Acknowledging Our History and Moving Toward Equity and Justice in Medical Education

Combating Oppression:

ACKNOWLEDGING OUR HISTORY AND MOVING TOWARD EQUITY AND JUSTICE IN MEDICAL EDUCATION

Denise M. Connor, MD

Oppression is deeply and painfully woven into the fabric of U.S.

society; experiences with racism, homophobia, transphobia, and sexism (to name just a few instruments of oppression) profoundly impact countless individuals in our culture. Throughout its history and into the present day, medical education has been complicit with these and other forms of oppression, supporting and sustaining them in both seen and unseen ways. Alarming data about the beliefs and practices of modern-day medical students provides evidence for the ways in which medical education is, at best, failing to interrupt, and at worst, perpetuating the harmful impact of these destructive forces on individuals and communities.

For example, we are graduating medical students in the modern era who believe that the skin of Black persons is thicker and has fewer nerve endings than that of white people1 — dangerous beliefs rooted in a false notion of race as biology that leads directly to harmful decisions to provide less pain medication to Black patients, including Black children suffering with appendicitis.2 We are graduating medical students in the modern era who, when seeing standardized patients with an identical set of symptoms meant to depict angina, are significantly more likely to diagnose angina in a white man than in a Black woman, and at the same time are more likely to rate the Black woman’s general health status as lower than the white man’s.3 These findings are deeply disturbing and relate directly to the hidden curriculum that exists in medical education that quietly supports and operationalizes racism in medicine, often in ways that are unintentional yet extremely impactful.4 Similarly problematic and harmful messages, both implicit and explicit, related to individuals from many other communities that have been historically marginalized abound in our system of medical education.

Because medical education propagates harmful beliefs and practices and sustains them over time, it is one of the key levers we must use to move toward equity and justice within our healthcare system. With this goal in mind, many medical schools have begun to consider how to become forces for anti-oppression and anti-racism. At the University of California, San Francisco (UCSF), we are launching a new Anti-Oppression Curriculum (AOC) that will build upon prior work focused on diversity, equity, and inclusion at UCSF, including the recent Differences Matter campaign.5 Through intentional, longitudinal changes across our entire fouryear curriculum, we hope to impact learners, clinicians, and ultimately patients and their communities. This effort aims both to shape the next generation of physicians’ views on how racism and other forms of oppression harm individuals and communities, and to offer opportunities for students to learn how to engage with strategies to disrupt those harms in partnership with patients and their communities. In parallel, we hope to expand the understanding of practicing clinicians and trainees who work with UCSF medical students in the clinical setting in ways that will ultimately have a positive impact on individuals seeking healthcare. Students engaging in a curriculum focused on anti-oppression will be encouraged to raise questions when they arrive in the clinical setting—for example, our learners will be equipped with a critical lens that will promote inquiry into how race is being used in clinical risk scores and algorithms and whether that use is appropriate or harmful. In a positive and respectful learning climate, these queries will have the power to raise awareness of issues that have been previously normalized and unquestioned in the way we practice medicine. To support these discussions, our AOC will focus on providing faculty development opportunities for clinicians to expand their understanding of these critical domains, to enable faculty to engage effectively with students on these topics.

The arc of how race has been incorporated (or not) into clinical teaching cases can provide us with helpful insights

into where we have been and where we need to go in a key area of our curriculum: the representations of patients. When educational leaders recognized that stereotypes and racism were being unintentionally reinforced by cases used in medical school curricula (e.g. Black patients being disproportionately represented as experiencing homelessness or struggling with substance use disorder), many schools made a well-intentioned decision to remove racial identity from clinical teaching cases unless race was deemed ‘clinically relevant.’6 This well-meaning but ultimately misguided ‘colorblind approach’ approach leads to at least two problematic outcomes. First, it serves to center white patients—because the assumptions embedded in white supremacy unfortunately still influence our educational communities, when race is not mentioned, white race is often assumed as the default. Second, the approach to only mention race when it is felt to be ‘clinically relevant’ silently reinforces false notions of race as biology and buttresses ideas about fundamental differences between individuals of different races—a subset of diseases tend to be learned inappropriately as diseases of Black persons (e.g. Sickle Cell Anemia, which in fact is related to genetic ancestry across many regions of the world, as opposed to Black race), while others which affect a diverse array of patients are implicitly taught as diseases of the default white patient.

Given how much pattern recognition ultimately forms the basis of diagnostic thinking, these distorted views of diseases baked into early medical education can have long-lasting implications for students’ future reasoning. Additionally, this approach prevents us from recognizing and teaching about the impact of racism as a critical structural determinant of health, and strips patients of their social context, communities, and personhood in ways that prevents exploration and discussion of the experiences, strengths, and resiliency of individuals seeking healthcare. Looking back at this issue demonstrates its complexity, and the nuance that is needed when considering how to be anti-racist and anti-oppressive in medical education—there are no quick fixes.

As a starting point in this work, transparency, engagement, and partnership with students and communities around these complex topics will be essential. Encouraging a critical eye and creating opportunities for reflection within medical education in ways that encourage question-asking and problem-posing will be key to uncovering the hidden biases and false assumptions that underlie traditional views of health and disease.7,8 In fact, many of our students are well ahead of faculty in their understanding of the myriad forms and impacts of oppression. This differential knowledge between learners and teachers is a particular challenge for medical educators who have been acculturated to the notion of expertise and ‘seniority’ going hand-in-hand. Moving toward anti-oppression in medical education will require us to become comfortable co-learning with our students and giving students opportunities to share their own expertise—a shift in perspective and in approach that will require us to let go of some of the traditionally rigid hierarchy of medical education. Paulo Freire, a pioneer in the field of antioppressive pedagogy, has described learners and teachers as “co-investigators,” a paradigm that can help us re-think our approach to teaching.7 While this shift will be a challenge for many, it has the potential to be a transformative, positive force for anti-oppression in healthcare. If students can come to expect this kind of co-learning and partnership in their medical education, they will be much more equipped to bring the same spirit of partnership to their clinical teams and patients in the future. Kevin Kumashiro, a scholar whose work focuses on anti-oppression in education, has wisely noted: “an anti-oppressive teacher is not something that someone is. Rather, it is something that someone is always becoming.”8 This view is equally valid for a curriculum that aims to be anti-oppressive. As we continue to work towards anti-oppression and equity in medical education, we do so with great humility, with a keen awareness of the work of so many in the generations before our own, and with an understanding that this effort has no endpoint. Rather, our work toward anti-oppression in medical education will be valid only if we understand that constant striving, learning, and growth are intrinsic to the process. By keeping our goal of health equity at the forefront of the AOC, we hope to center patients and communities, and to move our institution closer to the promise and potential of truly equitable, compassionate, and humanistic healthcare.

Denise M. Connor, MD, is an Associate Professor of Medicine, Director of the AntiOppression Curriculum, and Gold-Headed Cane Endowed Teaching Chair in Internal Medicine at UCSF; and member of the San Francisco VA Medical Center's Hospital Medicine Division.

References

1. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci

U S A. 2016;113(16):4296-4301. doi:10.1073/pnas.1516047113 2. Goyal MK, Kuppermann N, Cleary SD, Teach SJ, Chamberlain JM. Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments. JAMA Pediatr. 2015;169(11):996-1002. doi:10.1001/jamapediatrics.2015.1915 3. Rathore SS, Lenert LA, Weinfurt KP, et al. The effects of patient sex and race on medical students’ ratings of quality of life. Am J Med. 2000;108(7):561-566. doi:10.1016/s0002-9343(00)00352-1 4. Amutah C, Greenidge K, Mante A, et al. Misrepresenting Race - The

Role of Medical Schools in Propagating Physician Bias. N Engl J Med. 2021;384(9):872-878. doi:10.1056/NEJMms2025768 5. Differences Matter | UCSF School of Medicine. Accessed April 21, 2021. https://medschool.ucsf.edu/differences-matter 6. Deng M, Kelly M, Garg M. Decoding Race: Assessing Racial Stereotypes and Bias in the UCSF Medical School Curriculum. Presented at the: American Medical Association Accelerating Change in Medical

Education Consortium Meeting; 2017; Ann Arbor, MI. 7. Freire P. Pedagogy of the Oppressed. 50th Anniversary Edition.

Bloomsbury Publishing; 2018. 8. Kumashiro K. Against Common Sense: Teaching and Learning toward

Social Justice. 3rd Edition. Routledge; 2015.