In recognition and celebration of Black History Month and this year’s theme of Black Health and Wellness, and in continuing with our year-long series diving into some of the recommendations and action steps emanating from the 2021 Macy Conference on COVID-19 and its impact on medical and nursing education, this February Macy Notes blog post features an interview I recently conducted with Dowin Boatright, MD, MBA, MHS, and Nientara Anderson, MD, MHS. Dr. Boatright, Assistant Professor of Emergency Medicine and Officer for Diversity and Inclusion in the Department of Emergency Medicine at Yale University School of Medicine, and Dr. Anderson, a second-year resident in the Department of Psychiatry at the Yale University School of Medicine, have both practical and scholarly interests in promoting equity and countering racism in the learning environment. During our interview, I asked Dr. Boatright and Dr. Anderson to reflect upon action step 1.4 from the conference recommendations (included in its entirety below) and how it might begin to address some of the issues and problems related to Black Health and Wellness.
Action Step 1.4. Health system and HPE (health professions education) leaders and educators must collaborate with learners on educational program direction, working in partnership to evaluate existing policies for bias; implement equitable recruitment policies and practices; foster retention of a diverse student body; develop unbiased and flexible advancement policies; design and evaluate bias-free curricula and assessment; and develop community engagement initiatives.
Holly J. Humphrey (HH): A year ago this January, Journal of General Internal Medicine published a piece that you authored: “A Roadmap for Diversity in Medicine During the Age of COVID-19 and George Floyd.” Can you reflect upon this last year and share your thoughts related to the recommendations that you and your co-authors proposed in this piece?
Dowin Boatright and Nientara Anderson (DB and NA): When we wrote “A Roadmap for Diversity in Medicine” we laid out concrete steps that academic medical centers can take to demonstrate their commitment to anti-racism. Most of our recommendations are related to transparency, investment of resources, and re-examining institutional conventions and processes that we now know are sources of racial bias in medicine.
Institutions must begin by unearthing and acknowledging specific institutional histories of racism. The recent efforts by Johns Hopkins to honor the legacy of Henrietta Lacks is one example. Acknowledging the impact of racism in medicine can be done even in small changes. For example, rather than using the expression “Underrepresented in Medicine” or URiM, the terms “Historically Excluded from Medicine” or “Historically Marginalized in Medicine” are more historically accurate descriptors of how racism has affected the demographics of today’s physician workforce.
Academic medical centers must also continue to collect data about their current clinical outcomes and be transparent about any health inequities they find and how they will address them. COVID-19 has brought the issue of racial health disparities into new focus and individual institutions must examine how they contribute to these disparities. Health equity dashboards are one emerging tool for hospitals to examine and address health and healthcare inequities.
Dedicated funding and staffing for diversity and inclusion must be identified and protected. Guaranteed funding for Chief Diversity Officers and intra-institutional minority organizations ensures not only the quality of their initiatives but grants DEI officers the financial independence to implement policies and programs that can challenge dominant institutional values when necessary.
Academic medical institutions must invest time and resources into cultivating a diverse healthcare workforce by establishing longitudinal pathway programs, reforming admissions, and providing supportive environments for minority trainees and faculty. This will require building partnerships with local schools, activating alumni networks of mentors, and providing financial aid to students enrolled in pipeline programs.
We outlined several other suggestions for actionable changes to medical admissions in our paper “Blackface in White Space: Using Admissions to Address Racism in Medical Education.” In order to support minoritized trainees and faculty, the culture of racial exclusion, microaggressions, and discrimination in medicine must be addressed. These efforts may even include re-thinking the physical environment in medical institutions.
Finally, future physicians should have a sophisticated understanding of how racism has impacted and continues to shape both the medical system and the lives of their patients of color. Therefore, education on race, racism, and social determinants of health must not be treated as peripheral to the core content of medical education.
HH: This year’s Black History Month focuses on the theme of “Black Health and Wellness” and the ways in which American healthcare has often underserved the Black community. How can action step 1.4 from the 2021 Macy Conference address some of the issues and problems that are related to this theme?
DB and NA: Fundamentally, action step 1.4 involves creating a learning environment in health professions education where all individuals are welcome and can thrive regardless of their backgrounds or identities. This environment will catalyze the recruitment and retention of diverse individuals, and we know that a diverse biomedical workforce will benefit not just Black patients but all patients.
The ‘diversity dividend’ in medicine and science is well documented. Diverse research teams produce better science, publish in higher impact journals, and are cited more often than investigative teams that are homogenous in terms of gender and ethnicity. Diverse research teams also produce more innovative work. Increasing the diversity of the biomedical workforce may better align the national biomedical research agenda with the needs of the population.
We also see a benefit to a diverse workforce in terms of patient care. Physician workforce diversity has been associated with increased patient satisfaction and patient self-reports of higher quality care. Additionally, the influence of physicians of color on expanding healthcare access in this country is well described.
Furthermore, a diverse and inclusive learning environment enhances the quality of the educational experience, for all students. A racially/ethnically diverse student body engenders a more robust learning environment that results in more thoughtful, open-minded, and humanistic healthcare providers. Medical students report that student body racial/ethnic diversity results in greater exposure to alternative points of view, enhanced classroom discussions, and an improved overall educational experience, as well as higher levels of cultural competency and egalitarian attitudes to access to health care.
HH: In 2020, you received a funding from the Macy Foundation for your project “The Promoting Diversity, Group Inclusion, and Equity (ProDiGIE) Study in Medical Education.” What was the impetus and what were the factors that led you to focus on these issues? Can you describe how this study’s results can be used to assess the climate of diversity, equity, and inclusion in medical schools?
DB and NA: Our research group had recently completed a study examining changes in the diversity of medical students after the Liaison Committee on Medical Education (LCME) introduced its diversity accreditation standards. We found statistically significant gains in the percentage of Black, Hispanic, and all female students after the diversity standards were introduced. Despite these gains in matriculant diversity, we were concerned that the climate of equity and inclusion in medical school was underappreciated and understudied.
When we reviewed data from the Association of American Medical Colleges (AAMC), we found that students of color were significantly more likely than their White peers to report both general mistreatment and discrimination. Additionally, we have consistently demonstrated inequity in Alpha Omega Alpha honor society membership by race/ethnicity and, recently, by socioeconomic status as well.
At the time, we were unaware of any measures of equity and inclusion that were routinely used by medical schools on a national level. Consequently, we wanted to create a measure of equity and inclusion that was generalizable, scalable, and sustainable. Using the wealth of data that the AAMC collects annually, we are in the process of validating an instrument that can provide detailed information to medical schools about their learning environment and how their schools compare to other medical schools nationally.
Our hope is that these data can be used to improve the climate of medical school education and develop novel, evidence-based interventions to make the learning environment more equitable and inclusive.
HH: This action step calls upon HPE leaders and educators to collaborate with learners to achieve the outlined activities (evaluate existing policies for bias; implement equitable recruitment policies and practices; foster retention of a diverse student body; develop unbiased and flexible advancement policies; design and evaluate bias-free curricula and assessment; and develop community engagement initiatives). What are some of the challenges in collaborating with learners on these areas? Why is it important?
DB and NA: Speaking with learners is critical, and we think there should be a special emphasis on collaborating with learners from minoritized backgrounds, including learners who are Black, Indigenous, People of Color (BIPOC), LGBTQ, differently abled, and who hold other marginalized identities. Learners, especially those with historically oppressed identities, are increasingly well-informed and fluent in topics related to social justice and health equity, and including them in strategic planning of DEI initiatives should be routine practice.
However, institutions must ensure that collaborating with learners does not result in over-taxing those learners and transferring the burden of DEI work onto medical students and residents, particularly those within marginalized groups. We once interviewed a highly accomplished medical resident about how race influenced his experience in graduate medical education, and he told us, “Black people are asked to fix the Black problems,” which is a common but unacceptable reality. Even in our own experiences, we have both occasionally felt drained by the responsibilities for DEI reform that have been placed on our shoulders.
Instead, collaboration with learners should mean that institutional and DEI leadership listen and are responsive to their learners’ needs, that they can identify and counteract racial and gender fragility in dominant groups, and that they are transparent and community-minded in all their DEI efforts. We also cannot overstate the need to provide compensation, protected time, and administrative support for learners who are involved in working to improve the training environment. HPE leaders can benefit from insights and lived experiences of learners, but this collaboration must not become exploitation.
The Office of Diversity and Multicultural Affairs’ Fellows program at the Brown Alpert Medical School is an excellent example of a program that involves collaboration with students to advance DEI work while also providing financial compensation, leadership opportunities, and mentorship.
HH: What aspect of Black History Month is most relevant to your personal journeys as health professionals?
DB and NA: As a cis-gendered Black man [Dr. Boatright] and a and a cis-gendered Sri Lankan woman of Tamil and Sinhalese heritage [Dr. Anderson], we have different relationships to Black history and how it has affected our individual journeys as healthcare professionals. But something we have in common is our desire to bring Black history—particularly Black history that has been suppressed, buried, or ignored—into mainstream conversations about changing medicine and medical education in the US.
This common purpose is aptly represented by two paintings that Dr. Anderson uses in a class she leads at the Yale School of Medicine each year. The first painting is an 18th-century group portrait of Elihu Yale, his family, and an enslaved child. Elihu Yale served as a governor of the East India Company, which was an agent of British imperialism in South Asia, and also oversaw the shipping of enslaved people. In this painting, Elihu Yale is depicted in a position of power and surrounded by symbols of his wealth, including an enslaved child wearing a padlocked collar. To us, the contrast between Elihu Yale and the enslaved child represents the relationship between dominant White narratives that often-silenced Black histories of medicine in the US. As two people of color whose ancestors were subject to European colonization and slavery, this portrait also embodies the struggle we face in our personal relationships with Yale.
The other painting is a 2020 piece by Titus Kaphar, entitled “Enough About You.” In this artwork, Kaphar literally reframes the Elihu Yale portrait by placing a gold frame solely around the image of the Black child and then crumpling the image of Elihu Yale, reducing the importance of the White subjects and elevating the portrait of the Black child. Kaphar also paints the child without the metal neck collar and redirects the child’s gaze away from Elihu Yale and directly out of the canvas. In doing so, Kaphar changes the Black child’s relationship to Elihu Yale, thus challenging us to engage with the child’s history and subjectivity and to consider the changes in racial hierarchies of power necessary to center Black history. For both of us, the portrait of Elihu Yale embodies the erasure of Black history in medicine and the brutal ways in which our personal histories were impacted by European conquest, while Kaphar’s painting represents our hopes and ambitions for re-imagining medicine in ways that uplift and center Black history.