#6 Anti-Racism in Medical Education

January 18, 2022 | By Molly Heublein

With Dr Consuelo H. Wilkins

Summary

Listen as our knowledgeable guest Dr Consuelo H. Wilkins @DrCHWilkins discusses antiracism in medicine, specifically at the interpersonal level- how to discuss this with your team and address aggressions- and at the broader level- how can we work toward systemic change.  Dr Wilkins stresses that this is a challenging and nuanced topic.  When considering initiatives, we need content experts leading the discussion, and a careful consideration of what goals are and how we can reach them- move past implicit bias training to embracing anti-racism.

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Credits

• Producers/writers/hosts: Era Kryzhanovskaya MD,  Molly Heublein MD
• Cover Art/Show Notes: Andrew DeLaat
• Guest: Consuelo H. Wilkins MD, MSCI

CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner/ Best piece of advice
• Picks of the Week
• Kashlak case 1
• Race as a social construct
• Structural racism
• Hiding behind the nobility of medicine
• Becoming an anti-racist
• Recruitment committees
• DEI training initiatives 
• Kashlak Case 2
• Training initiatives continued
• Beyond unconscious bias training
• Addressing aggressions
• Take home points
• Outro

Anti-Racism in Medical Education Pearls

1. Dr Wilkins’ highlights that this is a serious and in depth conversation that is challenging to fit in on rounds, but one place she likes to start is by asking learners when they first became aware of their race and race in general.  She points out that most of us were not specifically taught about race, but learned subconsciously.  It is challenging to unlearn something that we never purposely/consciously learned.
2. We need to acknowledge the racist history of medicine as part of the healing process and to let us move forward toward an antiracist approach to medicine. 
3. When considering DEI training initiatives: establish the problem, specific aims,  markers of success, and what is the best route to solve the problem- think right to left instead of left to right.
4. Anti-racism initiatives should also be led by those with expertise in this area and ideally by a team with members from different backgrounds. 
5. It is important to create a culture where it is expected to upstand and call out aggressions when they occur, ideally without putting the spotlight on the individual.

Anti-racism in medical education Notes

Race as a social construct 

Race is a social construct and we should be including patients’ race in the social history if it is clinically relevant. If a learner includes race in the initial part of a presentation (i.e. out of a social history), Dr Wilkins’ makes a point to ask why it is included (Finucane 2014).  She also stresses that we should be identifying patients by the race they identify with rather than assumptions.  

Awareness of structural racism may be important when considering a patient’s social history.  Dr Wilkins’ highlights that discussing race is a serious and in depth conversation that is challenging to fit in on rounds, but one place she likes to start is by asking learners when they first became aware of their race and race in general.  She points out that most of us were not specifically taught about race, but learned subconsciously.  It is challenging to unlearn something that we never purposely/consciously learned.  This can be a good starting point for highlighting inherent flaws in the perceptions of race and encouraging changing perceptions. Starting inward (self work) and then moving outward (institutions). 

We cannot hide behind the nobleness of medicine

Medicine has been part of the racist society that perpetuated disparities.  To quote from Dr Wilkins’ recent publication, “The nobleness of medicine and nursing has long provided a cover for health care professionals to distance themselves from racism”.   Being aware of the racist history of medicine can help us keep perspective on our current situation and future.   For example, Samuel Cartwright practiced medicine in the antebellum period and offered “scientific” support for ongoing slave oppression.   It is  important to recognize that we cannot be as objective as we intend to be when we are dependent on textbooks and cases to discuss and understand race when they are created by people who do not fully understand the experiences of marginalized and minoritized people.  Accepting these racist underpinnings is a way to heal and move forward.  (Paul 2020)

Becoming an anti-racist

Dr Wilkin’s pushes us to move away from a “non-racist” approach and instead push toward an anti-racist approach.   Treating all patients equally is not the goal.  We do not need equal treatment because there is a broad range of humans.  The goal instead should be health equity, helping people get to their optimal state by individualized care.   Acknowledge the richness in human variation.

Recruitment committees 

When considering increasing hiring or retention of underrepresented groups, it is important to look at the makeup of the committee and who is involved in the search.  Ideally we should include someone with expertise, knowledge, training, and experience of the challenges some of the candidates may have faced.  Consider what is the process for identifying and recruiting URM applicants?  Is the review process holistic? How are aspects of structural racism affecting particular candidates and the opportunities they may have access to? Be aware of avoiding the minority tax: while it may seem best to draw upon URM faculty to be part of these committees, we also need to avoid overburdening these faculty and avoid expecting that they have the time or passion to dedicate themselves to these initiatives.  

DEI training initiatives

When considering starting a project addressing health disparities, Dr. Wilkins stresses the point that the leaders of these should have content expertise (don’t just start something without having the expertise there) in this area and that gathering more perspectives using a team approach is best.  It is important to consider the specific goals and outcomes for these projects.  Establish the problem (what are you trying to solve?), specific aims, markers of success (improve patient satisfaction? Increase staff retention from URM groups? Create change in climate surveys?), and what is the best route to solve the problem- think right to left instead of left to right.  Iteration is important– be open to fixing a design if things are not working well.  Dr Wilkins sees enthusiastic people pushing forward to start these initiatives, and worries that if these are not done well they can perpetuate these complex biases and actually worsen the problem.

Unconscious bias training

Unconscious bias or implicit bias training has not shown significant changes in measurable outcomes, so this is the bare minimum (Hagiwara 2020).  It can only be a beginning, and to benefit requires self reflection and humility.  So in that way, implicit bias training likely only benefits those who need it the least, i.e. those already committed to introspection and change. The place where implicit bias training may have the most benefit (mitigate its impact) is in places like the emergency department that require on the spot decisions.  Dr Wilkins looks to the business literature to learn more about this, for example the Harvard Business Review (Dobbin and Kalev 2016).   Dr Wilkins recommends moving past implicit bias training to anti-racism training: how do we start to dismantle structures and policies that perpetuate racism.   

Addressing microaggressions

Dr Wilkins prefers the term “aggressions” over microaggressions.   When possible, acknowledge the aggression in the moment.  Acknowledge how these actions or words are offensive or inappropriate.  It is important to create a culture where it is expected to upstand and call out aggressions when they occur, ideally without putting the spotlight on the individual.  Highlight that our teams are expected to be treated with respect.  Sometimes in the moment it can be difficult to intervene, these are emotionally triggering and even with good preparation, we don’t always respond to these as well as we could. 

Consider having a conversation with a learner in advance to discuss how they would best like you to upstand for them.  Start the conversation early, “when an aggression occurs, how would you feel most supported by my words or actions?.” (Bullock 2021) 

Offering a debrief is important.  A learner may be ready to talk about a situation shortly after the event of the aggression, but they may not be yet (or ever).  We should leave it open to the learners’ needs. 

Dr. Wilkins Take Home Points

Think right to left- what are we doing in our work.  Ideas can sound great, but unless we are really considering our goals and how to measure success we may not be advancing.

We need to acknowledge the racist history of medicine as part of the healing process and to let us move forward toward an antiracist approach to medicine.  

Other Stuff

CitationsWilkins CH, Williams M, Kaur K, DeBaun MR. Academic Medicine’s Journey Toward Racial Equity Must Be Grounded in History: Recommendations for Becoming an Antiracist Academic Medical Center. Acad Med. 2021 Nov 1;96(11):1507-1512. doi: 10.1097/ACM.0000000000004374. PMID: 34432719; PMCID: PMC8542070.

Links

1. Dr Wilkins’ book recommendation Caste by Isabel Wilkerson 
2. Molly’s pick of the week: Era’s paper Factors Associated with a Career in Primary Care Medicine: Continuity Clinic Experience Matters published in Journal of General Internal Medicine.  
3. Era’s pick of the week: using an exercise ball as a chair. Dr. Wilkin’s chair/wobble example

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Goal

Listeners will become familiar with approaches to addressing antiracism in medicine as it relates to medical education and the pipeline of future providers. 

Learning objectives

After listening to this episode listeners will…  

1. Review models/examples educators taking steps to be anti-racist
2. Name one commitment they would like to make to help their local class, institution, or healthcare system become more anti-racist
3. Consider an approach to addressing aggressions in the learning space

Disclosures

Dr Wilkins eports no relevant financial disclosures. The Curbsiders Teach report no relevant financial disclosures. 

Citation

Wilkins C, Heublein M, Kryzhanovskaya E. “#6 Anti-Racism in Medical Education. The Curbsiders Teach Podcast. http://thecurbsiders.com/teach.  January 18, 2022.