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Special Article

Racism as an Adverse Childhood Experience: An Interactive Workshop to Train Pediatricians to Address Racism in Clinical Care

Loe, Irene M. MD*; Froehlich, Tanya E. MD, MS; Edrees, Hanein H. MD; Spinks-Franklin, Adiaha MD, MPH§; the R.A.C.E. C.A.R.D. Collaborative

Author Information
Journal of Developmental & Behavioral Pediatrics: August 2021 - Volume 42 - Issue 6 - p 502-511
doi: 10.1097/DBP.0000000000000984

The US populace is growing in racial and ethnic diversity, with the 2012 US Census Bureau report revealing that non-White persons will become the majority in 2043 if current trends continue.1 These shifting demographics, coupled with the election of Barack Obama as the first non-White president of the United States in 2008, led some to declare that the United States had become a “post-racial” nation in which majority and minority groups received equitable treatment. However, recent surveys and events documenting increases in racism and racist behavior across the country belie this optimism. Most Americans surveyed in 2019, regardless of race or ethnicity, reported that race relations in the United States are “generally bad” and that expression of racist views has become more common over the past few years.2 Recent events—including the stark increase in violent hate crimes motivated by race/ethnicity,3 George Floyd's murder at the hands of police and similar incidences of police brutality, and the disproportionate COVID-19 morbidity and mortality experienced by non-White groups4—have highlighted the physical and health dangers that accompany increasing racial tensions in the United States.

In addition to these more overt examples of the danger posed to health by racism and racial bias, more pernicious effects have been identified. Specifically, racism has long been identified as a toxic stressor linked to negative health outcomes in children and adults.5–8 Like other chronic stressors recognized as adverse child experiences (ACEs), the experience of racism leads to a chronically elevated allostatic load and results in adverse neuroendocrine, neural, inflammatory, and epigenetic responses.9 Because of this cascade, being the target of racism is marked by the same biological signature as other ACEs—chronically elevated cortisol, poor glucose regulation, a weakened immune system, changes in neuronal connections, and modifications in DNA methylation and acetylation.10 However, racism was not included in the landmark Centers for Disease Control and Prevention and Kaiser Permanente ACE study showing the link between ACE exposure and negative adult health outcomes.11 Although more recent ACE studies have included racism/discrimination,12,13 there is still not widespread clinical recognition that racism is an ACE. At this juncture, it is critical to improve health care providers' knowledge of the deleterious mental, psychological, and physical health outcomes associated with racism5–8 if they are to provide appropriate and empathetic care to our increasingly culturally heterogeneous patient population.

As such, calls have been made to enhance providers' skills when caring for racial and ethnic minority populations.14–16 However, previous efforts have been criticized for focusing primarily on promoting “cultural competence” rather than on the development of “critical consciousness”—an awareness that places medicine in a cultural and historical context and enables the promotion of social justice in health care.17 Indeed, there is a lack of systematic teaching on the effects of racism and racial bias on health, as evidenced by the lack of American Board of Pediatrics content specifications related to racism and racial/ethnic health inequities on the general pediatric and developmental-behavioral pediatrics subspecialty board examinations.18,19 Furthermore, even if clinicians are aware of racism's adverse health effects as an abstract concept, many are unsure of how they can address racism and racial bias in their clinical practices. To provide maximal support to patients who have been the target of racism, providers must not avoid difficult conversations and dialogue about race and racism, aim to understand the saliency of these experiences, and be familiar with practical strategies for inquiring and counseling about racism to offset adverse health effects.

Hence, our aim was to address these critical gaps in pediatric medical education and to provide an initial framework for pediatric professionals by developing and evaluating an educational workshop on racism as an adverse childhood experience. The workshop used a combination of didactic and interactive activities to equip providers with the knowledge, tools, and strategies to inquire about racism with their patients during clinical encounters. These workshops were conducted at the annual meetings for the Society for Developmental-Behavioral Pediatrics in 201820 and the Pediatric Academic Societies in 2019.21

METHODS

Through a scholarly approach, we used Kern's 6-Step Approach to Curriculum Development for Medical Education to develop the workshop curriculum that was implemented at the 2 national meetings.22 Kern's 6-Step Approach provides “a practical, theoretically sound approach to developing, implementing, evaluating, and continually improving educational experiences” and includes the following 6 steps: (1) problem identification and general needs assessment, (2) targeted needs assessment, (3) goals and objectives, (4) educational strategies, (5) implementation, and (6) feedback and evaluation. These are described below.

Problem Identification and General Needs Assessment

A search of the medical and educational literature, as well as examination of the American Board of Pediatrics content specifications for general and developmental-behavioral pediatrics (DBP), found scant evidence of required competencies or pertinent and introspective trainings for pediatric providers on inquiring about and discussing the topics of race and racism during clinical encounters to support children and families.18,19,23

Targeted Needs Assessment

Initial needs of our targeted learners were assessed through dissemination of a link to an online survey posted on the Society for Developmental-Behavioral Pediatrics (SDBP) online discussion board in December 2017 and January 2018. At that time, there were 818 SDBP member “subscribers” to the discussion board (subscribers receive an email update summarizing posts on the discussion board; total number of members in 2018 was 884), but the total number that “clicked” or opened the post is unknown. Among the 54 respondents, 42 (78%) endorsed a desire to learn more about how issues of race affect child development and behavior through a session at the SDBP Annual Meeting. To further assess learning needs on the complex topic of race and racism, respondents were also asked to rate 5 topics in order of interest: “Racism as Another Adverse Childhood Experience,” “Racial and Ethnic Identity Development in Children,” “Immigration Status and Deportation Threat: Effects on Child Development and Behavior,” “Teaching Children to Be Anti-Racists,” and “Racial Socialization and Racial Literacy.” Among these 5 topics, “Racism as Another Adverse Childhood Experience” was the most preferred and thus was chosen as the focus for our first educational offering.

Goals and Objectives

The goal of our “Racism as Another Adverse Childhood Experience” educational workshop was to help promote the learner's comfort and preparation in addressing the topics of race and racism in their clinical practice, as well as assess satisfaction with the workshop. We created 8 specific learning objectives (Table 1) to direct educational content and methods. The first 4 focused on content knowledge related to definitions of racism and related terms, developmental progression of racial awareness, adverse childhood experiences (ACEs), and adverse physical and mental health effects of racism. The last 4 focused on building skills of providers to address racism during clinical encounters, including approaches to offer guidance to caregivers on having conversations with their children. Interactive cases provided opportunities for role play and discussion and included a variety of case scenarios in which clinicians address children, adolescents, and/or parents or caregivers.

Table 1. - Learning Objectives
1. Define “racism” and distinguish racism from “bigotry” and “prejudice.”
2. Describe the normal progression of the development of racial awareness through early childhood, school age, and adolescence and how the stages of racial awareness correlate with Piaget's theory of cognitive development.
3. Review the original ACEs study and studies that assessed the effects of ACEs on pediatric and underserved populations.
4. Identify the adverse effects of racism on the physical and mental health of children and adolescents.
5. Explain ways of addressing experiences with racism and their perception of race in a culturally sensitive manner with patients and families.
6. Use a standardized questionnaire to inquire about racism and offer resources to parents for talking to their children about race.
7. Implement interview and discussion skills that participants have learned and practiced during peer-guided, interactive cases.
8. Inquire about and respond to patients' adverse experiences related to racism with greater confidence and comfort.
ACE, adverse childhood experience.

Educational Strategies

The curriculum was designed by a team of 15 DBP professionals and trainees, including a range of disciplines (DBP, psychology, and social work), male and female genders, a wide variety of racial and ethnic groups (e.g., African-American, East Asian, South Asian, Middle Eastern, White, Latinx, and multiracial/ethnic), and multiple religious backgrounds (Hindu, Jewish, Christian, Muslim, Buddhist, and Agnostic). The session was presented as a 3-hour workshop that included multiple elements and educational methods (Table 2). It began with a welcome and introduction of “ground rules” to support the development of a “safe space” to ensure participation and mutual respect. We next presented a panel of didactic and interactive activities and resources (described below) to appeal to participants' varied styles of learning. Selection of these activities/resources was guided by a conceptual framework based on self-determination theory (SDT), a model that includes 3 basic needs: (1) Autonomy as the desire to be the originator of one's actions, (2) Competence as the desire to feel effective in one's actions, and (3) Relatedness as the desire to feel connected to others.24

  1. Starting with a live audience engagement platform called Poll EverywhereTM, participants' attitudes and comfort regarding the aspects of race at baseline were assessed and visually illustrated to the group (detailed below). Participants' active involvement in the poll addressed the SDT need of Autonomy and Relatedness because they could see their responses projected alongside the responses of others.
  2. Videos of children's experiences with race from the public domain were interspersed throughout the workshop to provide breaks and comedic relief from didactic, information intensive sections.
  3. Slides with speaker presentations provided background on (1) terms related to racism; (2) the spurious development of race as a biologic construct; (3) the role of implicit bias; (4) racial awareness and normal child development; (5) ACEs and their effects on health; and (6) impact of racism on child development, behavior, and health. These knowledge-rich, evidence-based didactic portions addressed the SDT need of enhancing Competence.
  4. Individual, small, and large group activities provided experiential learning and reflection for participants. For example, to highlight types of privilege, during the “Privilege Stand” moderators read a list of childhood experiences; participants stood up if they had that past experience or remained seated if they had not. During the “Microaggressions Matching Game,” participants sorted statement cards with possible interpretations, highlighting how seemingly innocuous statements might be offensive to listeners. Both of these interactive activities addressed the SDT need of Autonomy. The “Privilege Stand” also enhanced Relatedness because participants gained first-hand experience of promotion or demotion of status based on childhood experiences.
  5. Peer-guided case-based discussion and practice was the penultimate activity before the conclusion. Within small groups, workshop authors facilitated discussion and role play of 2 to 3 cases drawn from an assortment of approximately 25 cases. These cases included families of varied racial and ethnic background and specifically raised issues of race or racism during clinic scenarios with pediatricians. At the end of the workshop, participants were provided with the “Race and Children Clinician's Resource Guide.” The guide included multiple resources, as well as each case, a facilitator's version of cases with prompts (i.e., What would you say/do next? How would you approach this situation with his parents? How would you counsel this patient, and how would you counsel her parents?) and pearls for discussion, self-reflection exercises on race for individual self-exploration, and an infographic that illustrated levels of racism—internalized, interpersonal, institutional, and systemic. The case-based discussions exposed participants to different perspectives. Cases were designed to address the SDT need of Autonomy and Competence by helping participants apply the didactic knowledge to clinical scenarios.
  6. During the workshop, participants were also introduced to applicable clinical strategies, resources, and tools. Each participant received the Resource Guide in either electronic or paper format. In addition to the cases described above, it was composed of provider tip sheets and targeted resources for starting conversations about race with families, understanding stages in racial awareness and racial identity development, teaching children, and working with medical trainees. Links to internet sites included parent books, research articles, and children's books as resources for parents, teachers, and health care providers (Supplemental Material, Supplemental Digital Content 1, http://links.lww.com/JDBP/A308). Participants were also introduced to the Perceptions of Racism in Children and Youth, a standardized questionnaire for inquiring about perceptions of racism in children.25

Table 2. - Workshop Overview
Topic Addressed or Activity and Corresponding Objectives
1. Welcome and Introduction
Objective: Provide participants experiential learning opportunities to become comfortable talking about race and racism.
2. “Racial Awareness and Normal Child Development”
Objectives: Define “racism” and distinguish racism from “bigotry” and “prejudice.” Describe the normal progression of the development of racial awareness through early childhood, school age, and adolescence.
3. “Adverse Childhood Experiences: An Overview”
Objective: Review the original ACEs study and other studies that assessed the effects of ACEs on pediatric and underserved populations.
4. “Impact of Racism on Child Development, Behavior, and Health”
Objective: Identify the adverse effects of racism on the physical and mental health of children and adolescents.
5. Comedy Video (provides comedic relief with an opportunity to find humor in this emotionally laden topic)
6. “Addressing the Elephant in the Room: How Developmental Pediatric Providers Can Address Racism During Clinic Encounters”
Objectives: Explain ways of addressing experiences with racism and their perception of race in a culturally sensitive manner with patients and families. Use a standardized questionnaire to inquire about racism and offer resources to parents for talking to their children about race.
7. Case Discussion and Practice
Objectives: Implement interview and discussion skills that participants have learned and practiced during peer-guided, interactive cases. Inquire about and respond to patients' adverse experiences related to racism with greater confidence and comfort.
8. Comedy Video (provides comedic relief with an opportunity to find humor in this emotionally laden topic)
9. Summary and Resources
Objectives: To consolidate the session into succinct learning points. To review resources that can help participants build their comfort and skill in addressing race and racism in clinical practice.
ACE, adverse childhood experience.

Implementation

The workshop was initially presented in its 3-hour format at the SDBP Annual Meeting and then at Pediatric Academic Societies (PAS). Both workshops provided continuing education credit. Information about the workshop was widely distributed to the attendees of both meetings through standard conference promotional materials.

Feedback and Evaluation

We conducted program evaluation using 2 measures: participant responses to Poll EverywhereTM and a program evaluation form. The evaluation form for the SDBP workshop was written and completed at the end of the workshop before dismissal, whereas the form for the PAS workshop was a modified, shorter version on Survey Monkey™ that was emailed to participants immediately after completion of the workshop.

Poll EverywhereTM collected participants' baseline responses regarding attitudes and comfort with the following: (1) How often do you think about your race (4-point Likert scale: often, sometimes, rarely, or never)? (2) How comfortable are you with talking about race and racism in general (3-point scale: quite comfortable, somewhat comfortable, or not comfortable at all)? (3) How often do you ask your patients about racism or racial discrimination (4-point scale: often, sometimes, rarely, or never)? At the end of the workshop, participants received a follow-up item to assess change in comfort level: Rate how comfortable you now feel talking about race and racism (3-point scale: quite comfortable, somewhat comfortable, or not comfortable at all).

The program evaluation form asked participants to rate the overall session (5-point Likert scale: 1 = poor to 5 = excellent). Participants rated how well 5 learning objectives (objectives 1–4 and 7) were completed by the end of the workshop (5-point scale: 1 = not completed to 5 = fully completed). Participants were asked about their intent to change based on the workshop (yes/no) and to describe one intended specific change (free text). Participant self-assessment included ratings both preworkshop and postworkshop for the level of preparation or comfort with skills-based activities, which included skills based on 3 learning objectives (objectives 5, 6, and 8) (5-point scale: 1 = not prepared or comfortable to 5 = very prepared/very comfortable). Participants were asked about what they found most helpful in the session (free text) and what they would add or change about the workshop (free text). Descriptive statistics were used to characterize the means and frequencies of responses. The paired t test was used to compare participant self-assessment ratings for preworkshop/postworkshop preparation or comfort with skills. Free text responses were analyzed for themes and frequency.

RESULTS

Poll EverywhereTM results were collected from participants at the Society for Developmental-Behavioral Pediatrics (SDBP) and Pediatric Academic Societies (PAS) workshops. Patterns of results across both workshops varied across questions, so the data were not combined. Responses to the baseline question of “How often do you think about your race?” indicated that thoughts about one's race were relatively common among participants choosing to attend the workshop: 39% (n = 19) of SDBP and 55% (n = 34) of PAS participants thought about their race “often,” whereas only 12% (n = 6) and 10% (n = 6) of SDBP and PAS participants, respectively, thought about their race “rarely” to “never” (Fig. 1). Despite high awareness of one's own race, participants responded that they were unlikely to address racial issues during clinical visits. When asked the baseline question of “How often do you ask patients about racism or racial discrimination?”, only 2% (n = 1) of SDBP and 3% (n = 2) of PAS participants responded “often,” whereas 32% (n = 17) of SDBP participants and 27% (n = 16) of PAS participants responded “never” (Fig. 1). Of note, improvements in “comfort level in talking about race/racism” were noted after attending the workshop, as participants responding that they were “quite comfortable” increased from 33% (n = 17) to 51% (n = 22) for SDBP attendees preworkshop to postworkshop. For PAS attendees, “quite comfortable ratings” increased from 33% (n = 21) to 64% (n = 7), but these results should be interpreted with caution, given the very low response rate at the end of the workshop (Fig. 2). No participants endorsed that they were “not comfortable at all” with talking about race/racism postworkshop at either SDBP or PAS. We had the same result at a subsequent presentation of the workshop at Emory University with larger participant numbers, as 0 of 52 participants endorsed that they were “not comfortable at all” (data available on request).

Figure 1.
Figure 1.:
Poll EverywhereTM participant baseline responses. PAS, Pediatric Academic Societies; SDBP, Society for Developmental-Behavioral Pediatrics.
Figure 2.
Figure 2.:
Poll EverywhereTM participant change in comfort level talking about race and racism in general from preworkshop to postworkshop. PAS, Pediatric Academic Societies; SDBP, Society for Developmental-Behavioral Pediatricians.

For the program evaluation, results from the 2 workshops (SDBP n = 54; PAS n = 23) were analyzed separately. Because of a similar pattern of results from each workshop, the data were combined (N = 77). Ratings of the overall session were high, with 95% of respondents rating it 4 (n = 12; 15.6%) or 5 (n = 61; 79%), with 5 being excellent. As shown in Figure 3, ratings for completion of learning objectives were also uniformly high with most participants rating each 4 or 5 (scale of 1 = not completed to 5 = fully completed). We also evaluated change in preparation or comfort level for 4 skills-based activities preworkshop versus postworkshop, including the following: (1) counseling of patients to address experiences of racism in a culturally sensitive manner, (2) utilization of a standardized questionnaire to inquire about racism, (3) offering resources to families to talk about race, and (4) inquiring about and responding to patients' adverse experiences related to racism. The paired t test for change in preparation or comfort level for all 4 of these skills-based activities showed significant change of 1.5 to 2.2 points (all p < 0.001), indicating increased preparation and comfort on pre–self-assessment to post–self-assessment ratings (Table 3).

Figure 3.
Figure 3.:
Participants' ratings of workshop learning objectives (number of responses; 5-point scale, 1 = not complete to 5 = fully complete). LO, learning objective.
Table 3. - Preworkshop/Postworkshop Participant Change in Preparation or Comfort Level with Skills-Based Activities
Questionsa N Mean Difference SD 95% CI of the Difference t p
Lower Upper
1. Counsel patients and families to address experiences with racism and perception of race in a culturally sensitive manner 66 −1.5 0.85 −1.72 −1.31 −14.6 <0.001
2. Use a standardized questionnaire to inquire about racism 65 −2.2 1.03 −2.44 −1.93 −17.1 <0.001
3. Offer resources to parents for talking to their children about race 65 −1.9 0.89 −2.14 −1.70 −17.4 <0.001
4. Inquire about and respond to patients' adverse experiences related to racism 65 −1.8 1.04 −2.04 −1.53 −13.9 <0.001
aEstimate your level of comfort (before today's session and after) regarding the following knowledge, attitudes, or skills (5-point scale: 1 = not prepared or comfortable to 5 = very prepared/comfortable).

All participants at both sessions endorsed positive intent to make a clinical change in practice based on the workshop. Qualitative review of free text responses about practice change indicated that most of the respondents would ask patients and families about racism and adversity. Several respondents indicated that they would also inquire about immigration issues and safety plans in the case of deportation. On review of free text responses for what was most helpful during the session, over half of SDBP respondents (18 of 33) and almost one-third of PAS respondents (8 of 23) endorsed the interactive cases/case-based, small group discussion. Tools, strategies, and resources were also frequently cited as helpful. In addition to their appreciation of the workshop aspects geared toward direct application to clinical care, participants also rated didactic components highly and appreciated the current literature on the adverse effects of racism and the framing of racism as an adverse childhood experience. In response to what participants would change about the workshop, several respondents indicated that they would have preferred a longer workshop, despite the 3-hour duration being among the longest sessions offered at SDBP or PAS.

DISCUSSION

Using the conceptual framework of self-determination theory24 and the best-practice curriculum development model of Kern's 6 steps,22 we developed an interactive workshop to help prepare pediatricians to address race and racism during clinical encounters with children and families. Given the paucity of such curricula and participants' own preworkshop endorsement that only 2% to 3% “often” asked patients about racism or racial discrimination, whereas 27% to 32% “never” asked, this effort fills a critical gap in pediatric medical education. Program evaluation results indicate that the workshop was well-received, with attendees indicating increases in comfort level in talking about race and racism in general. Moreover, significant gains were achieved in participants' reported preparedness to apply skills learned in the workshop to the clinical care setting, specifically through inquiring and counseling families about adverse experiences related to racism, using a standardized questionnaire to inquire about racism, and offering families resources to talk to their children about race.

Our intervention is consistent with a number of recommendations made in the Institute of Medicine's (IOM) landmark report on Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.14 Specifically, our “Privilege Stand” and “Microaggressions Matching Game” activities facilitated reflection and were geared toward increasing awareness and cultural sensitivity, whereas videos of children's experiences with racism were included to increase participants' knowledge and empathy. As recommended by the IOM, we also used didactics to increase participant knowledge of terms related to race and racism as well as their awareness of the impact of sociocultural factors on individual patients' health, behaviors, and quality of care. Furthermore, in line with IOM recommendations, we included resources and case-based discussions to endow participants with the needed tools and skills to approach patient care visits with cultural sensitivity and humility. Our efforts add to the wellspring of curricula to address racism in medical education and to promote antiracism efforts in clinical care,26 as well as to the nascent literature evaluating such curricula. Although other medical education efforts have addressed training in adverse childhood experiences (ACEs),27 to our knowledge, this is the first training to specifically address racism as an ACE and the first antiracism training developed specifically for developmental-behavioral pediatric trainees and practitioners. However, 1- or 2-session antiracism trainings for family medicine and interdisciplinary mixed group (e.g., internal medicine, health psychology, and nurse practitioner trainees) learners have been developed and evaluated.28–30 Similar to our workshop, these trainings included (1) didactics addressing core topics, such as the historical context of race and racism, understanding of key terms and levels of racism, implicit bias, and microaggressions, and (2) case-based discussion.

Importantly, our workshop was unique and distinct from these previous trainings in our presentation of content on racial identity development in children and videos focused on experiences of racism by children. An additional significant strength of our workshop was the inclusion of the Implicit Association Test (IAT)31 as a crucial tool for participants to understand and probe their own implicit biases because a previous study found that medical students who took the IAT at the beginning of medical school demonstrated a change in implicit racial attitudes when reevaluated at the end of medical school.32 Review of the previous literature also suggests that the development of our workshop by a diverse group of racial, ethnic, and religious minority group members likely had important ramifications for the content delivered. Specifically, a previous study found that the inclusion of racial and ethnic majority group members in the development of a medical school curriculum on racism led to a shift in power dynamics such that minority group voices became “quieter,” leading to concerns about marginalization.33

In addition to our workshop's notable strengths, there were several limitations. There was a very low response rate to the initial targeted needs assessment survey inquiring about Society for Developmental-Behavioral Pediatrics (SDBP) members' interest in workshops on race-related topics. Electronic communication overload likely contributed to a low response rate because the survey link was disseminated through a discussion board listserv. Survey respondents were also likely to be biased toward interest in the overall topic. However, we did have a larger number of SDBP workshop registrants (N = 57) than the number of members indicating interest through survey responses (N = 42 of 54). In future work, a variety of methods should be used to solicit professional society member input. Similarly, qualitative and quantitative work with families and patients around their experiences with adverse effects of racism and interactions with or supports from health professionals could inform future work using a patient-centered lens.

For Pediatric Academic Societies (PAS), the response rate for the program evaluation emailed to participants after the workshop was low, with less than half of the PAS participants who participated in the intrasession Poll Everywhere surveys responding to the emailed program evaluation. Because PAS also administered its own meeting program evaluation (whose results are not reported here as the questions were not congruent to those asked for the SDBP workshop), response fatigue may have contributed to our low PAS postsession response rate. By contrast, SDBP participants completed the program evaluation form in-person at the end of session, which likely contributed to a higher response rate. We also experienced a significant decline in respondents to the closing Poll Everywhere™ survey at PAS; thus, results should be interpreted with caution. The conference room at PAS was too small to meet the demand of interested attendees (as advance registration is not required for individual workshops), resulting in rearrangement of the room and barred entry for some meeting attendees by conference fire marshals. These circumstances delayed the start of the workshop and caused it to run over time, with some participants leaving before the end. An additional limitation is that we did not collect participant demographics, racial/ethnic affiliations, professional discipline (e.g., general pediatrics, developmental-behavioral pediatrics, psychology, and social work), or level of training/education at either meeting, so we are unable to stratify results or test interactions to determine whether certain groups found the workshop to be more impactful than others. Given the small sample size and lack of details about participants, generalizability of results may be limited. Furthermore, although we attempted administration of a long-term (6-months postworkshop) follow-up survey of SDBP participants, the response rate was too low for meaningful analysis.

CONCLUSIONS AND FUTURE DIRECTIONS

Our workshop was developed through a scholarly approach and improved participants' reported postworkshop comfort level in addressing racism during clinical encounters through the introduction of practice-based skills and tools/resources. Ideally, the workshop would be replicated and refined and undergo an iterative, rigorous evaluation process to better understand what modifications may be needed to increase the workshop's benefits for specific learners based on racial/ethnic background, professional discipline, or training/education group and the longer-term impact of this training on providers and patient/family experiences. After the Pediatric Academic Societies meeting, there were multiple invitations from pediatric departments to present the workshop at their home institutions. Representatives from the workshop team presented at one academic center and at the Centers for Disease Control before the disruption of the COVID-19 pandemic. The authors plan to continue the workshop presentations postpandemic (Contact senior author Adiaha Spinks-Franklin at [email protected] for additional information about the workshop for presentation or resource materials) including ongoing refinement and evaluation, with the hope that increased exposure to the topic of racism as an adverse childhood experience encourages the participating faculty and institutions to start and/or continue their own efforts with antiracism curricula.

How best to train health professionals in antiracist practice that results in lasting behavioral change and positive patient outcomes remains unclear. There have been several calls to incorporate training on race and racism across health professions at academic health centers and at earlier stages of education before independent clinical practice.17,23,34,35 Such an approach has emphasized the need for health professions faculty to receive “proper training through intense and introspective faculty development. Training should cover how best to engage in, sustain, and deepen interracial dialogue on difficult topics such as race and racism.”23 Other efforts focus on the evaluation and revision of current case-based teaching. A recent workgroup comprising medical students and faculty conducted a literature review to identify challenges and best practices for teaching and learning about race and culture in medicine.36 After developing an analytic framework based on the review, the authors analyzed several virtual patient teaching cases to identify 6 main themes describing common pitfalls or mistakes in the presentation of race and culture. Based on these themes, the authors then developed an evidence-based guide for systematic case revision.36 Detailed efforts on the part of academic faculty using such an approach could help educators reflect on how patient information is presented and “unpack” the way stereotypes have become ingrained in medical education.

In addition, certifying medical boards and accreditation councils should be petitioned to include meaningful content specifications on racism as a social determinant of health with adverse outcomes to ensure that this content is required in training. Other medical educators have called for an addition to the 6 core competencies put forth by the Accreditation Council for Graduate Medical Education to include one focused on “structural competency, health equity, and social responsibility.”37 Castillo and colleagues argued that the current core competency of systems-based practice focuses on complex systems and physicians' roles within them but is “largely health care centric and does not train physicians to engage with the complexities of health or to partner with systems and communities that are outside health care.”37 The authors proposed that to address the health and social inequities in our society, graduate medical education must critically realign itself with structural change to address health inequity.

Our program evaluation responses indicated that a longer session was desirable, suggesting receptivity to longitudinal approaches to skill-building and ongoing education. In line with tenets of self-determination theory and adult learning models, a mix of learning approaches, such as journal clubs, book clubs, facilitated discussion and case reviews, and faculty role-modeling, should be incorporated and studied in future longitudinal curricula. Embedding such approaches could provide a safe and supportive learning environment, signaling to participants that there is an environmental-cultural change coupled with individual provider/practitioner change. Moreover, given the deeply entrenched nature of racism and racial tensions in our society, it is likely that longitudinal training curricula that incorporate observable behavior changes and skill attainments in the short- and long-term, rather than one-time sessions, are needed to maximize efficacy.28 Long-term provider behavioral change and competency will likely depend on ongoing work to enhance (1) participants' self-awareness to address implicit racial and ethnic biases; (2) understanding of the role of racism in child, adolescent, and adult health outcomes; and (3) skill-building to address racism at internalized and interpersonal levels with patients and families. All of these approaches should be further studied to understand which components are effective.

Future medical education research should also go well beyond presurveys/postsurveys to determine long-term impact on providers, as well as patients and families. As mentioned above, qualitative and quantitative work with patients and families would provide a family-centered approach to inform the development of future curricula. Feedback from families postintervention is another critical way to assess outcomes. In addition to family-centered approaches, efforts to increase the diversity of the health professions workforce to better reflect the diversity of the general population are needed. Various studies have found benefits for patients when there is concordance of race/ethnicity between patients and providers.38,39 The benefits of increasing workforce diversity, in particular by training and hiring providers from underrepresented racial and ethnic backgrounds, also extend to medical students and other physicians.38,40

It is also imperative to address racism at institutional and systemic levels across health care and medical education systems. We hope that our workshop to train health care professionals to inquire about racism with patients and families can serve as an entry point in the complex process of addressing racism at multiple levels in health care. By developing skills at an individualized level, we hope to empower health care professionals to view themselves as advocates, not only at a patient and family level but also more broadly as agents of change in society. Future educational strategies should include systems-level policy and advocacy training with multitiered approaches to address racism on manifold levels.

ACKNOWLEDGMENTS

The authors also thank Simon Abimosleh, BS, for assistance with literature review.

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Keywords:

race; racism; adverse childhood experience; medical education

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