When it comes to medical school orientation, students expect to meet equally anxious peers, hear a rundown of the curriculum, and get to know the professors and advisors who will guide them. However, that day will be a little different for first-year students at University of South Florida Morsani College of Medicine. "We are doing a poverty simulation as part of our orientation," reveals Shirley Smith, director of student diversity and enrichment at University of South Florida (USF). "Students will be placed into family units and experience a month in the life of a family on a limited, fixed income. They will see what it's like to try to make ends meet and just keep your family intact and housed."
The goal of this simulation is simple: to reveal the often-experienced social impediments to health, and in the process, teach these future doctors to care, in addition to cure.
A growing number of medical schools are intent on reducing the racial disparities by raising awareness of the social determinants of health: issues such as lack of transportation, food insecurity, housing, poverty, and isolation that play a critical role in a patient's life and ability to get care. "Doctors need to understand the medical consequences of social disparities, know how to address them, learn where they came from and how to change that," says Sarita Warrier, MD, interim associate dean for medical education at The Warren Alpert Medical School of Brown University. "Medical school is the perfect time to do it." The idea is to bake this concept into the curriculum rather than just offer a few electives.
Wake Forest School of Medicine implemented a health-equity curriculum for third-year students in 2018. Lessons on those social factors are embedded into all of the rotations such as surgery, internal medicine, and pediatrics. Students are also required to work with community-based organizations in Winston-Salem, NC. "It has been really impactful for the students because of the material they're able to see in real life," observes Nancy Marie Denizard-Thompson, MD, associate professor of internal medicine and program architect at Wake Forest School of Medicine. "The students are asking patients about their transportation, how they access their medical care or their food. That way, they know how to adjust a plan so that patients are really able to actualize the care that we provide."
These programs hope to give students a different perspective. If a patient is not following dietary advice, it could be because they live in a food desert and don't have access to healthier options. If they aren't taking their medication, it could be because they cannot afford it. Armed with this knowledge, a provider can direct them to other hospital services, like meeting with a social worker or enrolling in a program that can help them meet their needs.
Health statistics have long painted a bleak picture for patients of color. Black women are six times more likely to die during pregnancy and childbirth. Racial and ethnic minorities receive disparate treatment for chest pain, acute coronary events, stroke symptoms, and brain injuries during emergency room visits. They are more likely to die in the emergency room than white patients.
A deep-seated mistrust in the system has developed in certain communities. A 2020 poll conducted by the Kaiser Family Foundation on health and race revealed that 6 out of 10 Black adults said they don't trust doctors to do what is best for them. One in 5 say they have been treated unfairly because of race in the past year.
"Patients are constantly telling me they felt discriminated against," says Robin Collin, DO, an internist and pediatrician in Durham, NC. They talk of being disbelieved, denied tests, treatment, and pain medication.
A founding member of the Coalition to Advance Anti-Racism in Medicine (CAAM), Collin says biases are cemented early on in a doctor's career. "When I reflect on residency, you kind of just group individuals, basically, you stereotype," she reflects. "'This is how they talk' or 'This is where they're from.' There's this callousness that develops somewhat as a survival mechanism, to try to just get through. But it dehumanizes the person and it also dehumanizes you. We — physicians, nurses, and all allied health professionals — need better training in that regard."
These medical schools also encourage a great deal of self-reflection from students. Terrie Mendelson, MD, director of graduate medical education at Dignity Health, St. Mary's Medical Center, San Francisco, and associate professor of Medicine at University of California San Francisco (UCSF), notes that people often come to the table with their own set of biases and beliefs based on how they were raised. There are things even new students need to unlearn. "It's necessary to recognize your unconscious biases and consciously practice anti-racism, which is different than just wishing that you didn't have racist thoughts," she warns. "It is really important because it helps you recognize those little bits of it that are in your own brain, too. And that helps you understand where patients might see something that you wouldn't have realized they saw. And then you start seeing it happening to you and around you, too."
Old School vs New School
A decade ago, these issues were rarely, if ever, talked about in the classroom and at some universities, they still are not welcome discussions. "This generation of students is ready to have these discussions about the impact of racism in health care," notes Warrier, who helped implement the first version of the enhanced curriculum at Brown University in 2015.
"But many of the physicians who they work with, including in clinical settings, are not. We do spend time talking with students about ways they can handle that. I would say that remains one of our largest challenges."
Among the complaints are that it takes the focus away from actual treatment or requires too much time. That, however, couldn't be farther from the truth, encourages Denizard-Thompson. "It's one or two questions that really can be revealing. It might take a little bit more time on the front end, but I think it saves you so much more time long term."
For example, if a patient is constantly missing appointments, some doctors assume they are not making their care a priority. But what if they are absent because they don't have transportation or their job would not let them leave to make it on time. "We have the students ask a few of these questions early on, so that you get a better sense of the resources needed," explains Denizard-Thompson. "The more that you can build rapport with patients, that trust really goes a long way."
Why Change Now?
Even universities that were hesitant to make major course changes in the past have softened that stance in the last year. A big motivator? The protests following George Floyd's death and conversations about how COVID-19 disproportionately affected communities of color. "At home, people had a chance to slow down and see what was happening and what others have been saying has been occurring forever," says Smith of USF. "There is no way to deny its truth after seeing that horrific murder live. I think medical professionals really took the opportunity to push agendas we've been trying to push for a very long time."
"The health equity goal is to also diversify medicine," says Fatuma-Ayaan B. Rinderknecht, an MD candidate at UCSF. "We have developed a pipeline program with over 100 mentees who identify as underrepresented in medicine and pair them with a medical student mentor. We meet once a month and have seminars."
Naomi Nkinsi, a fourth-year medical student at the University of Washington School of Medicine and master's student at the University of Washington School of Public Health, decided to force the change she wanted to see. During class slide presentations, professors often showed dehumanizing images of Black patients, and white patients were shown smiling, happy, and well-to-do. While she admits it wasn't likely intentional, it reinforces stereotypes.
"There is a kind of inherent bias in the way they are looking for images," says Nkinsi, a member of the Institute for Healing and Justice, a student group fighting institutional racism in health care. "We were only ever depicted when they are talking about STIs, diabetes, or dying during childbirth. It's almost as though we don't exist in medicine outside of this context. So, it's not hard to imagine why people go out and practice medicine with so much bias. That's how we are being taught to practice it. The fact that professors and administrators don't see these issues until it's pointed out to them shows they were taught with the same bias."
It's too soon to quantify the impact of these social justice curriculums, but there is plenty of anecdotal evidence of the benefit. "Throughout the year, we try to do some reflection pieces with the students where they talk about their experience," explains Deepak Palakshappa, MD, assistant professor of general internal medicine and pediatrics at Wake Forest. "Oftentimes, you really hear very powerful messages from them. You know, seeing the same patient they saw in the emergency room at the soup kitchen they happen to be working at the following week. So you start to see that the 15-minute clinic visit is only a very small portion of a person's life."
It's a small start to what will eventually be an evolution in treatment outcomes. The students are now graduating medical school with not only greater awareness, but also a drive to make things right, professors say. "They are better able to be true patient advocates," Warrier says. "I am hopeful that they all think of reducing disparities in the populations that they serve as an important part of their jobs as physicians."
When Joel Bervell started medical school 3 years ago, he and his peers were struck by how medical schools inadvertently continue to promote racial bias. He found dermatology to be one of the most problematic areas. In certain classes, almost all of the examples of diseases were on white skin. Even common conditions can look very different on dark complexions, but how would a new doctor even know what to look for? So Bervell, a student at Washington State University's Elson S. Floyd College of Medicine, launched a series of videos titled "Racial Biases in Medicine," which showed how certain conditions appear on both light and dark skin. He also addresses everything from why sickle cell isn't just a "Black disease" to the cognitive bias the NFL employed when evaluating concussions of Black players.
He now has more than 190,000 TikTok followers, 45,000 devotees on Instagram, and his videos have received more than 15,000,000 impressions across social media. "I address how far medical school education must still go to incorporate an anti-racism curriculum," he adds. "Seeing the surprised responses from students, physicians, and the general public has been incredible."
Though, perhaps his proudest moment was learning that a viewer was inspired to get a mole checked out after watching one of his videos. It turned out to be cancerous. "So often in medical school, you learn all these disconnected facts and wonder if you'll ever have the chance to impact a patient's life with the knowledge. Knowing that the content and information that I've created is encouraging people to take health into their own hands and potentially saving lives has made me all the more confident that I'm in the right profession," Bervell says. "I wanted to be a part of the movement, I'm not just standing by and watching anymore, but really wanting to make change, wanting to educate," he adds.
Race and Diagnostic Tools
For over 100 years, race has been used to diagnose and treat certain conditions. However, the use of race as a diagnostic tool is often flawed and inaccurate. Here are the most problematic examples.
The VBAC Calculator
When trying to determine if a patient should consider a vaginal birth after a cesarean (VBAC), clinicians take into account several factors: age, height, weight, and delivery history. Until 2021, patients were also asked if they are Black or Hispanic, but research proved race is not a factor in predicting the success of a VBAC.
Kidney function is determined by four factors: age, gender, race (Black or not Black), and levels of creatinine — the waste that kidneys filter out of blood. This formula was created when experts presumed Black people had higher muscle mass, which would lead to high kidney function. Although researchers now say this assumption is flawed and dangerous, the eGFR is still widely used in most hospitals.
One of the most widely used tools in medicine, the pulse oximeter measures oxygen in the blood by shining a light through the finger. A recent study showed that it is three times more likely to give the wrong reading in patients with dark skin.
This century-old device to test lung function was once used to justify slavery. Inventor Samuel Cartwright claimed that Black people had weaker lungs so backbreaking work in the fields was essential to develop them. To this day, a race correction is still used when measuring the lung function of Black patients to account for supposedly shallower breaths.