by Ross E. McKinney, Norma Poll-Hunter and Lisa D. Howley
The following blog is an editorial found in the latest issue of American Journal of Bioethics. You can find it here: https://www.tandfonline.com/toc/uajb20/21/9?nav=tocList
Racism is a complex problem in the US that is institutionalized, personally mediated, and internalized (Jones 2000). Within medical education the recognition and response to structural racism is beginning to take shape in response to COVID-19 and recognition of the nature of anti-Black public acts. The verity of structural racism as a major cause of health-related disparities is clear, as is the need for a framework for understanding and informing medical education to address the problem. While a reasonable organizational goal is to diminish acts of racism through education, undergraduate medical education, the primary domain of the Association of American Medical Colleges (AAMC), is only one mechanism for beginning to address structural racism, and its role is somewhat limited. The physician-in-training needs to learn the art of understanding the individual with whom they are in a provider relationship, the context of that relationship, as well as the art of how to continue to stay informed and advance their knowledge, skills and behaviors in many domains, including diversity, equity, inclusion, and anti-racism.
Moving Away from Ahistorical Perspectives
In this issue of AJOB, Berger and Miller make the case that cultural competence is limited in value and ethnocentric (Berger and Miller 2021). Most of the article is spent illustrating how the Association of American Medical Colleges (AAMC), of which the authors of this editorial are all employees, and the Liaison Committee on Medical Education (LCME) (jointly managed by the AAMC and the American Medical Association) failed to address racism by focusing on cultural competence. The authors assert that medical educators have “tended to minimize core drivers of health disparities” and refer to a series of AAMC documents from 2005 to 2012. In the last 10 years, the AAMC and the broader medical education community have evolved from those positions (Acosta and Ackerman-Barger 2017), while acknowledging there is significant work ahead. Most of the article is, thus, beating a dead straw man, with AAMC work playing the role of straw man, and the fact that the cited documents no longer reflect the organization’s positions calls into question the significance of their arguments. Berger and Miller’s article should thus be viewed as an archival piece, documenting positions held by the AAMC in the first decade of the twenty-first Century. Their arguments regarding a path forward are stronger than their approach to history. However, we appreciate that recognizing history and building from it is critical to advancing equity, diversity and inclusion.
Promotion of Continuous Learning
As noted in their response to Berger and Miller, Ray and Davis highlight that the AAMC and academic health centers are products of US history and culture that is notable for acts of genocide, chattel slavery, and the continued presence of economic disparities (Ray and Davis 2021). The AAMC continues to learn, reflect and act to account for harms and to advance anti-racism, inclusion and equity. It seems worthwhile to note that many of the points Berger and Miller make are entirely consistent with current AAMC positions and initiatives. Our critique of their manuscript is not regarding their goals or forward looking strategies: rather that they use historical positions and seem to believe those positions reflect the present. All organizations evolve. A standard liberal position on the social constructs of race and racism 15 years ago would have focused on cultural competence. The absence of language then reflecting concerns about structural racism in medical education is almost as noteworthy as the absence of description of mRNA vaccines in the curriculum. Neither were current considerations in 2005.
The information that follows is intended to provide the reader with a snapshot of information on current standards and efforts to address health disparities, systemic racism and cultural humility within the academic medicine community. Unfortunately, space restrictions do not allow us to fully elaborate on the many efforts over the past decade. For more in depth information, we encourage the reader to visit the website located here: https://www.aamc.org/news-insights/racism-and-health.
Current Standards and National Efforts to Address Health Equity and anti-Racism
The current LCME standards regarding Cultural Competence and Health Care Disparities are provided below, although there are other standards that include elements relevant to diversity and equity (Liaison Committee of Medical Education 2021).
7.6. Cultural Competence and Health Care Disparities
The faculty of a medical school ensure that the medical curriculum provides opportunities for medical students to learn to recognize and appropriately address biases in themselves, in others, and in the health care delivery process. The medical curriculum includes content regarding the following:
- The diverse manner in which people perceive health and illness and respond to various symptoms, diseases, and treatments
- The basic principles of culturally competent health care
- Recognition of the impact of disparities in health care on all populations and potential methods to eliminate health care disparities
- The knowledge, skills, and core professional attributes needed to provide effective care in a multidimensional and diverse society
There are three central themes to LCME standard 7.6. First, students need to be aware of their own biases. Second, students need to understand that there are differences in health status at both an individual and a population level, and third, students need to understand that their patients may not perceive health-related issues in the same way that they, the students, do. Those differences may be due to cultural differences, but they may also reflect individual values and choices. Students need to work to understand their patients, their values, and the broader context of their patients’ lives and the health care context as thoroughly as possible.
The AAMC has and continues to approach issues related to equity and racism from many directions. For example, a national initiative was launched in 2019 to develop new cross-continuum competencies in diversity, equity and inclusion. These new competencies include anti-racism and support many of the critical points made by Berger and Miller. The AAMC’s 2020 Strategic Plan is strongly rooted in the principles of equity and justice and several actions are underway that, again, reflect current evidence and thought in this space. First, there is a focus on health equity and the important work of ensuring that schools of medicine and academic medical centers are community partners. Working to understand and foster this goal, the AAMC created a new Center for Health Justice where “achieving health justice means digging up the common roots of these injustices—including racism, classism, and misogyny—and making sure our policies are oriented toward equity.” (The AAMC Center for Health Justice 2021) In 2021, the AAMC community of medical education senior leaders also offered an extensive plan to eliminate systemic racism in medical education with numerous short and long term strategies and goals (Medical Education Senior Leaders 2021).
Necessity of Multidisciplinary and Multisector Perspectives
The commentaries in response to Berger and Miller, including this one, underscore that any one framework, including cultural competence, is insufficient to advance equity. For example, authors propose inclusion of techniques like structural competencies, trauma informed care, and intersectionality, but each in-and-of itself is insufficient. There are multiple frameworks and perspectives to be held in balance to fully understand and learn how to act on all forms of racism and exclusion in medical education. These responses demonstrate how critical it is to address the complexity of equity from multidisciplinary (e.g. history, ethics, anthropology, psychology, public health) and multi-sector perspectives (e.g. economy, environment, health care systems).
Another important aspect for addressing racism is increasing the diversity of the health care and academic medicine workforce. Berger and Miller do not mention it, but the under-representation of Black/African American, American Indian and Alaska Native, Hispanic/Latino, and Native Hawaiian and Other Pacific Islander communities has been a persistent problem (Acosta, Poll-Hunter, and Eliason 2017). Addressing systemic barriers, including racism, that permeate from as early as Pre-K through medical education has a renewed focus through the AAMC strategic plan. Again, we do not have the space to fully elaborate, but there are multiple efforts underway to increase and diversify our physician workforce. By doing so, we will be better positioned to advance equity and other systems based exclusionary practices. AAMC’s ultimate goal is to contribute to the ending of structural racism, or at the very least to minimize its effect on health outcomes. Roughly 80% of health outcomes are dependent on factors outside the healthcare system (environment, genetics, economic status, educational background, behaviors, food access, community) (Hood et al. 2016). Academic medical centers can make a difference in many of the domains outside medical care if they have the will and the willingness to work with their communities to advance equity (Association of American Medical Colleges 2018).
All three authors are employed by the Association of American Medical Colleges, Washington, DC. They have no other conflicts of interest to disclose.