Article In Brief
Neurology departments are incorporating greater awareness and training for trainees on health care disparities, sources of implicit bias, and social determinants of health. Here, they describe their curricula and future directions for training opportunities.
In the aftermath of the police killing of George Floyd and other high-profile cases as well as heightened demands to address systemic racism, neurology residency programs are taking a hard look at ways doctors can do their part by delivering more equitable care.
Residency programs from across the country are introducing both formal and informal curricula to train doctors to be more inclusive, culturally and racially humble and competent, and less prone to relying on implicit biases in treatment decision-making.
The COVID-19 pandemic, which disproportionately impacted Black, Indigenous, and Hispanic communities, has also added a sense of urgency to the need to educate upcoming neurologists not just about which populations of patients are particularly vulnerable to disease and poor outcomes, but how a doctor's biases and actions might put patients at risk for not getting the care they need.
“Black patients have worse stroke outcomes. Black patients are not receiving equal medical management for epilepsy or undergoing epilepsy surgery at the same rates as their White counterparts. The list goes on and on,” said Jason Chisholm, MD, a fourth-year chief academic neurology resident at the University of Kentucky, who helped implement the anti-racism and social justice in medicine curriculum, which was developed by faculty member, Ima M. Ebong, MD, assistant professor of neurology and the department's director of diversity and inclusion.
The monthly one-hour Zoom sessions revolve around curated and relevant journal articles, covering such topics as racial disparities in neurologic care access and utilization, dealing with racist patients (including ones who request a White doctor only), and barriers and facilitators of stroke recovery. Dr. Chisholm said that about 50 neurology faculty members, residents, and medical students have been attending these didactic sessions.
“We have to think about patients' backgrounds and how that can impact their care,” from whether they do follow-up appointments or whether they are given certain tests or therapies, he said.
“I think we have created a very safe space for people to talk about these things,” said Dr. Chisholm, who will soon begin a fellowship in epilepsy at Cleveland Clinic. “I think it is very important for me as a White male to better understand patient perspectives and what they are going through so that I can deliver optimum, equitable health care.”
The Training at Rush
Neurology residents have also taken a lead at Rush University in helping to introduce more learning about racial inequality.
“In neurology there is a long history of health disparities...[as it relates to care for] dementia, cognitive care, stroke, stroke recovery, migraine. There is a lot of inequity even among patients who do come and seek care with us,” said Pausha Pinna, DO, a third-year neurology resident who teamed up with fourth-year neurology resident David Walker, MD, to create a program that focuses on racism and inequality through the lens of medicine.
“It was really triggered after George Floyd's death and as Black Lives Matter became more prominent,” Dr. Pinna said. “We realized this was an under-addressed area of our education so far.”
The initiative includes a lecture by Starane A. Shepherd, MD, assistant professor of neurology and neurocritical care specialist at Rush, which provides a historical perspective on why the medical system has less credibility among Black and other underrepresented communities and how that concern could impact their care. The program, which was launched for residents and will be expanding to third-year medical students, also includes small-group discussion sessions that focus on the many facets of health disparities, including the role of implicit bias on the part of doctors, Dr. Pinna said.
“We've had a great response. I had a lot of students say, ‘I am glad we are talking about this,” or ‘Wow, I knew this disparity existed, but I didn't know how much,’” said Dr. Pinna, who hopes that the initiative becomes a regular part of neurology training at Rush.
The UCSF Curriculum
The neurology department at the University of California, San Francisco (UCSF) has had a formal diversity, equity and inclusion curriculum as part of its residency training program since 2015, though the events of the past year have made it seem more relevant than ever, said Nicole Rosendale, MD, assistant professor of neurology, who started the diversity program when she was a neurology resident.
“In my day-to-day care for patients and talks with my co-residents, I found certain aspects of clinical care involving underserved communities were not being addressed in the curriculum.” For instance, even at a large academic medical center like UCSF, situated in a city with a sizable LBGTQ+ population, there was not a lot of attention given to understanding LBGTQ+ identity and how that might impact the care of patients with neurologic conditions, she said.
In an article she coauthored for Neurology Clinical Practice in April, Dr. Rosendale noted that “recent events, including the deaths of George Floyd and Breonna Taylor, have brought renewed attention and galvanized a movement for racial justice throughout the country and in academic neurology.”
“Training in diversity, equity and inclusion is vital to providing culturally appropriate care. However, if we are not training our future clinicians to be culturally humble and responsive, how can we ensure that they deliver care in this manner?” the authors of the article said.
Dr. Rosendale and colleagues described lessons learned from implementing the UCSF program that could be helpful to other residency programs considering similar initiatives. Some of their suggestions: Training should be led by a multidisciplinary team with experienced educators; sustainability of the curriculum requires broad departmental buy-in from leadership to junior faculty to the residents themselves; the curriculum needs to balance training on fundamental topics with flexibility to change in response to current events and the needs of the community; and the sessions need to be practical.
The UCSF training program began as a series of six didactic sessions and has evolved into a coordinated curriculum of 12 topics that alternate every other year. The current curriculum ensures residents are trained in introductory topics, such as structural determinants of health and relationship-centered communication, as well as how to apply these skills in caring for specific populations, such as LGBTQ+ individuals and those experiencing homelessness, Dr. Rosendale said. The program strives to be fact- and evidence-based, drawing upon published research and data.
No matter the topic, “We always want to keep the focus on practicality,” Dr. Rosendale said. “How does this influence the dynamic? What can you do to change your practice to be more inclusive?”
University of Maryland's Curriculum
Camilo Gutierrez, MD, associate professor and vice chair for education in the department of neurology at the University of Maryland School of Medicine, said the neurology department has created a one-year non-clinical curriculum that includes topics such as implicit bias, microaggression and health literacy.
The curriculum, which will target neurology residents first and, depending on the response, then medical students, will be being offered once every one-and-a half years, he said.
Dr. Gutierrez said the attitude of “this is not my problem” that some doctors had when it came to issues around racial inequity has been replaced by “there is a lot we can do.”
“We really have a lot of impact on the quality of care based on race,” Dr. Gutierrez said, noting that process of change should begin with examining “our own biases.”
Dr. Gutierrez, who also is a diversity, equity and inclusion officer, said there is a review underway of all teaching materials and lectures to make sure they meet standards of equity and inclusion. He said, for example, that photos used in lectures about obesity might show only Black people eating fast food, which could give the impression that White people don't have weight problems or that they don't eat unhealthy food. He said having inclusive learning materials is also critical to understanding the full spectrum of disease, such as how a certain type of rash may look different on light skin compared to dark skin.
Dr. Gutierrez said he is a bit envious of how today's upcoming doctors are being taught that they need to look beyond their medical institutions. “They are being taught about the importance of understanding the community,” he said.
UPenn: Emphasis on Racial Disparities
Roy H. Hamilton, MD, MS, FAAN, associate professor of neurology and assistant dean for cultural affairs and diversity at University of Pennsylvania's Perelman School of Medicine, said neurology training would be lacking without an emphasis on racial disparities, especially since many neurologic conditions are more prevalent in minority communities. The neurology department at UPenn began to focus on diversity and inclusion in its training program in 2017, but the initiative is now seen as the core of everything the department does, from hiring to promoting staff to training students and residents.
Neurology residents at Penn participate in a separate monthly health equity lecture series, which addresses the topic of health disparities across various subspecialities in neurology. In addition, discussion of health disparities is integrated into every subspecialty lecture series and is therefore revisited many times in many contexts throughout their training, Dr. Hamilton said.
“I think it is important to recognize how much the disparities in care are the result of biases in physicians, and not just barriers to access,” Dr. Hamilton said. For instance, “there is an implicit bias that persons of color are less likely to comply with medications,” so they may not be offered treatments for neurologic and other disorders, he said.
Dr. Hamilton said that while not all medical students or residents may agree on what needs to be done to combat racism and social injustice in society, he doesn't worry that some may view these issues as political.
“I do not think it is a political statement to say that we hope for the best health and greatest quality of life for all of our patients,” he said.
Drs. Pinna and Chisholm had no disclosures. Dr. Rosendale receives personal compensation from the AAN for her role in the editorial board of Neurology. Dr. Hamilton has received payment for speaking as an expert on the topic of diversity in science and medicine for Alexion and Starfish Neuroscience.