To the Editor
Amidst national conversations and tensions about race, there is growing recognition that physicians have a responsibility to understand structural racism, its historical roots, and its implications for health disparities.1 Despite increasing efforts, the existing methods employed to discuss racial inequality in physician training—health disparities, cultural competency, and implicit bias—are often incomplete or problematic. Contemporary medical education finds itself underequipped to address structural racism in medicine.
Though health disparities curricula have been amplified, these courses often provide only content on the existence of health inequities rather than teaching critical perspectives that illuminate the social, historic, and economic legacies that fundamentally generate health disparities and marginalize people of color. Well-intentioned cultural competency curricula, favored in the past, often mobilize stereotypes of people of color in efforts to cite behavioral choices as likely causes of health disparities. This pathologizes patient populations and omits instruction on systemic forces that create the environments within which people exert autonomy. While implicit bias curricula encourage increased recognition of personal prejudices, their pedagogical approaches fail to consider structural inequities that generate pervasive bias. Absent broader context, implicit bias training can normalize bias and neglect examination of differences in power that enable individuals and institutions to systematically enact prejudice. Lastly, despite research demonstrating that false belief in innate racial biologic difference increases measures of physician prejudice, race continues to be portrayed as a biologic variable in medical education.2 A significant number of medical students continue to understand race as an innate characteristic.2
Critical race theory (CRT), born in legal studies and further developed in education scholarship, is a framework that centers experiential knowledge, challenges dominant ideology, and mobilizes interdisciplinary and intersectional methodology in order to examine inequality.3 Ultimately, it “seeks to identify, analyze, and transform those structural and cultural aspects of society that maintain the subordination and marginalization of People of Color.”3 Teaching CRT offers a process for physicians-in-training to meaningfully understand the causes and consequences of race and racism, namely by locating inequity and interrogating power structures. It equips learners with the faculty to recognize and articulate unjust practices against people of color, in society and in medicine itself, and therefore represents an important strategy for addressing gaps in critical content and perspective in medical education. In light of persistent racial inequality, medical education should teach CRT so that future doctors are more prepared to discuss and treat racial inequities, in and outside of the clinic.
Third-year medical student, Warren Alpert Medical School of Brown University, Providence, Rhode Island; Jennifer_Tsai@brown.edu.
MPH student, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, and medical student, Icahn School of Medicine at Mount Sinai, New York, New York.
1. Hardeman RR, Medina EM, Kozhimannil KB. Structural racism and supporting black lives—The role of health professionals. N Engl J Med. 2016;375:21132115.
2. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113:42964301.
3. Solorzano DG. Images and words that wound: Critical race theory, racial stereotyping, and teacher education. Teach Educ Q. 1997;24:519.