A Call to Address Racism in Medical Education

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Do No Harm is the motto of modern medicine, and we cannot truthfully uphold it if we continue to ignore the systematic discrimination against Black patients in medicine. Black people comprise 13.4% of the US population as of the most recent census estimates, and yet as a group has the most abysmal healthcare outcomes. For licensing bodies, including but not limited to USMLECOMLEX, NBOME, ANCC, PACCC, NCSBN, CNPEMCC and NCC-PA to ensure that the most qualified candidates progress in the medical field, they have a duty to ensure that future healthcare providers not only understand racial disparities within medicine, but also how it affects the diagnosis, treatment, prognosis, and prevalence of diseases. Accreditation bodies, including but not limited to, LCME, COCA, CACMS, CASN, CCNE, ARC-PA, CAPTE, AOTA, and ECFMG must update their requirements for certification to ensure health care graduates are adequately prepared to care for a diverse patient population.  We call on these licensing bodies to take immediate action to address the gaps in the curriculum and material tested in licensing examinations of future medical professionals.

Students demand to see, including but not limited to, the following changes: 

  1. Mandatory anti-racism and culture-sensitivity training every year of school for faculty, staff, and students. 
  2. Provide images of common and serious conditions/presentations in patients with different Fitzpatrick skin types in learning material and examinations
  3. Include racial inequality and cultural sensitivity clinical scenarios in regards to medical ethics in learning material and examinations

The following are extremely worrisome statistics:  

  • Diabetes: African Americans are 60% more likely to be diagnosed with diabetes and twice as likely to suffer from complications including limb loss, blindness, kidney disease, and terminal heart disease than non-Hispanic whites (US Department of Minority Health)
  • Cancer: Black women experience the highest incidence and highest mortality of breast cancer - 71% 5-year survival rate for breast cancer for Black women vs 86% of white women. Black men have the nation's highest rates of developing and dying from prostate and lung cancers. Studies suggest that the poor cancer outcomes Black people face are more likely to be attributable to lack of suitable and equitable care compared to what white cancer patients receive (Esnaola NF, Ford ME. Racial differences and disparities in cancer care and outcomes: where's the rub? 2012).
  • Cardiovascular health: Heart disease kills 50% more African Americans than whites. "Although African American adults are 40 percent more likely to have high blood pressure, they are less likely than their non-Hispanic white counterparts to have their blood pressure under control" (US Department of Minority Health).
  • Maternal health: Black women are 3-4 times more likely to experience pregnancy-related death than their white counterparts across education and income levels. Black women have earlier onset preeclampsia and lack access to quality contraceptive care, counseling, and abortions (National Partnership for Women and Families). 
  • Infectious disease: African Americans are 2.5 times more likely to die from Hepatitis than whites (National Vital Statics Report, CDC, 2017). Black Hepatitis C patients are more likely to die from liver failure as they are less likely to receive aggressive treatment or get liver transplants (Howell, C. Racial Disparities in Liver Transplantation for Hepatitis B: To Be or Not to Be, 2009). 49% of HIV infected Americans are Black, 86% of children with AIDS are African American or Hispanic. Black people are 10 times more likely to develop AIDS than white people. However, Black patients are less likely to access prevention services due to stigma, discrimination, and homophobia (CDC, NCHHSTP Atlas Plus, Accessed February 2020).
  • Mental health: Black women have the highest rates of depression and suicide has increased by 200% for young Black men in 20 years (Woods, D. We Ain’t Crazy, Just Coping With a Crazy System, 2012). Women of color are more likely to experience postpartum mental illness and yet are less likely to receive treatment (Broomfield, R. African American Women and Postpartum Depression, 2014). Only 1 in 3 African Americans who need mental health care receive it (Mental Health Disparities: African Americans, American Psychiatric Association, 2017).

Black patients are diagnosed later, treated with fewer pain medications, and have worse outcomes. Many of the factors listed above have been studied controlling for socioeconomic status and show that Black people are still disproportionately at a higher risk. A 2016 study showed that 67% of medical students held false beliefs about Black patients’ pain threshold and biological differences, thereby demonstrating that unconscious racial biases are rampant (Hoffman et al, Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between Blacks and whites, 2016; Chapman et al, Physicians and Implicit Bias, 2013). AI systems used by hospitals and insurance companies to refer patients with complex diseases have shown racial bias in the algorithm and that Black patients were less likely to be referred than white patients (Obermeyer et al. Dissecting Racial Bias in an Algorithm Used to Manage the Health of Populations, 2019). Additionally, mistrust in healthcare among the public is growing, with 15-25% of hospital admissions linked to noncompliance, and 40% of patients found not adhering to their medication regimen (WHO). The commonly held belief is that the poor health outcomes for Black patients are due to some kind of genetic predisposition and superstitious disdain for medicine, but this mindset ignores the history of exploitation of and experimentation on Black people at the hands of the medical profession (Washington, H. Medical Apartheid, 2007). 

These are all signs of systemic issues in healthcare. As future leaders in healthcare, we must have these conversations and train to be actively anti-racist as part of the curriculum. “In a society that sees casual racism among its most powerful leaders, white people can ignore the power of racism all around, or they can choose to acknowledge and confront it.” - Romano, MJ. White Privilege in a White Coat: How Racism Shaped my Medical Education, 2018

Edit - June 12/2020: List of licensing bodies now includes COMLEX and NBOME. List of accreditation bodies now includes COCA. 

- June 24/2020: Removed the requested change "Use of question stems including Black, Asian, and ethnic minority patients in more than stereotypical cases. For example, not every Black male has Sickle Cell Anemia." The assumption of racial background (for example, if no race is mentioned, there might be a tendency to imagine the patient to be white) is one rooted in implicit bias. While our own implicit bias must be addressed, it is a personal task for each of us that can be aided with the anti-racism curriculum, and not one that can be addressed with less stereotypical question stems. 

-June 28/2020: List of licencing bodies has been updated to include NCC-PA

-July 3/2020: List of accreditation bodies has been updated to include AOTA and CAPTE.