Can US Medical Schools Teach About Structural Racism?

Abstract

Policy Points.

• There need to be sweeping changes to medical school curricula that addresses structural racism in medicine and how to attend to this in medical practice.

• The Liaison Committee on Medical Education should develop and promulgate specific learning objectives and curricular offerings that require medical schools to teach about structural racism and antiracist medical practice in ways that are robust and standardized.

• The federal government, through the Health Resources and Services Administration, should prioritize support for antiracism education in medical schools, residency, and continuing medical education in similar ways and with similar effort in scale and scope to its support for primary care, providing technical assistance and grants for programs across the educational spectrum that provide antiracist training.

• State governments should mandate, as part of continuing education requirements for physicians, 2 or more hours per recertification cycle of antiracist training.

Context

Since the beginning of COVID‐19 and the rise of social justice movements sparked by the murders of George Floyd and Breonna Taylor in the summer of 2020, many medical schools have made public statements committing themselves to become antiracist institutions. The notions that US society generally, and medicine, are rife with structural racism no longer seems as controversial in the academic community. Challenges remain, however, in how this basic understanding gets translated into medical education practice. Understanding where the profession must go should start with understanding where we currently are.

Methods

Prior to the events of 2020, in the spring of 2018, we conducted nine key informant interviews to learn about the challenges and best practices from schools deemed to be positive deviants in teaching about structural racism.

Findings

Our interviews showed that even those schools deemed positive deviants in the amount of teaching done about structural racism faced significant barriers in providing a robust education.

Conclusions

Significant structural change, perhaps far beyond what most schools consider themselves willing and able to engage in, will be necessary if future US physicians are to fully understand and address structural racism as it affects their profession, their practice, and their patients.

Ongoing civil rights issues, such as new restrictions on voting rights and the continued disproportionate killing of African Americans by law enforcement agents in the United States, are bringing new attention to the persistent challenge of racism and racism's dramatic effect on health inequities. Adding to the chronic burden of these inequities, the COVID‐19 pandemic has resulted in a disproportionate burden of disease morbidity and mortality on communities of color. Specifically, throughout the pandemic, African Americans have experienced challenges in housing stability and are dying at 2.1 times the rate of non‐Hispanic White people and Indigenous Americans, and Hispanic/Latinx people experienced COVID‐19 infection rates at almost three times the rate of non‐Hispanic White people. ¹ Long‐standing institutional distrust because of historical and persistent racist medical practices, as well as ongoing experiences of structural violence, limited access to quality health care, and policies such as redlining and siting hazardous waste sites in communities of color have negatively impacted African American communities and other communities of color. ² , ³ , ⁴ , ⁵ More broadly, racial differences in health status and in quality of health care for all major causes of morbidity and mortality remain critical problems for the United States. On average, people of color are poorer, live in more dangerous environments, work in more dangerous occupations, and have less access to quality housing, education, and employment. ⁶ , ⁷ , ⁸ Gaps in access to care and in the quality of care provided to people of color are also large and enduring. Furthermore, these differences are caused, not by differences in individual ability or motivation, but by structures of society that limit access and opportunity in all these sectors for people of color. ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ Poor health among people of color, in other words, is caused by structural racism.

In the aftermath of the murders of African Americans from Tamir Rice to George Floyd and the generalized increased awareness of the role of structural racism in society that the murders provoked, many medical schools, pushed by calls to action from both the Association of American Medical Colleges (AAMC) and student advocacy efforts, have committed themselves to becoming antiracist and to teaching their students to understand and address racism in the systems in which they practice and in their patients’ lives. ¹⁴ , ¹⁵ , ¹⁶ Such a commitment is necessary. The historical, cultural, and societal foundations for racism are baked into medicine. Medical education reifies racist tactics, microaggressions, and discrimination in insidious ways—both in the basic science and clinical education. ¹⁷ As a result, students of color may come to feel excluded and devalued, and their performance as students can suffer as a result. ¹⁸ White students observing these dynamics may identify as allies and wish or seek to support their colleagues of color, but, with limited power and perspective, may come to accept these racist structures as normal and fair. Medical schools must, therefore, not only teach their students about racism and how to address it but most actively engage in eliminating all vestiges of structural racism from their policies, practices, procedures, and culture.

Medical educators, theorists, and practitioners have long considered understanding causal mechanisms as central to identifying and selecting diagnostic and treatment strategies, and there is growing recognition of the need to extend such causal understanding to the social world and social sciences. ¹⁹ , ²⁰ , ²¹ Given the ongoing violence targeting African Americans in the United States, there have been calls for integrating antiracism training into medical school curricula. ²² Medical schools have been piloting antiracism modules into existing medical education. ²³ , ²⁴ Also, residency programs have begun to integrate antiracism curriculum into their training programs. ²⁵ Pedagogical theories that pertain to teaching about social justice speak to the need for methods that allow for a deep understanding of social constructs and the roles of power, hierarchy, and oppression in creating these constructs. ²⁶ , ²⁷ Such methods include storytelling, bringing in the unique and varied voices of people of color, and challenging notions of objectivity. ²⁷ Teaching with these methods and about such constructs requires an educational environment that allows for the development of trust between teachers and students, the creation of open forums for discussion, and active engagement with both cognitive and emotional reactions to the material taught.

There is a great danger, however, that efforts to be “antiracist” will be too limited in scale and scope and will fail to create any real, meaningful changes within medical education that will reform and transform how emerging physicians attend to and address racism. ²⁸ Medical educators have cautioned against quick, surface fixes to medical school curricula that do nothing more than acknowledge that racism exists in medicine. ²⁹ Others have argued that better frameworks need to be integrated into medical education to address root causes of racism in medicine. ³⁰ Furthermore, educators have called for more structural changes within medical education that reflect reparative justice processes and desegregation efforts within clinical teaching. ³¹ , ³² Collectively, these educators have renewed calls for major reform and restructuring within medicine. ³³

This suggests that teaching about racism cannot be done in a superficial way but requires faculty expertise and curricular time to allow students to deeply engage with the complexities of race and racism in US society. Unfortunately, there is scant evidence that medical schools do address racism in their curricula in any deep or meaningful way.

Methods

Based on a survey we conducted in 2018 (unpublished data, Schlaff et al.), we identified 12 respondents from among 56 responding medical school faculty who were, what we considered, positive outliers in the attention given to structural racism in their curricula. The survey subgroup of US allopathic schools came from all regions of the United States, included roughly equal numbers of public and private schools, and included one Historically Black University, showing no significant differences in school characteristics compared with the entire 155 allopathic schools. The 12 respondents who were considered positive outliers, reporting that their school provided at least 2 hours of teaching about structural racism, were recruited for a semistructured, in‐depth interview. The purpose of the interview was to determine what facilitated the development and teaching of a relatively robust curriculum on racism as well as what barriers limited or continue to limit the ability to teach this material. The 12 survey respondents were contacted, and a total of nine (n = 9) consented to an online interview. All interviews were video‐ and audio‐recorded via WebEx technology, and extensive memoing was completed for each interview. ³⁴ , ³⁵ Qualitative saturation was reached after five interviews as no additional data or themes emerged after analyzing five surveys; however, it was determined to use all interviews for the qualitative data analysis to support qualitative robustness.

Interviews were transcribed and manually coded using a grounded theory framework, and emergent themes were identified from the transcription. ³⁶ As Keene suggests, the use of multiple coders, double coding, and establishing intercoder agreement is from the desire for rigor over robustness in the quantitative method and may not be appropriate within qualitative data analysis. ³⁷ For Keene and others, coding as part of the qualitative analytic process does not require multiple coders to ensure contextual robustness but rather methodological consistency among coding cycles, which allows for emergent themes to come from the qualitative evidence. Social scientists have often used single coders to contextualize qualitative findings and have found that interrater reliability may not necessarily be needed when methodological consistency with coding has been maintained and well established. ³⁸ , ³⁹ , ⁴⁰ , ⁴¹

The data from the in‐depth interviews were triangulated with the memoing and survey data to complete qualitative data analysis. ³⁴ , ³⁵

The study was approved by the Tufts University Social, Behavioral and Educational Research institutional review board.

Results

Twelve respondents to our survey met the criteria and were invited to interview. Nine respondents consented: three from the Northeast, two from the South, three from the Midwest, and one from the Northwest. Five of the nine respondents were from public schools, corresponding exactly to the proportion of public institutions among allopathic medical schools in the United States. None were from Historically Black Colleges and Universities. Seven respondents were faculty: three were MDs, two were in public health, and two in social sciences. Two were physicians who held administrative positions: one as provost and one as an officer of diversity and inclusion. Demographic information was not collected.

All interviews were conducted by one researcher (A.L.S.) and recorded on WebEx. Interviews lasted between 45 minutes and 1 hour. Interviews were transcribed and imported into NVivo 12 for open, axial, and focused coding toward the identification of emergent themes. ³⁸

Qualitatively, medical schools indicated a range of pedagogical approaches to teaching about structural racism. Teaching content, time, and format varied greatly among the respondents, ranging from several lectures and discussion groups embedded in a course on health care systems to full, multiyear courses that covered social determinants of health in detail. However, three themes emerged: institutional issues, pedagogical issues, and competencies (Table 1). Quotes are provided below for themes and subthemes. Initials preceding each quote are pseudonyms to protect confidentiality.

Table 1.

Interview Themes

Theme	Subthemes	Key Elements of Subthemes
1) Institutional issues are contexts and conditions of the medical school and how the institution delivers specific academic units of service within the rules and regulations of accreditation standards within the medical school's mission and vision for undergraduate medical training.	A) Pedagogical flux B) Institutional barriers	a) Ongoing curricular reforms and transitions in medical education b) Faculty capacity issues and lack of robust expertise and facilitation skills c) Decentralized nature of clinical education d) Monitoring and evaluation of antiracism curriculum e) Lack of evidence‐based benchmarks on antiracism educational impacts f) Resource constraints g) Uneven strengthening of faculty and institutional resources to support antiracism curriculum
2) Pedagogical issues	A) Content (what to teach) B) Process (how to teach) C) Intersectionality (experiences)	a) Existing scaffolding or sociocultural environment(s) that enable processes to identify what to teach and how to teach antiracism curricula b) Uneven readiness within and across institutions to engage in antiracism teaching and learning environments c) Evidence‐based standards to support teaching and learning about antiracism in medicine d) Facilitated processes within teaching and learning environments that include intersectional experiences explicitly e) Support and resources to support teacher/student colearning and education f) Improving and integrating processes to support different stages of learning about antiracism in medicine g) Dynamic accountability and facilitation processes to address repair, healing, and reconciliation within medical education as awareness of racism in medicine increases
3) Competencies	A) Clinical (science of medicine) B) Nonclinical (art of medicine)	a) Uncertainty with what clinical competencies count toward antiracism b) Issues of transparency and accountability for implicit biases and assumptions in clinical care c) Addressing attunement to how social determinants of health inform provider–patient care d) Ongoing iterations and improvements in learning processes for addressing antiracism practices e) Concerns over how to sustain lifelong learning in dismantling racism in medicine f) Strengthening educational opportunities to support antiracism advocacy and practices in clinical practices g) Identifying educational processes and approaches that increase systems thinking about racism and its impact on medicine

Theme One: Institutional Issues

The theme of “institutional issues” reflects the contexts and conditions of the medical school and how the institution delivers specific academic units of service within the rules and regulations of accreditation standards within the medical school's mission and vision for undergraduate medical training. The predominant characteristic of this theme reflects subjects’ experiences within their academic setting and issues that are structural to their medical school establishment. After coding, two predominant subthemes emerged, characterizing the overarching institutional issues that subjects faced in delivering any kind of antiracism educational material, training, and teaching: 1) pedagogical flux and 2) institutional barriers.

Subtheme A: Pedagogical Flux. All respondents describe their programs as being in transition, with faculty changing and adapting their teaching from year to year, often in an environment of ongoing curricular reform occurring across the entire MD program.

T.O.: “It's a class that we taught it for the first time last year—it's kind of an offshoot and has been evolving over the years. But we really got the full class last year when we implemented a new curriculum.”

T.I.: “It has expanded and changed every year over the past 3 years.”

Subtheme B: Institutional Barriers. Significant barriers to doing more, and to being as effective as faculty would like, included the challenge of threading the curriculum into the clinical years. The decentralized nature of clinical education and the inability to reach—let alone train—clinical faculty results in an inability to actively bring this curriculum into clinical practice and to assess its effect.

F.V.: “In terms of the clinical years, it's more scattered in terms of specific topics that get covered in different clerkships and clinical rotations. […] We're aware that we can't have this just be a first year and maybe a little of a second year thing and then sort of be like okay we've talked about race and now move off to your clinical years. […] There needs to be reflection and engagement and discussion that's ongoing about it.”

T.O.: “I can do this for three weeks, but if you are not reinforcing it, the students are not going to adsorb it; they're not going to understand the importance as they move later on into their curriculum. I was concerned because I did not necessarily feel that my colleagues were reinforcing it a lot. […] I think there's a big gap between when the students see me and when they move into their clinical rotations, especially if it is not reinforced. […] We have the students for a couple of years, and then we send them out to all these community sites—and we have dozens and dozens of community sites. We have eight different hospitals. We have no control.”

T.F.: “Like most places, we are probably not doing even what we should be doing in the clinical years. […] Our students are in so many sites.”

T.I.: “Most of what the students get on racism, unconscious bias, [and] other types of things is in the first two years. […] Where I think we don't do a good job necessarily is bringing it to their third‐ and fourth‐year rotations.”

Other challenges relate to faculty and resources. Faculty issues include resistance, lack of comfort with teaching the material, lack of faculty development, and limited faculty of color. Some faculty do not agree that the material should be taught, and among those that do are varying degrees of comfort with teaching the “soft” sciences, accepting themselves as expert enough to teach, and managing difficult conversations among students. Lack of time and resources for faculty development, and the lack of diversity among the faculty, compound these problems.

B.C.: “It's primarily a case‐based, small group course, which means to some extent what the students get about structural racism depended on their small group leader. There's a lot of variability in faculty strengths. […] I do not have enough faculty or enough resources for faculty development.”

F.V.: “We have small group discussion that is beneficial, but, you know, I think there are levels of expertise or ability to facilitate those discussions that are required. I think it is really challenging to sort of train faculty to do that well.”

All respondents noted resource constraints related to curricular time and funding for faculty slots. Descriptions and beliefs about the depth of institutional support to continue and develop teaching about racism varied widely, even among faculty in programs with relatively robust curricula, with some noting a strong and ongoing push by school leadership to teach this material and others voicing concern that, if they and one or two others left the institution, the teaching that they did would disappear.

B.C.: “One reason I will not leave in the nearish future is I don't think we are at the sustainability point. I don't think it would last without me. I just haven't yet seen it translate to deep engagement from the top to the bottom.”

T.O.: “It also helps that I have some of my supervisors and some of my faculty colleagues above me like my associate dean, and in medical education, they recognized this years ago as well. […] Institutional commitment is there. I've never got the sense it would disappear. The big challenge is now, especially with all of our budget cuts and our inability to hire anyone, if I left, there would be a big panic of who is going to do it. It really does fall on me.”

T.I.: “I would say the commitment is very deep. Has that translated yet into having a deep curriculum, to have a broad curriculum, to have the faculty development that we need to really support the continued messaging through third and fourth year and continue into residency? No, not yet.”

Theme Two: Pedagogical Issues

A second overarching theme identified specific pedagogical issues, challenges, and characteristics that medical educators shared when delivering antiracism curricula. This theme encompassed the delivery of antiracism content in undergraduate medical settings and the spectrum of processes that are involved in delivering this content. Subjects reflected on what strategies, methods, and tools supported this work while including adaptive ways they responded to institutional conditions and contexts. The diversity of responses indicates how medical schools are not all starting with the same commitments or levels of “readiness” in delivering antiracism training in undergraduate medical education.

Subtheme A: Content. Programs that offered the most extensive teaching regarding social determinants of health and racism shared several important features. Regarding content, faculty at these programs stressed the importance of embedding material that could be viewed as ideological or controversial in more generally accepted frames for medical education. This included having discussions and the testing of implicit bias embedded in a broader introduction to the science of cognitive error and evidence‐based medicine as well as discussions of racial identity and racism in broader discussions of personal and professional identity and culture.

B.C.: “We actually start with a culture of medicine section. When you think of medicine as a culture, what do you expect? We try to bring about the idea that you are going to be in three cultures: your patient's, yours, and the culture of medicine. […] We try to situate implicit bias as, look, there is this range of biases that you as a future doctor [have that] will affect the way that you treat patients.”

F.V.: “We try not to make it, ‘This is when we are going to talk about race and racism and everything else we don't talk about it.’ We try to integrate it into everything.”

T.I.: “If we start teaching structural racism without a lot of buildup and stuff around it, you can't do it in isolation: it is guaranteed to have a backlash.”

Respondents were asked about, and all agreed with, the notion that to teach about racism, one must get to a person's heart as well as their head. Diverse ideas about how to do this were shared, including the use of true stories and narratives delivered directly by people of color, the use of role plays, having students discuss their personal experiences, the use of literature and of creative writing, experiential and community service learning, and reflective discussions.

B.C.: “If we don't establish the relationships between people, then we never get to the point of having the dialogue.”

F.V.: “We try to highlight the story and make it a personal way for people to understand that this isn't just talking about racism—using that word, which doesn't help them.”

T.I.: “I think patient stories are so resonate, and we employ that a lot; we bring in patients who have experienced things including racism, sexism, and homophobia—so when students see that this isn't something the professor told me that this isn't something theoretical. This real, living, breathing, talking‐to‐me person had this experience.”

Respondents were also asked how they overcome resistance by students to the material, and they offered many of these same techniques. They also stressed a set of issues that link to processes of education and institutional commitment. These include the need to have a diverse faculty and student body, to prepare students for difficult discussions by grounding them in the science and social science linked to understanding how racism and implicit bias operate, to provide enough time in stable small group discussions to allow trust to develop, and to thread this material into the clinical years when students can truly reflect on how this material and their attitudes to it affect their clinical abilities and relationships with patients.

Subtheme B: Process. Common themes related to process focused on the need for small group work and reflection guided by faculty experienced with guiding discussions about race and racism.

T.O.: “We've moved away from didactic. Everything we do is very hands on engaged or small groups or in the community. Faculty kind of rotate around, listen in on the conversation, and prompt the students where needed. Again, short on faculty—not enough faculty.”

T.I.: “Most of the Science of Health Care Delivery curriculum is a flipped classroom model, and so there is prework and reading or videos or whatever it is, and classroom time is spent with discussion with small group work with presentations.”

Faculty who were able to teach a relatively robust curriculum related to racism noted several shared facilitators. Central to this was the role of students, who often requested and responded positively to such teaching and were often noted to be “ahead of the faculty” in seeing the importance of and understanding the role of racism in medical education.

F.V.: “Medical students were concerned that race was not being addressed overtly. […] A group of students actually started going through all the lecture slides of every course and identifying where race was mentioned and raising questions on how it was mentioned and the fact that there was no socioeconomic discussion about that.”

T.O.: “Some of our students of color came to us and said, ‘You're not being strong enough.’ […] They're the ones who are bringing up and questioning social determinants.”

T.F.: “Our students were the ones who got race out of the rounding presentations—they raised hell about it.”

Other common and key facilitators include a strong department (or departments) and faculty with interest and expertise in medical ethics, social science, and humanities; support of senior leadership; and the context of curricular reform that allowed for change and experimentation. The presence of deans and offices of diversity and inclusion, and the role of the AAMC in encouraging the creation of such offices, were also frequently cited as a facilitator, even though few such offices were directly involved in curriculum development.

In addition to institutional barriers cited above, interviewees noted that the variability of knowledge, attitudes, and life experience among students created several challenges in the educational sessions themselves. Whereas some students are eager for more content and discussion about this material, others are vocal in their dissatisfaction and belief that the material is unnecessary and the time wasted. Some White students are resistant to the notion that racism exists at all, and respondents reported on how expressions of complacency, insensitivity, hostility, defensiveness, or even expressed fear of saying anything at all can jeopardize the group trust needed to have constructive conversations.

B.C.: “It was a really uncomfortable conversation with people just saying, ‘well, look, it's so much higher in the Black population and, look, Black teenage girls are having babies at much higher rates than White teenage girls’ and then jumping to ‘and the problem is that Black girls are getting pregnant.’ That went really badly; their biases came right out before we could get to the discussion really.”

F.V.: “Students come at it from such different perspectives so that how to manage that discussion is really challenging. There's still a sector of students who are, you know, ‘Oh no, not race again.’”

T.O.: “It's still uncomfortable for a lot of our students. […] There were students who were making disparaging comments out loud to their group members when they were out in some of these neighborhoods. […] White students saying, ‘I don't believe White privilege exists’ [and] ‘Quit preaching to me—I didn't know I was coming to a liberal school.’”

Students of color are at times surprised and upset by students who resist the education, and they can be frustrated with what they perceive as the time spent on what they view as basic and remedial education or with limited faculty skill in managing what they consider inappropriate comments.

T.I.: “The students of color or [lesbian, gay, bisexual, transgender] were feeling that there were things being said by their fellow students that were not being called out by faculty or being discussed.”

B.C.: “I did have a student in the fall who felt that one of her peers was making deliberately racist comments intended to upset her.”

Other student issues include student concern with test and performance competency. Some students may resist paying attention to material that is not clearly linked to either testing or to clearly articulated clinical competency. Respondents agreed that assessment was difficult.

B.C.: “Assessment is a weakness. We don't know how to assess this stuff, largely. […] On a population level, you can show the impact of structural racism. It's really hard to completely prove that at the individual level. If I can't totally prove it, how concrete can I really be in my language and in my teaching?”

Theme Three: Competencies

The third emergent theme addressed clinical and nonclinical skills, methods, tools, strategies, and knowledge to engage with racism in medicine. Subjects critically reflected on the importance of ongoing and active confrontation and transparency with implicit biases, assumptions, and normative frameworks that continue to inform racism in medicine while integrating evidence‐based tactics and processes that supported learning communities of faculty, staff, and students to wrestle with and attend to actualizing antiracist medical institutions. This theme specifically identified how this could be tackled through clinical competencies and nonclinical competencies.

Subtheme A: Clinical Competencies. Although respondents articulated a strong belief that understanding racism would make physicians better clinicians, they struggled to articulate the clinical competencies that require such understanding. Several expressed discomfort with putting this education in the restricted context of competency.

T.F.: “I'm not sure about the penetrance of and the presence of authenticity beyond passing a shelf exam or a [United States Medical Licensing Exam]. Performance isn't necessarily connected to authenticity. I don't know if it is just our hubris to think that we are going to have some impact on what's underneath the performance, but I think we have to try to because it is what is underneath that will generate responses that don't fit the K‐type questions they're used to.”

Common areas that did emerge in the interviews as needed competencies include the ability to ameliorate the effects of one's implicit biases; to listen for cues about a patient's concerns; to create a genuine bond with a patient that in turn allows for the development of trust; to screen for the effects of social determinants of a patient's health; and to avoid victim blaming and instead to work with patients to eliminate those determinants and their effects. These competencies are downstream to the sociocultural structural realities of how power and privilege govern the rules, regulations, and approaches that reinforce and reify racism in medicine. Interviewees referred to persistent and entrenched systems of discrimination, oppression, and sociocultural contexts that continue to fuel White supremacy that is historically embedded into everyday life through policies, rule, practices, and regulations such as intergenerational trauma that may be connected to and informed by the social determinants to health (i.e., redlining, access to clean water, adequate health insurance, etc.). The following quotes reflect how antiracism curriculum must take seriously the sociopolitical and historical contexts connected to racism and how this work is not only about awareness but also identifying diverse strategies, techniques, tools, approaches, frameworks, learning processes, and theories that can inform antiracism curricula in teaching and training future physicians.

B.C.: “Everything that I have learned in my experience is that that has been really essential knowledge to being a doctor: that you can't treat someone in isolation, that you can't not understand societal forces that are at work. […] If you don't recognize the role…that structural racism plays in constraining your patients’ healthy choices and options, then you're going to end up blaming them for not improving their health.”

T.O.: “We connect it to the first few sessions of our clinical medicine course where students are learning how to do the interview and build a history. We're talking about social issues and the environmental issues that affect people's health now when you are doing the interview and you're building that history; when you are building that social history, what do you need to ask? […] You are going to be working in this community. […] We have a lot of disparities. Just teaching about disparities alone without talking about the underlying systemic racism that goes along with it and contributes to it—we feel like a lot of our students were walking away with the feeling that disparities are to some extent the fault of the individual.”

F.V.: “The interpersonal to be a good clinician that requires keeping in check your own judgment about the patient and your own bias. Many of these biases are created by social structures that we all live in—so understanding why do I have this particular response to patients.”

T.F.: “We like the structural humility approach. […] It is a set of skills rather than ticking off a box. We try to break down what structural humility is in terms of scanning, identifying, describing, introjecting, [and] acting.”

T.I.: “Where it does apply is an individual[’s] or family's overall health and understanding where they come from and understanding where their head is when they walk into the doctor's office. To understand that structural racism that may have affected their DNA now that we know in terms of the intergenerational trauma […] but to understand that there are things beyond [socioeconomic status] for that physician sitting in the office.”

Subtheme B: Nonclinical Competencies. Respondents also discussed a variety of nonclinical competencies that providers should have in such domains as practice management, community work, research, quality improvement, patient advocacy, and (for some physicians) political advocacy.

F.V.: “In terms of the broader and systems piece of this, I think again, partly, we're asking doctors to do more and think more about medical care than we ever have before. To put it bluntly if we are going to reduce health care costs and we're going to have better quality care, we're going to have a more efficient system: you know all of that implicates equity. It's part of expecting physicians to be part of solving those problems.”

T.O.: “We try to introduce—with our students—and we're trying to find ways to reinforce it even more—is really talking to our students about advocacy.”

T.I.: “Advocacy is that session is advocacy writ large. It's about both how the physician might advocate for the individual patient, how they might then advocate for health system change, versus how as an individual they might go out and advocate for a change in the law.”

T.F.: “Part of the social and health systems thread is each student does a patient safety or a quality improvement project during their outpatient rotation.”

Several spoke to broader educational goals—to have physicians develop more power of observation, self‐reflection, and an ability to think independently and creatively about the meaning of their professional work and their role in it.

B.C.: “I tell them in the beginning that I hope that at the end of the year they have found one thing besides individual patient focused clinical medicine that they love and want to make part of their clinical career. It can be research. It could be patient safety. It can be leadership in a health care institution. It can be advocacy. It can be policy development.”

T.I.: “The other part is empowering physicians—that is, one of the barriers that we have—even for those wonderful people who get it who buy into structural racism—it's wearying—and helping to inspire our colleagues—medical students and our colleagues—that they can make a difference. It's empowering and informing physicians that their work in this space is important and they should keep doing it even if they don't see the benefit.”

T.F.: “We're trying to instill lifelong skepticism and reflection and asking, ‘how can I do this differently and what is my part in this?’ Preserve their observing egos and observing eyes. […] Our curricula need to teach them to resist and reflect, reflect and resist, and they will change medicine.”

Limitations

Key informant interviews were directed to faculty who, based on a survey, were positive deviants, i.e., who noted that their school taught more about structural racism than most who responded. We received replies from only 56 of the 148 allopathic schools contacted, however, and the level of commitment to the subject matter at schools that did not reply could not be ascertained. Committed faculty at these schools, had they been interviewed, may have raised different themes and issues that could not be explored.

Discussion

It is also noteworthy that the method to identify who to survey and interview at each medical school was complicated and time consuming. A glance at any medical school website will quickly allow identification of the core preclinical courses and the clinical clerkships as well as the faculty who teach them. Despite the Liaison Committee on Medical Education (LCME) requirements that medical curricula contain “behavioral and socioeconomic sciences” and teach about societal problems, cultural competence, and health disparities, it is not so easy to find out if, how, when, or where this material is taught. There is no specific requirement for coursework in the social determinants of health generally or racism specifically. There are no true standards or generally agreed‐on methodologies, and, therefore, these subjects can be addressed at a very superficial level. As indicated under the theme of pedagogical challenges, what and how to teach about racism in medicine and engaging with the experiences of intersectionality posed significant obstacles for medical educators ranging from the lack of capacity within the faculty to fully address teaching issues to the overwhelming complexity of emergent issues within time constraints across all years of the curriculum. This speaks to a broader challenge for medical education that we teach more and more the science of medicine, losing time and focus for teaching the art of medicine and how to be a healer and caregiver of people as well as a treater of diseases.

As Dr. David Acosta, chief diversity officer for the AAMC, stated,

In 2011, the AAMC encouraged academic medical institutions to embrace a framework for diversity that included removing social and legal barriers to diversity, intentionally integrating diversity into teaching, and embedding diversity into the core workings of the institution. That hasn't happened. In fact, data suggests that persistent, structural racism and widespread implicit and explicit bias has created an exclusionary environment for many students and faculty. ⁴²

The challenges and barriers identified by the key informants are of great concern. The formal and informal rules, regulations, and contexts that regulate an entire system of interaction or structural barriers to providing a robust and meaningful curriculum that is antiracist in content, process, and practice are formidable. Integral to the aspirational manifestation of embedding antiracism into medical school teaching and training, key informants reflected on the need for establishing evidence‐based curricular and assessment approaches to address structural racism that could be embedded into LCME accreditation requirements that speak to the spirit of actualizing AAMC diversity frameworks. Contextual challenges related to assessment, evaluation, and accountability in implementing antiracism curricula were highlighted by key informants suggesting that there is a need for changes in medical school structures that support these activities well beyond those which schools may be ready to enact. This aspirational vision provides transformational leadership opportunities within medical schools to support sustainable changes in medical curriculum to address racism in the discipline. These structures include faculty composition, resources, faculty and student diversity, the socialization of students and faculty, institutional support, curricular design and evaluation, and the relationships between medical schools and their clinical partners and faculty. They suggest that the actions and change required of medical education institutions may be far greater than most understand or are prepared to undertake.

The US health system did not, by itself, create racism, nor can it, by itself, eradicate it. Students and faculty alike are often woefully unprepared to discuss racism at a level of sophistication necessary to understand and address it, and time is in short supply for what is, in effect, remedial education. Nevertheless, the historical and continuing role of the medical profession in sustaining racism, and the profound effects of racism on health, require that we do more. Given the power, authority, and influence of medicine in American society, there is a responsibility and obligation among medical educators to engage in collective efforts more proactively across medical schools toward larger curricular reforms. Individual faculty, individual medical schools, and the national leaders in medical education should all step forward to raise consciousness about this critical subject, to articulate that curriculum is as important as diversity and inclusion efforts in addressing racism in medicine and in society and to support efforts to create national standards and systems of accountability for teaching future physicians about racism in a manner as robustly done for the basic and clinical sciences.

Funding/Support: The authors have no financial support to disclose.

Conflict of Interest Disclosure: The authors have no conflicts of interest to disclose.

Acknowledgments: The authors would like to thank the medical school faculty and administrators for completing the survey and additionally thank the interview participants.