Racism and anti-racism in medical education: a cross-sectional study of Finnish medical students’ perspectives

Abstract

Background

Racism negatively impacts health, and it has both structural and interpersonal manifestations in medicine. In Finnish medical education, diversity, equity, and inclusion work is still in its infancy. This is the first study examining Finnish medical students’ perspectives on racism and anti-racism during their studies.

Methods

An online survey was distributed to medical students across Finland. The responses (N = 150) were analyzed using mixed methods, with descriptive statistics applied to quantitative data and inductive content analysis applied to qualitative data.

Results

Only 25% of participants recalled receiving formal education on racism during their medical studies.

Most respondents lacked knowledge of where to access reference materials showing symptoms on skin of colour, whereas they were confident locating the same materials for light skin.

Limited curriculum content was considered the most significant barrier to learning about anti-racism in medicine.

39% observed racism in educational settings, but only 26% of these bystanders intervened. Intervention is made more difficult when the perpetrator is a senior clinician.

40% of racialized minority students had been the target of racism at medical school.

Overall, students wished for additional supports and learning opportunities as part of their mandatory studies.

Conclusion

There is a need for curriculum reforms promoting anti-racism education, bystander intervention training, safe reporting pathways, and engagement with diagnostic resources depicting symptoms on skin of colour.

The study has implications for Finnish medical education and for research on Diversity, Equity, Inclusion, and Belonging in healthcare more broadly.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-09360-y.

Background

Race is a social construct with no strict genetic basis [1]. Yet, discrimination and violence resulting from one’s categorization into a racial group deemed as inferior— which we know as “racism”— have very real impacts on those who endure it. As described in the ecosocial theory of disease distribution, stress and abuse that result from structural, interpersonal, intergenerational, and internalized forms of racism have negative impacts on the health of those affected [2, 3].

Within Western medicine, racism and white normativity are insidious, having longstanding roots in eugenics and “scientific racism” [4–6]. Indeed, medicine has long been weaponized for the purposes of white supremacist ideology; the racist medical experiments conducted in Nazi Germany are a well-known example [4]. Despite the Declaration of Geneva and important advancements in medical ethics, racism continues to manifest in healthcare settings around the world [7], and white normativity is a persistent barrier to social accountability in health professions education [8–10]. For example, a 2025 study of 43 countries across six continents found that most life support training organizations exclusively use white, male manikins in their training, although white men make up a minority of the global population [11]. This is just one example of structural racism and sexism as materialized in medical education.

Finland and the other Nordic countries are known internationally for their high quality of life and history of leadership in women’s rights. Finland, specifically, has ranked annually since 2018 as being the “happiest country in the world”, where “happiness” is understood as life satisfaction, rather than joy [12]. Perhaps in part due to their almost utopian reputations for gender equality, “Finnish/Nordic exceptionalism” has led to structural racism being overlooked or outright denied in these countries under an ethos of colour-blindness [13, 14]. Indeed, across the Nordic region, health professions education often assumes a culturally neutral stance that obscures systemic inequalities [15]. In the context of growing racial diversity across Europe, this purported neutrality is especially problematic in Finland, which was ranked in the 2023 Being Black in the EU report as having the highest rates of anti-Black racism in the entire European Union [16].

Ironically, Finnish people have not always been considered white by others. In fact, the process and project of Finns “becoming white” in the early 20th century was seen by early patriots as a means of gaining the influence necessary to establish the nation’s independence [17]. In line with the ideology of eugenics, state-sanctioned practices of compulsory sterilization violated the reproductive rights of minority groups, such as Roma, Sámi, and women with disabilities [18]. These “heritage hygiene” practices had legal backing until the year 1970 but persist in less overt forms [18]. More recently, disparities in access to infertility treatment have been documented for women of Somali background in Finland, who represent the country’s largest racialized minority group [18].

Healthcare providers have a responsibility to treat patients according to their needs, without discrimination. While there is a paucity of systematic studies from the Finnish context, investigative journalism reports and interviews with healthcare professionals in Finland have revealed instances of anti-Black and anti-Brown racism in clinical interactions [19, 20]. These reports indicate that racist harassment is both experienced by and perpetrated by healthcare professionals. Mentions of medical racism in the media are corroborated by academic research on nursing, which highlights how non-white nurses in Finland experience racist harassment at their workplaces— often in the absence of intervention from bystanders [21, 22]. Conversely, recent studies from the Finnish university context have demonstrated students’ lack of confidence or preparedness to intervene in overt racism [23, 24].

Beyond supporting students in recognizing implicit biases and harmful behaviour, Medical Critical Race Theory empowers students to confront injustice and become agents of change for the promotion of equity in medicine [25]. It moves beyond the micro-level, interpersonal dimension to examine how health inequalities stem from racism in medical practices, institutions, policies, and ultimately, all structures of society [25]. In Finland, structural racism and white normativity impact education beginning in primary school [26, 27] and continue throughout the student’s educational pathway, including into higher education [28]. Finnish medical education is not immune; a 2022 study uncovered that only 0.8% of images in Finnish dermatological textbooks represented symptoms of disease on skin of colour [29]. This is only one example of white normativity in medical education in Finland.

While anti-racism in medical education is receiving increasing attention globally, much of the existing scholarship remains concentrated in the United States, with limited research from European contexts [7, 30]. In particular, there is a notable absence of empirical studies examining how medical students in Finland perceive and engage with anti-racism. This gap is especially concerning given the documented presence of racism in the Finnish healthcare and education systems.

To address this gap, this study explores Finnish medical students’ perspectives on racism and anti-racism in medical education. To the best of our knowledge, this is the first research project to ask Finnish medical students directly about the topic. By centering students’ voices, this study contributes to the growing international discourse on equity in medical education and offers insights that may inform future research and curricular reforms, both in Finland and beyond.

Methods

Research design and aims

This cross-sectional study used a survey instrument to explore medical students’ perspectives on racism and anti-racism in medical education. More specifically, this study investigated medical students’ perspectives on (1) accessibility of education on anti-racism in medicine, (2) what supports and hinders anti-racism learning, (3) their own experiences of racism, (4) bystander intervention, and (5) necessary curriculum changes to address racism in healthcare. The survey included 28 multiple-choice and scale-based items (Likert-type or 1–10), six demographic questions, and 12 optional open-ended questions that provided participants the opportunity to elaborate on their responses. Ad-hoc questionnaire items were utilized because of the unavailability of existing instruments that would have suited the purposes of the research. A copy of the survey is available in the supplementary materials as Additional File 1.

In the original design, 14 research questions were analyzed in depth within a master’s thesis written primarily for Finnish audiences [31]. This article offers a distinct contribution by synthesizing findings most relevant to the global medical education community and situating them within international literature, thereby extending the implications beyond the national scope of the thesis.

Participants and setting

The study population was comprised of undergraduate medical students enrolled at Finland’s five medical schools: the University of Eastern Finland (Kuopio), the University of Helsinki, the University of Oulu, the University of Tampere, and the University of Turku.

At the time of writing, the most recently published statistics indicate that there are approximately 4,833 medical students in Finland [32]. This number excludes Finnish citizens studying medicine abroad.

After closing the survey, it was determined that 214 respondents selected “I consent” and continued to the survey. Two respondents selected “I do not consent” and were automatically redirected to the exit page. By the end of the survey, 37 respondents had dropped out or chose not to click “submit” on their responses. All 37 non-submitted responses were removed from the final dataset, as it was understood that consent had been withdrawn. The final number of valid responses is thus 150, or 80.2% of all responses.

Table 1 offers a comparison of the demographics of the sample population and the target population.

Table 1.

Comparison of demographics between the survey sample population and the target population. Percentages may not add to 100%, as “Prefer not to respond” responses were excluded. Data on the target population, which consisted of current medical students in Finland, were obtained from the Vipunen statistics service

Demographic group	Survey sample (%)	Target population (%)
Age: 18–21	16,7	17,4
22–25	49,3	47,8
26–29	23,3	23,6
30–34	6,7	7,3
35+	2,7	3,9
Gender: Woman	72,7	64,2
Man	22,7	35,8
Nonbinary	2,7	Data not available
University of Helsinki	5,3	19,4
University of Turku	10,0	19,8
University of Tampere	34,0	18,7
University of Oulu	34,7	20,2
University of Eastern Finland (Kuopio)	14,0	21,9
Racialized minority identity	6,7	Data not available

As illustrated in Table 1, the average participant in this study was a white woman aged 22–25, studying in her 3rd year of medical school in Finland.

The survey sample (N = 150) represents approximately 3% of the target population. The largest demographic difference between the target population and the sample population exists within the distribution of respondents across the five medical schools in Finland. Notably, only 5,3% of respondents were students at the University of Helsinki, which currently hosts 19,4% of all medical students in Finland.

Ethical considerations

The study adhered to the ethical principles outlined in the Declaration of Helsinki. Informed consent was obtained electronically from all participants prior to survey commencement. Consent could be withdrawn at any point before the final submission of one’s responses. The last survey page reminded participants of the planned publication of pseudonymized comments and aggregate data. Only responses from participants who provided consent at both the beginning and end of the survey were included in the analysis. Importantly, the research was based on information without data security risks (i.e., no identity or contact details were collected), and the study was conducted in accordance with the Finnish National Board on Research Integrity standards for human sciences. Participation was voluntary, with safeguards such as “prefer not to respond” options for multi-select items and optional open-ended questions.

Data collection

The data were collected using an online survey built and managed on REDCap electronic data capture tools hosted at the University of Helsinki. REDCap (Research Electronic Data Capture) is a web-based software platform designed to support secure data collection for research studies [33]. To ensure linguistic accessibility, the survey and participant information sheets were provided in Finnish, Swedish, and English.

Recruitment was facilitated by collaboration with student associations at each institution, enabling nationwide survey coverage. The survey was open from March 13 to April 11, 2025.

Data analysis

An exploratory mixed-methods approach was used to analyze the data, allowing for integration of quantitative and qualitative findings [34].

Quantitative analysis

Descriptive statistics were used to characterize the sample and address frequency-based questions. Statistical analyses were performed using R [35] in RStudio [36]. Initial code drafts were generated using Google Gemini, an AI tool. No participant data were uploaded to Gemini, and all code was manually reviewed and edited for accuracy.

Qualitative analysis

The open-response data were analyzed using inductive content analysis. At its core, inductive content analysis involves closely reading and familiarizing oneself with a qualitative dataset, assigning codes (labels) to meaningful segments of text, and grouping and refining the codes to reveal themes for interpretation [37].

ATLAS.ti Web (version 9.18.0) was used to support the qualitative analysis and to generate TreeMap diagrams visualizing the frequency and hierarchy of codes [38]. In a TreeMap diagram, each rectangle represents a different code, and its area is proportional to the number of times the code appeared.

Results

The responses offered by the 150 participants in this research were analyzed using qualitative and quantitative methods, as detailed in the previous section. The results obtained are presented below and are contextualized and interpreted in the Discussion. The quantitative dataset is provided in the supplementary materials; see Additional File 2.

Limited formal education on anti-racism in medicine

Only 25% of respondents recalled receiving education about racism as part of their medical studies. Additionally, many students felt that the extent of this education was limited. For example:

[We only had one] 3-hour seminar on the topic during four years of studies. (Participant 192)

Despite limited curriculum content, there is evidence that at least some students have taken the matter into their own hands, engaging in self-directed learning through online sources and social media:

I follow social media accounts of doctors and students who raise awareness about racism in medicine and help followers reflect on their own prejudices and professional skills, such as recognizing skin changes on dark skin.

(Participant 7)

Conversely, participants reported that experiences of working or studying abroad increased their awareness of their gaps in learning:

Working in [Southeast Asia] with locals (…) highlighted the limitations of my knowledge regarding skin symptoms and typical signs of diseases in people with dark skin.

(Participant 126)

Moreover, most of the respondents did not know where to access reference materials showing symptoms on dark skin. Specifically, only 20% of participants agreed that they could locate reference materials for skin of colour, compared to 77% for light skin. Within that 20%, less than 1% (one out of 150 students) completely agreed that they could locate reference materials showing symptoms on skin of colour. Figure 1 illustrates participants’ aggregate responses to the relevant questions: “To what extent do you agree with the following statement? I know where to access reference materials showing medical symptoms and conditions on (light)/(dark) skin tones.”

Fig. 1.

Diverging bar chart representing participants’ ability to locate reference materials on light vs. dark skin

Barriers and supports for anti-racism learning

Through a multi-select question asking students about barriers to their learning about anti-racism in medicine, limited curriculum content was revealed as the most widespread barrier, acknowledged by 61% of respondents. Time constraints (43%) and a lack of accessible resources (16%) were also highlighted. Still, almost a third of students (29%) felt that there were no significant barriers to their ability to learn about anti-racism in medicine.

In terms of desired supports, 68% of respondents wished for “more training and workshops” on the theme of racism in medicine. “Inclusion of racism literature in curriculum” was a close second, at 67%. “Mentoring by anti-racist faculty” was wished for by 32% of students, and “peer support groups” were wished for by 11% of students.

Experiences of racism and bystander intervention

Out of the 150 participants, 39% reported witnessing racism in their medical education settings. Of these observers, only 26% (or 10% of the total sample) reported having personally intervened in the situation(s).

Furthermore, students’ comment-box responses suggested that they find it most difficult to intervene in racism when power dynamics are involved, such as when the perpetrator is a senior clinician. The participant quote below exemplifies the issue:

It’s very difficult, for example, as a medical student, to address a senior’s racism in a work situation where you are dependent on the senior’s consultations. I’ve been in such situations before, and they are very challenging. More training or advice is needed for this.

(Participant 89)

Of those participants who identified as belonging to racialized minority communities, 40% (four out of 10) reported having experienced racism in their medical education environments.

This discrimination weighs heavily on the affected students, some of which expressed feelings of disenfranchisement:

As a racialized person, I feel that despite all my efforts and experiences, I am quite powerless to influence racism, especially at a structural level.

(Participant 209)

What changes do students view as necessary to address racism in healthcare?

At the end of the survey, 44 students responded to the open-response question “In your opinion, what changes are needed in medical education to address racism in healthcare?”

The responses were analyzed using inductive content analysis [37] and codes were created by hand using the platform ATLAS.ti (web version 9.18.0). A TreeMap diagram (Fig. 2), also made with ATLAS.ti, shows the main codes that emerged from the data:

Fig. 2.

A TreeMap diagram representing the changes students believed necessary to address racism in medicine

The most discussed changes spontaneously suggested by students were “Increased mandatory education about racism in medicine” (20 separate comments) and “Additional and updated resources, i.e. images” (18 separate comments). Other comments addressed the extensive and pervasive nature of medical racism. For example, participants discussed the importance of anti-racism on a broader societal level and the potential of continuing education interventions to address healthcare providers’ racist attitudes. At the same time, some students expressed their opposition to enacting any changes to the status quo of medical education (six separate comments):

There is no need for anything different from the current [structure of medical education].

(Participant 134)

Overall, many participants wished for more education about racism in the curriculum, but some felt that anti-racism is not a priority and rejected the notion of increasing mandatory education on racism in medicine.

Discussion

The findings of this research indicate that a shift from “soft” to “critical” global citizenship education in medical programs would be beneficial [39]. While many students reported attending token seminars on multiculturalism, few encountered meaningful opportunities to grapple with the colonial and white supremacist legacy of Western medicine, or to reflect on their own positionality. Such omissions represent a missed opportunity to cultivate not only more informed doctors, but also more just and accountable medical institutions.

Finland’s global reputation for educational excellence and high life satisfaction stands in stark contrast with its documented prevalence of anti-Black racism [16]. The expressions of exhaustion by racialized minority participants in this study underscore the importance of white ally involvement in countering the racism embedded within Finnish societal structures, including the medical education system.

The low proportion of students (25%) who recalled receiving formal education on racism in medicine highlights a critical gap in the curriculum. Similarly, the finding that only 20% of participants knew where to locate reference materials depicting symptoms on skin of colour is consistent with previous research on the rarity of images depicting patients of colour in Finnish medical textbooks [29] and the underrepresentation of melanin-rich skin in Google Images searches carried out in the US [40, 41]. These findings align with critical race scholarship emphasizing racism as a systemic issue— one that is not limited to overt acts of discrimination, but is deeply embedded in healthcare institutions and practices [2, 25].

Although most students expressed a desire for more education on racism, some did not view anti-racism efforts as a priority. This may reflect a lack of understanding of the systemic nature of racism and its implications for healthcare, or myths of colour-blindness and Nordic exceptionalism [28]. Indeed, it has been suggested that “race illiteracy” is a key obstacle to equity in healthcare [42].

The finding that 40% of racialized minority students reported being targets of racism during their medical education is deeply troubling. Such a high prevalence suggests that racism is not an isolated occurrence, but a persistent feature of the medical learning environment in Finland. Experiences of racism can negatively impact medical students’ mental health, academic performance, career advancement, and sense of belonging within the profession [43]. Medical schools must take action to provide anti-racist institutional support, such as by implementing truly safe reporting mechanisms and meaningful training for faculty and students. Cross-Nordic initiatives to support students of colour in medicine would also be important, given the recent evidence that similar problems are facing other Nordic countries, such as Norway [44], Sweden [45, 46], and Denmark [47, 48].

The findings of this study also highlight the importance of bystander intervention as a critical component of anti-racism efforts. Despite evidence of improved health outcomes associated with bystander intervention [49], students reported feeling unprepared to intervene, particularly in clinical settings where authority dynamics are involved. This finding is in line with Lyons et al.’s qualitative work on bystander intervention in Finnish universities, where authority dynamics were also identified as barriers to intervention in racism [23]. A gap in preparedness is suggested by the present results, too, as only 26% of bystanders who noticed racism had also intervened in it. This percentage is similar to that reported by Zacheus and colleagues, who measured that 30% of student participants from Finnish universities had intervened in racism at least once [24]. Students’ low rates of intervention and low preparedness scores indicate a need for targeted training in bystander intervention strategies, which should empower them to disrupt racism in their universities and clinical environments. Promisingly, research from the UK and the US has demonstrated the benefits of incorporating bystander intervention training into medical education [50–52].

Overall, the findings suggested the following reforms to Finnish medical curricula: universal anti-racism education, bystander intervention training, safer reporting channels, and further inclusion of diverse medical learning and reference resources.

Limitations

The findings should be considered in light of the study’s limitations. Specifically, the sample represented only 150 students, or 3% of the target population, and there were significant biases in the distribution of respondents across the five medical schools in Finland. Additionally, it is possible that students with strong feelings either for or against anti-racism might be more inclined to participate, resulting in self-selection bias. Therefore, the results cannot be understood to represent the entire target population. Moreover, it should not be assumed that results collected in the Finnish context reflect the state of medical education elsewhere in the world. The temporal context of the research should also be noted, as each new generation of medical students and instructors changes the dynamics and culture of their educational environments. The results can thus be considered a partial snapshot of racism and anti-racism in medical education in Finland during the spring of 2025.

Future directions

Further research on anti-racism in medical education is urgently needed. Lives and livelihoods are indeed at stake, not only in Finland, but anywhere that white-normative medical resources are used to guide decision-making, and everywhere that willing or ignorant misuse of power leads to unequal care for marginalized patients. Future projects could explore:

• ◦ Anti-racism in nursing education. This is especially relevant in the Finnish context, as nurses are generally the first practitioners that patients consult about their medical concerns.

• ◦ The development of continuing education courses on anti-racist medical care, and analysis of learners’ feedback on these courses.

• ◦ Differences in racialized minority patient experiences in public versus private healthcare centres (to what extent does viewing the patient primarily as a “tax expenditure” versus primarily as a “customer” affect the quality of care offered to minorities? ) or in fee-for-service versus value-based care settings [53].

• ◦ The development of equitable and inclusive teaching resources for anti-racist medical education.

• ◦ Faculty perceptions and awareness of racism in medicine.

• ◦ The development of validated scale instruments measuring students’ medical anti-racism competence.

Comparative and international research would also be of interest.

Conclusion

This cross-sectional study employed mixed methods to conduct a survey of medical students enrolled at Finnish universities, focusing on their perspectives on racism and anti-racism in medical education. Novel findings were obtained about the systemic and interpersonal manifestations of racism in medical education, including curriculum limitations, bystander passivity, and race illiteracy. The findings underscore a need for further research on this subject and interventions that expand beyond superficial diversity efforts toward a more critical, justice-centered approach.

The physical and psychological harms of racism are not episodic— they are ongoing, cumulative, and transgenerational [2]. Without intervention, they will continue to damage the health of individuals and communities for years to come. Conversely, embedding anti-racist principles into medical education and institutional practices today offers a powerful opportunity: to break this cycle and support lasting wellbeing for generations of patients and health professionals.

Authors’ contributions

EDA developed the initial research concept, acquired the data, and drafted the manuscript. EDA, PM, and JS contributed to the design of the work, the analysis and interpretation of the data, and the revision of the manuscript. All authors read and approved the final manuscript.

Funding

Open Access funding provided by University of Helsinki (including Helsinki University Central Hospital). Open access funded by Helsinki University Library. This work was supported by the Strategic Research Council at the Academy of Finland (grant number: 358272 for JS).

Data availability

The quantitative data analyzed in this study are provided as a CSV file in the Supplementary Materials (Additional File 2). To protect participants’ privacy, the qualitative data are not publicly available; however, a pseudonymized copy can be obtained from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Ethics approval for this study was waived in accordance with the Finnish national standards for master’s thesis research as the research was based on information without data security risks (i.e., no identity or contact details were collected).

The research was performed according to the ethical principles of the Declaration of Helsinki and the requirements of the University of Helsinki’s Research Ethics Committee in the Humanities and Social and Behavioural Sciences. All participants provided their informed consent to participate in the research before proceeding to the survey. Consent could be revoked at any point up until the final submission of survey responses.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.