Battling Entrenched Attitudes About the Value of Racism in Medical Education: Perspectives from Third-Year Medical Students

ZainaB Balogun, jeyani naRayan, allie heymann, anna li univeRsity oF PittsBuRgh sChool oF meDiCine

In 1966, Martin Luther King Jr. stated, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” Minority populations, particularly Black Americans and indigenous populations, have long carried a larger disease burden compared to non-minority populations, as measured by both quality of life and life expectancy1 Medical biases intentionally introduced into health care to uphold systems of oppression hundreds of years ago have persisted and continue to contribute to injustices in health care. These include false beliefs such as the idea that Black people have thicker skin and thus higher pain tolerance, a belief which currently leads to Black people being prescribed less pain medication in the emergency room2. While it is well known that we have a problem, finding ways to measure and systemically eliminate racial bias in medicine has remained a challenge.

It begs the question: where does this bias originate? A 2016 study from the University of Virginia showed that students carry racial biases as they enter medical school, and these biases are present throughout the first two didactic years2. While bias has been demonstrated to improve over the four years of medical education, especially after clinical rotations, even resident doctors continue to believe and perpetuate falsehoods about race in medical care3. In that vein, we want to understand what factors endure in our educational system to allow racial bias to persist despite acknowledging that the problem exists.

Understanding the various sources of bias and the factors that perpetuate them in medical education is vital to targeting solutions to eliminate it. We have all been raised in a world built with racist systems that have shaped our core beliefs. It is therefore inevitable that these beliefs are held by students as they enter medical school. Prior to our own medical training, we had often heard in the news that certain diseases, such as cardiovascular disease, are more prevalent in Black people. There was, however, no discussion about how racism underlies the lack of access to care, environmental exposures, and socioeconomic inequality that predispose these populations to those diseases, leaving us to think that the underlying cause was instead a fundamental genetic difference. Medical education continues to facilitate racial biases even as it introduces curriculum discussing these complexities. Despite coursework focused on racism, the fundamental framework taught by medical schools for developing differential diagnoses is biased in the way it considers a patient’s race. When studying for board exams, for example, pattern recognition becomes an essential skill, and we are taught to automatically associate certain diagnoses with particular races. In a clinical vignette that presents a patient with Tay-Sachs disease, we are implicitly programmed to identify an Ashkenazi Jewish patient. While the genetic mutation that causes the disease is more common in this population, we fail to understand the nuances in the factors that contribute to this commonality and the fact that Tay-Sachs can also be found in FrenchCanadians and Cajun populations4. Similarly, we are taught that when a vignette presents us with an immigrant, we can assume they are unvaccinated. This particular association encourages the racist belief that health care and other services in the US are superior to those in other countries and that immigrants have poor health literacy and health care decision-making capacity.

Eliciting a medical history, including vaccination status, should involve seeking an unbiased understanding of each patient’s literacy and health care needs. Race is often used in medicine as a proxy for these other factors. While simple heuristics can help win students points in a timely fashion during an examination, they become hardwired into our brains as physicians. Ultimately these heuristics prevent us from producing a broad differential, leading to inaccurate or incomplete diagnoses made from premature conclusions. Coming off the first step of the medical board examination and transitioning into a clinical environment as third year medical students, we have to unlearn these simple mental maps to remove a patient’s race from the equation. Frustratingly, we are forced to maintain them for the standardized SHELF examinations that are licensed by the National Board of Medical Examiners (NBME) at the end of every clinical specialty rotation. By retraining medical students to take into account the direct factors influencing medical conditions rather than operating on heuristics, clinical outcomes will be improved.

There is an abundance of retroactive studies looking at the impact of racial bias, and they state that it is up to medical schools to take proactive steps to educate their students about the injustices of the past while equipping them to promote equitable practices in the future5. Our institution has taken strides to address historical racial and socioeconomic injustices and has been integrating solutions across the curriculum.

One example is a Racism in Medicine (RIM) course that we took in the spring of second year. This course discusses several ways in which structural racism bleeds into medical education and hospital care, and how it ultimately plays a role in poor health care delivery and clinical outcomes. Yet student discourse about the class was unsettling and accentuated issues with racism education in the medical school curriculum. Some individuals questioned the necessity of the course and thought that it was sufficient to simply be kind to all patients. This kind of sentiment highlights the need for introducing a curriculum discussing racism significantly earlier than the end of second year. In addition, discussions of racism should not be compartmentalized and should be implemented in all clinical vignettes from Cardiology to Immunology. This is what would best prepare us to provide holistic care with consideration of social and environmental factors while crafting diagnoses and treatment plans.

Another sentiment that emerged from post-RIM discourse was that the course was badly timed because it was taught during medical board examination preparation. This further emphasizes the point that having discussions about racism incorporated into all coursework in medical school prevents it from being deemed less important than other subjects or somehow in conflict with study priorities. Finally, some felt there should be an actionable component to the course that facilitates immersion into the community to fully understand the experiences of our patients instead of limiting education to discourse. Overall, points raised by our class demonstrate that the discussion of racism in medicine has significant room for improvement.

It is up to the medical institution to optimize the efficacy of the racism curriculum to best challenge and eliminate the implicit biases that students with diverse backgrounds may possess. Ideally, medical schools would start the first year with a medical racism course to illustrate errors perpetrated by the medical system in the past. This first-year course should also create an avenue to dispel any myths about minority health that have been perpetuated throughout the health care system. For example, it isn’t enough to dispel the notion that Black skin is thicker than other skin tones6. There needs to be deliberate education on why that is not the case using peer-reviewed evidence. It is also important to impress upon students the importance of considering how decisions made in developing scientific methodologies can disadvantage certain populations. For example, the MDRD equation was developed by including race data in the model used to calculate eGFR. The equation reports a higher eGFR (by a factor of 1.210) if a patient is identified as Black. This type of calculation can result in a misguided clinical interpretation of a patient’s kidney function and may result in delayed referral to specialist care or listing for kidney transplantation3. While there are active calls to remove this algorithm from clinical decision making, this equation is still universally taught across medical schools. Students need to understand why algorithms like this have limitations and are inequitable.

Medical education must also demonstrate the difference between racial bias, which is based on falsehoods and prejudice and racial awareness, which is based on reliable scientific data. The goal should not be to provide everyone with the same medical care, but rather with the same quality of care. This requires tailoring medicine to the individual. The loose correlations between race, ancestry, socioeconomic factors, and other social determinants of health have led to doctors using race as a proxy, which at best is inaccurate and at worst leads to dangerous biases and suboptimal care. Racial bias and racial awareness can be easily confused, and doctors should take care to make sure their treatment of patients is based on authentic scientific research and not prejudice. These are just a few ways to encourage medical students to reflect on their implicit biases early in training. Thus, every student starts medical school cognizant of their biased beliefs and motivated to actively challenge them.

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And like any other disease, the disease of racism in medicine should be tested and measured in board examination questions to understand progress and measure competency. Medical injustice to minority patients cannot be swept under the rug. Historical grievances and mistrust among minority populations have often been blamed for continued disparities in the quality of and access to health care, while in reality the health care system is solely responsible for these disparities. We must take steps beyond apologizing to ensure that every patient has access to equitable care without receiving a poor outcome due to their skin color. Medical schools bear a crucial part of this responsibility. As such, they must teach racial competency in a way that is appropriately nuanced and overturns long-held biases. In addition, they must measure the success of these interventions over time. The mark of a truly enlightened medical school will be graduates that are racially aware physicians and practitioners of equitable medicine.

REFERENCES:

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2. 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 Apr 19;113(16):4296-301. doi: 10.1073/pnas.1516047113. Epub 2016 Apr 4. PMID: 27044069; PMCID: PMC4843483.

3. Vyas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight - Reconsidering the Use of Race Correction in Clinical Algorithms. N Engl J Med. 2020 Aug 27;383(9):874-882. doi: 10.1056/ NEJMms2004740. Epub 2020 Jun 17. PMID: 32853499.

4. Preston, D. and Shapiro, B., 2022. ClinicalKey. [online] Clinicalkey. com. Available at: <https://www. clinicalkey.com/#!/content/book/3s2.0-B9780323661805000316> [Accessed 17 September 2022].

5. Weiner, S. (2021, May 25). AAMC News. Medical schools overhaul curricula to fight inequities. Retrieved from https://www.aamc.org/newsinsights/medical-schools-overhaulcurricula-fight-inequities

6. Voegeli R, Rawlings AV, Summers B. Facial skin pigmentation is not related to stratum corneum cohesion, basal transepidermal water loss, barrier integrity and barrier repair. Int J Cosmet Sci. 2015 Apr;37(2):241-52. doi: 10.1111/ics.12189. Epub 2015 Jan 21. PMID: 25482263.