Aletha Maybank, MD, MPH: Welcome to Prioritizing Equity. Today, we are discussing medical education, where it is and where it needs to go. In our recently released AMA strategic plan to embed racial justice and advance equity, we highlight that if we are to impact health and well-being significantly, we must strategically assign greater value to the root causes, political and structural and social realities that actually produce inequity. And so increasingly, this is described as moving upstream or an upstreamist approach in health care. We need to talk about these issues in a different way and we need to educate students in a different and more broad way to really address root causes in health equities, both within the traditional clinical settings, but also within larger communities' health institutions of which they occupy and to transform the structures that really generate health and equity.
To really helped us do this today and dive deeper into the discussion, I am pleased to welcome two dynamic voices and leaders in this work who are joining me in this conversation. We have Dr Candice Chen, who is associate professor at the Fitzhugh Mullan Institute for Health Workforce Equity at the George Washington University and Dr Utibe Essien, who is assistant professor of Medicine at the University of Pittsburgh School of Medicine. Thanks to you both for joining me today. I always start off with asking, where are you physically? And how are you doing? Dr Chen, do you want to start?
Candice Chen, MD, MPH: Sure, absolutely. Physically I am outside of Washington D.C. and I can say right now we are very busy, and I think that it's good that we're very busy because the issues that we care about that we're going to talk about today are rising in attention, which is going to be creating opportunities for us. I think we're as good as we can be right now.
Maybank: Thank you. Dr Essien?
Utibe R. Essien, MD, MPH: Sure. Thank you again for having us. I am physically right outside of Pittsburgh, Pennsylvania, and doing well. The sun is shining today and so it's a positive day and really looking forward to this conversation.
Maybank: Yes, the sun is helpful. The change, at least on the East Coast, is it's starting to feel good. That's for sure. Okay, so Dr Chen, I'm going to start with you and just really talk about this history about embedding equity in education. And so, the legendary Dr Fitzhugh Mullan led the way along with others in advocating for the inclusion of social consciousness and upstream opportunities in medical education and really beyond. And so can you speak to that history for listeners who may not be aware of the movement? And we'll talk a little bit more, but can you just talk about the movement itself?
Chen: Yeah, absolutely. And for those that don't know, we lost Fitz about a year and a half ago, and one of the very last pieces that he wrote was published by Academic Medicine. In fact, he submitted it the week that he passed effectively, and it talks about his entire life as civil rights doctor and starting from being a civil rights activist in the 1960s when he was in medical school and a medical student association that was a precursor for the American Medical Student Association.
But I'm going to take this a little bit closer to the present, which is a lot of our work began a little bit before 2010, and the culmination of some of that early work was a social mission rankings of medical schools, which looked at three major outcomes of medical schools and then kind of had the audacity to rank all of the medical schools. And the outcomes that we looked at were, how many of the graduates were actually in primary care? Post-residency, in practice, in primary care. How many were working in underserved communities in health professional shortage areas? And what did the diversity of those classes look like? And you might not be surprised, but the rankings effectively flipped the U.S. News and World Report rankings upside down. Got a little bit of a reaction from the community, but also, I think what it helped us do is really recognize that there were people in organizations, in medical schools across the U.S. who were doing this very hard work. This work that was not being incentivized in any other way.
And what came out of that was a realization that we needed to create a space for people to be able to come together, to realize they're not alone and to be able to share their best practices and share their challenges and share their solutions for those practices in a place where they could also find unity and organize and then begin to advocate for those things. And from that, we initially held a meeting, the first Beyond Flexner Conference, which was held in Tulsa, Oklahoma, which is not commonplace for big medical meetings. That meeting I think was about 150 people. It was only medical schools at that. It was focused on medical schools at that time and was partnered with the University of Oklahoma Community Campus.
And from there, a second meeting happened in New Mexico. And after the New Mexico meeting, the kind of volunteer planning committee came together and said, “Hey, we need more in this space.” And that's how the Beyond Flexner Alliance was founded. In addition to saying, “We need more in this space,” there was also a very clear, “We need to be interprofessional.” And so since that meeting in 2015 in New Mexico, Beyond Flexner Alliance was founded as well as an intentional movement to be interprofessional. And we've held five total meetings. We just had our virtual national conference and it is just … it remains a space …. for people need an opportunity to be able to share their initiatives and find like-minded people and find community. But we hope that what it is, is a kind of a seed that will grow and so we're really excited. What you're doing at the American Medical Association and actually what we're starting to see at some of the other major organizations, the ACGME in terms of really starting to grapple with these social mission issues.
Maybank: Yes. Thank you for that. And so seeding kind of other work and other opportunities, Dr Essien, I think about you along with a collective of brilliant and dynamic students and residents launched the Antiracism in Medicine podcast. I've had a wonderful opportunity to participate in, but can you share kind of what led to that? Because I think it's a very similar context. One, I just think of who has come before us to kind of plant those seeds, but also this need to be together, this need to organize outside of the structures that exist in order to push the work forward. And so can you share the story of kind of what has led to you doing that as well?
Essien: Yeah, definitely. And so I'm so grateful to my colleagues, my family as I call them, who we've been working on this podcast together for about a year now. And again, thank you, Dr Maybank, for joining us on episode five. Shout out to that episode with Dr Camara Jones which was really a beautiful kind of re-imagining of the feature of antiracism in medicine and specifically in medical education. Back in May of last year, when we were all kind of dealing with the data points, the news articles, headlines coming out around COVID-19's disparities, George Floyd was murdered, and I was on the clinical service, on the teaching service as a attending, getting ready to start my first day when that happened. And it just brought me right back to when I was a resident about six or so years ago, when Eric Garner was the first one to share those now kind of words have been etched in our memories, “I can't breathe.”
And how I showed up to work the next day, heading over to the ICU, spent a full 24 hours, a full week, a full month in a clinical experience and not having anyone talk about it, not having his death or the subsequent acquittal of the police officers who murdered him really referenced or brought up. And that was really devastating for me as a trainee, going through that experience and realizing now as an attending, fast forward five years later, that I couldn't kind of live within that silence again. I had a Black medical student on my team, a Black resident on the team, but more importantly, so many Black patients and just humans. Humans who are living through this moment. And so really trying to learn how to have these challenging conversations about race and racism and how it influences the world outside of our hospital walls and the very health of our patients was really the big driver for this podcast.
And got to connect with my brother, Dr Dereck Paul and we together have really put this amazing team that has started these conversations and realizing that we don't know enough personally, just from lived experiences about what racism's impact on our health is. And so we have to check in with the experts, and we've had folks, like I mentioned, like Dr Camara Jones, Dr Giselle Corbie-Smith, Dr Kimberly Manning, Professor Dorothy Roberts, these real leaders in the field about racism and the history of racism. From Edwin Lindo, the use of race in clinical calculators on the wards. From Dr Eneanya and Dr Tsai. We've just had so many powerful conversations that we really do think has filled a gap that was needed, not just to how to talk with our patients and our community members about race, but how we as providers can also kind of develop that historic perspective as well.
Maybank: Absolutely. Thank you. And I think it has filled a gap. For both of you, through all of this kind of movement building, I'm going to call it that because you are activists at the same time, what do you think has been the greatest wins or those unexpected wins in doing the work that you've done? Dr Chen?
Chen: One of the big wins for us was actually going back to the social mission rankings paper, which again published in 2010 and this past March U.S. News and World Report released a number of new medical school rankings, including most diverse medical schools, schools producing the most primary care providers, schools producing the most people who go into rural areas, going to underserved areas. The translation of these issues that are so important into actual metrics. And then the next, I think the next thing that we really need to do is to move from metrics to actual accountability. And so that has been almost a big one for us, but there's still so much more work to be done beyond that. And I think there's so much work to be, as kind of highlighted inside of organizations. And how do we develop metrics and accountability for organizations? How do we then hold those organizations accountable for these activities? Is it through our accrediting bodies? Is it through our funding mechanisms? And in requiring reporting on things that actually matter to communities?
And so, we do a lot of work in those areas. We've got a lot of projects like the health workforce diversity charter that launched just earlier this year, that looks not only at medicine, right now, 10 different professions. We have something called the Social Mission Metrics Initiative, but it's all about how to increase uptake of those things and the use of those metrics, measurements tools, ultimately to get change.
Maybank: Great. And Dr Essien, unexpected successes and opportunities that have come from doing this.
Essien: Yeah, this work, I think for us, we started out with this idea that we can kind of fill a gap and fill a need and have important conversations. And I don't think we appreciated just how much that role was needed. I think over the last year, we can probably imagine the dozens of emails each of us on the team and others have received about our school is starting an antiracist curriculum— what should we do? We want an anti-racism grand rounds, noon conference, pre-curriculum, pre-medical curriculum, medical first year med student elective, kind of the list goes on. And our podcast is now starting to fill that gap. And it's been really cool, to the Columbia pre-medical students from the SNMA reached out to us to ask us about the podcast and the conversations we're having. All the way through to residents here at the University of Pittsburgh incorporating the podcast into their anti-racism curriculum.
And so, we've really seen this embedded within the medical education training system. And I think like Dr Chen mentioned, the sustainability is going to be key. How do we move from a few medical students for the most part who are doing this in their free time, if we're being honest, unpaid volunteers, to actually really incorporate it and embed it within our traditional curricula? And I think until we do that, we're not really going to be able to see the investments we hope to make.
Maybank: You're absolutely right. And we're going to talk more about kind of what that looks like moving forward in those kind of structural changes that are needed. Before we get there though.
Chen: Can I add one more thing?
Chen: One of the other things then kind of stuck out and what we've learned I think over the past 10 years again since, 2010 is the power of students. In the Beyond Flexner Alliance, we see so much interest and students coming together. And for example, the Beyond Flexner Alliance just launched its first student assembly, and it is just growing and they are active and they want change. After the 2010 release of our social mission rankings, Vanderbilt University was last, placed last in the rankings. And we saw a student movement inside of Vanderbilt to say, “White and Blacks, what are we going to do about this?” And they developed a social mission committee. The power of students is amazing, and we should be supporting that empowerment. And they will then demand change, exactly.
Maybank: I totally agree. Within AMA, Med Student Section and Dr Essien is very familiar with Rohan, who's a student, and an AMA and a student leader on the Council of Medical Education. Along with several students, they're the ones who really pushed the anti-racism policies that AMA drafted and pushed those policies. Lots of movements are usually led by young voices, and I think we see that happening in medicine and it's a beautiful thing. And I'm glad to see that people of my generation are embracing it. I'm no longer a student or young, but we're embracing it, and I think that's really important. And so speaking of, Dr Chen, you mentioned accountability. And so one of the acknowledgements in our strategic plan as AMA is really related to the Flexner Report of 1910, hence the words of your alliance, Beyond Flexner.
And for those who don't know the Flexner Report, there's lots of history in it, you can look at the strategic plan to find out more and other pieces. But basically the outcomes of it. And so there was the intended consequence, to create greater rigor is the narrative around it in medical school education. And there were unintended consequences or intended, who knows? It's hard to know intention at that time and does it really matter? It's all about impact. And so there was a recommendation of the closure of five of the seven Black med schools and all of the women med schools, but it also really solidified medical education's focus on exclusively basic and clinical sciences. And so it's, we as AMA, that our Council of Medical Education commissioned the report with the support of the Carnegie Foundation. And so does it matter that we as AMA acknowledge that history that has led to present day harm? And answer please as directly as you choose to answer, because we're saying we need to acknowledge it. And it's good to know what other folks are thinking about that as well.
Essien: I was going to let Dr Chen go first, but I'm happy to…
Chen: I was going to say, as an organization or working with an organization that is named directly in opposition, I think of the Flexner Report and the unintended, we'll say unintended consequences of the Flexner Report. I think I might be biased in that, of course I think history matters and what happened as a result of that history and how we got to where we are, whether you're talking about the impact on the diversity of our medical schools or whether you're talking about the kind of move towards ivory tower medical education and the ongoing struggles that we have. Unpacking that to actually get medical schools, academic health centers and those products of those schools, the future physicians who are ready to do upstream medicine, who are ready to do community medicine. How can we expect them be centered in communities when we don't train them in ways that are centered in communities? I think it matters.
Essien: Yeah, I think that that's right. Again, I was a history minor and so I have a little bias around how important history is. All these books in the background, I think are a resemblance of the fact that we're learning so much, not just from our biology professors as pre-med students or our attendings on the wards, but from the scholars who have done these deep dives to provide us with this history. And I think acknowledging Harriet Washington and historians, like Ibram Kendi who had brought at least to me, this knowledge and perspective so that I can hop on a conversation on a talk, on a call and say, “Do you guys know and appreciate this history that thousands of Black medical students missed out on an opportunity of training because of the closure of these medical schools and what that means for the diversity efforts that we're all trying to embark upon right now?”
And speaking of Beyond Flexner, thinking about just what funding has looked like for historically Black colleges and universities over the last several decades and how certain institutions have missed out on funding, from Maryland to Tennessee at the state and federal level due to biases, due to discrimination, due to segregation that again has really just decreased that pipeline. And so I think acknowledging and learning the history is so critical. Obviously I don't think all of us in the health professions programs can spend our entire curriculum learning history. We have to be able to learn how to take care of patients as well. But I think the history just really makes this transition to a focus on the social rather than just the biologic or genetic impacts of health be way easier and smoother for us.
Maybank: Absolutely. And to that point, so you're right, we have to make sure we're learning about caring for our patients, but I think about the role of faculty and attendings, if we're moving in this direction to teach beyond the basic and clinical sciences, how they have been taught because they've been in the system. And so there's a gap. And I would imagine discomfort for many in teaching positions or students to even talk about these concepts around equity and justice. How great is this gap from your experience? As Dr Chen, you mentioned that students are pushing, but how great is this gap? And what really needs to happen to fix that gap between kind of faculty knowledge, awareness, skills, behaviors in these areas?
Chen: I think the gap is large, but I think that again, from our work in Beyond Flexner Alliance, I have been incredibly impressed by the fact that across medical schools or nursing schools or dental schools, there are people, there are these people that have been doing this hard work for a very long time. They are not the majority, and they need to be supported. They need to have funding to support their programs. They need to be invested in. They need to see career advancement. And if we invest in these people, I think that they can start to make a difference. I think one of the goals that you are describing though is the fact that you're absolutely right. Right now, we're starting to ask faculty and leadership to do things that they actually have little to no skill set in doing.
And so, there is the question of how do we support these people who want to do the right thing, will make mistakes as they're doing things that are difficult? How do we allow them a little bit of grace, but continue to push them to make change? Again, sometimes I go to the Beyond Flexner conferences and I'm just surrounded by these amazing people. People just like Dr Essien and I think, “Oh my gosh, we've got this.” And then we all go. But then we know we all go back to our own organizations and again, there are these oftentimes siloed, not well-funded, not well-supported individuals in there. And we have to change that around them. We have to put pressure, having students demand something different, but also all of us demanding something different. And everybody kind of stepping up to the plate to learn and to figure out how to do this better.
Maybank: Yeah. Thanks. Dr Essien, you're there in the space.
Essien: Yeah. No, I think that that's right. Dr Chen's saying that first, this is such an important question. And secondly that, yes, the gap is large. And I think all throughout the past year, we've seen such prominent examples of this, whether it's colleagues downplaying the role of diversity in medicine or downplaying the role of structural racism and its impact on our health and health outcomes. And so, but beyond those examples, we're seeing that people like was mentioned are not well equipped for this work. They don't have the time to do this, all these emails and the asks around how to talk about racism are being placed on top of the clinical work that my colleagues and I are leading or the research efforts that we are funding our careers through. Or the histology or pulmonology or dermatology courses we are already leading and then folks are being asked, “Oh, by the way, our students need this. Can you please add this to your job description?”
And so, I think appreciating and acknowledging just how overwhelming this past year has been for so many and realizing that we need more than just a handful like Dr Chen was mentioning, who have been thinking about this work for probably longer than any of us really knew what the phrase anti-racism meant, to be a part of this work and be a part of this mission. And I think the more we tie these themes into our competencies and medical training, we will see more experts coming out of the training experience there.
Maybank: Yes. And so moving towards the close of the show and the end of the show, what do we do to move forward? How do we reimagine medical education? What are the things that need to happen? And what are the priority changes really that need to occur? There are many things that need to occur. I think we're all clear about that, but what do you think are kind of really the initial steps that would be really helpful? Whether on the programmatic end or the policy and structural end, which I think is a thing for most of us are, we know really would have big sweeping change. Can you speak to that Dr Chen?
Chen: Yeah, absolutely. I tend to like to think on a policy level, so I'm going to go there, and I'm going to go back to that issue of measurement and accountability and how we develop our incentives and our payments and support. And some of the things I think about, for example, recently the NIH actually did a request for information on how do we adjust issues of diversity as well as disparities. I think it was a combination of how do we adjust the issue of diversity within the research workforce, we'll say, as well as how do you advance research around disparities? And when we responded, one of the things that we pointed out is that NIH has funded at over $30 billion. A lot of that funding goes out to our medical schools. And how they structure the requirements around the grant programs, if they valued and asked for the diversity of teams, if they asked for what is your organization doing in terms of addressing diversity, equity, inclusion? And took those things into consideration in the making of awards, that would be a huge incentive for organizations to start making change.
The other place that I'll say is Medicare, graduate medical education payments squarely in the space of education. It is the largest public investment in workforce development, in physician development, approaching $15 billion a year goes out to teaching hospitals. And in 2010, MedPAC made recommendations that included leveraging those funds to address diversity as well as other needed changes in our physician workforce, in our training. In 2014, the National Academy of Medicine again made recommendations for how do we change those payments and establish some accountability in that system so that the $15 billion that we put out, that comes out of our pockets as citizens and goes to support the training of future physicians actually then produces a workforce that's equitable itself. And then also able to address equity for communities. I think there are, I want to say it's low hanging fruit. Unfortunately it's incredibly political when you're starting to put accountability around $15 billion, but it's there. It can be done. It needs to be done.
Maybank: Thank you. Dr Essien?
Essien: Yeah. I think I'll stay higher level as well and kind of think about health system leaders and what they can be doing today. I think first, like we mentioned, we need to hire the experts and bring in the folks who have again been doing this work for decades, who are not necessarily in our health professionals training, but maybe sociologists, anthropologists, historians, who can really provide us with the perspective that we need to be able to move this work forward. And so we are not relying on medical students who should be studying for their board exam, who should be learning the profession of medicine from the experts and not necessarily giving their time and their talent to this work. Though again, they are so, so socially motivated and invested in this work.
I think second is investing in this minority tax reform is now being referred to as just a yesterday article, came out in the New England Journal of Medicine about how the same people who are being asked to diversify our health professions workforce are being asked to teach about anti-racism, are being asked to lead community engagement work and are being asked to kind of be the face of health disparities research. And so having one person lead all of those efforts is simply impossible. And also, unfortunately we know that kind of my third point is around prioritizing this work. Is that to date it has not been promoted and supported in the same way as those NIH grants or foundational grants have been supported. And so, I think if we truly do want to sustain this work, we have to prioritize that, those investments and those efforts in a way that really is meaningful is going to be fulfilling so that we can keep these incredible educators within this work. And again, train the future of tomorrow.
Maybank: Fantastic. You both gave wonderful solutions, and that's what the audience really needs to hear. And I think at this point in time, even with our strategic plan, I think about there's an accountability, but there's a responsibility piece in that, that when you start to put out information and directions of which health care should go, we have to be responsible for providing the information of how to get there. And especially in a space where people just haven't been working. I just wanted to really thank you for your contributions today and your contributions for not just today, but contributions that you do every single day for our students, but for the field of health and medicine overall. And thanks to everyone for listening in. For any more information on our strategic plan, you can go to ama-assn.org/equityplan. Thank you all for joining us and see you the next time.
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