Developing a Culture of Equity and Equality in Graduate Medical Education


 Author: Treven Cade

While certainly not beginning the discussion, nor finishing it, previously this year multiple leaders in the healthcare field addressed racial inequalities and inequities: equality being an equal distribution to all individuals, while equity is the distribution that best fits an individual’s needs (“Equity vs Equality''). These prominent figures include the President of the ACGME, Dr. Thomas Nasca, and the CEO of the AAMC, and the board chairs, David Skorton and Joseph Kerschner respectively). Nasca discussed that these dilemmas concern both medical education and the clinical workforce, while also mentioning the decade-old problem of the underrepresentation of Black Americans in the healthcare field. In fact, Black Americans, both men, and women combined, represent 5% of all physicians in America. The latter healthcare leaders emphasized supporting medical students by listening to their perspectives and embracing community collaboration as an additional mission for healthcare facilities - the others being medical education, clinical care, and research (Boyle). Both organizations, while proposing varying solutions, were concerned with future minority representation in medicine.

Skorton noted that progress has been made, mainly by referencing the recent name change of the Abraham Flexner Award, noting Flexner’s outdated ideas concerning racism and sexism; however, one can indeed argue this to be a performative measure, supported by the fact it does not relate to his colleague’s potential solution of community collaboration. More substantively, Kerschner adds that well-being, student debt, transitions to residencies, and increased diversity are tangible ways in which to address racial issues in healthcare. As these leaders are urging hospitals and education institutions to embrace equity and equality while offering non-substantive performative measures and potential frameworks to success, how are these ideas circulating in the actual healthcare industry?

Before inquiring into multiple journals, articles, and opinion pieces that address these concerns, it is necessary to discuss the responsibility medical journals have in regard to discussing and solving racial discrimination and the like. The JAMA discusses this concept precisely, as the journal believed that, “racism has received comparatively little attention in research published in medical journals” (Ogedegbe). Gbenga Ogedegbe, the author, breaks down the importance of medical journals in three parts: 1) journals are the prominent way in which emerging issues are discussed, 2) journals provide multiple ways in which to advance one’s career, and 3) journals, through their circulation of research, have turned medicine into evidence-based practice. Along with these components of a journal, creative ways can be found to address racial issues or any medical dilemma. For example, “JAMA Network Open is calling for papers devoted to the issues of structural racism and its manifestation in health care delivery, academic advancement, medical education, and training” (Ogedegbe). In regard to this essay, the journal’s task of discussing emerging ideas and their focus on evidence-based practice will be the primary concern. Although using journals in innovative ways could very well provide means to advance one’s career when done correctly. As of recently, the problems brought about by racism and discrimination in healthcare have increased, which enhances the discussion on how these issues can be addressed.

Racism permeates healthcare in multiple ways. For example, one could discuss how minority groups are disproportionately affected by ailments and their access to healthcare, or one could focus upon the lack of racially diverse medical staff. In other words, racism in healthcare can affect both patients and the operations of medical facilities. Beginning with racial inequalities with minority patients, these persons experience a number of higher risks. In regard to Black Americans, they experience lower life expectancy, higher blood pressure, have lower vaccination rates, and as well as racism’s effect on mental health. Many ordinary facets of medical care, such as, “[p]ain treatment, Emergency care, pregnancy, chronic illnesses, and mental health dilemmas,” are riddled with racial disparities (Rees). These dilemmas could be the result of many factors; however, “economic disparities between racial groups make it more difficult for some to get health insurance, preventing people from getting medical care . . . In 2014, around 20% of Black adults could not access health insurance compared to 10% in white and Asian adults.” (Rees). However, and as stated previously, discrimination against patients is only half of the problem, the other being discrimination amongst medical workers.

Minority medical workers and students are underrepresented in medical education and practice. A study done by Urban Health Today found that out of 134,000 surgeon applicants, only 15%, or 21,000, were a part of an underrepresented group in medicine, which includes all minority groups (D’Onofrio). This number, the author states, remained stagnant over a period of eight years. While this data does not extend to medical school applicants, it can be said that this is a result of lower medical school applications as well, as the same individuals would go from medical school to specialty care. With this in mind, “’[t]hese findings support the claim that underrepresentation of racial/ethnic minorities is a broader issue that extends beyond surgery, starting from entry into medical school and beyond residency’” (D’Onofrio). The authors suggest funding for programs focused on diversity for medical school and specialty residencies. 

In a separate article, also discussing minority underrepresentation in medicine, three Black American doctors (Antwione Haywood, Nathan Delafield, and David Wilkes) give their suggestions for dissolving this racial gap. To provide initial background, these suggestions are instigated from the fact that Black men represent 3% of all physicians (and a similar number can be found for Black women). Beginning with these recommendations, Haywood notes that there is much more to potential applicants than test scores and the like and that it is disingenuous to view them as numbers or statistics, calling these “unmeasured forms of capital” (Weiner). Along with this, Haywood adds that Black men in medicine add a unique sense of adaptability and perseverance. To harness an individual’s full potential, Haywood recommends that medical schools and institutions ought support the mental and financial health of their students or workers. In regard to minorities in medicine, this would work to make a safe space to discuss financial and other areas of concern. 

Similarly, Delafield adds that Black men in medicine represent resilience, as they, “[have] overcome systemic racism and unequal educational opportunities, among other challenges” (Weiner). Delafield seems to suggest that medical workers should give back to their own community, as he leads by his own example: “‘I serve in a medically disadvantaged community where I can serve as an example to my community members, to [those] who struggle with the same obstacles that I had as a young child’” (Weiner). He proposes medical workers to ask what they have done for student advocacy and diversity. This could specifically assist minority groups in medicine if similar-experienced-people are there to help them along with their medical school or work experience; however, since minority groups are already underrepresented, finding people of that group to also advocate for others may be challenging. Lastly, Wilkes proposes the normalization of no. As medical workers are stereotypically busy, learning to say no is a skill in itself and could prove beneficial: “[a]ll of you listening today, particularly if you’re a person of color, are being asked to do so many different things that can spread you very thin” and undermine your chances of advancement, he cautioned” (Weiner). These three healthcare workers all provide unique perspectives and solutions that would each benefit minority students and healthcare workers in varying ways.

Investigative journalist and founder of the New York Times Magazine’s 1619 Project, Nikole Hannah-Jones, recently spoke at an AAMC meeting to discuss systematic racism in healthcare. She, also, emphasized the lack of representation of minorities in medicine. Her proposed solutions to lessening this systematic racism include an enhanced K-12 education that provides equal opportunities to students of color. In regard to graduate experiences Ibram Kendi, an associate of Hannah-Jones and author of his own right, states, “[o]ne of the first steps in that process is to collect detailed demographic data on who is applying, being accepted to, and graduating from medical school . . . This information can help leaders know where they might be falling short of their professed commitment to diversity and what policies they can change to correct the problems” (Balch). The utilization of this data could also help prospective minority students choose an academic path, as “Hannah-Jones found that historically Black colleges and universities (HBCUs) were more successful at sending Black students on to graduate from medical schools than historically White colleges, including Ivy League institutions” (Balch). Increasing the number of minority students in medical education would surely, given time, increase minority representation in medicine.

Racial discrepancies could also be addressed indirectly, or by programs not specifically tailored to race. One such example is a Californian initiative that aims to build residency programs in areas where they simply do not exist: “[t]he program office is seeking hospitals that don’t now have residency programs, encouraging them to start one, and providing resources including small ‘feasibility grants’ that enable hospitals to explore their options” (Waters). These new residencies while not exclusive to minority groups will nonetheless provide opportunities for all applicable individuals. Likewise, if these residencies are constructed in areas where no such programs have existed, it would inevitably lead to some increase in medical diversification. Initiatives such as these will most likely become more popular in the near future as they have the capability to address racial inequality and the ongoing physician shortage in America, which is arguably healthcare’s greatest existential threat in our country.

Racial Discrimination, and the disadvantages it brings about, have become a new focus for an increasing number of medical institutions. These new practices and ways of thinking have been discussed in numerous medical journals and are continuing to be circulated. These issues have primarily been brought about by the underrepresentation of Black Americans in healthcare, and they will likely not cease until that issue is addressed. This essay has addressed the numerous ways in which this underrepresentation can begin to be addressed. All facets of healthcare, from education to the workforce, will likely have to undergo multiple different practices, as this issue cannot be addressed simply or by a single institution.

Sources
Balch, Bridget. “Curing Health Care of Racism: Nikole Hannah-Jones and Ibram X. Kendi, Ph.D., Call on Institutions to Foster Change.” AAMC. November 17, 2020,
https://www.aamc.org/news-insights/curing-health-care-racism-nikole-hannah-jones-and-ibram-x-kendi-phd-call-institutions-foster-change.

Boyle, Patrick. “AAMC Leaders Challenge Academic Medicine: Do More, Right Now, to Help the Nation Heal.” AAMC. November 17, 2020. https://www.aamc.org/news-insights/aamc-leaders-challenge-academic-medicine-do-more-right-now-help-nation-heal.

D’Onofrio, Kaitlyn. “Racial diversity is Still Lacking Among Prospective and Current Students in Surgery Programs.” Urban Health Today. November 3, 2020, https://www.docwirenews.com/urban-health-today/urban-health-picks/racial-diversity-is-still-lacking-among-prospective-and-current-students-in-surgery-programs/.

“Equity vs Equality.” Northwestern Health Unit. https://www.nwhu.on.ca/ourservices/Pages/Equity-vs-Equality.aspx.

Nasca, Thomas. “A Message from Dr. Thomas J. Nasca.” ACGME. June 5, 2020,  https://www.acgme.org/Newsroom/Newsroom-Details/ArticleID/10299/A-Message-from-Dr-Thomas-J-Nasca.

Ogedegbe, Gbenga. “Responsibility of Medical Journals in Addressing Racism in Healthcare.” JAMA Network. August 20, 2020, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2769567.

Rees, Mathieu. “Racism in Healthcare: What You Need to Know.” Reviewed by Alana Biggers. Medical News Today. September 16, 2020. https://www.medicalnewstoday.com/articles/racism-in-healthcare#emergency-care.

Waters, Rob. “Project Aims to Treat Doctor Shortage, Lack of Diversity with New Medical Residencies.” CHCF. October 16, 2020, 
https://www.chcf.org/blog/project-aims-treat-doctor-shortage-lack-diversity-new-medical-residencies/.

Weiner, Stacy. “Black Men Make Up Less than 3% of Physicians. That Requires Immediate Action, Say Leaders in Academic Medicine.” AAMC. November 23, 2020,
https://www.aamc.org/news-insights/black-men-make-less-3-physicians-requires-immediate-action-say-leaders-academic-medicine.

 

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