The Medical School Tackling 'Inherently Racist' Training

Siobhan Harris

Disclosures

September 04, 2020

The University of Bristol Medical School says the way doctors are trained is 'inherently racist'.

It's making changes to its curriculum to make sure teaching encompasses clinical signs on black and brown skin rather than just focusing on presentations on white skin.

Dr Joseph Hartland is helping to lead the antiracism task force together with his co-chair Dr Kathreena Kurian.

Dr Kathreena Kurian

It comes after students, led by fourth year medic Eva Larkai, pushed for reform. They believed their training didn't properly prepare them for treating Black, Asian and Minority Ethnic people, which could compromise the safety of patients.

The General Medical Council is taking this on board.

Prof Colin Melville, medical director and director of education and standards at the GMC said: "We will work with the UK's medical schools on guidance that includes ethnically diverse examples of case presentations in their curricula. It's important that we continue to listen and act to make sure diversity is properly represented in all aspects of medical teaching and learning."

Medscape UK caught up with Eva Larkai and Dr Joseph Hartland to ask them about the antiracism initiative.

Q&A

Why did you feel reform was needed?

Eva Larkai

Eva Larkai: The racism that exists in medicine and the lack of diversity in our medical education has impacts that can be felt across the healthcare sector; affecting medical students, doctors, and crucially, the healthcare experiences of Black, Asian and other Ethnic Minority patients.

For example, we know that the presentation of important clinical signs and conditions differs across ethnic groups, and we also know that unconscious racial bias has led to adverse health outcomes in Black, Asian and other Ethnic Minority groups.

For me, most concerning is the generation of doctors who are not being trained to care adequately and holistically for the multiethnic population in the UK, and across the world. If our medical education does not address these issues, then health inequalities will inevitably remain, or widen.

For years, students like myself have campaigned to push for a more inclusive medical school curriculum but we felt that things have remained slow to change. I set up the Black, Asian and Minority Ethnic (BAME) medical student group at my medical school, and co-founded the organisation 'BME Medics' to work collaboratively with students, staff and other organisations to push for long-term institutional culture change. Most recently, I orchestrated a response with other students to demand specific actions are taken to strengthen the work our medical school had started in their attempts to foster an antiracist environment and implement curriculum reform.

What prompted the changes at the University of Bristol Medical School?

Dr Joseph Hartland

Dr Joseph Hartland: Over the summer we issued a statement that as a medical school we were taking an antiracist approach to tackling racism within medicine, and part of this was our intention to decolonise our undergraduate curriculum. Subsequently our BAME medical student group wrote a letter to the school with a series of demands for adjustments they wished to see to bring this about. Since then we have worked in partnership with our students to implement changes that we believe will create a medical curriculum which is both fair and representative of Black, Asian, and Minority Ethnic people in the UK.

We believe these changes are necessary because nearly all current medical education focuses predominately on the manifestation of clinical signs and disease in White patients. This is connected to societal forms of racism that have dictated the content of medical textbooks, medical education, and medical leadership for a very long time. At the University of Bristol we want not only to change our curriculum to more adequately reflect the diverse population of the UK but to also examine the underlying culture that has, for example, created the absence of darker skin in clinical teaching.

It has long been identified that patients from BAME backgrounds have significant health inequalities, and that the causes of these are complex. We believe it is vital for patient safety that our graduating medical students are confident in their diagnosis and management of patients no matter their ethnic background.

What actual changes can be made by the medical school to help tackle this inherent racism?

Eva Larkai: It is difficult to overlook the fact that White people and white skin have been central to our medical education. We are simply asking that our medical curriculum is inclusive of all groups, including those from Black, Asian or other ethnic backgrounds who often seem to be improperly considered or an afterthought. If not, the health and social needs of these groups will not be adequately met.

The work to 'decolonise' or tackle inherent racism in medical education won't occur overnight, but requires a deliberate and continuous commitment. In my opinion, there are some important places to start. I think there needs to be greater research efforts to better understand the relationship between race and existing health inequalities, to ensure that high-quality evidence forms the basis of the actions that are taken for curriculum and healthcare reform. I also think that attempts make the curriculum more inclusive, shouldn't be an 'add-on agenda', but integrated throughout our medical education. For example, greater inclusion of individuals from various ethnic backgrounds and their differing health and social needs in lecture materials, vignettes for clinical case presentations and our medical school clinical exams. I also think our medical education should provide opportunities to explore and reflect upon unconscious racial biases, particularly how this may impact upon clinical judgement.  As an aside, I think there should be a concerted effort to support Black, Asian and other Ethnic Minority students who have experienced racial harassment from peers and patients. Research has shown that many medical schools don't have systems set up for students to report these incidents and access relevant support.

Importantly, the weight of this work should not fall solely on BAME students and professionals. Advocating for these issues on top of educational and clinical demands, and in addition to the marginalisation and discrimination that many have reported, can be taxing. All of our medical educators and programme directors must share the importance of these issues, and need to be willing to put in the work to source the necessary resources, funding, and expertise to implement the necessary changes.

Dr Joseph Hartland: We are implementing many different changes to our curriculum, from the teaching of clinical signs to discussions around the history of race in medicine.

Key changes we have identified include:

  • Improving the representation of darker skin in our dermatology teaching and in the teaching of clinical signs. Examples that may be connected to medical emergencies include the different presentation of cyanosis in patients with white skin and patients with black skin, and how to identify erythema in patients with dark skin

  • Training on spotting unconscious bias and helping students and staff more confidently report and act on racism

  • Improving diverse and authentic representation in our case-based learning

  • Focusing on areas of clear health inequality and exploring the causes – for example, the increased levels of maternal mortality in Black women

Which particular conditions and diseases don't tend to take into account the different presentations with black and brown skin?

Dr Joseph Hartland: A key example of this is images associated with a meningitis rash. A simple Google search will demonstrate that most images within textbooks and the public domain focus on the presentation of this rash in white skin. Parents, patients, students, and health professionals are all very likely to have some idea how to identify this life-threatening clinical sign in White patients, and yet far fewer of them will be confident in diagnosing this in a patient with darker skin, where it can be much harder to see. Another example is that of cyanosis, which is often described as a blue discolouration of the lips in White patients. This can be much harder to see in dark skin and may manifest as dusky or grey discolouration, much easier to spot in the oral mucous membranes.

Eva Larkai: This is a challenging question as there are far too many conditions to name. For example, almost every skin condition appears differently on darker skin tones, from more common conditions such as eczema, to rashes associated with infectious or autoimmune diseases and skin cancers. Clinical signs such as paleness and red and inflamed skin will also appear differently. But aside from visual signs and dermatological conditions that affect the skin specifically, there are also conditions that are more prevalent in Ethnic Minority communities, such as sickle cell disease, type 2 diabetes and cardiovascular diseases.

There are also stark health disparities seen in mental health and child and maternal health. For example, studies have indicated that the maternal mortality rate is five times higher in Black women compared with their White counterparts, and a recent study in the US shows that Black newborn babies are three times more likely to die if cared for by White doctors.

I've named just a few examples, but it is clear that there are issues that must be addressed across specialities and the healthcare sector at large.

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