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Scholarly Perspectives

A Framework for Developing Antiracist Medical Educators and Practitioner–Scholars

Sotto-Santiago, Sylk EdD, MBA, MPS1; Poll-Hunter, Norma PhD2; Trice, Traci MD3; Buenconsejo-Lum, Lee MD4; Golden, Sherita MD, MHS5; Howell, Joy MD6; Jacobs, Nicole PhD7; Lee, Winona MD8; Mason, Hyacinth PhD, MPH9; Ogunyemi, Dotun MD10; Crespo, Waleska PhD11; Lamba, Sangeeta MD, MS-HPEd12

Author Information
doi: 10.1097/ACM.0000000000004385

Abstract

In 2020, the United States experienced a renewed national awakening to the issues of racial injustice, including the ongoing senseless loss of Black lives at the hands of police and the disproportionate impact of the COVID-19 pandemic on communities of color, specifically Black, American Indian and Alaska Native, Hispanic/Latino/a/x, and Native Hawaiian and other Pacific Islander communities. 1 Regrettably, academic medicine is far from immune from such issues of racial injustice and inequity.

The important relationship between academic health centers and their surrounding communities cannot be understated. Academic health centers are often anchor institutions and inextricably tied to the economic well-being of their communities, beyond the traditional contributions they make to education, research, and patient care. These institutions serve as major job producers and financial contributors to community development. 2 As part of their local communities, educators, clinicians, and researchers must help center community voices and actively commit to dismantling racism within and outside the walls of academia. The academic medicine community has long grappled with its own acceptance and normalization of behaviors, practices, and policies that perpetuate racial inequities. 3,4 This complicity has had far-reaching effects, negatively impacting patients, especially those who identify as Black, Indigenous, or People of Color.

On June 1, 2020, the Association of American Medical Colleges (AAMC) challenged all academic medicine leaders to “move from rhetoric to action to eliminate the inequities in our care, research, and education of tomorrow’s doctors.” 5 This call to action involves addressing antiracism at the individual, interpersonal, institutional, and societal levels. In addition, in response to the national reckoning on racial injustice that is taking place today, most medical schools have hosted town halls to allow members to share their perspectives, grieve, facilitate healing, and consider solutions. Medical education senior leaders also developed an action plan aspiring to eliminate racism in medical education. 6 Medical students have stepped up to advocate for change and are demanding concrete action, including the development of antiracist curricula and learning environments. 7–9

However, these calls are not new. The American Public Health Association was among the first to name racism as a public health crisis in 2020. 10 Also, in 2015, medical students across the United States joined to form White Coats for Black Lives, which has proposed a set of antiracism criteria by which to judge medical school curricula; the results of that evaluation have been released as a racial justice scorecard. 11

In addition, many faculty have expressed a desire and need to develop their skills so they can be better equipped to facilitate discussions on race and racism. This underscores a gap between learners and faculty on social justice issues. Current students and residents compared with faculty demonstrate a greater awareness of social justice topics such as the history of racism in medicine, structural and institutional racism, structural competency, socioecological determinants of health, and health inequities. 12,13 As such, faculty development in these areas must be prioritized because “before any curriculum on race and racism can be developed for [health professional] students, and before faculty can begin facilitating conversations about race and racism, faculty must receive proper training through intense and introspective faculty development.” 14

Over the last 4 decades, academic health centers have increasingly emphasized cultural competence education and, most recently, unconscious/implicit bias education. 15 While these concepts are important, they do not address the root causes of social inequities. Faculty need more specific skills to talk about race and racism. 14 Embedded within the principles of lifelong learning, cultural humility, and antiracism, the goal of faculty development must be moving faculty through their own journey of (re)learning.

Because creating antiracist learning and work environments is critical to achieving and maintaining inclusion, increasing workforce diversity, and promoting health equity for patients, this work cannot be relegated to a few faculty champions. 16–19 For meaningful and transformational change, all faculty must be prepared to achieve antiracism goals across all dimensions of medical education and practice. As academic health centers across the United States prioritize antiracist strategies, leaders are seeking tools, frameworks, expertise, and programs that are best suited to meet this imminent need.

With increasing demands for such guidance, we came together to explore best practices, common competencies, and frameworks related to antiracism education. We serve as members of the AAMC’s Group on Diversity and Inclusion and Group on Faculty Affairs. Our focus was primarily on preparing faculty to foster antiracist learning environments at traditionally predominantly White medical schools, recognizing that the culture of historically Black colleges and universities may have such dialogue more embedded in the institutional culture. In this Scholarly Perspective, we describe our collaborative work to define racism and antiracism education; propose a framework for antiracism education for faculty development; outline key elements to successfully build faculty capacity in providing antiracism education; and design the implementation, assessment, and measurement of the success of such a program. We also include considerations for program planning using concrete examples from our own institutions.

Naming and Defining Racism

Racism is a system of structuring opportunity and assigning value based on the social interpretation of how a person looks (what is called “race”), which unfairly disadvantages some individuals and communities, unfairly advantages others, and saps the strength of the whole society. 20,21 Racism can be defined as prejudice, discrimination, or antagonism directed against someone of a different race based on the belief that one’s own race is superior; it occurs in both overt and subtle ways. Racism is an umbrella concept that encompasses specific mechanisms that operate at the intrapersonal, interpersonal, institutional, and systemic levels of a socioecological framework. It is important to have an awareness and understanding of how racism operates in society and at academic health centers.

Components of Antiracism Education

Antiracism education emerged from the broader field of multicultural education more than 30 years ago as a way to dismantle racism through the development of new curricula and positive pedagogic practices. 22 In today’s learning environment, antiracism education is expected to create an inclusive learning environment that engages communities while acknowledging discomfort, tension, and vulnerability when addressing issues centered on race. 8,23,24 When combined with a critical andragogy approach and culturally relevant and inclusive methodologies, antiracism education can serve as a tool to transform and equip faculty with the knowledge, skills, confidence, and empowerment to own their teaching, agency, and activism. 25

To successfully deliver antiracism education, faculty need professional development that is informed by the history and structure of racism so they can address the implicit and explicit biases that propagate racist ideology. However, the state of faculty development in this area is very limited, especially when it addresses oppression.

The literature on antiracism education for faculty development shares common threads of self-reflection on identity, power, and positionality. Given that faculty were students once in a system that was dominated by White historical perspectives, they must unlearn and relearn the truths about racial history that were often omitted from curricula. 26 In the case of academic medicine, this includes the historical connection between racism, health disparities, and inequities.

Another thread in antiracism education is the critical examination of structural barriers impeding equity, including the structural and social determinants of health. Faculty development must move individuals away from deficit thinking toward asset-based thinking that elevates the value and unique contributions of historically marginalized and minoritized groups rather than views them as unlikely to successfully complete a learning trajectory given so-called inherent deficits. 27 The success of antiracism curricula relies on a robust infrastructure, human power, and resources, with explicit, high-quality education that engages learners, inviting them to participate in advocacy and activism. 6,28

Framework for Developing Antiracist Medical Educators and Practitioner–Scholars

Based on these key components of antiracism education, we propose the following conceptual framework for antiracism education for faculty development (see Figure 1). The 4 core focus areas emerged from a literature review and collective discussions among the authors. These focus areas are building foundational awareness, expanding foundational knowledge on antiracism, embedding antiracism education into practice, and dismantling oppressive structures and measuring progress, toward the ultimate goal of fostering antiracist practitioner–scholars or individuals who both carry out the work of antiracism in practice and study its implementation and outcomes. 29–42

F1
Figure 1:
Conceptual framework for antiracism education for faculty development. The key elements of this framework include: (1) foundational awareness: an awareness of one’s own privilege and biases and how microaggressions and implicit bias impact decisions and practice; (2) foundational knowledge: an understanding of antiracism concepts and theories that spur deeper listening, reflection, and action; (3) embedding antiracism education into practice: practices that translate foundational awareness and knowledge into action in all academic health center mission areas: education, clinical care, community service, and research; and (4) dismantling oppressive structures: actions at all levels that dismantle systems of oppression within the academy (with both individual and institutional impact). The goal is to foster antiracist medical educators and practitioner–scholars who use ongoing unlearning and learning to become champions practicing inclusive antiracist behaviors with the ultimate goal of developing antiracist practitioners and becoming an antiracist organization.

Our framework is guided by several principles related to the implementation of antiracism education. 33 First, antiracism education benefits learners from both majority and minoritized groups in becoming just citizens. Second, our framework is part of a comprehensive approach that addresses both structural changes and attitudinal-behavioral changes at the individual level to combat racism effectively. Third, it offers an institutional approach from which to examine the visible and hidden curricula, unspoken expectations, representation, policies, and assessment practices that may inadvertently reinforce institutional racism. Fourth, our framework is grounded in the premise of cultural wealth and asset-based thinking, which emphasize how racially minoritized groups positively contribute to society and institutions, exhibiting great knowledge, skills, and abilities while resisting and surviving racism and other forms of oppression. 43

Institutional leaders must consider how progress and outcomes toward building antiracist medical educators will be defined and measured and how capacity will be built within their systems so this work can reach all faculty. In the following sections, we outline strategies for the successful planning and implementation of our antiracist faculty development framework according to the 4 core focus areas.

Building foundational awareness

Building foundational awareness begins with an understanding of one’s own biases (both explicit and implicit) and an openness to being curious and humble throughout one’s learning. Building on this awareness, the key aims of our framework include understanding prejudice, acknowledging one’s own racial identity and existing biases, becoming familiar with cultural humility, building empathy for diverse populations, and fostering collaborations with those from diverse backgrounds. 44 Focusing on power imbalances within historical and modern contexts, antiracism education allows learners to explore identity, intersectionality, and institutional structures. The dismantling of systemic barriers that perpetuate racism begins with honest and, at times, difficult but necessary reflection and authentic dialogue as part of faculty development.

Expanding foundational knowledge on antiracism

Faculty should then build on their foundational awareness to understand the legacy of colonization and slavery and the history of race and racism in medicine. The relevance of these topics to faculty practice is important to highlight, and their connection should be made to long-standing and pervasive health and health care disparities in the United States and to the social and biological consequences of racism that confine certain groups to intergenerational disadvantage and suboptimal health. This context is useful to advance faculty thinking and provide a baseline assessment of their knowledge.

Important foundational concepts to teach as part of a faculty development program include:

  • Historical context (e.g., race as a social not a biological construct, eugenics, social Darwinism, White supremacy);
  • Social and structural determinants of health and structural competencies 45;
  • The relationship between structural racism, social and structural determinants of health, and health care inequities;
  • The range of manifestations and impacts of implicit bias (e.g., recruitment, retention, promotion, mentoring, salary, satisfaction, patient care); and
  • An appraisal of individual and institutional attention to social justice and engagement in community service, community-based work, and/or advocacy.

Knowledge development can be facilitated through communities of practice where faculty can learn from each other and gain support. 46

Embedding antiracism education into practice

Antiracism education for faculty development is best embedded in an institutional environment that fosters inclusion. Then, antiracism education can be integrated into existing diversity, equity, and inclusion (DEI) efforts that are part of organizational missions and institutional operations, which aim to develop equity-minded faculty who embody a commitment to DEI in practice. 47–49 However, the long-term goals in an inclusive academy also require a specific focus on antiracist policies and practices to produce the desired institutional outcomes.

Many faculty express a desire and commitment to integrate inclusive education practices into their work; however, they may struggle to truly engage in culturally responsive teaching. Few faculty development programs provide ample and adequate space for individuals to fully develop or hone these skills. 50 This challenge may be further magnified by a lack of faculty comfort and expertise with teaching antiracism topics. Therefore, to develop, implement, and monitor a faculty development program designed to promote an antiracist learning environment, 2 key ingredients are needed: (1) leadership engagement and support and (2) faculty development resources.

Leadership engagement and support.

The antiracism movement in academic medicine requires leaders who are constant in their commitment to DEI and who have invested in their own antiracist foundational awareness and knowledge. 6 This facilitates statements becoming actions rather than simply performative measures. Also, senior leaders who have the fortitude to engage all key stakeholders will ensure the success of antiracism education for faculty development. Communicating that antiracism education is the responsibility of every faculty member, not just historically minoritized faculty members, is an example of a practice taken by engaged and inclusive leaders. Equally important is leaders developing an overarching strategy for the institution that can provide structure and guidance to faculty while allowing units to have tailored support based on their differing capacities to engage with antiracism efforts. Table 1 offers examples of antiracism education leadership engagement strategies.

T1
Table 1:
Antiracism Education Leadership Engagement Strategies

Faculty development resources.

The field of faculty development in higher education initially began to stimulate instructional improvement but has since grown in academic medicine to align faculty needs and societal imperatives. 51,52 Adequate resources to provide successful faculty development are essential. In addition to the usual faculty development considerations, antiracism education also requires an assessment of the availability of experts who will lead such work. Because the availability of these experts may be limited, leveraging institutional strengths is important, such as faculty who are already engaged in this work in other schools or departments of education, sociology, public health, and psychology within the larger university. Building institutional capacity also should include engaging, training, and enhancing champions who can reach out to their own spheres of influence and magnify the reach of antiracist work.

Centralized support may be needed to build capacity and scalability (i.e., training of trainers), including but not limited to the faculty and educational affairs, diversity, and dean’s offices. This would allow each department to develop capacity for providing ongoing learning while also focusing on embedding education into practice and aligning with institutional efforts.

Antiracism education is most effective when it is coordinated and staged across all stakeholders and settings, including undergraduate and graduate medical education and learners, faculty, and staff, rather than taught in siloes. This requires buy-in from the larger system, including alignment with the health system’s DEI initiatives. Antiracism education that is tailored to the context of each unit and faculty role (clinical, research, education) may not only spur innovation but also effectively resonate with learners. Some tailored curricular examples include using racial literacy tools such as explicitly naming racism as a barrier to health equity or clear examples of race-conscious care and the (ir)relevance of race as a risk factor for disease, as well as encouraging the work of dismantling oppressive systems within specialties. Supplemental Digital Appendix 1 (available at https://links.lww.com/ACADMED/B179) offers examples of antiracism education for faculty development from our own institutions.

Dismantling oppressive structures and measuring progress

To dismantle racism, faculty development must be delivered longitudinally to combat the pervasive messages that reinforce racist principles and practices within society. Sessions could include mixed groups of learners such as students, residents, and faculty; however, thoughtful consideration of the comfort of participants in such groups given potential power dynamics is needed during planning. In addition, interactive workshops that include content delivery and small group activity with concrete action item takeaways and opportunities for reflection are ideal. Continuing medical education credit could be awarded to encourage faculty participation. The importance of offering opportunities to practice what is learned and build the capacity of faculty leaders cannot be overemphasized. It is critical to engage antiracist practitioner–scholars in the process of reviewing and restructuring institutional policies to bring about meaningful change and hold systems accountable to not only identify areas of need but also measure progress. Taking these steps can lead to coalition building across the institution.

Outcomes of antiracism education for faculty development can and should be measured at both the system and individual levels. For example, repeated assessment of unit/institutional climate through validated surveys such as the AAMC’s Diversity Engagement Survey may offer valuable foundational information as well as assess the impact of system-wide faculty development efforts. However, surveys alone may not be enough, and more qualitative approaches like dedicated focus groups within each department may be needed to assess the needs unique to each environment as well as the impact of faculty development on behaviors and attitudes. Reports (both quantitative and qualitative) of incidents related to bias gathered through learner mistreatment and/or faculty surveys are another way to measure progress and identify pockets where more targeted interventions may be needed. Diversity metrics and dashboards that track the hiring and retention of diverse faculty may also serve as surrogate markers of success for institutions.

At the individual level, beyond participant reports of satisfaction and perceptions of value, other measures of success include changes in knowledge, self-reported increases in comfort and confidence addressing issues related to race and racism, and attention to or changes in curricula that incorporate topics related to antiracism. 25 Longer-term measures include an increase in faculty participation in advocacy and community engagement, student evaluations that reflect a more inclusive learning environment, and, though difficult to measure, positive patient outcomes with an impact on health equity.

Next Steps

As medical educators, we believe, first, that antiracism education for faculty development should explicitly present broader and more accurate sharing of historical facts and offer strategies for educators to learn how to facilitate students’ exploration of how racism as a social determinant of health has impacted patients and communities of color. 53 Second, discussions about antiracism must be centered on one’s own identity and positionality within the relationship of power and privilege. As educators, our positionality determines how questions in the curricula are constructed, how lessons are designed, and how we negotiate students’ responses. Third, we should consider cultural humility and curiosity as the foundation on which to build antiracist conversations with learners and peers. Last, we must investigate how undergraduate and graduate medical education are bringing to the forefront the power imbalances in physician–patient communications within health care systems, among academic and leadership hierarchies, and within the culture and climate of institutions. 24

Recently, the AAMC referred to “the dehumanizing and damaging effects of structural racism throughout our country” and put forward the AAMC Framework for Addressing and Eliminating Racism at the AAMC, in Academic Medicine, and Beyond. 54 This framework concisely calls for concrete action as individuals, as the AAMC, as part of the academic medicine community, and as part of the broader community to speak out and eliminate racism to improve the health of people everywhere. Many other organizations are also calling for change. In November 2020, the American Medical Association released a declaration naming “racism as a public health threat,” identifying race as a social construct, and calling for an end to “racial essentialism.” 55

Here, we propose a framework for antiracism education for faculty development. We recognize that this is a growing area of work that has limitations in the lack of validated assessments to measure the short- and long-term effectiveness of such a proposed framework. Current assessments may introduce potential bias into the analytic process. For example, racial bias has been observed in formative assessments by faculty during clinical rotations and in their letters of recommendation 56; and faculty development as a discipline has struggled to identify culturally relevant practices for learning. 57 Each institution needs to systematically implement and monitor any faculty development initiatives, considering the needs of both new hires and the faculty already in place. Next steps should determine how to measure whether faculty development programs and any resulting increase in awareness, knowledge, and skills lead to actual changes in behavior and pedagogy and ultimately whether programs mitigate health inequities for marginalized populations.

Conclusion

We must approach the development and implementation of antiracism education for faculty development with the same focus on scholarship and academic rigor as we do for other elements of medical education. To accomplish this goal, antiracist skills must be a core leadership competency and an element on which faculty are evaluated and incentivized. This will ensure that all key educational leaders have the necessary expertise to teach antiracism. We can no longer rely on a small community of DEI leaders to be the only faculty responsible for this work. The approach we present here elevates these DEI leaders to the role of content experts who train others and build capacity using scalable programs that can be evaluated, published, and disseminated, thus also contributing to the promotion and tenure of these DEI leaders. Finally, medical schools need to develop collaborative antiracism education programs with their affiliated health systems where patient care is delivered.

Taking an ahistorical approach to providing medical care to marginalized populations is no longer tolerable. Educators must acknowledge the impact of systemic racism on the structural and social determinants of health and ensure that educational practices and health system policies do not perpetuate disparities. Coming to terms with our past in academic medicine and creating antiracism faculty development programs will enable us to move into a future where we will be less likely to repeat the same mistakes.

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