by Rachel Fabi, PhD, Vivian V. Altiery De Jesús, MBE, and Liz Stokes, JD, MA, RN
In this series we ask bioethicists to respond to a question that embodies current challenges for bioethics, medicine, or health care. In this blog, three bioethicists were asked to share their thoughts on “How can medical and nursing schools prepare students to respond to the social and racial inequities created and worsened by the COVID-19 pandemic?” Here are their responses:
Rachel Fabi, PhD
As an educator in a medical school who teaches a course on physicians and social responsibility, I have seen a dramatic rise in student interest in advocacy for structural changes, especially in response to the COVID-19 pandemic and the racial reckoning that accompanied it. Although the American Medical Association (AMA) urges physicians to “advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being,” the accreditation standards of medical schools do not require training on how to advocate for change. Notably, the same is not true of nursing standards, which do include advocacy. Many students who want to address social inequities often don’t know where to start, and may either become overwhelmed and give up, or try to create structural change from scratch without knowing how to do so effectively. I join the chorus of voices calling for health professions programs to require the teaching of advocacy skills in response to social and racial inequities.
The advice I offer my students, and which I believe can benefit all students seeking to address social and racial inequity, is not to reinvent the wheel. Rather, we should teach students how to find partners already working in the spaces they care about and offer them their time and expertise. Medical/nursing students are uniquely positioned to observe the health effects of inequity on patients, and to understand how structures contribute to these inequities, but they often do not have deep roots in the communities they serve, and may not know the exact nature of the problem in their specific community. By partnering with and learning from organizations and individuals who know the problem, preferably organizations by and for the population they serve, health professions students can contribute to advocacy efforts more effectively. Personal stories are often the most compelling evidence that policymakers can hear—bringing clinical knowledge together with community experiences to bear on structural issues can be a powerful way to effect real, lasting change. Critically, it should not be left up to individual students to learn how to form community partnerships in pursuit of advocacy. Curricula should incorporate community-based learning with partner organizations that can teach concrete advocacy skills and make use of the clinical insights our students can provide.
COVID-19’s disruption of an already unjust system creates an obligation for academic medical centers to forge and maintain community partnerships to fill the gaps. With the right partnerships and training, medical and nursing students can and must learn to confront structural injustice head-on.
Thank you to Caitlin Nye, MSN, RN, NPD-BC, CHSE, for her sharing her expertise and thoughtful comments on this blog post.
Vivian V. Altiery De Jesús, MBE
As a fourth-year medical student (MS4) and bioethicist I have experienced the challenges the COVID-19 pandemic has caused in medical education. It was Déjà vu. As a third-year medical student (MS3) in 2017, Hurricane María devastated Puerto Rico. The ethical challenges and concerns were similar. Disasters, such as natural phenomena or pandemics, worsen racial and social inequities. But how can medical schools prepare students to respond to the inequity crisis caused by disasters?
Introducing epistemic injustice, when patients’ narratives are not equally believed, can help in at least two ways. The first is to directly address racial and social inequities. The second is to contribute to the professional identity formation (PIF) of medical students. Dr. Hedy Wald, defines PIF as a dynamic and complex internalization of the medical professional values. The PIF process, however, is not easily identified by trainees. Hence, having the risk of constructing a negative PIF; which in turn would create physicians who engage in social and racial inequities.
There are many interventions that facilitate PIF and I believe that ethics and humanism are excellent venues. Addressing social and racial inequities is fundamental for the patient, society, and the medical professional. If epistemic injustice is taught throughout medical school, then medical students will have a tool against social and racial inequities. This would mitigate health discrimination and positively impact medical students’ PIF. But what is epistemic injustice and how can it help physicians improve healthcare outcomes?
Epistemic injustice occurs when “patients’ testimonies are often dismissed as irrelevant, confused, too emotional, unhelpful or time consuming”. This occurs due to healthcare provider prejudice. An example is the higher risk of suboptimal pain management in Latinx and African American populations. I remember as an MS3 when my resident said, “This is a drug-seeking behavior patient”. The patient’s narrative was dismissed as “drug-seeking” even before the introductions. His healthcare outcome was worsened from the very beginning. At that time, I was not aware of epistemic injustice nor aware of its consequences.
Without explicit guidance, there is a higher risk for medical students to repeat such behavior. Having a mentor during my Master of Bioethics that discussed about epistemic injustice after clinical cases helped me link topics such as bias, stigma, and discrimination. It allowed me to materialize those “abstract” terms and think about the consequences. I believe that teaching students epistemic injustice since first-year and then actively engaging with the concept during clinical years, will provide the students and society many benefits.
First, epistemic injustice creates awareness in the trainee. Second, awareness and mitigation will enhance patients’ health outcomes by protecting them from the harms caused by inequities. Third, awareness of epistemic injustice positively impacts medical students’ PIF. Serving as a potential teaching resource where abstracts concepts can be linked with real life scenarios. Lastly, this will not only mitigate inequities and healthcare discrimination during COVID-19 pandemic, but also, during non-pandemic times. Preparing medical students to respond inequities, is preparing the future healthcare work force to mitigate a pandemic within a pandemic.
Liz Stokes, JD, MA, RN
Nursing has mastered the art of developing exquisitely skilled nurses; rising to the challenge of this current COVID-19 pandemic and responding with courage and conviction. Yet, a “good” nurse is not just skilled but is also ethical and moral. Nurses commit to a contract with society to provide care, regardless of sociodemographics. A good nurse delivers care without bias, prejudice, or judgment. However, many nursing schools have failed to address the perpetuation of racism, hatred, and bigotry in our health system with their students and graduates.
It is a lofty and perhaps unrealistic goal for schools of nursing to produce only antiracist nurses; racist beliefs and behaviors develop long before college. Ideally, students should enter prelicensure programs with the foundational knowledge modeled by other countries that begins teaching ethical principles of health in secondary education. Schools of nursing should teach about systemic racism, health disparities, and the historical exploitation of people of color (POC), yet we cannot expect that these classes alone will “fix” racist behavior. Because moral behavior is shaped by experience, nursing students must have exposure to inclusive clinical experiences that reshape preconceived beliefs before entering the profession.
A colleague recently shared that she was that racist nurse when she began her nursing career 40 years ago. She was raised to believe that racism was acceptable. Bigotry was ingrained in her moral being and as a nurse, she discriminated against Black patients. Years of experience caring for patients of color had to pass for her to reshape her moral character. She reckoned with her prejudiced and racist behavior. Today, she runs a private clinic catering to the needs of POC and undocumented women, and she advocates for the eradication of racism and disparate care.
Years of research chronicles how racism leads to discrimination in health care. COVID-19 confirms this as we see disproportionately tragic effects on communities of color. Great emphasis is placed on teaching the hard sciences, which are of course essential to competent practice. Yet, schools of nursing cannot sacrifice teaching the social and behavioral sciences, especially during a time when rationing and allocation of resources are at the forefront of health care decisions.Nursing schools must be unique and innovative in their approaches to tackle racism. The University of Washington Schools of Nursing leads the way with the creation of their Center for Antiracism in Nursing, designed to support underrepresented students, promote inclusivity, and conduct research to combat racism in health care. Schools of Nursing must aggressively work to diversify their student and faculty populations, and through cultural humility, foster a safe and inclusive environment. Nursing schools must also remind alumni to reaffirm their social missions in nursing. Every clinician must be an advocate for change. Accountability requires acknowledging the racist behavior of others or even oneself and having uncomfortable conversations. Everyone must commit to intolerance at all levels: from the provost, the nursing student applicants, and everyone in between.