The COVID-19 pandemic and its disproportionate impact on Black and Brown people, along with the murders of George Floyd, Ahmaud Arbery, Breonna Taylor, and so many others, have again made clear the enormous and tragic effects of structural racism. Structural racism manifests in the “institutions, culture, history, ideology, and codified practices that generate and perpetuate inequity among racial and ethnic groups.” 1 Society experiences the results of structural racism in the legacy of redlining and housing discrimination, in the disproportionate incarceration of Black people, in the victims of police violence, and more. Structural racism has a profound influence on the health of Black/African American, Indigenous, and People of Color (BIPOC). 2 Health professionals should not only recognize structural racism as a core driver of health disparities but also actively confront and work to dismantle it. To foster these capacities, educators should include structural racism in medical curricula. While some guidance is available for educators who want to teach learners to recognize and confront structural racism, 3 educational tools are lacking, especially in graduate medical education. Using Critical Consciousness (CC) Theory, we developed a novel travel experience for residents and faculty to foster a deeper understanding of structural racism and explore strategies to dismantle it in our own community.
CC, developed by educator Paulo Freire, 4 is a useful framework for teaching learners to recognize and confront structural racism. Learners analyze how structural racism perpetuates injustice, consider their own capacity to change, and take action to confront injustice. CC has received little attention in medical education, in part because fostering CC requires that educators prioritize space for this type of learning and reflection. Protecting time for reflection during residency training is challenging given competing demands on trainees’ time and on their physical and emotional energy.
Literature on transformative travel explains how travel offers a unique opportunity to develop CC. When learners travel, the intellectual distance they place between themselves and the subjects they are learning about narrows, and for some, disappears altogether. Tuan identified the connection between physical environment and human perception, such that being in new environments can make one think differently. 5 Morgan notes, “undertaking an actual journey involving a profound engagement with unfamiliar places and experiences, a person may experience a degree of disruption … sufficient to engender transformative learning.” 6 Sitting in discomfort, surfacing tensions that are often ignored, and creating new spaces for healing and change are the real opportunities of travel. Travel is admittedly an unusual learning strategy in medical education; however, medical educators cannot dismantle structural racism by continuing to conduct business as usual. We must be open to new models of teaching and learning.
In a novel approach to confronting structural racism locally, faculty and residents from the University of California, San Francisco (UCSF) Pediatric Leaders Advancing Health Equity (PLUS) residency program traveled to the American South to explore not only the historical drivers of structural racism but also the resistance mounted by the Civil Rights Movement. Although structural racism has relevance to many different racial groups in the United States, given the scale and impact of systemic oppression on Black/African American people, we specifically sought to deepen our understanding of the historical underpinnings of anti-Black racism. We anticipated that participants would emerge with strategies to recognize and dismantle structural racism in their own home environment.
A trip to Georgia and Alabama
In April 2019, 16 residents and 12 faculty members spent 5 days visiting historical sites and meeting with civil rights and community leaders in the American South (Table 1). Of these participants, 17 (61%) identified as being from racial/ethnic groups that are underrepresented in medicine (Black/African American, Latinx, Native American). The trip, funded through an anonymous grant, took place during a call-free rotation to allow residents to attend with minimal effect on clinical service. We developed learning objectives for the trip that aligned with the residency program’s curricular goals: to recognize and value the history and knowledge that communities bring to health and wellness, to apply a structural competency lens in patient interactions, to gain skills to recognize and dismantle systems of oppression, to embody cultural humility, and to reflect upon and further develop adaptive leadership skills.
We recognize that travel is not necessary to bear witness to the impact of structural racism and anti-Black racism. Black residents of the San Francisco Bay Area are twice as likely to die from COVID-19, have a life expectancy that is 7 years lower than White people, experience homelessness at a higher rate, are more likely to die at the hands of police, and are disproportionately incarcerated. 7 Racism is always proximate, whether one chooses to acknowledge it or not. We anticipated that traveling to the American South—the birthplace of the Civil Rights Movement—would, given its unique concentration of monuments and museums, allow us to deepen our understanding of the context of structural racism, anti-Black racism in the United States, and the power of social movements. We aimed to apply this knowledge to addressing structural racism in the San Francisco Bay Area upon our return.
In designing the trip, we used the critical pedagogy techniques identified by Halman and colleagues to foster a CC of structural racism. These include creating cognitive disequilibrium, recognizing the value of everyone in the room, promoting authentic dialogue, sharing and inviting stories, questioning the status quo, and challenging the power hierarchy. 8 Examples of how we applied some of these techniques follow.
Create cognitive disequilibrium.
Led by an experienced local tour guide, we traveled by bus to 10 sites over 5 days. Visiting new places, talking with local leaders, and hearing stories from community members allowed participants to build upon existing knowledge and take in new information while experiencing the disruption of unfamiliar places. We used discussion and writing prompts to encourage participants to reflect on their experiences and consider how they might apply insights from the trip to work in the Bay Area.
Recognize the value of everyone in the room.
We used cultural humility, “the practice of lifelong critical self-reflection and self-critique while redressing the power imbalances,” 9 as a foundational practice. Most participants participated in cultural humility training before the trip. We intentionally established that all participants, faculty members and residents alike, were learners, and we encouraged open sharing of ideas and experiences. We held 2 dinner meetings before the trip to build relationships, create group agreements, and gather input on the planned activities.
Promote authentic dialogue.
We implemented a unique approach to promoting authentic dialogue through race-based affinity group meetings, facilitated spaces for participants to gather by self-identified racial/ethnic groups to discuss their experiences. Creating space for BIPOC to gather without White people is an important strategy in acknowledging racial harm. These spaces are essential for supporting people of color and for working toward racial justice. 10 We created 3 groups: for Black/African American participants, for non-Black/non-African American people of color, and for White participants. The groups allowed participants to engage in self-reflection and self-critique through the gaze of their own racialized experiences.
We collected feedback on the trip through open-ended surveys administered at the end of the trip. We also collected data from open-ended surveys 1, 6, and 12 months after our return. The University of California, San Francisco Institutional Review Board (IRB) approved gathering and reporting the data below (IRB #17-22695, reference #244120).
The end-of-week surveys had a 96% completion rate (27/28). Overall, the trip was well received, garnering an average net promoter score (how likely would you be to recommend this trip to a friend/colleague?) of 9.6/10 (standard deviation [SD]: 0.87). Using a scale of 1 to 3, where 1 signifies “did not contribute” and 3 signifies “contributed a lot,” participants reported learning directly from national/local leaders (average: 2.88, SD: 0.33). They also reported that being in the physical space where events occurred contributed greatly to their understanding of structural racism (average: 2.92, SD: 0.28) and that the trip greatly helped to strengthen their practice of cultural humility (average: 2.92, SD: 0.27) (see Table 2). Thematic analysis of open-ended survey responses revealed the following 3 areas for improvement: clarity around faculty role, the need for skilled facilitators for race-based affinity groups, and a need to emphasize that stories belong to the storytellers.
Clarity around faculty role.
Before we left, we established that both the faculty and resident participants were learners. However, assigned faculty leadership roles and the high faculty-to-resident ratio left residents feeling they were under scrutiny. In the future, we would create more opportunities for resident leadership on the trip itself.
Race-based affinity groups provide a space for healing and require skilled facilitators.
Race-based affinity group meetings provided an important space for processing and healing, particularly for Black/African American participants. While the Black/African American group and the people of color group each had experienced facilitators, the White affinity group did not. This limited the White affinity group participants’ ability to explore concepts of fragility, privilege, and allyship. We reinforce the importance of racial affinity groups for processing and healing and note the importance of engaging experienced facilitators to lead discussions.
Stories belong to the storytellers.
Black pain was ubiquitous as we confronted anti-Black racism and White supremacy through learning about the history of slavery, the terrorism of lynching, and the Jim Crow laws in the South. We heard painful stories of suffering, as well as inspiring stories of resistance. In encouraging storytelling, educators and facilitators must be mindful to avoid the exploitation of pain and suffering for the purpose of teaching. Consistent with the principles of cultural humility, we recommend explicitly reminding participants to remain conscious of whose stories are told, who tells the stories, and how stories are used.
Open-ended surveys were emailed to 28 participants at 1, 6, and 12 months after the trip. Completion rates were 61% (n = 17) at 1 month, 43% (n = 12) at 6 months, and 57% (n = 16) at 12 months. Using thematic analysis, we identified 3 major themes that persisted across all 3 time points (see Table 3): Participants experienced (1) a transformed understanding of systemic racism, (2) a greater commitment to speaking up, and (3) cultural humility.
Theme 1: Transformed understanding of systemic racism.
Participants described an enhanced understanding of structural racism in the United States and a more profound recognition of structural racism in the world around them. Those who already possessed a sophisticated understanding of structural racism shared that the trip helped them see their work in a new way. Participants’ responses at the 12-month survey suggest that, for many, structural racism became an important, transformative lens through which to view inequities and disparities.
Theme 2: Commitment to speaking up and acting.
Participants described a deeper calling and more bravery to denounce interpersonal and structural racism. Actions included initiating conversations with colleagues about racism, advocating for patients, and advancing their own learning around concepts of privilege and allyship.
Theme 3: Cultural humility.
Improved commitment to and practice of cultural humility both with patients and in community work emerged as a third theme. Participants reported listening more and that they more often saw patients as whole people in the context of their communities. They noted actively seeking community input and elevating and amplifying community voices in their work.
Our experience demonstrates that using principles of cultural humility and critical pedagogy during travel can help learners recognize and confront structural racism in their local environments.
We recognize that travel may not feel feasible for every medical educator seeking to teach structural racism. Some of the key components of this trip—being in the physical space where historical events occurred, learning directly from local and national leaders, and being in community with others working toward health equity—can be replicated in sites closer to home. Visiting nearby locations of historical significance can help learners deepen their understanding of structural racism and its ongoing legacy. Meaningful and equitable relationships with community partners, in which community members’ experience and knowledge are valued, can help learners practice cultural humility. Learners have much to gain from engaging in dialogue and listening to community members in their own settings who are willing to share their experiences of racism and its effects on their health. Creating intentional opportunities for reflection through spaces like race-based affinity group meetings can help learners better understand their own racial identities and their potential to enact change. More research is needed to help educators apply these techniques in local learning environments.
Dismantling structural racism is essential to achieving health equity. This trip demonstrated the power of stepping outside of the traditional learning environment to deepen participants’ understandings of structural racism. Teaching structural racism requires that we medical educators embrace new and potentially uncomfortable educational approaches. We need to invest in developing more strategies to address structural racism in medical education. Until we do, we risk perpetuating the same systems we are hoping to dismantle.
The authors are indebted to Rhea Boyd, Y-Vonne Hutchinson, Manny Bramble, Charles Alphin Sr, Bernard Lafayette Jr, and Alison Gold for their contributions to the trip. The authors appreciate the support of Daniel West and Pam Simms Mackey. The authors are grateful to the faculty and residents from the University of California, San Francisco Pediatric Leaders Advancing Health Equity residency program for their participation. The authors are deeply thankful to the anonymous donors who made this trip possible.
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