Creator: DKalderon, for OpMed Doximity, ‘This Diversity is Not Real‘

Medicine, and hand-in-hand with it, medical education, have a long history of perpetuating structural and institutional racism, to the direct harm of Black, Indigenous, Latinx and other communities of color.  I wrote about my own experience here.This is only my own personal narrative, whereas there is a growing body of research evidence that illustrates racism in medical education occurs across many dimensions, from selective advantages throughout K-12, to college preparation, to admissions processes, during medical school, residency, and among physicians both in- and outside academic medicine.

Below are some – not a literature review- studies on racism in medical school, or what is technically known as “Undergraduate Medical Education,” which were published just in the last few years. I include one from 2007 to remind us all that the passage of time has not led to major improvements.

Finally, it’s important to note that many in academia have  provided guidelines on how to improve diversity in medical schools. Here’s one example that could be adapted to target racial equity (not just “diversity”): Young ME, Thomas A, Varpio L, et al. Facilitating admissions of diverse students: A six-point, evidence-informed framework for pipeline and program development. Perspect Med Educ. 2017;6(2):82-90. doi:10.1007/s40037-017-0341-5

And here’s a set of recommendations for reform of AOA elections: Boatright D, O’Connor PG, E Miller J. Racial Privilege and Medical Student Awards: Addressing Racial Disparities in Alpha Omega Alpha Honor Society Membership. J Gen Intern Med. 2020 Aug 31. doi: 10.1007/s11606-020-06161-x. Epub ahead of print. PMID: 32869203.

Racism in Undergraduate Medical Education

Teshome BG, Desai MM, Gross CP, Hill KA, Li F, Samuels EA, Wong AH, Xu Y, Boatright DH. Marginalized identities, mistreatment, discrimination, and burnout among US medical students: cross sectional survey and retrospective cohort study. BMJ. 2022 Mar 22;376:e065984. doi: 10.1136/bmj-2021-065984. PMID: 35318190; PMCID: PMC8938931.

O’Marr JM, Chan SM, Crawford L, Wong AH, Samuels E, Boatright D. Perceptions on Burnout and the Medical School Learning Environment of Medical Students Who Are Underrepresented in Medicine. JAMA Netw Open. 2022;5(2):e220115. doi:10.1001/jamanetworkopen.2022.0115

Weiss J, Balasuriya L, Cramer LD, Nunez-Smith M, Genao I, Gonzalez-Colaso R, Wong AH, Samuels EA, Latimore D, Boatright D, Sharifi M. Medical Students’ Demographic Characteristics and Their Perceptions of Faculty Role Modeling of Respect for Diversity. JAMA Netw Open. 2021 Jun 1;4(6):e2112795. doi: 10.1001/jamanetworkopen.2021.12795. PMID: 34086032; PMCID: PMC8178710.

Anderson N, Lett E, Asabor EN et al. The Association of Microaggressions with Depressive Symptoms and Institutional Satisfaction Among a National Cohort of Medical Students. JGIM 2021. https://doi.org/10.1007/s11606-021-06786-6

Bullock JL, Lockspeier T, del Pino-Jones A, Richards R, Teherani A, Hauer KE. They don’t see a lot of people my color: A mixed methods study of racial/ethnic stereotype threat among medical students on core clerkships. Acad Med. 2020. doi: 10.1097/ACM.0000000000003628

Ackerman-Barger K, Boatright D, Gonzalez-Colaso R, Orozco R, Latimore D. Seeking inclusion excellence: Understanding racial microaggressions as experienced by Underrepresented Medical and Nursing Students. Acad Med. 2020;95(5):758-763. doi:10.1097/ACM.0000000000003077

Hill, Katherine A., et al. Assessment of the prevalence of medical student mistreatment by sex, race/ethnicity, and sexual orientation.” JAMA Internal Medicine. 2020: 653-665. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2761274

Wyatt TR, Rockich-Winston N, Taylor TR, White D. What Does Context Have to Do With Anything? A Study of Professional Identity Formation in Physician-Trainees Considered Underrepresented in Medicine. Acad Med. 2020 Oct;95(10):1587-1593. doi: 10.1097/ACM.0000000000003192. PMID: 32079956.

Low D, Pollack SW, Liao ZC, et al. Racial/Ethnic Disparities in Clinical Grading in Medical School. Teach Learn Med. 2019;31(5):487-496. doi:10.1080/10401334.2019.1597724

Espaillat A, Panna DK, Goede DL, Gurka MJ, Novak MA, Zaidi Z. An exploratory study on microaggressions in medical school: What are they and why should we care?. Perspect Med Educ. 2019;8(3):143-151. doi:10.1007/s40037-019-0516-3

Phelan SM, Burke SE, Cunningham BA, et al. The Effects of Racism in Medical Education on Students’ Decisions to Practice in Underserved or Minority Communities. Acad Med. 2019;94(8):1178-1189. doi:10.1097/ACM.0000000000002719

Wijesekera TP, Kim M, Moore EZ, Sorenson O, Ross DA. All Other Things Being Equal: Exploring Racial and Gender Disparities in Medical School Honor Society Induction. Acad Med. 2019;94(4):562-569. doi:10.1097/ACM.0000000000002463

Claridge H, Stone K, Ussher M. The ethnicity attainment gap among medical and biomedical science students: a qualitative study. BMC Med Educ. 2018;18(1):325. Published 2018 Dec 29. doi:10.1186/s12909-018-1426-5

Teherani A, Hauer, K, Fernandez A, King T,  Lucey, C. How small differences in assessed clinical performance amplify to large differences in grades and awards: A cascade with serious consequences for students Underrepresented in Medicine. Acad Med.  93(9): 1286-1292 doi: 10.1097/ACM.0000000000002323

Ross DA, Boatright D, Nunez-Smith M, Jordan A, Chekroud A, Moore EZ. Differences in words used to describe racial and gender groups in Medical Student Performance Evaluations. PLoS One. 2017;12(8):e0181659. Published 2017 Aug 9. doi:10.1371/journal.pone.0181659

Boatright D, Ross D, O’Connor P, Moore E, Nunez-Smith M. Racial Disparities in Medical Student Membership in the Alpha Omega Alpha Honor Society. JAMA Intern Med. 2017;177(5):659-665. doi:10.1001/jamainternmed.2016.9623

Hardeman RR, Przedworski JM, Burke S, et al. Association Between Perceived Medical School Diversity Climate and Change in Depressive Symptoms Among Medical Students: A Report from the Medical Student CHANGE Study. J Natl Med Assoc. 2016;108(4):225-235. doi:10.1016/j.jnma.2016.08.005

Burgess DJ, Burke SE, Cunningham BA, et al. Medical students’ learning orientation regarding interracial interactions affects preparedness to care for minority patients: a report from Medical Student CHANGES. BMC Med Educ. 2016;16(1):254. Published 2016 Sep 29. doi:10.1186/s12909-016-0769-z

van Ryn M, Hardeman R, Phelan SM, et al. Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report. J Gen Intern Med. 2015;30(12):1748-1756. doi:10.1007/s11606-015-3447-7

Ackerman-Barger, Kupiri, Debra Bakerjian, and Darin Latimore. How health professions educators can mitigate underrepresented students’ experiences of marginalization: Stereotype threat, internalized bias, and microaggressions. Journal of Best Practices in Health Professions Diversity 8.2 (2015): 1060-1070.

Sánchez JP, Peters L, Lee-Rey E, et al. Racial and ethnic minority medical students’ perceptions of and interest in careers in academic medicine. Acad Med. 2013;88(9):1299-1307. doi:10.1097/ACM.0b013e31829f87a7

Hung R, McClendon J, Henderson A, Evans Y, Colquitt R, Saha S. Student perspectives on diversity and the cultural climate at a U.S. medical school. Acad Med. 2007;82(2):184-192. doi:10.1097/ACM.0b013e31802d936a

A worker disinfects an area of the Xindian district to prevent the spread of COVID-19 in New Taipei City, Taiwan, on Monday. Sam Yeh/Getty Images

In some countries, the healthcare delivery system is considered part of, and incorporated into, a national public health response.  One of the most notable recent examples is the Taiwan response to the COVID-19 outbreak, in which the outbreak has been  very much contained, particularly given to the island’s proximity and social and economic relations with China and its population density.

If you live in the United States,  you know this type of coordinated response is not possible to conduct through our healthcare system, because our healthcare is optimized to provide reimbursable services, not health.  We have fragmented care, a patchwork of coverage that is worsening as unemployment skyrockets, and thereby the inability to have a coordinated data infrastructure.

Many have suggested that the U.S. is incapable of responding to the COVID-19 pandemic because of “cultural” differences from Asian countries, but that is misleading. Prior to this pandemic, the CDC has led a U.S. (and even international) in response to many others, from Zika to H1N1. South Korea and Taiwan are democracies- it is not a given that democracy is incompatible with public health, or that citizens are incapable of following guidelines (including wearing masks on a regular basis).

Blaming our culture absolves our policymakers of responsibility and does not account for the effects that leadership has on our culture. History has shown us time and again that U.S. political leaders’ appeals to racial prejudice (whether overt or subtle) have enabled policymakers to defeat attempts to have a more just healthcare system, whether a national health system, single payer insurance, or guaranteed coverage in a competitive market. If we have “cultural” barriers, it is not our love of liberty– it is that our leaders have understood that racialized arguments can falsely convince people that health justice threatens liberty.

A successful public health effort requires features leading above U.S. healthcare, including: (1) equitable testing, (2) culturally and linguistically appropriate community-based contact tracing, (3) resources to enable those infected to safely quarantine, and (4) centralized secure data systems for tracking.

Our national and local governments have provided re-opening guidelines based upon broad indicators for testing, tracing, health system capacity, disease transmission, and mortality. Reliance upon population-based numbers  ignores the importance of equity on any metric, and thus there will continue to be outbreaks in marginalized communities, whether Black neighborhoods, under-resourced nursing homes, meat-packing plants, immigration detention centers, jails and prisons, or tribal nations.

People are dying, and particularly people of color. This is not due to our culture, but due to our policy choice to rely an unjust system to manage, fumbling, with this pandemic.

(Pamela S Karlan, Art Lien, from, Howe A. “Argument analysis: Justices divided on federal protections for LGBT employees”, SCOTUS Blog, Oct. 8. 2019)

On October 8, the Supreme Court of the United States heard oral arguments on two cases that address whether or not Title VII applies to discrimination on the basis of sexual orientation and gender identity.

Title VII of the Civil Rights Act of 1964 states:

“It shall be an unlawful employment practice for an employer to fail or refuse to hire or to discharge any individual, or otherwise to discriminate against any individual with respect to his compensation, terms, conditions, or privileges of employment, because of such individual’s race, color, religion, sex, or national origin.”Strict textualists argue that sex refers to male vs. female sex only, and thus the law does not apply to sexual orientation and gender identity. There are many pathways by which this affects health outcomes, particularly the health and well-being of sexual orientation and gender identity minorities (SGM). With respect to health care, how do civil rights protections for SGM communities square with Department of Health and Human Services rules that protect healthcare entities and providers on the basis of conscience and religious liberty?In our paper published in JAMA Network Open today, we describe primary care provider experiences of bias, harassment, and discrimination in a deeply underserved region of California.  SGM providers described severe actions taken against them by colleagues, staff, and healthcare administrators, including threats to licensure, denial of hospital privileges, and loss of insurance contracts. As a result, SGM providers have left the region, or remain highly guarded on their status.This is a limited exploratory study- we cannot make any claims as to how widespread these actions are, whether in California or other parts of the country.  We note that this raises several critical policy questions that affect healthcare workforce, physician supply, and ultimately, efforts to address healthcare inequities for SGM communities:

Do Title VII protections apply to SGM individuals?Do Title VII protections apply to physicians, particularly in states like California where they are not actually employees?Do HHS regulations protect healthcare entities with conscience and religious objections, who choose to say, deny admitting privileges to SGM providers?