Racism has been embedded in the institution of medicine and medical education for centuries. The origin is linked to Samuel Morton, Josiah Nott, and Paul Broca’s theory of racial inferiority, which permeates throughout the teachings of modern medical practice. 1 Today, racism in medicine manifests in many ways including, through the use of race as a risk factor for pathology, even though the literature clearly defines race as a socially derived concept that is founded on unequal distribution of power. 2–4 This misuse of the social construct of race creates an improper connection between race, genetics, and sociological racial disparities, which perpetuates the misconception that there are biologically derived racial differences. 5,6 This misconception is connected to the stunting of physicians’ clinical reasoning and the disproportionate level of health care disparities experienced by communities of color. 6 These phenomena converge in the experiences of trainees and physicians of color who, despite being members of the institution of medicine, are still subject to the social injustices of racism. These experiences may involve the explicit and hidden curriculum about race in undergraduate and graduate medical education; a lack of representation; overt racism from colleagues and patients; and the implicit and explicit biases expressed by supervisors, colleagues, and patients. 7
Given the diverse clinical and educational environment of Boston University School of Medicine (BUSM) and the role that all medical schools play in preparing students to care for, work with, and advocate to ensure health equity for all patients, we believe the work of removing racist ideologies and practices from medical curricula is of critical importance for all medical educators. 8 In this article, we describe the ways in which the curriculum at BUSM has unintentionally reified the disproven notion of biological races and describe the curricular analysis undertaken to dismantle these harmful concepts with the goal of promoting health equity through a more inclusive curriculum. The key findings of our analysis are transferable to other medical education institutions, and the described review process can support peer institutions as they engage in the imperative work of institutional reflection and addressing the salient ideas and practices that uphold racism in medicine.
Vertical Integration Group Commission and Design
To educate the next generation of physicians about racism in medicine and out of concern that the curriculum required critical assessment and change, we, a group of students and faculty at BUSM, initiated a longitudinal curriculum analysis. This analysis was performed through the creation of a vertical integration group (VIG), commissioned by the BUSM Medical Education Committee (MEC), from May 2019 to June 2020. The VIG was established at the intersection of student activism and institutional objectives. In spring 2019, 8 first-year BUSM medical students gathered to discuss the multiple instances of racism, microaggressions, noticeable conflations of race with biology, and concerns that racially grounded teaching of medical science was propagating systemic racism. Concurrently, the BUSM Medical Education Office (MEO) was in the midst of a comprehensive curricular reform focused on health equity. These students alongside 3 faculty mentors, in partnership with the associate dean for medical education, proposed the development of a VIG focused on racism in medicine to the MEC. On May 9, 2019, the Racism in Medicine VIG was launched and began a year-long curriculum review process, which culminated with the presentation of a 139-page comprehensive report that: (1) assessed BUSM’s 4-year curriculum as it relates to racism; (2) provided an external review of successful antiracism programs in select undergraduate medical education programs; and (3) provided high-level curricular recommendations, implementation strategies, and proposed racism in medicine and health equity competencies. 9
The VIG was charged with the primary outcome of producing a comprehensive report. 9 This report provides a detailed narrative of the internal assessment of the BUSM curriculum, external assessment of curricula at peer undergraduate medical institutions, and detailed appendices. Each of these sections is discussed in detail below.
The internal assessment examined the 4-year didactic curriculum and synthesized findings into preclerkship and clerkship sections. The assessment was conducted by a systematic review of every didactic lecture (slides), syllabus section (faculty guide, faculty notes, and course organization documents), and practice exam questions for instances of mention, discussion, or omission of race in the curriculum. An expanded team of invested students from all years of medical school reviewed these materials, entering their observations into information-gathering tools (see Supplemental Digital Appendices 1–3 at https://links.lww.com/ACADMED/B212). We also highlighted and explained instances when race was used appropriately by invested lecturers within our learning community. These findings were reviewed by the 3 faculty mentors and compiled in 2 appendices in the VIG report, 9 which respectively displayed the results for the preclerkship and clerkship courses. The findings were documented in this format to provide actionable items for faculty to address immediately. 9
The external assessment focused on 12 Liaison Committee on Medical Education–accredited medical schools’ curricula that were reviewed through examination of public-facing documentation (i.e., curricular overviews, antiracism program descriptions, and antiracism program development timelines) of their curricula as well as informational interviews of stakeholders at these institutions. The informational interviews focused on synthesizing best practices used and key lessons learned at each peer institution.
The appendices were developed to provide specific recommendations to preclerkship and clerkship faculty around best practices for using race and ethnicity in didactic material. The appendices detail every instance that a term related to race and ethnicity was used, the context it was used in, and the appropriateness of the term. We accompanied incorrect use of terms (i.e., in a manner that propagated the conflation of race, biology, and genetics, listed race as a risk factor, perpetuated a racial stereotype, etc.) with literature-based explanations of why the usage was incorrect and how to resolve the issue. Lastly, the appendices inform faculty of their use of images in their didactic materials and provide recommendations for diversifying images.
The report was edited and reviewed by clinical and foundational science faculty members before it was disseminated, and the findings of the VIG were presented and approved by the MEC on June 12, 2020. Tiered dissemination of the report was initiated subsequently to students, faculty, the greater Boston University community, and the broader national community of U.S. medical schools. We prioritized the dissemination of the report to a wide audience, targeting the student body first, given the 2020 U.S. national reckoning with racism and need for more transparent action around racism in medicine.
After dissemination, the MEO employed a tiered implementation strategy in conjunction with the VIG to address the findings. The core aspects of this implementation strategy were immediate didactic modification, faculty development, the development of an equity curriculum, and the creation of a Diversity and Inclusion Fellowship. The fellowship, which has continued, was funded for the academic year 2020–2021 by the BUSM Diversity & Inclusion Office, Boston University Institute for Healthy System Innovation & Policy, and the Vertex Foundation to support the MEO in the implementation of this work among other strategic BUSM initiatives. The 2020–2021 fellow specifically assisted with the development of the equity curriculum, supported faculty in addressing issues in their own curricula, and identified and acted on next steps that go beyond the scope of the curriculum-focused report, by working on projects such as the Glossary for Culture Transformation 10 to further foster a climate of inclusion.
Outcomes and Guiding Principles
The full report, “Is Race a Risk Factor? Creating Leadership and Education to Address Racism: An Analytical Review of Best Practices for BUSM Implementation,” encapsulates the findings and key deliverables of the VIG. 9 The deliverables were centered around factors that we determined were foundational for successful antiracist curricular and cultural change endeavors (List 1). While these factors were developed for the BUSM community, many can be implemented at a wide range of institutions.
The key curricular recommendations and overarching equity and specific racially focused equity competencies (see below) are derived from the internal and external curricular assessments described above. The curricular recommendations fall into the following domains: (1) challenging the persistence of biological/genetic notions of race, (2) embedding structural practices in medical education to dismantle racism in medicine, and (3) promoting institutional climate change (Figure 1). 9
Challenging the persistence of biological/genetic notions of race
The use of race as a differential marker for screening protocols (e.g., glomerular filtration rate [GFR], spirometry) and the etiology and management of disease perpetuate the false equivalency of biological risk groups with racial groups rather than endorsing the social construction of race. 2,5,7,11–13 In this context, the precision of language through the accurate framing of human variation and the impact of social determinants of health is imperative to avoid amplifying these dangerous misconceptions. The perpetuation of race-based medicine and disproven theories of genetic difference leads to worse health outcomes for patients of color. 6,14 We recommend addressing this cycle of racism in medicine head on to interrupt the propagation of these health disparities.
Permeating many undergraduate medical education curricula is the explicit listing of race as a risk factor for various health conditions. As noted by Jennifer Tsai, “rather than a risk factor that predicts disease or disability because of genetic susceptibility, race is better conceptualized as a risk marker—of vulnerability, bias, or systemic disadvantage.” 2 When race is identified as a risk factor, it mistakenly implies that race is genetic and/or biological and that there is an inherent feature of a race that can lead to a particular pathology. This misconception among medical trainees and educators can contribute to biased care practices, restricted clinical reasoning, and reduced accuracy of medical pedagogy, which may be an important explanation for the root causes of the lower quality of care experienced by racial and ethnic minorities. 6 Importantly, the disproportionate burden of disease seen in people of color cannot be explained by factors such as health care access, insurance status, and income. 15 Rather, structural issues impacted by racism, including access to safe housing, availability of clean water and air, disparities in the criminal justice system, and systemic bias throughout the health care system, are more proximal causes of the increased burden of disease on people of color. 15 For example, the diagnosis of non-White individuals with cystic fibrosis or other conditions that are typically associated with European ancestries is often delayed, leading to worse health care outcomes for patients of color with cystic fibrosis. 16
An impactful way to challenge the notion of the biological derivation of race is to explicitly name racism instead of race as a risk factor. 17 This can be applied when examining the disparities experienced by communities of color with respect to COVID-19. Communities of color are both more exposed to the SARS-CoV-2 virus and more susceptible to negative outcomes due to the greater burden of chronic conditions. 18 If the medical curriculum does not name racism explicitly, the false concept of racial health disparities being a result of biological differences will perpetuate the disparities themselves, eliminate the opportunity for effective intervention, and increase the risk of death for people of color. 17 To effectively prevent this domino effect, we recommend establishing that race is a social construct in the first year of medical school and explicitly defining and differentiating race, racism, biology, and genetics throughout the 4-year curriculum.
Embedding structural practices in medical education to dismantle racism in medicine
Due to the pervasive nature of the misconception that racial groups are biological groups, an intentional approach must be taken to disentangle these concepts and to describe populations, race, ethnicity, and ancestry more accurately, as well as to highlight the factors contributing to health disparities. We identified several strategies to establish an antiracist curriculum in undergraduate medical education, including (1) critical examination of the use of race in clinical vignettes and exam questions, (2) diversification of clipart and medical images, (3) critique of the strength of evidence in race-based medical practices, (4) inclusion of principal historical cases, (5) definition of specific racially focused equity competencies, and (6) piloting of curricular innovations via student-led initiatives.
Critically examine the use of race in clinical vignettes and exam questions.
With respect to employing race in a teaching case, without critical assessment and clear reasoning, educators risk reinforcing race-based pattern recognition of diseases, which may lead to bias in clinical reasoning and delivery of care. 19 Creating a false equivalence between racial groups and risk categories can lead to underdiagnosis and the inadvertent reinforcing of stereotypical connections between a racial group and a specific condition. This can also result in misdiagnosis in a patient from a different racial group affected by that same condition.
Diversify clipart and medical images.
Throughout undergraduate medical education, including in the BUSM curriculum, many lecturers and textbooks display images and clipart of individuals with light skin only. 20,21 Continuing to show images primarily of light-skinned patients and health care professionals reinforces power dynamics in which White skin is seen as the default in both groups and creates a knowledge gap in the ability to recognize symptoms in individuals with melanin-rich skin tones. This can result in missed diagnoses and can contribute to patient health disparities when physicians are only trained to recognize conditions on fair skin tones. 22 Additionally, it is harmful when lecturers assert that it is easier to learn dermatological conditions as they present on White skin first, as it perpetuates the idea that darker skin is difficult, problematic, or undesirable. There is a critical need to diversify pathology images, as well as stock images, to prepare students to be able to diagnose with greater accuracy and to challenge associations and assumptions about both patients and providers. 23
Critique the strength of evidence in race-based medical practices.
As described above, the practice of using race as a risk factor is pervasive throughout undergraduate medical education and undergirds widely accepted medical practices and foundational pieces of medical research. Faculty must maintain and model a critical and continual assessment of existing research so that the institution of medicine can begin to dismantle the salient and pervasive systematic racism embedded in it. For example, the current American College of Cardiology/American Heart Association treatment guidelines for hypertension, heart failure, and other cardiac conditions are based on race and explicitly propose theories of inherent genetic difference. 13,24 These guidelines exemplify that the U.S. medical system was founded on, and often remains complicit in, endorsing institutionalized racism. Rather than aligning the medical curriculum with these clinical recommendations simply because they have been promoted by the American College of Cardiology/American Heart Association or other professional societies, it is the responsibility of all educators to engage in antiracist pedagogy and transparently break down the origins of such recommendations to help students understand the existing flaws in the foundational science and its interpretation.
Include principal historical cases.
In addition to faculty development, intentionally teaching about the embedded aspects of structural racism in medicine is essential for all curricula. Throughout history, the perceived differences between races allowed for different standards of care, as well as for the unchecked experimentation and mistreatment of people of color by medical institutions, which has left Black Americans rightfully distrustful of the entire institution of medicine. 25 We recommend, at a minimum, teaching the following critical historical cases that demonstrate the harms of structural racism:
- Study of untreated syphilis: It is imperative that students understand that the natural history and deadly consequence of this disease were learned at the expense of the Black community in Tuskegee, Alabama. 26 When this study is not acknowledged directly, racism is perpetuated by providing implicit permission for devaluing Black bodies and Black lives under the insidious guise of acquiring medical knowledge. Importantly, we intentionally refer to this as the study of untreated syphilis, rather than emphasize the location of the study (Tuskegee) in the study name, to avoid further harming the community impacted by this study.
- HeLa cells: This cell line, the first to be propagated outside of the human body, was established under unethical conditions. The cells were obtained without proper consent from the deceased Black donor, Henrietta Lacks, or her family. Although the cell line went on to be instrumental in numerous medical breakthroughs, the ends do not justify the means. 27 The ethical implications of these actions, the impact of structural racism in the care of Black people, and the current strategies to involve the Lacks family in decisions on the use of their ancestor’s cells are critical to include in discussions on how these cells have revolutionized biomedical research. 28
- The spirometer and GFR: The histories of spirometry and GFR are 2 examples of how testing protocol and clinical diagnosis have been distorted by systemic racism. The race correction in the GFR algorithm is derived from the slavery era concept that Black people are more muscular and thus have higher levels of blood creatinine. For the spirometer, the race correction was embedded based on 19th-century theories of the physical distinction between races—namely, the belief that Black people had lower lung function. 13,29–31 The omission of the origins of these race-corrected formulas erroneously provides a subtext supporting a false biological connection between organ function or disease and race. 13,29–31
- Gynecological discoveries through unethical experimentation: It is essential to teach about the unethical and unanesthetized gynecological experiments on vulnerable enslaved Black people by James Marion Sims. These experiments have led to the creation of many foundational surgical techniques in the field of obstetrics and gynecology, but by glossing over the origins of these techniques, medical education becomes complicit in the methods used to develop them. 32
Define specific racially focused equity competencies.
The key curricular recommendations described herein were supplemented by the development of overarching equity and specific racially focused equity competencies. These 2 sets of competencies were developed in partnership with the BUSM MEO and are modeled on Perdomo and colleagues’ “Health equity rounds: An interdisciplinary case conference to address implicit bias and structural racism for faculty and trainees.” 33 The competencies are designed to ensure an intentional and longitudinal reinforcement of equity (Box 1) and racism-specific (Box 2) concepts across the 4-year curriculum. 9,29 Key components of the racism in medicine specific equity competencies are for students to: recognize the historical context of racism in medicine, establish a deep understanding of racism and race terminology, recognize racism’s role in pathology, develop skills to analyze the limitations and inherent racism in scientific research, and employ strategies to address structural racism in medicine at the individual and institutional levels. 9,33
Pilot curricular innovations via student-led initiatives.
Creating Leadership and Education to Address Racism (CLEAR) was developed as a student-led 6-week extracurricular enrichment series on racism in medicine. This program piloted recommendations from the VIG through seminar classes with experts who led discussions on a range of critical topics. For example, the fall 2019 CLEAR pilot curriculum featured sessions on the history of racism in medicine, antiracism 101, racism and genetics, critical race theory, racism on the wards, and clinical case review. CLEAR has been officially implemented as a BUSM student-led extracurricular enrichment series, but ultimately, we view this enrichment curriculum as a testing ground for educational activities that can be brought into the required medical curriculum.
Promoting institutional climate change
Importantly, the pedagogical strategies mentioned thus far are critical in providing the framework to build an antiracist medical education program, but without a radical transformation of the climate of academic medicine, these changes will not result in effective and durable change. 34 A key component of institutional climate change is developing a strong student–faculty partnership that opens lines of communication between experts in the field, students, faculty, and patients for collective education. By establishing a culture of trust and honesty, medical schools can begin to build a curriculum with an ethos of antiracism that permeates all aspects of medical education.
We recommend that foundational longitudinal faculty development be implemented to create sustainable culture change. Since faculty of color remain an underrepresented group in academic medicine, the majority of faculty cannot rely on lived experience; thus, the historical and structural contexts of racism in medicine must be taught and personal bias must be explored. 35 Faculty development, including antibias and microaggression bystander intervention training, has been implemented at BUSM during the 2020–2021 academic year. This training was held during protected time for course directors and doctoring faculty. Importantly, it is paramount that those teaching about race and racism are equipped with the language and a nuanced understanding of how hierarchies and bias contribute to structural inequities. This understanding will help ensure a safe atmosphere for all participants, especially for students with historically excluded identities, to prevent retraumatization. 36 There must also be an emphasis on expanded, advanced faculty training opportunities (e.g., history of racism in medicine workshops, inclusive pedagogical design trainings) and identification of faculty advocates who can contribute their perspective and expertise and provide a continuous presence of support to peers engaging in this work at an earlier point in the continuum.
Lastly, culture is changed by a continual partnership between faculty, staff, and students collectively examining the impact of racism on their lives and on their communities and engaging in opportunities to practice being an ally and upstander.
Limitations of This Work
First, the MEC’s charge to the VIG stipulated the scope of the work. Therefore, the analyses were limited solely to the undergraduate medical education curriculum with a decidedly scientific lens. In recognition that most medical institutions are not experts in racial justice, we recommend that all medical education institutions partner with local and national organizations with experts in racial justice and health equity to bolster faculty development, student engagement, and cultural change. We also acknowledge that the topic of racism in medicine has implications that extend to the areas of admissions; the culture and climate of an institution; interpersonal behavior and attitudes; grading, honorary recognition, and promotions practices; and policy and legislation. Second, although every effort was taken to conduct the analyses in a manner and provide recommendations that would be generalizable across all populations, the scope of this perspective is largely Afrocentric, and thus the themes represented in it are similarly limited in scope. Third, it is important to recognize that work of this nature can be subject to individual bias. Efforts were taken to minimize these effects through a robust data-gathering framework and multilevel review process for the generation of recommendations. Finally, significant efforts were undertaken to ensure the diversity in the team conducting this work. The team included a multiracial and multicultural alliance from all levels of training, from first-year medical students to the associate dean of medical education, and included consultations from faculty in areas spanning basic science and clinical practice.
This work has been a labor of love, desperation, and hope. We believe that BUSM and all undergraduate medical education institutions can create leadership and make an active commitment to dismantle the historical vestiges of racism within the institution of medicine and simultaneously endeavor to eliminate health care disparities. The historic and present reality of racism in America and in medicine has impacted medical education specifically, and more broadly, the practice of medicine, trainee experience, and patient outcomes, and has propelled us forward in this work in the hopes of creating a better future for patients, trainees, and the next generation of physicians. However, change must be global, and must not be limited to a single component of the educational experience. It is of the utmost importance not only to analyze and rectify the formal curriculum but also to intentionally investigate the institutional environment and the structural societal barriers that impact the health and well-being of people of color. 37 This work requires senior leadership support, a cohesive and comprehensive vision for change, faculty buy in, community partnership, and a global openness to change across all levels. Lastly, there must be a conscious effort to enact change without adding an additional form of oppression through the “diversity tax” on vulnerable student and faculty groups. 38 We recommend that leadership provide protected time and compensation for faculty and students who choose to engage in this transformative work. By prioritizing and embracing this work, each academic medical institution has the opportunity to transform the practice of medicine and impact millions of patient outcomes through a commitment to equity and inclusion.
Proposed Central Equity Competencies Developed at and for Boston University School of Medicine (BUSM)a
Central Equity Competencies 9
The BUSM graduate…
Recognizes instances and systems of inequity, comprehends the historical context and current drivers of inequity, reflects on their personal biases and privilege, analyzes medical literature through the lens of structural inequity, exhibits the medical knowledge to understand the physiologic response to inequity, recognizes the implications of inequity on health outcomes, and possesses the knowledge and practical skills to be an advocate for a more equitable environment in any health care setting.
Recognizes instances and systems of inequity and comprehends the historical context and current drivers
- Demonstrates an understanding of the historical and current sociopolitical factors affecting health equity for marginalized patient populations
- Demonstrates an understanding of the trust/mistrust of the health care system and the current structural factors that propagate inequity for marginalized populations
Reflects on their personal biases and privilege
- Demonstrates an awareness of personal bias and privilege and how it impacts patient care, health outcomes, and interprofessional relationships
Analyzes medical literature through the lens of structural inequity
- Exhibits the ability to critically examine the medical literature’s use of sociopolitical categorizations (i.e., race, refugee, etc.) and disease states
Exhibits the medical knowledge to understand the physiologic response to inequity
- Exhibits the medical knowledge of how inequity influences the development of pathology at the physiologic, neurocognitive, and epigenetic level
Recognizes the implications of inequality on health outcomes
- Recognizes medical and sociopolitical inequities and how they impact patient care and health outcomes
- Recognizes how stigmatizing language negatively impacts patient care and professional relationships
- Recognizes and comprehends how medical and sociopolitical inequities impact their colleagues personally and professionally
Possesses the knowledge and practical skill to be an advocate for a more equitable environment in any health care setting
- Demonstrates the ability to employ evidence-based strategies to advocate for creating equitable health care for marginalized populations
aThese competencies outline the expectations for all graduates of BUSM concerning equity across all groups that have been historically marginalized.
Proposed Racism in Medicine Specific Equity Competencies Developed at and for Boston University School of Medicine (BUSM)a
Racism in Medicine Specific Equity Competencies 9,29
The BUSM graduate…
- Recognizes the historical context and current manifestations of structural racism and its impact on the health care system
- Employs evidence-based tools to recognize and mitigate the effects of personally held implicit racial biases
- Identifies and analyzes the effects of implicit racial bias and structural racism in clinical scenarios and health outcomes
- Exhibits the scientific acumen to understand the difference between genetic variation, ancestry, and sociologically derived (race and racism) risk factors
- Exhibits the knowledge of how racial social inequity influences physiological pathology
- Analyzes medical literature with the historical understanding of racial inequity, identifies gaps in the medical literature, and is able to delineate where race is used or not used appropriately
- Employs evidence-based strategies to address structural racism at the individual and institutional levels to reduce the negative impact of implicit racial bias on patient care and interprofessional relationships
aThese competencies outline the expectations for all graduates of BUSM concerning equity across historically marginalized racial and ethnic groups.
Foundational Factors for Successful Antiracist Curricular and Cultural Change Endeavorsa
- Name and frame the impact of racism as a structural inequity
- Challenge the biological framework of race in the preclerkship and clerkship curricula
- Increase faculty development to empower faculty as changemakers
- Amplify tangible central endorsement to create collaborative buy in
- Establish a 4-year medical curriculum based on overarching equity and specific racially focused equity competencies
- Develop a systematic process for dynamic curricular review and didactic support
- Build a unified antiracist vision and shared language for all departments
- Create community, inter-, and intra-institutional partnerships with topic experts
- Establish a context-specific understanding of how structural racism has impacted the institution’s community and patient population
- Continue to foster student activism and engagement
aThese 10 factors are proposed to establish a strong underpinning for antiracist curricular and cultural changes within an undergraduate medical education institution.
The authors would like to thank their faculty mentors: M. Isabel Dominguez, PhD, Thea James, MD, Ebonie Woolcock, MD, MPH, Vonzella Bryant, MD, and Tejumola M Adegoke, MD, MPH; their fellow medical students: Diana Abbas, Rose Al Abosy, Emily Anderson, David Boamah, Preston Bulter, Patty Chen, Nirisha Commodore, Megan Davis, Andrea Delgado, Sojourna Ferguson, Enrique Garcia, Leah Hollander, Kenya Homsley, Racheal Kearney, S.G. Keller, Christopher Lyons, Kirsten Mojziszek, JaMon Patterson, Samara Muller-Peters, Sophie Rosenmoss, Gabo Sosa-Ebert, Maria Suarez, and Luke Wallace; and the leaders of the Boston University School of Medicine (BUSM) Creating Leadership and Education to Address Racism Student Enrichment Series. This article would not have been possible without their guidance and support. The authors would like to thank the members of the BUSM Medical Education Committee for this commission. Lastly, the authors would like to thank Emily Green, PhD, MA, assistant professor of medical science and assistant dean for faculty development at The Warren Alpert Medical School of Brown University, for her tools and generosity.
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