesn't happen anymore’. When you hear about it first hand from your colleagues. I think that really makes a huge statement.” “I really believe in the power of testimony. So listening to either minority patients or minority physicians talking about what their experience has been ... that perspective is really useful.” |
5) Outcome measures should be multilayered and include resident/faculty, patient, and system metrics. | A) Resident pre-post surveys/tests/interviews (for knowledge, attitudes, beliefs). Kirkpatrick Model. | “[To capture] people’s perceptions of the talk itself, whether they intend to change their practice ... surveys are offered right after the talk is given, by email" “Residents take the implicit bias test every so often” “Test or quiz … to reflect whatever knowledge was gained during that portion of the curriculum.” “A group discussion .. making sure that they’re applying the correct knowledge and guidelines to patients.” “Pretest post test ... of attitudes, beliefs, and … knowledge” “Assess … residents of color. How comfortable they … with the curriculum and ... how comfortable are they addressing their [program leadership] if there are issues, or if they’re being discriminated against. How confident are they about [being able to successfully] seek help [or] discuss those issues [with program staff, faculty, or leadership]?” |
B) Demographics tracking (%URM considered for interviews, matched, faculty, fellowship) | “The first thing is … keeping track of … how many [URM] residents we had in our program.” “whether or not the number of URM residents and faculty had increased over the years to have ... racial concordance to match our patient population.” “...how many residents of color have we admitted... how many of them have [completed the] program...” “...if your intern classes every year have a high representation of black male residents, but those residents are all not completing the program, then that’s obviously a problem.” “Track the number of residents who self identify as underrepresented in medicine who applied to our programs, who interview at our programs, and who get ranked.” |
C) Patient surveys | “[Are] patients not showing up for follow up visits? [Adhering to] medications?[Are] patients actually connected with care? [Do they] trust in the care that they’re receiving or trust the doctors that they have?... If ... not … why?” “Ask the patients to... to fill out a survey that says, hey, how did you feel about this?... Did you feel like your needs were met? [Then track responses over time]” |
D) Patient access or health outcome changes (changes in HbA1c, colonoscopy rates, renal referrals, medication adherence). Ask for community perspective | "Seeing if your community feels that we are doing everything in our power to make sure that people are treated equally and fairly.” “Are minority patients having shorter visits than white patients?... Getting more diagnosis codes that are associated with things like malingering or drug seeking behavior?... [look at] data points like the way care is delivered … whether it’s effective care.. [do] they [get] preventive medications? How many calls it takes to reach a physician? … All these sorts of access to care, metrics... You could see how those metrics change over time, particularly with the URMs.” “[Look at URM patients compared to white patients. Are they] getting their screenings? [Having] improvements in their A1C?” |
E) Track system changes such as resources allocation and fundings | "You’re not serious if it’s not embedded into the priorities of your strategic plan, if it’s not embedded with a person who’s actually hired, actually empowered by protected time and money, and if there aren’t evaluation systems to [ensure] this is happening... [You’re not serious if you’re] not giving them the same things that we give traditional researchers and predominantly white people in academic spaces.” |
F) Hire equity/disparity outcome metrics consultants | “There are black ... or people of color who have spent years training and building entire business[es] around antiracism work, who can come in and do workshops [or other anti-racism work] … budgets must be made to pay those people. Stop asking black and brown people to do this work for free. If you get a free product, it’s probably going to be low quality. The same way as hospitals ... pay millions of dollars for other things, they need to invest in this.” “There are Health Equity scholars embedded in communities who do the job of antiracism... who are building these metrics in real time. [Hire them to come up with metrics]…" |
6) Curricular strategies should be multipronged and include integration, be longitudinal | A) Integration into all other curriculum parts should occur. Longitudinal integration. | “Incorporate ideas from discussions into things that you’re doing in the clinic and the hospital.” “Something that starts in orientation and continues longitudinally throughout the program is really helpful.” |
B) Provide evidence and data to support teaching when available. Vast literature on health effects of racism as well as disparities and inequitable health outcomes – use it to teach residents. Ensure teaching is longitudinal and occurs throughout the residency. | “[Our approach is] three pronged... One...[look] at healthcare disparities and Health Equity and understand ... the data and [that] yes, there is a difference and … think about the root causes of what those differences are... Two is looking at structural factors like the race-based calculators... [other] structural racism and … social determinants of health rooted in historical [context... things like] lack of access to opportunities, loans, [etc.], … just all of the social and cultural factors that impact structural racism inside and outside of the healthcare system, that lead to different health outcomes. And three is implicit bias and micro-aggressions, and how that can lead to differential care.” “Physicians respond to data and numbers... [so you need to include this in] presentations.” |
C) Incorporate personal stories of experiences of racism in the medical system faced by patients as well as medical professionals. | “[Include] patient perspectives... have patients actually be there [maybe sometimes as part of] a panel talking about their experience.” “It’s not real until they actually see a person and they’re like, hey, you know, this is what happened to me.... Someone who already has some social capital so that they felt like they could speak in this space... another physician [to] talk about their experience as a patient or their experience … [of] racism so that they humanize it.” |
D) Create an equity journal club | “A good ... anti-racist library and journal club, [can be] really effective.” |
E) A broad range of topics were suggested. | “...other components that factor into healthcare would include housing discrimination, the criminal justice system, and even components of reproductive justice, which has been a very important talk about.... social political climate, and also... what’s happening in their own specific [city/town/state].” “... implicit bias and micro-aggressions, and how that can lead to differential care.” “what to do if you’re, you know, bystander” “learning about the local landscape...whether it’s redlining or [other local histories], it is really important to actually understand your patients' lived experiences where you find yourself practicing medicine.” |
F) Open safe space and allow for anonymous feedback | “Develop that kind of space where people could discuss things as they come up is pretty important, and … [utilizing] a trauma informed [approach] where people can contribute from all levels.” “[Have an] anonymous comment box where people can feel free to speak up about topics without having their name associated with [their comments].” “Developing openness in your program that allows for the residents and other team members and patients - the full community at the residency program - to be able to share perspectives” |
G) A broad range of “what not to do” recommendations were made | “You can’t just hire one tokenized black person with no budget, no protected time, no equitable advancement, or promotion.” [when discussing a part of residency where residents would visit a poor neighborhood adjacent to the hospital] “... don’t know if the word is voyeuristic, but it initially had been very problematic in the sense that it just felt more like [we were] touring this place as opposed to actually learning about the history and integrating ourselves [into the community].” [referring to the online system-wide required ‘bias’ courses] 1) “... at least from my experience, most people just check them off or don’t really pay that much attention.” 2) “...required training course that you do online that you have [to complete to get] your hospital privileges or clinic privileges, like … an EHR training, and I felt that was really useless because most of the time people just very quickly click through them...” "We implement systems, and nobody really cares about any form of evaluation... “ “...these one-time events [like posting a] mission statement... on a website, and that’s it.” |
H) Come up with unbiased way to deal with “concerns” raised about residents of color and recognize that URM residents might not always feel “safe” speaking out when they have questions | “[as a white male] I always feel confident and comfortable enough to say I don’t understand that or I can’t figure it out [but URM trainees might not feel they have the privilege or they will be penalized more harshly or perceived as incompetent].” |
| I) Consider creating safe “meeting” spaces where trainees of color can discuss their experiences with one another. | “... a group that was formed for minority students and they got a separate room, separate tutors, a space where they could talk about their experiences” |
7) Self-reflection, discomfort, engagement are all necessary. Champions needed. Consider effects of current events. | A) Need to address and advocate for change on a social level and in society at large, not just in medicine. Recognize that many of the murders that occur are traumatic for URM residents. | “There's so much work to do and we're barely scratching the surface with what we are doing... “ “There is a societal crisis … like George Floyd or just numerous atrocities that are happening societally that really impact our community.” |
B) Address potentially unrecognized or uncomfortable issues such as white fragility. | “[as a white person sometimes] you have to be uncomfortable, have to get to a place where you feel uncomfortable to grow." |
C) Each person engaging in this work should start by critically examining their own beliefs and biases | “... you know, I don’t believe I’m a racist and probably most people in medicine don’t, and yet we have these differing outcomes [about] which we have to be honest with ourselves … what can we do to bridge the gap?” |
D) Strategies that work for programs based in urban academic centers, might not work for more rural programs. Likewise, programs with many IMGs might need to consider a slightly different approach. | "... academic centers are often urban and almost always large well run systems ... when you try to take that same idea and move it to a [smaller more rural system] the concepts are very different, and the people are very different. If you don’t consider [this, then your efforts may] fall short”. (from a program director in a program with many IMGs) “... I have talked about colonialism and how we also can translate that to how our black population in the US has been treated historically, but not everyone seems to have that same connection ... I have had residents tell me ‘I grew up in [X country], no one has anything. Everyone suffers. Poverty is everywhere’ .... Many of them have told me ‘When I come to the US, I assume this is the best health care system in the world ... so why isn’t this patient taking their meds?’ So much of our curriculum content is geared towards US grads - I find it doesn’t always fit what I need for my [residents]." |