A panel of doctors met virtually on to discuss various topics related to racial inequity in healthcare, including social determinants of health, unconscious bias in medicine, and the experience of being a physician of color.
A video recording of the hour-long event is available to view. A transcript of the discussion is below. It has been lightly edited for length and readability.
Moderator
Eboni Peoples, Medical Student at University of Medicine & Health Sciences; AMSA Advocacy Chair for Race, Ethnicity, and Culture in Health Action Committee
Panelists
Dr. Taison Bell, Assistant Professor of Medicine, Divisions of Infectious Diseases and International Health and Pulmonary and Critical Care Medicine at University of Virginia; Director of the Medical Intensive Care Unit (ICU); Director of the UVA Summer Medical Leadership Program.
Dr. Valerie Fitzhugh, Associate Professor and Interim Chair of the Pathology Departments at Rutgers New Jersey Medical School and Rutgers Robert Wood Johnson Medical School
Dr. Edjah Nduom, Assistant Clinical Investigator, National Institute of Neurological Disorders and Stroke, National Institutes of Health; Co-Founder of Physicians for Criminal Justice Reform
Dr. Leigh-Ann Webb, Assistant Professor of Emergency Medicine, University of Virginia School of Medicine
Audio only:
What are the current challenges to address health care disparities in communities of color?
Dr. Edjah Nduom
So we look at social determinants of health, obviously. That’s a big, big part of what we’re dealing with here. You know, my organization, Physicians for Criminal Justice Reform looks at one narrow slice of that. And that’s to look at negative interactions with the criminal justice system and how those can impact health for people and communities.
There’s a myriad of ways that that can happen, whether that’s from the lack of mental health care that people can receive, maltreatment of substance abuse disorders where people are imprisoned instead of offered treatment. “That can be the poor care that people might experience when they’re incarcerated themselves or lack of availability of care if they’re coming out of an incarcerated situation, the economic effects on neighborhoods when they’re overpoliced.
One thing we’ve been talking about a lot is police brutality and you know, the constant bombardment of videos and things that we’re all exposed to on a routine basis. You can easily picture yourself falling asleep in a Wendy’s after a birthday party and ending up in a bad conversation. You can see yourself and inadvertently, whether you did or did not use a fake $20, handing that over to a clerk and going back to your car and minding your own business and ending up in an altercation because of an accusation that was never proven, and essentially given a death sentence.
That ever-present stress, that increase in cortisol, is going to affect everything that happens to you health-wise, from then on out. In medical school, I can’t say that I had a whole lot of conversations about what was going on with police or outside of the community or the stressors that we have, what the interplays would be. I like to think that med schools might have moved forward from that. But it’s hard to separate what happens to a patient individually from what’s going on in the community.
Then if I put on my other hat as a neurosurgeon scientist, and then you look at how people of color are often not offered clinical trials in the first place, or maybe don’t seek them out because of long-standing distrust of the scientific community. In many cases, they might miss out on the best new treatments that are coming down the pike. In my current practice setting, I don’t get to see as many people of color as you might expect being in Bethesda, right by D.C. And that’s a shame.
Dr. Taison Bell
One thing I want to add to the point about mistrust is that, you know, the trust between a physician and a patient is one of the most fundamental relationships to make the patient better.
And one of the points that I make with my students and residents and fellows who are talking about patients who are being, the key words being, “not compliant,” “not going along with the plan” is this trustworthiness.
We have to understand that it is earned mistrust. The U.S. healthcare system has worked extremely hard to gain the mistrust of the African American community, going back to experimentations at Tuskegee, stealing Henrietta Lacks body tissue, grave diggers in a Civil War era to inform medical students on anatomy, so the list just goes on and on and on.
And these stories are known in a black community, and if it’s not acknowledged and not approached with the right tact, then it is hard to bridge that gap sometimes. And if you further introduce unconscious bias into the situation … patients know that there is sometimes unequal care given according to race and ethnicity.
A second is accurate data collection. This was one of the efforts that Dr. Webb along with some other colleagues spearheaded, to call on the CDC, WHO, and other public health entities to actually release data on health disparities in COVID, a pandemic that was ravaging the country and continues to cause many, many problems.
But you’re not going to find a problem that you’re not looking for. If you’re not getting accurate data collection and finding out who our patients are, and where our disparities are, then you’re never going to be able to find the solution.
I saw it in the MMWR (Morbidity and Mortality Weekly Report) from the CDC back in the 1990s, that pointed to the need to more accurately reflect race and ethnicity and data collection. And by the time we get to COVID, that percentage of data collection that they are reporting out was actually worse than what they identified as a problem in 1994. So not having that accurate data just puts you two steps back when it comes to trying to figure out how to solve problems.
And then the third, I would say, is the nature of racism as it exists in the United States today. You know, when we think of racism, we think of acts of racism – the Ku Klux Klan, night riders, lynchings and the things that kind of populate our textbooks. Racism now is structural and baked into society. That means that it is the default to have inequities in how people live – wealth inequality, education inequality, job discrimination, housing discrimination – and these all translate to health outcomes.
What it means is that, if it’s a default, and you do nothing about it and aren’t actively thinking about it, then those problems are going to perpetuate and be ongoing. That’s the way it’s designed at this point.
So in order to actually combat systemic racism in healthcare and in society in general, you have to take an active, proactive approach to finding where these issues are, talking about them, being open about them, developing a comfort level with speaking about it, and then developing action plans in order to formulate corrective action.
That’s something that our country has just not gotten to the point. I’m happy to see that our collective consciousness seems to be rising. I just hope that we can take advantage of this moment to actually flip the script and actually develop a working language around talking about health disparities and racism.
Dr. Leigh-Ann Webb
I should add that it’s a big question. It’s a really big question. We could literally have a week-long conference about the question. It’s a really big question, because it’s a really big problem. We all recognize that, and it’s really been a problem for a long time.
For those of us who have been doing this for a while, and who have been in academics – I’m not a core researcher, but certainly have been following the research for quite some time –health disparities have been there for a long time.
As Taison said, we’re not seeing many gains over the years in health disparities. So as much as we are asking for equity and preaching equity and advocating for equity, the research looks very similar to when I first started in medical school. Maybe, yeah, we gained some since the Civil War, when they had the Freedmen’s Bureau medical division that was taking care of black people, and it was fully under-sourced. But we are not in a place where we can claim success. We have not eliminated health disparities. There’s a really long way to go.
And of course, during this COVID-19 pandemic, everything is amplified for everyone. It has fully exposed the faults. So the people who have been doing this for a long time and who’ve been seeing this and who have been living this, and our families have been living this for a long time, it was no surprise whatsoever that COVID hit Black America, specifically and other communities of color like it did, because we know, because we see it every day.
So we talk about the social determinants of health, and there are many, many, many social determinants of health. Again, that could be an entire hour-long lecture or more. But with COVID, we see things like hypertension, lung disease, diabetes, obesity – we see all those things. But you can’t talk about obesity and hypertension and diabetes without talking about food deserts, which is a social determinant of health.
And you can’t talk about things like socioeconomic status without talking about redlining that happened in the 1930s and how people, those communities, were disinvested. If people were actively encouraged not to invest in those communities, people could not get loans to buy their own homes in those communities.
And you can’t talk about our kids with higher rates of asthma and lung disease without talking about people just coming into these communities with these industries that are polluting the air, and landfills, and it’s something that keeps happening over and over again.
Cumberland County, Virginia is near us. We just a few months ago had to advocate to not have a landfill in a predominantly African American community. I can’t even take the trash out the day before in my neighborhood. I can’t put the trash can out without someone in the HOA complaining about it. But now you’re talking about putting an entire landfill in a community, literally. So you know, we see this, you know, Taison referred to it as structural racism or systemic racism. It has really pervaded our culture.
Those are the social determinants of health they were talking about. We haven’t even gotten to access to care, and there are many different forms of access. And maybe once you do access care, are you getting the same type of care? Does your provider have implicit bias or overt racism, because that exists with providers too. I have seen it myself.
We study all of these things. We kind of talk about them separately a little bit, but they’re all intermixed in real life, and it is kind of hard to separate them out. Hopefully we can get to a little bit in the conversation talking about the solutions as well.
What has been your experience with stereotypes while wearing your white coat? Did you reach out for help? Did you find support from your institution? And what do you do when you are confronted with a colleague who is racist?
Dr. Valerie Fitzhugh
Oh, a lot to unpack there. I’ll start with a story first, because people always remember stories. And this is something I shared on Twitter in the #blackintheivory hashtag. If you follow Twitter, I would invite you to look at the stories of the academics who have had the courage to share, because it’s really interesting what people have gone through.
So this is probably five or six years ago. I hate autopsies, but being in an academic institution, every once in a while, I get stuck doing one. And when I do that with my residents, of course, you know, I’m in the morgue with them, teaching them.
So for whatever reason, that particular day, instead of taking the back stairs out of the department down to the morgue, which would have been the fast way to go, I decided to take the long walk to the morgue. And as I was getting toward the elevators, just around the corner from my department, a white lady came up to me with a bag of her empty Burger King and said ‘can you put this in the trash for me?’
And I’m wearing scrubs, an ID. Our janitorial staff does not wear scrubs. There was no question that I was a physician in the hospital and badge blazing MD. I literally just said, ‘the trash bins are over there,’ and I just got on the elevator and kept my day moving.
The issue of course is that I was alone. There was really no colleague who was there to help me in that moment. But it was just like, I’m looking at this woman, like, you’ve got to be kidding me, right? You see what I’m wearing. You see how I’m dressed?
I can’t even say … I work in the hospital that I went to medical school … and how many times I’ve been stopped by security in my white coat. “Where’s your ID?” versus colleagues of mine walking right past them to get onto the elevator. So you know that people do see us differently.
I’m fortunate because at Rutgers New Jersey Medical School, we talk a lot about diversity. We just had a big diversity panel last week in the wake of what happened to George Floyd and Brianna Taylor. We started having these difficult conversations, because we need to be doing more, and we know we need to be doing more. My institution seems to be invested in really helping colleagues of color be able to have that safe space and then find their voice.
In terms of racist colleagues, I think that depends on your level. It’s much easier for me at the Associate Professor level, who’s been a decade plus out to be able to say, let me tell you what you said that wasn’t cool. I wouldn’t have even been able to do that five years ago. And as a medical student, that puts you in a really uncomfortable place, because you’re looking at these people for letters of recommendation.F You’re looking at these people who are going to control where you might match for residency, where you may go on to in life. So as a student, it’s much harder to speak up and find your voice in those situations. You can attempt to have that one-on-one as a student, but I think it’s very, very difficult.
As a faculty member, I’ve had to have those conversations people, and I try not to embarrass folks in a meeting as much as I want to check somebody in a meeting. I try not to do it. I will pull them aside and say, ‘Listen, let me discuss with you what you said. Let me tell you how that was perceived by me as a person of color.’ Because I’m the only black person in my department at either school. So it’s not like there are other people for me to bounce these things off. I’ll say, ‘You know, let’s just take five minutes and talk about that.’ I think that’s really, really important. And that’s something that on the faculty level, I can do much more…I shouldn’t say much more safely. I mean, I guess a little more safely because I’m in a place where, you know, I’ve done the things I need to do, and if I decided tomorrow to go open a daycare and do that instead I could, but I think on the student level, that it’s very, very difficult to combat it at a higher level.
Now, I will say amongst each other, if you hear other students speaking that way and you hear other students putting down communities of color, then you absolutely should say something, because those are the people who are going to be taking care of your families, my family, me as I get older. I don’t want to have to go to a doctor who I know is going to look at me and you know and think, ‘Okay, well, she’s a little bit heavy. She must be eating McDonald’s every day.’ But that’s actually not the case at all. It has nothing to do with where I’m eating or what I’m eating. You know, my issues are my issues, but to assume that a patient’s a certain thing because of how they look will get you into a world of trouble.
So yes, speak amongst each other. Definitely speak up. You know, there seems to be a trend these days with people putting this stuff on full blast on Facebook, and I don’t know if you want to go that route to embarrass your colleagues. But I do think that these difficult conversations between students are going to become crucially important, as you will be the providers for the future.
Dr. Leigh-Ann Webb
I don’t like to embarrass people, but oftentimes I get people to embarrass themselves. And that’s kind of the best way to go about it. I use appreciative inquiry. So I will stop and say, ‘What do you mean when you say that’ and I will make people clarify or encourage them to clarify what they mean on the spot in the meeting.
And if I think they didn’t dig deep enough, I’m like, ‘Oh, well, what do you mean by this? And what do you mean by this?’ And it kind of goes down the rabbit hole, and then suddenly, everyone’s kind of like, this is awkward, and then the conversation moves on.
Then sometimes that person actually will come to me after the meeting and say, ‘you know, this is how I feel about it,’ and we might have a conversation, and I find that is way more productive to get them to back themselves into a corner than me calling them out.
I’m an assistant professor. So maybe that’s part of it too, because I don’t pull as much weight as the associate professors or the people in leadership positions. But I do like using appreciative inquiry.
I think it’s really hard as a medical student to navigate this successfully, even in areas where you have anonymous ways to air your grievances. I think it’s very hard because a lot of these situations are very specific. So as soon as you report it, even if it’s anonymous, that person knows who you are, and there’s some retribution at some point. Everyone says medical students can speak up about everything, but they can’t speak up about sensitive things. It’s because you probably have a legitimate reason, because there’s some retribution of some sort. I try to advocate on behalf of medical students, particularly when there’s someone who is known to be problematic. That doesn’t happen a ton. I think my colleagues at University of Virginia are actually pretty good, but it happens. I see it happen more with residents than I do with attendings, at least where I work, and I try to be an advocate on behalf of the students.
Dr. Taison Bell
I can say that when I was a medical student, I was also in a similar position. I observed but didn’t call things out because you’re in a very different position. But man, when I became an attending, I can talk about these things all the time. I make a point on my rounds to point out things like microaggressions and interactions and sexism, racism. We talked about Juneteenth last year. I’ll make your rounds on June 19, so I can introduce and have the platform that I can use to talk about these issues.
There was actually one day in my ICU where there were two patients side-by-side. They were both men who were both in their late 30s. They were both acutely agitated for almost the same cause – one had an underlying TBI and another one had, I think, had a history of seizures. One of them was black. One of them was white. One of them had psych called and security called and meds administered. And the other person was reassured. They had a sitter and was a kind of eased out of their acutely agitated state.
You could probably guess which patient had the security come in and rough them up. It was my second week working at UVA as an attending. After we rounded, I asked my team, now what factors do you think went into two patients with the exact same problem being treated very differently? And there was a lot of silence, but I’ve learned to be comfortable with that silence and let it fester a little bit so that people can be uncomfortable and create that tension. Then I later stepped into that tension and said, you know, this is a form of unconscious bias. It’s something that we’re not going to notice if we don’t speak about it or mention it, certainly if we’re not looking for it, but this is something that we have to be mindful of as we’re trying to provide care. We could provide different care to a person just based on how they look and what we perceive about them.
I think every black physician has been mistaken for transport or anyone else other than that physician.Mine was, I had a patient transfer from an outside hospital, and I walked into the room and the patient said, ‘Oh, are you going to take me down to a CAT scan?’ And I said, actually, I’m the one who decided to fly you over here and ordered the CAT scan.
I try not to get bogged down in all of these moments, because some of them are just funny in the people’s ignorance, and I got to move on with my day. But one of the things I learned … I didn’t do this consciously, but I’ve noticed that when I go into patients’ rooms, I enter, announce my name immediately in a loud voice and actually hold my badge out. It was made so that patients who can’t see that well can see that you’re a doctor and even has a color code. And that’s kind of been a saving grace for me because I enter the room, I say ‘I am Dr. Bell,’ pull my badge out. Everyone knows I’m a physician right off the bat. I probably have saved a few patients that uncomfortable interaction where they will mistake me for transport. I don’t do it purposefully, but it’s something I’ve noticed I’ve done to step into that space immediately, so that I just don’t have to deal with it. Everyone has their coping mechanisms. I would say before that it probably happened on a weekly basis, where I would be mistaken for someone other than a physician.
Dr. Leigh-Ann Webb
Also I’d say that usually it’s a person of color who’s speaking up at this level, at sort of the attending level as well. And what we really need is for everyone to speak up, when they hear things like that and call them out, not just amongst yourself, but when you are an attending, feel free to speak up. It doesn’t matter what color you are, what race you are, if you think that there’s a microaggression against the patient or against your colleagues, speak up in whatever way that you feel is comfortable and safe for you.
Why is there a medical culture to dismiss the pain of a black patient?
Dr. Valerie Fitzhugh
I mean, sadly, I think a lot of it really is systemic racism, and a lot of it goes back to how black people were experimented on during slavery, after slavery. Dr. Webb brought up Tuskegee – you know, these are things that are rampant in culture, and it was seen as okay to do this to black people. Unfortunately, depending on how you’re raised and how you see different situations, you don’t just grow out of that when you go to medical school, unless somebody has that difficult conversation with you.
They’ve done surveys where they’ve asked people, how do you perceive the pain tolerance of patient X versus patient Y? For some reason, everyone seems to think that black people can just take so much more pain. I can tell you, I’ve had two babies, I can’t take any more pain than anybody else.
But the reality is we’re just seen as these strong people, and it’s not just the poorest amongst us. The fact that Serena Williams can go in, have a baby, practically tell you I am having another PE, and have people not believe her when she already had one – that’s what that’s what we live with. That’s what we’re working with. I think a lot of it goes back, unfortunately, to systemic racism and the fact that we’re just not believed.
I see now in the comment, the Tuskegee syphilis study, which was a big one. I mean, we’ve been seeing this in our culture from time immemorial, pretty much. That’s why we have so many issues when it comes to trust in our community of physicians. The reality is, there aren’t enough black physicians to see every black person in the country. And that would be the same, I think, for most ethnic groups. So for those people who want to see someone of color who looks like them, knowing how low our numbers are in medicine, you know, across the board, that becomes an issue, especially when we get back to that issue of trust.
Dr. Leigh-Ann Webb
I agree. And I see Tyson posted that link. That’s a really good article to read. Good in that it informs us, but it does talk about something that’s very heavy, something that needs to be addressed.
Slave owners did justify slavery and the inhumane treatment of black men and women and medical research. That is how they justified it. Because if you said that someone is human and fully equal to you, there’s no way you’re going to do that to them. We see multiple instances of that throughout history.
We’re talking right now a lot about the monuments that are coming down, particularly the Robert E. Lee monument, about an hour from us in Richmond, Virginia, is coming down. The Civil War, or at least the beginning of the end of the Civil War, was April 9 1865, when we surrender to Grant. And it wasn’t until a couple months later that slaves were actually free.
But when they were freed, they didn’t have anywhere to go. They didn’t have a residence. They were essentially living in crowded living conditions, old prisons, wherever they could find. And there were no organized hospitals to speak of, really, for almost anyone. The white poor did have some privately funded hospitals. Black people were not allowed to be seen there. And then other people were getting private care by physicians in their homes.
So there was a crisis in health care, a public health crisis for black people in the country. No one really cared about it. But the Freedmen’s Bureau medical division was an under-resourced kind of mess that was formed between 1865 and 1872. And that closed down when there was a little bit of progress. So both in slavery, where it’s like keep my slaves well enough to work for me so that I can have economic prosperity, and with the Freedmen’s Bureau, the government’s like we’ll keep them well enough, but we don’t really want to continue to fund the health care of black people. We talk about like sort of this separate but equal segregated hospital after the Freedmen’s Bureau hospital shut down, and they weren’t all separate and equal.
There also weren’t enough hospitals to treat all black people, so some black people ended up being treated literally in the basement of hospitals. My hospital and Taison’s hospital, where we work now at University of Virginia is one of those hospitals, and there are still people alive to this day who remember being treated in the basement of our hospital. And those stories are told to their daughters and sons and told to their daughters and sons and theirs. So this is an intergenerational thing to both the mistrust of the medical profession in the black community, as well as mistrust with trials. This is deeply rooted in the fabric, is weaved into the fabric of our society.
And another study at the University of Virginia, which was actually where I went to medical school, like 50% of the students held at least one false belief against black people. That was done in 2016. So that was that black people didn’t age the same as white people. Their nerve endings weren’t as sensitive as white people. Our skin was thicker than white people. And we see this playing out in the literature time and time again that black people’s pain is not treated in the same way that white people’s pain is, particularly in the emergency medicine literature, which is what I do. I work in the emergency department. People with sickle cell crisis are under treated for pain. People who come in, even for a fractured extremity like an orthopedic injury … black people are less likely to get pain medication compared to white people. This is a problem that we’ve seen for a very long time, and it’s deeply rooted in racism and deeply rooted in slavery and the after-effects of that.
In 2018, the Association of American Medical Colleges reported that among active physicians in our country, only 5% identified as being Black or African American. That same year, only 3.6% of full time U.S. medical faculty members were Black or African American. What outreach initiatives can be implemented to encourage a more diverse applicant pool and the involvement of underrepresented groups in medicine?
Dr. Edjah Nduom
The NIH, in particular, has a lot of pipeline programs. I think that pipeline programs are fantastic. And AMSA and SNMA have MAPS and pipeline programs. I think a lot of us wanted to participate in pipeline programs as we were coming through, and I enjoy speaking to high school students and undergrads and giving them the little tools and tricks that I have to hopefully help them make it through.
But there’s only so many of the students that are out there that can go through pipeline programs, and if I talk to a high school student today, it’s going to take another 15-plus years for them to become a neurosurgeon.
So the question I often ask departments and hospitals and academic departments is, well, what can you do right now? It turns out that your average neurosurgery department or medical school or faculty, that’s looking for people to employ could do something right now to improve and to increase their recruitment of diverse candidates.
There are changes they could be making right now in how they evaluate faculty, how they promote faculty. You know, I don’t know what’s going on with Dr. Bell. I look, and I see he’s an assistant professor with all the things that he’s doing. I’m like, ‘How long is it gonna take him to make associate? Is there’s something going on there?’ I don’t know.
You know, if you looked at my NIH profile through last year, you’d see that I was something called a Staff Clinician. And if you look at the stuff that I was doing, that might not line up with what I was providing in service to the institution.
Then when other people of color see, well, you know, people don’t seem to be advancing in academics, maybe they decide to go out into private practice. Then there’s less faculty in the medical schools to kind of bring people in and engage in the mentoring and stuff like that. Then the mentoring often doesn’t show up in your promotion and tenure committee, so then you spend less time on that, and you need to publish more, so maybe do a little bit less mentoring, so spend a little bit less time on that pipeline program because it’s not valued. And the person that’s really engaged in the pipeline program crashes out of academics, right?
Medical school is the same thing. If we’re looking at strictly MCAT scores, you know the cost of taking these MCAT classes is astronomical, and people who have time to get tutored outside of school or take additional classes while they’re in undergrad and make sure that they can boost up their resume – there are different disparities that happen there.
I know when I applied to the NIH as a high school student, as a college student, as a medical student, I never got in, because I didn’t know that the way the NIH worked is … to get into a lab, you put the application in, but then you had to contact labs. And it really helped if you knew somebody who knew somebody at the lab, who would tell them to look at your resume and get in. So there’s a lot of kids of people that work at the NIH or working in labs at the NIH, maybe not their lab, maybe not their Institute, but they get in, so disparities get propagated that way.
So there are things that you can do in how you evaluate students, undergrad students who applied in the last round to get into medical school. There were plenty, I assure you, of Black, Hispanic, whatever underrepresented group you want, who wanted to get into medical school last year and didn’t get in. What are we doing for those kids? What are we doing for the people graduating residency that want to stay in academics, but don’t get told about the job at the institution they want to work at because they have some under the table deals already to hire one of their residents or someone that they know. How do we change that? How do we keep the faculty that are engaged in these pipeline programs and trying to recruit and mentor people who are not represented in medicine going forward?
I’m not saying this to disparage the pipeline programs. I think the pipeline programs are important, and they do build the base of people who will have the skills that people recognize right now. If you have time, there’s a fantastic chapter written by Dr. Kimberly Griffin Haynes. She was a few years ahead of me at Stanford. She wrote a really, really fantastic and very long chapter on the recruitment and retention of faculty in academic departments and what’s being done wrong. And really the overarching point to me was, sometimes there’s a problem what the ivory tower is looking at.
It’s not a problem with us. It’s not a problem with the pipeline. It’s not the problem with the people that are applying for these positions. It might be what the ivory tower has decided to value. And if the ivory tower is going to wait until everybody out there who looks like me looks like the people already in the ivory tower as far as their CV and the resume and the qualifications, then we may never see equity. We may never see diversity in the ivory tower. And it may be that the ivory tower itself has to change what it values in order to bring a different type of person in.
Dr. Leigh-Ann Webb
I’d also be remiss if I didn’t address the culture of medicine in all this, because I think that a lot of times … medical students have a hard time. That’s all medical students with the culture of medicine, which can be malignant, depending on where you go, but particularly students of color in feeling unsupported. Part of that is not having enough faculty of color at institutions, at most institutions but also in residency.
I’ve seen people come in residency and say, ‘I want to go into academics and I want to do this and I want to do that,’ and the work they want to do, which may be in diversity or maybe not, isn’t valued as highly as someone else’s work, but also by the end of residency, they’re just completely burned out, and they’re like, you know what? I think I’m done. I think I’m going to go. I’m going to take a private job and make a lot of money and just sort of be done with it.
Some people may need that, and they might come back to academics later, but I also think we need to make the environment of both undergraduate education and graduate medical education more welcoming for people who would like to go into academics.
What can we do to ensure our medical school programs are providing education and training about unconscious bias? For example, most of my standardized patients have been white, if not all of them? How can we as medical students or premed encourage the medical curriculum to incorporate training in diversity?
Dr. Valerie Fitzhugh:
There’s two angles to look at. There’s training of the medical folks, so medical students, residents, et cetera, in unconscious bias. And then there’s training the standardized patients, because you have to ensure those standardized patients are going to grade students all the same way, and they can’t have their biases be introduced as they’re grading patients for things like graduation OSCEs and OSCEs for your medical rotation, your Pedes rotation.
So there’s two things to look at, and one of the things I will say is that Rutgers New Jersey Medical School does really well is that they implemented that for both. So the standardized patients have to go through bias training, because that’s just something the school implements, because they insist on it, and we’ve been fortunate in that the medical school population … we’re still not where I would love to see a medical school population be in terms of diversity, but we’re a lot closer than a lot of other places.
For the student side of it, all of our medical students actually get for all four years a thread called “Health Equities and Social Justice,” where they learn about those social determinants of health. They get unconscious bias training through their four years of medical school.
So they’re being hit with it, and it’s interesting because I’ve sat in some of those small groups, and you can see some of those moments of discomfort where people are getting tripped up and it’s kind of like, ‘Oooh, should I have said that? Is that the right thing to say?’ And it’s good for them to have those experiences earlier rather than later.
So I think that’s something the school has done very well, but I think you have to train from both sides. It can’t be just one side or the other. It has to be both the students, residents, faculty, at the medical school level, but then our standardized patients who are going to be grading you, and not just in the schools, but at the NBME, because you take that Step 2 CS or if you’re in osteopathic school, then you’re taking the Level 2 physical exam, that’s really important to ensure that you are being fairly graded the way you need to be graded. So I think it has to come from both sides.
Dr. Edjah Nduom
I would remember, don’t lose your spot in medical school by being an activist. I think there’s a level to everything, but the group of you as a class are consumers, and you are paying a lot of money to this institution to get an education, and if that medical education does not include things that are extremely important to your education to be an effective physician in the future, then you as a group – whether that’s your AMSA chapter, whether that’s your SNMA chapter, whether that’s multiple student groups as a whole can go to that curriculum committee and say this is something you need to provide, whether that’s through the various reviews I do in various classes or formally through a committee, you can demand.
Dr. Bell put together a document from Penn, which is where I went to medical school and has a long tradition from the SNMA and Latino Medical Student Association who have really pushed the administration to include some things, and there has been some backlash, but there’s strength in numbers, and if you can organize around these things, you can actually see significant change around the curriculum.
Dr. Taison Bell
I can give an example. So I found this document in the course of the University of Virginia’s students who had a town hall with the dean of the whole school and the dean of the curriculum, where they were talking about potential changes to the curriculum, to introduce more diversity and unconscious bias training and make it something that was part of the curriculum and that you did not have the option to opt out of.
They were met with some pushback about straining the curriculum and making people potentially uncomfortable and people may not want to have that training and blah blah blah, but the students came back and basically said ‘That’s not acceptable. My discomfort is daily and it’s important for us to be culturally competent and capable physicians in order to deliver high-quality health care. That is an absolute requirement. If we want to graduate from the University of Virginia. That should be a requirement to attain that degree to go through this sort of training.’
So they asked for another meeting with the dean to discuss this issue specifically, because they gave the answer out, and the answer wasn’t good enough, and they’re going to have this meeting coming up next week, so they’re using guidance from this document to inform their talking points for the meeting and looking to get this put into the curriculum.
Dr. Leigh-Ann Webb
I’m not sure that bias training is the most effective way to do this. I think health equity and all of those things definitely need to be integrated into the medical education – undergraduate medical education and graduate medical education.
But bias training has been shown to, the effects have been show to last for like a couple days where people are like ‘Oh’ and then it’s ‘Now I’m going to revert to the implicit bias that’s been built for however long they’ve been alive.’ If you’re in medical training, you’re late 20s, early 30s and things are in you, because we’re part of this society.
I love data. I’m a bit of data geek. I’m on the Data Action Team at University of Virginia for the department of Emergency Medicine. So I believe in ‘discretion mediation.’ So, do not take away all of the discretion, because obviously as clinicians we need that. We need to be nuanced in our care of patients, but I’ll give you one example of what I call discretion mediation.
Don’t try to Google it, because it doesn’t actually exist as a term.
For COVID-19, we noticed in the emergency department that there was a disparity in testing for patients who came in for COVID. We noticed because I asked the question. If I had not asked the question, it would never have come onto anyone’s radar. So I asked the question. Because I’m the physician lead on the Data Action Team, I was easily able to access the answer to that question and found that our suspicions are true.
We have a screening process, so if you screen positive based on your symptoms, you are a person of interest or a person under investigation and you come back and we treat you in a different area and so on and so forth until we rule you out for COVID or rule you in for COVID.
So of the people who were screening positive, white people were more likely to be tested, and black patients were more likely to be taken off of COVID precautions and not tested at all. And of the people who were screening negative, white patients were more likely to be tested and black patients were not being tested at nearly the same rate, even if they screened negative.
So to get down to the root of that, what we have now is 1) we added some social, some vulnerable populations, so if anyone is a person of color specifically, if anyone is Black, Hispanic, or if you live in communal living environment, like jail, or if you’re homeless, or literally you’re living in a home where you can’t socially isolate, we added that to the screening process, so that we would capture a little bit more of the vulnerability there.
On the flip side, when a provider, usually a resident, goes to order a test, if the patient screens positive for symptoms and positive for these additional factors that we added in, it takes them to a screen, it alerts them, it says ‘This patient is positive.’ It takes them to the test. It makes it very easy for them to order the test, and if they know, actually I’m not going to order that test, you have to pick from a small list of why you don’t order the test.
And then the same thing for the patients screening negative, who then the provider says, ‘Actually I am going to order the test on this white female who screened negative and also doesn’t have any risk factors,’ it does the same thing when you go to order the test. It says, ‘It doesn’t seem like this patient is high risk – why are you ordering the test?’ And it’s a short list.
And some of those might have good reason to order the test, but it helps us to better understand why people are taking actions that they’re taking, and it helps to mediate any bias. So we’ve actually seen a change in that. The numbers are starting to level out a little bit more. We don’t have equal populations of black and white and everything else, so we expect there will be some differences based on who shows up at the front door, but we have seen some success with that as well. So I think hitting this with multiple different areas in multiple different ways, but I like discretion mediation, though as physicians we don’t really love when people take control out of our hands, but I’m like take it away, take the bias away also.
Dr. Taison Bell
I know we’re over time, but I wanted to point out one thing that Dr. Webb said. That was, ‘Asking the question’ and how important that is.
So how refreshing and potentially game-changing would it have been if COVID starts and from the get-go our leaders at the hospital level, the government level, were asking how is this affecting our underserved population, our Black and Brown communities, our Latinx communities, our populations that we know experience adverse health outcomes and then we’re looking at this data proactively and asking these questions proactively, so we don’t get to weeks and weeks down the road, after thousands of people have lost their lives? We could actually think about the problems in real time as they evolve.
There’s a viral pandemic that causes disproportionate outcomes both in screenings and mortality and morbidity that disproportionately affects Black and Brown communities. It is called influenza. It happens every single year, and we have the same disparities play out. A different virus with the same outcome that happens year after year, and it’s so baked into our medical lexicon that we just expect it every winter, but this is what plays out.
And we need to ask those questions too. If we have a view through our racial equity lens, we ask these questions proactively, and we’re asking people like Dr. Webb, ‘How are we testing in the emergency room? How are our ambulatory visits? Are we having disproportionate outcomes when it comes to screening, testing, isolating?’
That’s what needs to change about health care delivery going forward. This needs to be an anti-racist approach to delivering better health care. That means actively ask the question, find the solution, but more importantly be comfortable talking about these issues.
Dr. Leigh-Ann Webb
I wanted to end this conversation on a call-to-action. … Change starts with you. If you choose to change by voting, that is fine, but it also starts at home. I think medical students in particular often feel like they don’t have a voice, but you do have a voice. You have agency. You need to look at this as like, your time, your treasures, your talents, and see what you can do to help fix the problem. You don’t have a lot of treasure right now. I get that. You also don’t have a lot of time, but you are all full of talent. I fully believe you can change the world. You can do it. I encourage all of you to dig deeper and find your voice. Find what you can do, because if we all do our part, we collectively can really make an impact on society and on medicine.
Thank you to Eboni Peoples for securing our guest speakers, and enormous thanks to our fantastic panel for sitting down and discussing this topic with us. Follow the panel on Twitter to show your support:
