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Scholarly Perspectives

Student-Led Efforts to Advance Anti-Racist Medical Education

Afolabi, Titilayo MS; Borowsky, Hannah M.; Cordero, Daniella M.; Paul, Dereck W. Jr MS; Said, Jordan Taylor; Sandoval, Raquel Sofia; Davis, Denise MD; Ölveczky, Daniele MD, MS; Chatterjee, Avik MD, MPH

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doi: 10.1097/ACM.0000000000004043
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Abstract

In the early 1960s, the University of California, San Francisco (UCSF) School of Medicine was still known as the “plantation on the hill.” 1 People of color worked as custodial staff in segregated facilities and went years without promotion or fair pay. Following in the footsteps of Dr. Martin Luther King Jr, a coalition of employees formed a historic advocacy organization called the Black Caucus. 1 Through their collective action, the Black Caucus improved the working conditions of service staff on campus. Further, Black Caucus members demanded that the UCSF School of Medicine admit more students of color, citing their belief that diversifying medicine was the essential path to equity for the community at large. 1

Across the country, at Harvard Medical School (HMS), another, similarly consequential history of exclusion occurred. In 1850, the first 3 Black students to matriculate to HMS were expelled by the faculty and dean Oliver Wendell Holmes in response to then fellow-students’ protests. 2 For decades, Black students continued to face interpersonal and institutional racism that prevented them from gaining admission to HMS and other U.S. medical schools. The number of Black medical students in the United States remained below 1,000 until the late 1960s, and until that time, most students were enrolled at historically Black medical schools. 3 In 2016, a first-year medical student at HMS presented the story of the expulsion of the school’s first Black students 2 and brought to light the institution’s decades-long effort to impede diversity within the medical profession. Determined to create a modern-day movement to recognize and rectify the generations of discrimination by medical institutions, this student and other like-minded students formed the Racial Justice Coalition (RJC) at HMS.

Though medical schools have made progress toward improving diversity, inclusion, and equity, and although support for activism has grown since these historic events, medical students continue to face discrimination based on their race, as well as on other aspects of their identities. 4,5 How medical institutions have historically treated students, faculty, and staff of color reflects the same deeply rooted structural racism that patients experience. 6 Structural racism is defined as “differential access to the goods, services, and opportunities of society by race.” 7

In response, over the past decade, medical schools across the United States have increasingly committed to diversity, 8 while also developing an awareness that simply increasing the number of students, faculty, and staff from diverse backgrounds is in itself insufficient to address structural health inequities. Many schools are making efforts both to incorporate social medicine courses into their curricula 9 and to prepare trainees to recognize and address structural racism and unconscious bias. 10 Notably, medical students are playing an important role in advancing these efforts by advocating for and developing more rigorous, socially conscious, and anti-racist curricula. 11 By explicitly designing curricula to empower trainees to dismantle systems of oppression in medical practice, medicine as an institution can begin to recognize and rectify the harm it has inflicted on marginalized communities. 12,13

As students and faculty at HMS and UCSF, we reflect on our and our colleagues’ collective efforts to move toward anti-racist medical curricula at our schools. Throughout this article, “students” refers to the groups of student activists at our respective institutions who have been directly involved in designing, executing, and supporting efforts to make medical education accountable to the communities that medicine has disproportionately harmed. The purpose of this article is to highlight especially illustrative, though certainly not comprehensive, examples of how student activism, specifically at HMS and UCSF School of Medicine, have reshaped medical education. We detail steps that students have taken toward this goal, including (1) responding to the existing curriculum, (2) developing new curricula, (3) examining and working to improve the learning environment, and (4) exploring and working to redress exclusionary practices in student assessment. We celebrate that which has been achieved in partnership with our institutions and highlight that which we have yet to accomplish.

Responding to the Existing Curriculum

Health care professionals care for patients whose medical concerns exist within the larger social context of their lives. To serve all patients equitably, physicians must be equipped with a conscious understanding of how social and structural factors shape health. 14 Research indicates that persistent racial disparities in health are due to the pervasive effects of structural racism. 15 When medical training fails to properly educate students regarding race and the imperfect use of racial categories in patient care, medical institutions risk perpetuating not only interpersonal racism in the form of inequitable treatment decisions 16 but also structural racism.

As it is traditionally taught in medical education, race is considered a biological risk factor and even an indication for differences in treatment at times 17—yet racial categories remain inadequate for describing the heterogeneous groups that they have so often been used to describe. 18 Race is a social construct and is historically a product of systems of oppression. 19 Race is not a reliable proxy for genetic differences. 20–22 For example, individuals who identify as African American in the United States vary widely from one another in genetic makeup, with differences in genetic admixtures from Europe, the Americas, and Africa. 23

Despite the detrimental consequences and inaccuracy of race-based medicine, the use of race in medical school curricula and clinical practices often lacks nuance. 18 Student members of RJC at HMS examined the preclinical curriculum in an effort to find and respond to problematic examples of race-based medicine. They noted that students were taught that formulas used in popular equations for estimated glomerular filtration rate (eGFR) included a correction factor for patients considered Black, but not for patients of other racial groups. The reason, as stated by the National Kidney Foundation, is the “higher average muscle mass and creatinine generation rate in African Americans.” 24 Inspired by scholars such as Professor Dorothy Roberts, RJC students questioned whether race was a reliable proxy for muscle mass—and whether the use of the racial correction factor may reinforce racial biases and lead to further disparities in the treatment of Black patients. 25 The implication of an artificially higher eGFR value also raised the concern that diagnosis of chronic kidney disease might be delayed in Black patients, which could exacerbate existing racial disparities in kidney disease. 26,27

These observations prompted a productive dialogue between students and faculty at HMS who worked together to consider how the teaching of eGFR might be altered in the classroom and in clinical practice. Ultimately, in early March 2017, faculty at Beth Israel Deaconess Medical Center, an HMS affiliate, removed the racial correction factor from the electronic medical record. 28 In June 2020, Mass General Brigham followed suit by removing the eGFR racial multiplier from the Epic medical record. 29 Race—while essential to consider in our journey toward equity—is not a proxy for genes, and medical education and laboratory tests that treat it as such introduce bias into clinical reasoning. The role that race should play in clinical decision making remains unclear, but students, such as those described here, have assisted in instigating deeper discussion regarding its use. 30

HMS students identified not only the need to reform the teaching of eGFR values but also the critical need for more robust discussions of race-based health inequities throughout the curriculum. In response to the elimination in 2018 of the dedicated session on race, which had typically been part of the social medicine course, students organized an optional, complementary session on race and racism in medicine. The session included a mini-lecture on critical race theory, which had never been taught to HMS students in the required social medicine course. The optional session was incredibly popular and, importantly, resulted in both the reinstatement of a dedicated small-group session on race and racism and the incorporation of the mini-lecture on critical race theory into the official curriculum the following year. In subsequent years, RJC students have continued to examine existing curricular offerings for gaps and have offered complementary sessions to fill these gaps on topics such as the health of indigenous people and the intersectionality of racism and homelessness. We celebrate the educational influence of these student-led sessions and paracurricular offerings, as well as the faculty partnerships that have transformed student efforts into enduring curricular change.

Developing New Curricula

In addition to reforming existing curricula, students have identified a need for entirely new learning experiences and have worked with their institutions to create new curricula explicitly grounded in anti-racist principles. At UCSF, students involved in curricular change have drawn inspiration from the ethos of student activism and the powerful history of student organizing exemplified by White Coats for Black Lives (WC4BL). WC4BL, which now has chapters at over 50 medical schools, formed as a national organization in 2014 31 when students at U.S. medical schools staged a “die-in,” lying on the ground in their white coats to recognize the deaths of Black men Eric Garner and Michael Brown who had been killed by police earlier that year. 32 Following the student demonstration at UCSF, the university committed $9.6 million to a new initiative, the Differences Matter Initiative, which included a new orientation curriculum that immediately introduces incoming students to race-based health inequities. 33

Beyond inspiring the orientation curriculum, students at UCSF have helped to create a vision for medical education that prioritizes the need for every physician to understand systemic privilege, oppression, bias, and historical trauma. At UCSF, first-year students encounter the bulk of curriculum related to race and other social determinants of health during 2 separate 3-week courses: Health and the Individual in the fall and Health and Society in the spring. Although these courses represent a commitment by the UCSF School of Medicine to prioritize social science and public health, student activists continue to advocate improvements in the quality of the curricula and challenge the confinement of race-related topics to discrete blocks. 34 Seeking to improve content and pedagogy and to facilitate conversations about race, students led an effort, in 2017–2018, to review the Health and the Individual course. The review yielded strategies to increase the rigor of the curriculum, including the following:

  1. including and compensating as teachers experts in sociology, critical race theory, and gender studies, as well as community members with relevant lived experience,
  2. placing inequities in the context of structural violence (e.g., racial disparities in the context of structural racism, gender disparities in the context of institutional sexism), and
  3. drawing on more challenging reading materials and discussion questions to hold students to standards equivalent to those required in other preclinical courses.

Students shared the results of their review with faculty leaders and have worked in partnership to create new sessions for the course that draw on the developed strategies.

A powerful example of curriculum that speaks to all 3 of these strategies is the work of the Structural Competency Working Group, a San Francisco Bay Area group composed of students, clinicians, scholars, public health professionals, and community members. In a student-led project, the working group developed a structural competency training curriculum that challenges students to consider how disease is influenced by social context and, further, how social context is influenced by structural forces such as capitalism, racism, and sexism. 35 The training has been implemented over a hundred times, including for all UCSF first-year students. During the training, students work through a case study of a 37-year-old man who presents in the emergency department (ED) after being found on the street drinking alcohol. 36 Going beyond the information they might obtain in a traditional medical history, students learn about an extended series of events that brought the patient to the ED. The next step in the activity challenges students to think about the structural underpinnings for each event in the patient’s journey to the hospital. For example, each of the following could contribute to this patient’s story: the legacy of colonialism, systemic marginalization and violence against indigenous communities, the North American Free Trade Agreement, U.S. immigration policies, gentrification, and the lack of accessibility to health care in the United States. 35,36

In evaluations of this structural competency curriculum, students reported that the curriculum changed how they think about patients by challenging misconceptions and disrupting a tendency to blame patients. 36 Further, participants reported feeling reminded of why they entered medicine in the first place. 36 This type of learning experience epitomizes the strategies highlighted in the student review of the Health and the Individual course. The structural competency curriculum draws on expertise from fields not traditionally included in medical education, approaches inequities from a structural lens, and challenges students to engage with issues of identity at a higher level. Structural competency, which represents a crucial aspect of medical training, must not exist as an occasional stand-alone session, but rather as an embedded, integral part of how students learn about every disease process. 14

In addition to examining formal curricular offerings, students at UCSF have helped create anti-racist learning experiences by organizing extracurricular experiences for peers. 37 In a WC4BL-sponsored session led by local community organizers, students were challenged to consider the responsibility of physicians and the potential power of direct action in reforming health care. Further, UCSF School of Medicine students started an elective called Dialogue to Action: Cultivating Medical Leadership, through which students learn advocacy and leadership skills while examining topics including the medical–industrial complex and the importance of communication across differences.

Examining and Working to Improve the Learning Environment

An increasing proportion (over 30%) of the U.S. population identifies as Black, Latinx, or Native American, yet this population constituted just over 11% of U.S. medical school graduates in 2019. 38 Unsurprisingly, students from backgrounds that are underrepresented in medicine (UIM) have long experienced and reported discrimination and microaggressions—subtle slights against individuals perceived to be members of a marginalized group—by patients, peers, and faculty evaluators. 39–41

Medical education must explicitly teach trainees the skills required to cultivate a nonoppressive, anti-racist working and learning environment. At HMS, in case-based collaborative learning groups, students are tasked with facilitating not only their own learning but also that of their team members; that is, groups of 3 to 4 students are preassigned by faculty for the duration of course blocks. This model is excellent preparation for doctoring, which centers on team dynamics and interpersonal relationships 42; however, some students feel the power dynamics among individuals within the teams may create a harmful learning environment for some students, often women of color, who may be disproportionately doubted, interrogated, and/or ignored. RJC students have designed and implemented a workshop to directly address harmful interpersonal dynamics in the classroom. First-year students read and reflect on a series of scenarios describing difficult encounters in collaborative groups and then work together to devise strategies addressing the issues that each case raises.

Interpersonal relationships have also affected dynamics in clinical care. Based on internal surveys completed by a majority of 3 successive first-year classes at HMS, over 80% of responding students had experienced or witnessed a microaggression in a clinical setting during their first year of medical school. RJC members collaborated with faculty volunteers to create a 2-hour workshop entitled Building a Toolkit for Medical and Dental Students: Addressing Microaggressions and Discrimination on the Wards. 43 The workshop was first implemented in 2018. During the active learning session, students discussed cases of microaggressions and discrimination that were based on the real clinical experiences of their classmates. Students learned how to recognize microaggressions and discrimination, as well as, importantly, how to apply a framework of action 44 that would better equip them to respond if they encounter such situations in the future. Students surveyed after the workshop reported that the experience increased their confidence in their abilities to address instances of microaggressions and discrimination in the clinical setting. 43 Using feedback from the postworkshop surveys, students and faculty improved the offering and have led the session each year with similar results—even in its current virtual format (internal report). The workshop has been adapted at other U.S. medical schools and was one of the top 10 most downloaded publications on MedEdPORTAL in 2020.

Exploring and Working to Redress Exclusionary Practices in Student Assessment

Disparate outcomes in student assessment at medical schools reflect many of the problems that students of color face in the learning environment. In 2018, UCSF School of Medicine leaders conducted and published unprecedented research illuminating significant disparities in clerkship grading. Specifically, over the period studied (2013–2016), UIM students received half as many honors grades as non-UIM students, and UIM students were 3 times less likely than non-UIM students to be selected for honor society membership. 45 Based on their analysis of the data and a review of the educational literature, the study authors hypothesized a multitude of factors at various levels—from interpersonal to structural—that disproportionately affect UIM students and may explain the disparity in honors grades. Factors include, but are not limited to, exposure to microaggressions and racism, differential patient assignments, responses to allegations of discrimination, and lack of race-consciousness by supervisors (an attempt to “not see race at all,” which ignores the existence and persistence of racism). 45 Additional research, led by a UCSF medical student, showed that UIM students were more likely to experience stereotype threat (the fear of conforming to negative stereotypes) on clerkships, which, in turn, is negatively associated with receiving honors grades. 46 The studies suggested that decades-long efforts to educate faculty on the role of bias had not been sufficient to provide a safe and equitable learning environment.

These results from UCSF, along with national data reflecting similar trends, led students, faculty, and administrators to advocate pass/fail grading. 47 The Class of 2021 at UCSF School of Medicine was the first to be graded on a pass/fail system for core clinical clerkships. While an important first step, abolishing clerkship grades does not remove the underlying factors that have contributed to grading disparities in the first place. Moreover, some are concerned about the increased weight placed on licensing exams as evaluative tools. 48,49 The evolution of medical student assessment presents new challenges for medical schools and residency programs, which must work together to develop and implement more equitable methods of assessing trainees in the clinical environment. This case of reforms to student evaluations at the UCSF School of Medicine exemplifies the need to collect data detailing racial disparities to identify and rectify structural inequities.

Conclusion

As medical institutions work to address the experiences of marginalized communities in seeking care and working and training within the health care system, medical schools can lead by ensuring that trainees encounter curricula, learning environments, and evaluation practices that reflect a serious commitment to an anti-racist education. Student activists, in partnership with committed faculty at their medical schools, have successfully advanced aspects of medical education in service of preparing future physicians to provide better care for underserved communities. Ultimately, however, sustained, effective efforts require institutional support and funding. It should not be the responsibility of students, often from underrepresented backgrounds, to simultaneously balance participating in and reforming the curricula. This burden further contributes to the minority tax 50 and can detract from other academic endeavors, which may further exacerbate disparities in access to training and future career opportunities. Medical schools should support students’ efforts by forming a diverse committee of experts to take decisive actions, including the following:

  1. evaluating existing curricula according to rigorous institutional standards and criteria for teaching medicine in an anti-racist manner,
  2. creating and assessing the effect of innovative anti-racist curricular offerings, and
  3. developing, piloting, and evaluating more equitable methods of student assessment.

A multidisciplinary, institution-wide effort is required to empower future physicians to dismantle, rather than perpetuate, structural inequities in the practice and teaching of medicine.

Acknowledgments:

The authors wish to thank Dr. Leo Eisenstein, Dr. Cameron Nutt, Dr. Danial Ceasar, Dr. Danika Barry, Dr. Mubeen Shakir, Daniel Gonzalez, Dr. Michelle Morse, Dr. Jenny Tsai, Dr. Lanny Smith, and all members of the Harvard Medical School Racial Justice Coalition, both past and present, for their advocacy and leadership. They also thank Sheyda Aboii, Anthony Bell, Carmen Lee, Leora Morinis, Eric Smith, and Juhi Varshney for their leadership in many of the efforts highlighted in this piece, as well as the student activists who preceded them, especially members of the University of California, San Francisco (UCSF) White Coats for Black Lives (WC4BL) Class of 2020 and the original founders of WC4BL. Finally, the authors thank the Black scholars and activists who did similar work before this time but who were not given recognition or, worse, received retribution for their advocacy, especially the founding and early members of the UCSF Black Caucus and the 3 Black medical students who initially integrated Harvard Medical School in 1850—Daniel Laing, Isaac Snowden, and Martin Delaney.

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