Over the past year, racial violence erupted in our country in places such as Ferguson, Missouri; New York City; Baltimore; Charleston, South Carolina; and San Francisco. Many of these incidents involved the police. A person with mental illness died after an altercation with police that escalated to a point that might have been avoided. In one case, an undocumented immigrant, recently in police custody, was involved in shooting a tourist, raising concerns about border security and fueling discrimination against other recent immigrants. In my own community in New Mexico, a mentally ill homeless man was killed after a standoff with police, which led to marches and protests. In some cities there were riots, although in Charleston, the noble response of the survivors and the mayor, after racist murders by a civilian, fostered healing. But in most cases where police were involved, polarization has occurred or deepened, with some community members supporting the police and others supporting the victims of police violence.
Some medical students responded by participating in protests and calling for an institutional review of disparities in health care and stronger actions to address racial discrimination. And as the number of incidents increased, colleagues reached out to me to discuss these issues in Academic Medicine.
My first reaction was to try to define the nature of the issues and then decide whether they fall within the scope of topics covered by Academic Medicine. I also pondered what roles the clinical, medical education, and medical research communities could play to help address the problem of racial violence in our country. In the rest of this editorial, I will share my thoughts on these two questions.
Regarding the first question, of whether racial violence is an area appropriate to our journal, I maintain that it is, since this topic is part of larger topics—the causes and prevention of violence of many kinds, treatment of those injured by violence, how to teach these topics, and findings of research about them—that the journal presents.
Racial violence is a clinical issue that results in morbidity and mortality to members of several groups in our population. If we can argue that one of the goals of our academic health centers (AHCs) is to improve the health of our population, the role of violence of all types—a leading cause of death among men between the ages of 15 and 24, nationally and worldwide1,2—is an important issue for various communities and Academic Medicine to address. AHCs have participated in the prevention of violence as well as its treatment by establishing trauma centers and trauma systems, and have trained trauma surgeons, emergency physicians, and others who care for victims of violence. Regarding these victims, there are significant racial differences. In a recent article, Sumner et al3 noted that for non-Hispanic blacks, homicide is the leading cause of death from ages 1 to 44 years in the United States, while for non-Hispanic whites, it is the fifth most common cause of death.
Racial violence is also important to the journal as a topic for medical education. But teaching students and residents to understand racial violence requires knowledge and experience beyond the usual education they receive. It is crucial that they learn that violence occurs within a web of social relationships and conditions; understanding how these connect requires unique expertise and guidance. And students need to learn that even the basic principles of patient-centered care are often difficult to achieve when a victim of violence is also threatening violence to caregivers, as many do. Let me illustrate, drawing on my own experiences in the emergency department (ED).
The victims of violence who arrive in the ED are often in the custody of police, and these victims may become violent to those trying to care for them. It can be very difficult to develop a caring relationship with a patient who is frightened, angry, intoxicated, confused, or mentally ill, and the presence of police can add to this complexity. We have medications that can induce a sleepy, fugue state and reduce the patient’s screaming and flailing. Everyone wears gloves and protective gear.
In these situations, I am grateful for the presence of police. These violent patients threaten me and the staff, and I am glad the police are there with them for our protection. Usually, as the street drugs or alcohol wear off or the medications that we administer take effect, the situation can quiet down. I am sometimes amazed at how the most violent, angry patients can gradually become reasonable and cooperative over time, even those who have committed heinous crimes. I often wonder how it all began, what set events in motion and made this the day when the person would explode.
Daday et al4 have shown that the victims and the perpetrators of violence are not very different. Given some small changes in the environment—a gun in a different place, a different mix of people—the alleged perpetrator in front of me might well have been the one murdered. Often, it is the social environment in which the perpetrators and victims live, not just their personal flaws, that may determine their fate.
And as for the police, I believe their behavior is also deeply influenced by the social context of their jobs. Although there are individual police officers who use poor judgment, are racist, or otherwise behave badly, the police officers I have worked with are typically responsible, conscientious people, and I find myself worried about their safety when they leave the ED. I have cared for many of them over the years when they were shot or were injured in a motor vehicle crash. When I hear about a shooting by a police officer that was not necessary, I think of all the split-second decisions that police have to make, just as I have to make them in the ED, and I have great understanding of the impossibility of making them all correctly. I wonder whether approaches we have used in health care to reduce medical error and patient harm might also apply to police-inflicted injuries.
The violent patients the police bring to me are mostly poor, with histories of alcohol or substance abuse or mental illness. Many of them have had previous arrests. When we finish treating them, the police sometimes release them from custody because their crimes may not be of great enough severity to require incarceration, and the jails are overcrowded. We often try to send these patients to an alcohol or drug rehabilitation program, if appropriate, but they usually prefer to return to the street, and we know that it will only be a matter of time before most of them return, often in worse condition. I emphasize that if we are to teach about violence, including racial violence, we must include education about the social context in which it occurs as well as the resources available to address important elements of that context.
And so when I hear about Fergusson, New York, Baltimore, and other cities where a police officer has killed someone, I have compassion for both of them, the officer and the victim. The criminal justice system will focus on innocence or guilt, but I think about shadows, fear, distrust, inadequate rehabilitation resources, inadequate mental health resources, lack of jobs, homelessness, dark alleys, uncertainty, danger, guns, alcohol, and split-second decisions. And in the case of the police, even if the training of police officers could better prepare them to detect and treat mental illness and substance abuse during an acute event with a response that would reduce the risk of violence, and even if racism—both in police and in the community—could be greatly diminished, there would still be those dark alleys and split-second decisions. Hesitation could mean an officer’s death. Ultimately it is we, the public, who depend on the police to answer the 911 call and protect us, and I think we bear some of the responsibility for the actions they take in attempting to fulfill their mandate. It is too easy to blame one or two individuals rather than looking deeper into the forces within our communities that lead to the mistrust and policing tactics used to maintain safety and control.
As to what we in academic medicine can do about racially motivated violence, I suggest the following three steps that medical education and research could take in helping to address this problem.
The first step is to accept that the problem of violence in its many forms, including racial violence, is a health and health care problem, and afford it the kind of attention in research funding, research activity, educational time, and clinical innovations that it deserves. Mercy et al1 describe the great progress that was made in the 1980s and 1990s when research contributed to our understanding of gun-related violence. Sumner et al3 showed the more recent progress that has been made in reducing injuries related to violence. We can apply the tools of such disciplines as epidemiology, sociology, psychology, history, and anthropology to understand the causes of homicide, including racially motivated homicide, and we can work with our social agencies and communities to identify interventions just as we have with infectious diseases like measles or polio, or environmental diseases like lead poisoning. We can teach our students and residents how to recognize when a patient’s injuries have been caused by violence, how to care for that patient, and how to help prevent future violence to that patient. We can also help students understand the social conditions of the perpetrators and the victims of violence. Funding for research on violence should be allocated to the problem of violence in proportion to the enormous toll it takes in our communities rather than holding it hostage to various political agendas. Medical education should continuously incorporate the relevant findings of such research.
The second step is for those of us who are medical educators to acknowledge and address the role of race and racism in contributing to violence and other disparities in health and health care. We can start by helping students realize that all of us harbor biases, whether consciously or not, regarding such characteristics as skin color, culture, language, class, religion, gender, sexual orientation, or sexual identity. These biases affect our judgment and treatment decisions, and we need to recognize this. Raising the consciousness of students—and faculty members—in this way can foster graduates whose practice of medicine is informed by that raised consciousness.
Recently, Katherine Brooks,5 a medical student, described her observations of racism during her medical education. While her experiences represent one person and one institution, they ring true; I doubt they are atypical. Fortunately, there are many ways to address her observations. An important one is to create a diverse, inclusive environment of work and patient care that welcomes and supports everyone.
Nivet,6 in this issue of the journal, has identified the following five new trends in AHCs where progress toward aspects of that goal has been made at many institutions but where improvement is still needed at others: (1) broadening definitions of diversity to include persons with disabilities and LGBT individuals, (2) developing diversity leadership opportunities at many medical schools, (3) recognizing diversity and inclusion as an important criterion for institutional excellence, (4) increasing recognition of the various subpopulations within minority and underrepresented groups, and (5) adopting a holistic admission approach in medical schools.
Regarding the last of these trends, Terregino et al7 in this issue describe implementation of an innovative holistic review approach during the medical school admission process. In their program, after an initial baseline criterion for grades and MCAT scores has been met, all the decisions for admission are then based on performance by students in a Multiple Mini Interview (MMI) process8 in which students participate in standardized scenarios and are evaluated on communication, professionalism, ethics, teamwork, and other important attributes and skills. The authors show how this approach increased acceptance of underrepresented minorities (URMs) compared with the use of other admission models.
Also in this issue, Jerant et al9 present their examination of the effect of the MMI on the admission process at the University of California, Davis, School of Medicine. They found that it did not advantage (but did not disadvantage) URM students but did result in higher rates of admission of those of lower socioeconomic status even though those students had slightly lower MMI scores. These different results suggest some variability between institutions in the scoring and use of the MMI for admissions decisions. Jerant et al recommend multi-institutional studies of the effects of the MMI on the admission process, which might help clarify these somewhat different results.
Bandiera et al10 also discuss changes in the admission process in their article in this issue. They describe the development of new principles to guide selection for residencies at the University of Toronto; these principles attempt to incorporate social accountability, diversity, and transparency into the decision-making process. All of these articles emphasize the importance of a diverse student body whose members are committed to serving the population.
The third step is probably the most difficult. This step involves what each of us as individuals can do within our communities. As physicians, nurses, and other medical professionals we are the beneficiaries of society’s trust. We are paid well, have high prestige, and have the opportunity to make enormous differences in our patients’ lives. However, where we will live, where our children go to school, and the opportunities available to us and our families are often different from where many of our patients live, where their children go to school, and the opportunities available to them. These contrasts may relate to differences in race, class, financial resources, or education, and they usually mean that we and our patients do not perceive the world and its problems and opportunities in the same way. To truly address the disparities around us, and address attitudes and behaviors such as those described by Brooks,5 we need to make efforts to bridge the gaps between ourselves and our patients. This can happen in many ways, such as consciousness-raising exercises within our institutions or directly reaching out to individuals and the communities we serve. We can facilitate this process by introducing our students and faculty into their nearby communities from the outset of medical school, helping them understand what they are experiencing there, and maintaining connections throughout the students’ education, as described by Rock et al.11
In our current issue, Gonzalez et al12 describe the development of a disparities and advocacy elective for first-year medical students that addresses social determinants of health, individual provider issues, and systemic contributions to disparities. While this is an elective, it provides the opportunity for individual and group engagement. Also in this issue, Girotti et al13 describe the creation and initial outcomes of an urban disparities track at the University of Illinois at Chicago College of Medicine to educate and support students interested in caring for patients in underserved communities. While not all students or faculty will chose to dedicate themselves in this way, many will.
All of these programs provide opportunities to address disparities and enlarge the consciousness of our current and future physicians. At a personal level we can make a greater effort through mentoring of URM students, residents, and faculty in scholarly endeavors and coaching to foster their advancement into levels of leadership at our institutions. And in all areas of our institutions, we must work harder to understand the challenges experienced by those who are different from the majority population, and create environments that honor and accept our various identities as we change our institutional culture.
One of the great gifts of medicine for those of us who are physicians and nurses is our entrée into the lives and stories of others. While such intimacy might be an intrusion in normal circumstances, in medicine it is part of our job because it helps us understand our patients’ values and priorities. And although this takes time and effort and may at times be uncomfortable, it allows us to make important therapeutic connections with patients. How well we succeed in making those connections is, at the deepest level, based on our degree of acceptance and tolerance of our patients, even those who are different from us. Medical education can help foster this openness to and appreciation of others. It is encouraging to know that under the right circumstances, when people who appear different from one another are exposed to one another, their attitudes can change toward increased acceptance and tolerance, in medicine and in other settings.14,15 Acceptance and tolerance are necessary for good medicine and are the behaviors we should strive for. And I think that on many levels most of us want to strive for them.
In 2008 I was in an apartment with a group of people of different races and political persuasions, and we were watching the election returns. When Barack Obama’s election was announced, there were many in the room who experienced a profound emotional reaction; some even had tears running down their faces. I believe that for a moment we glimpsed a society where race, culture, language, and gender would no longer be limitations. People would still be appreciated and recognized for their unique characteristics and attributes and would no longer be prevented from living in a certain neighborhood, getting selected for a certain job, or being welcomed into a club or school. I believe we recognized that if Barack Obama could be elected president of the United States, each of us and our children had the possibility of becoming what we wanted to be regardless of our racial, ethnic, or class origins. The tears I observed were for each of us and our country and the possibilities we envisioned.
Regardless of what any of us think of the success of the Obama presidency, I believe the moment of his election will be forever precious to our identity as a country and will help us find our way out of the current racial mistrust, police mistrust, and societal polarization. I hope medical education, guided by appropriate research, can help lead our society by teaching the thousands of students and residents that we send into our communities each year to be accepting and tolerant physicians who can genuinely connect to the wide variety of patients they will encounter. In this way, our students could be our avatars, representing academic medicine’s best values and vision, forging new connections and new identities that lead to better health for all.