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Racism in Medicine: Historical Foundations and Strategies for Advancing Health Equity

Learning Objectives
1. Describe basic terminology around Race and Racism
2. Classify how manifestations of racism are present in medicine practices
3. Identify opportunities and literature options for physicians to continue their health equity education
1 Credit CME

Racism in Medicine provides physicians and health care workers access to important historical foundations of medicine. Learners will have the opportunity to learn about race, racism, and the systems of power that influence the well-being of communities of color. This learning activity will provide examples of why it is crucial to complete health equity trainings in addition to medical education.

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Education from AMA Center for Health Equity
AMA’s online education to empower individuals and organizations, in health care and beyond, in advancing racial justice and equity. Learn more.

Video Transcript

Emily Cleveland Manchanda: Thank you to everybody who is here tonight. It is a pleasure to speak with you about this content and I will happily take questions as we get to the end.

So tonight, we are going to begin as those of us at the Center for Health Equity always begin each of our talks with a land and labor acknowledgement. We acknowledge that we are all living off of the stolen ancestral lands of indigenous peoples for thousands of years; we acknowledge the extraction of brilliance, energy, and life for labor forced upon people of African descent for more than 400 years; we celebrate the resilience and strength that all indigenous people and descendants of Africa have shown in this country and worldwide. We carry our ancestors in us and we are continually called to be better as we lead in this work.

I'd like to also acknowledge a few folks before we get started. Dr Nita Chary is a friend and colleague who has shaped my understanding of structural systems of power and oppression, and has contributed in part to this content.

Abigail Ortiz and Denny Butler-McKay at the southern Jamaica Plain Health Center in Boston are extraordinary racial justice leaders, and I owe them a great deal of credit for my own education and knowledge in this space.

And the Equitable Health Systems Integration team at the Center for Equity has also been another source of learning and growth for me as well.

I have no disclosures, but I would ask you to, as we start this talk, to think back to your first few months of intern year. I think most of you are physicians like me, and if you're anything like me, or as I was then, you were deeply and profoundly uncomfortable in those months. In retrospect, I know that's because I was learning a new way of seeing the hospital and the world that I lived in, and that discomfort that you experience in that moment may be similar to some of what you feel as you listen to this content, and it might be a sign that you're learning or being pushed beyond your comfort zone. So please do try to sit with those feelings and be open to new ideas and change as we talk about some difficult work.

Here's our agenda: we'll start by talking about race and racism. We'll talk about why race is a social construct and why that still matters. We'll talk about racism and privilege and the groundwater approach to thinking about these concepts. We'll also then talk about manifestations of racism in medicine, both on the interpersonal level and the institution level, as well as the systemic level, and I'll offer you some thoughts about what you might do to address this.

I'd like to begin with a quote, and just sort of center us in the moment where we're learning some of this content.

“So whatever it is, coronavirus has made the mighty kneel and brought the world to a halt like nothing else could. Our minds are still racing back and forth, longing for a return to normality, trying to stitch our future to our past, and refusing to acknowledge that rupture. But the rupture exists. And in the midst of this terrible despair, it offers us a chance to rethink the doomsday machine that we have built for ourselves. Nothing could be worse than a return to normality. Historically, pandemics have forced humans to break with the past and imagine their world anew, and this one is no different. It's a portal, a gateway between one world and the next. We can choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks and dead ideas, our dead rivers, and smoky skies behind us, or we can walk through it lightly, with little luggage, ready to imagine another world and ready to fight for it.”

So I invite you to bring not just your mind to this discussion, but also to connect with your body. Sit comfortably, just breathe for a moment, and as we talk about some difficult contents, try to stay connected with how you're feeling.

I'll ask you to consider with me that we cannot talk about racism without talking about white supremacy. Considering the scale of American history on this very short timeline and where the post-Civil Rights movement and post-Civil Rights era sits on this timeline, we're talking about very recent history. Racial inequality and inequities underlie all aspects of our society and the ways in which this system has worked have changed over the past 4 centuries.

Boston City Hospital where I work was founded in 1864, has been around for a long time and Harvard, where I trained for residency, has been around for even longer. Because we're going to talk about him a little bit, this is my father's timeline, he was born in 1952 and lived through some of the Civil Rights era. And I'd also just like to ground us in the knowledge that Michael Brown Jr.'s timeline was incredibly short. He was murdered by police in Ferguson, setting off the first wave of the Black Lives Matter movement in 2014, and just to acknowledge that while the systems have changed over time, the manifestations in terms of inequity and downstream real personal harm haven't stayed in many cases the same. Because of that, we no longer need bad people to perpetuate our racist systems.

I'll encourage you to move away from thinking about racism in terms of interpersonal actions, words, and behaviors because individual racists aren't a problem anymore. Now, I'm not saying that overtly racist behavior or words, are in any way acceptable, but we're going to talk about some of the less obvious ways in which we all through our actions, through our words, or our institutions continue to perpetuate inequity, and that being said, it is really important to explicitly talk about racism in order to identify the ways in which we can dismantle racism and other systems of oppression.

And historically, we've been really bad at that. The US health care industry avoids even talking about, let alone addressing racism. A recent article in Health Affairs looked at the top 4 medical journals in the world and found that they almost never published scientific articles that name racism as a driver of poor health outcomes and that started to change in 2020. You can see here that dramatic increase in the mention of the word racism, but we still lack empirical scientific research connecting the experience of racism to downstream health outcomes.

That's problematic because in medicine nearly everything we do or strive to do is based on evidence. We know that evidence is used to inform public policy, set public health guidelines, adjust government budgets, prioritize our research agendas, and determine standards of care as well as the treatments that insurance will cover. And so if we aren't talking about or studying racism and its health effects, it can be difficult to address it. We at least need to begin by naming it.

So let's talk about it. Race. I will spend some time talking about the concept of race and the science that does or does not support the ways in which we group people by race in the United States. So here when we think about race, we typically think about white, Black, Hispanic, Asian, Native American as our major categories, and we've been conditioned to see race as natural divisions within the human species based on apparent physical differences. However, race, just like other aspects of our identity, is socially constructed.

So what does that mean? We'll dig into it a little bit. Historically, probably in the 19th century and early 20th century, there were several, the idea of racial essentialism predominated. And so this is the idea that there were several mutually exclusive but tangentially overlapping groups based largely upon physical features like skin color and facial features. This understanding supported the development of race-based medicine. With leading physicians and scientists creating volumes of scientific data proving the biological distinctions between racial groups. The scientific racism in the 19th century created myths of biologic differences that persist today in medicine, including false beliefs about differences in pain tolerance and organ function.

A population approach to race identifies local populations that are thought to be somewhat different genetically from one another, but there are some overlap between the groups. The idea that each group has some unshared or genetic distinctiveness as well as some overlap to other groups predominated throughout the 20th century, and this is still how many people in America, including many physicians and scientists, think about race. This belief underlies the efforts to identify genetic differences that explain how disease prevalence differences—differs—excuse me, between racial groups or how people of different races respond differently to medications.

A more modern and scientifically accurate understanding of genetic diversity, though, supports this nested subset approach. Which reflects that there's no genetic or biological basis for race and that this is a truly political and social construction. There's more genetic variation within what we call racial groups, whether that's Black or white or Asian, or Native American than between any—and so to get into this I want to bring it home a little bit more concretely and just note that the same regional categories don't apply when you move from one society to another.

My husband right here at Grove is classified differently in different parts of the world and even within the same country. Here in the US, he's often classified as Asian or Southeast Asian, although sometimes people assume that he's mixed race, Black, Middle Eastern, or Hispanic, depending on his clothes, how he's speaking and with whom he is associating. When we are in different areas of the world. He looks different and he is interpreted differently. Importantly in Liberia, where we met 15 years ago, he was white and it's not just that he was perceived as being white like me, it's that he was noted to have a different skin tone, but he was still classified in the Liberian society as white and he was afforded the privileges that went along with whiteness in that society.

It's interesting because when we first began our relationship, we didn't really exist in an interracial relationship the way that we do in other racialized societies, and that was driven home, particularly when we visited South Africa where he's considered “colored” and our experience of our relationship in the way that people responded not just to him, but also to us, differed in those societies.

It's important because as Camara Jones has explained, when you step off a plane, your race changes and importantly, in racialized societies like our own, as your perceived race changes, so do your prospects for health, for wealth, and opportunity. And so, because race is just a social invention, maybe we could just be colorblind, and wouldn't that solve all of our problems? Maybe we can all just not talk about it, and eventually it will go away. Unfortunately, it's not true. We have to talk about race because, in many ways, it serves as a proxy for the experience of racism in America.

This chart comes from a working paper developed by the Racial Equity Institute in a disparate state of across multiple different aspects of our society: health, education, the criminal legal system, child welfare, finance. It demonstrates that compared to white Americans, Black Americans the higher rate of experiencing bad outcomes across every sector by an order of magnitude in some cases, because race is just a social and political invention, doesn't mean that it doesn't have real-world concrete biological consequences because of racism.

I'll put it in Black and white for you. This is the number of excess deaths each year that could have been prevented in the United States in 2005 pre-COVID, if the Black and white mortality gap could have been eliminated. We're not talking about small numbers of people, and we are still talking about real world, terrible outcomes, and deaths, and so we'll define racism, right?

Because if we're not talking just about race where we want to talk about racism, I'll offer you two opportunities to define it. The first comes from Camara Phyllis Jones. She defines racism as a system of structuring opportunity and assigning value based on the social interpretation of how one looks that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources.

Ibram X. Kendi defines racism as a marriage of racist policies and racist ideas that produces and normalizes racial inequities. And I think both of these definitions offer important ways of understanding how we can and should think about racism.

The flip side of racism is privilege, right? We can't talk about racism and the disadvantaged results without also talking about the advantage that's on the other side of privilege that can be defined as the advantages and immunities enjoyed by one dominant or powerful group or social class, again with the flip side being to the disadvantage of others. There are many forms of privilege, all of which relate to where our social identities situate us in proximity to power.

So I just want to spend a moment kind of digging into this concept, explaining the way that I think about privilege, particularly for myself, and share with you some of the framework that I use because this helps me to respond to people when they ask why they should feel guilty or take responsibility for the way things are since they didn't own slaves in the 1850s themselves. It's a key point for me personally, because on both sides of my family, I can trace my ancestors back to the original colonist settlers who arrived on the Mayflower and among the first families of Virginia and therefore were a part of the land theft from indigenous communities, and all of these systems of power and oppression that got set-up in our country and the benefits that came from that from being white.

So I want to tell you about my dad. This is Bob. I'll say before I get into this, that we have a great relationship and he knows that I share this content publicly. My dad works really, really hard and he has throughout his entire life. For fun he literally rides his bike up mountains, because apparently that's fun. He worked as a lawyer for years and had 60-hour work weeks for basically his entire career, including into his 60s. He's a great dad. He's an amazing grandfather. He plays a mean guitar and he is hilarious when he gets on the dance floor. He and my mom put 4 of us through college and they retired to New Hampshire a few years ago. They've offered us an incredible life with tons of support and love and safety and emotional support as well, and it's important for me to think about the ways in which his success and my own were and were not related simply to his own hard work. Maybe some of it was luck, but maybe some of it was structural and so we'll look back another generation.

The guy on the left here is my grandfather. My dad's dad went to med school on the GI Bill after serving as a marine in the South Pacific during World War II. This is him in 1943 or 1944 on either Guadalcanal, Okinawa, Peleliu, or [unintelligible]. We're not sure where the photo was taken, but if you've seen the HBO miniseries, “The Pacific” that was my grandfather's division. He came home, he finished college, and then medical school. Afterwards he became a surgical pathologist because he had a shrapnel injury that meant he couldn't stand up for long enough to be a surgeon as he had hoped. His wife was an aspiring concert pianist, but actually taught piano lessons out of their home. They perhaps, predictably settled down in the Lily-white suburbs in northern New Jersey and Florham Park. They bought and paid off their GI Bill-backed mortgage on their house in 1954 when they started with a $500.00 down payment. They went on to live on a live comfortable middle and then upper-middle-class life. It's important to note that Florham Park, where they lived, where my dad grew up—and essentially all suburban neighborhoods across the country—were intentionally created and maintained as white-only communities. This was done through the creation and enforcement of racist policies that were created by the US government, banking institutions, and neighborhood associations in a system that's referred to as redlining, which prevented Black families from obtaining mortgages in these same neighborhoods.

So, imagine with me, an alternate universe in which my grandfather were Black. If you'd returned from the Pacific and tried to go to med school in the 40s, because of the downstream effects and consequences of the Flexner report, there are incredibly few opportunities for Black folks to become physicians. Moreover, he would not have had access to government-subsidized homeownership because in the New York and New Jersey suburbs, while 67 000 mortgages were insured by the GI Bill, fewer than 100—that's less than 15%—of those were taken out by non-white individuals, and that's not because they didn't want subsidized homeownership opportunities. It's because they were systematically and intentionally excluded from that opportunity to build wealth.

And So what? Maybe that's just ancient history, right? Like this happens, what? 70 years ago? It's not though, because the government support for my grandfather's education and for their home allowed him to become a physician. Those combinations, in conjunction with the color of his skin, meant that they were allowed to live in a safe community where his kids could go to good schools, and use good hospitals for their health care.

My dad is in his late 60s and has passed all of those opportunities and safeties and supports down to his kids and by proxy to our partners and our children. All of those unearned advantages have been bolstered from the 50s onward, and certainly before that as well, by more recent policies that have supported us as we have achieved the American dream., essentially.

Those effects persist in our generation, and unfortunately, it's been supported by many of the things that have persistently kept others from achieving the same, the same privileges, and so I want to turn to the concept of white privilege, and I will offer you this definition that it is privilege, afforded by skin tone, which allows for presumed membership in the dominant racial group. It's also important to recognize that white privilege doesn't mean that white folks don't have hard lives. It just means that their lives haven't been harder because of the color of their skin. It's an important distinction because it's not, you know, privilege and oppression are not sort of zero-sum games.

So, we'll turn to some other history. We talked a little bit about redlining in Florham Park. Let's look at Boston, where I lived for a long time. Here's a map from the 1930s and 40s that was created by the Homeowners Loan Corporation, the green areas—and there were not very many in Boston—were considered good investments for mortgage lenders, while those yellow areas were definitely declining, and red areas were hazardous where they would not issue mortgages. It isn't a coincidence that the same map could represent a wide range of neighborhood-level differences, not just in economic terms, but also in health outcomes today.

So, for example, here's a map showing ED visits for asthma among kids between 2012 and 2015. And those darker areas of Roxbury, Dorchester, Roslindale, Chelsea are the same areas that were redlined and where a disproportionate number of Black and brown Bostonians continued to live today even more recently. Here's a map showing rates of COVID-19 infections by neighborhood and the similarities, I think are apparent. So, what's driving this right? How are housing and rates of asthma and COVID connected? Why is there a connection 70 years apart? Maybe it's socioeconomics wealth building through homeownership or maybe it's access to quality health care, right?

While those may play a role, I want to highlight a couple of quotes from the Institute of Medicine report, which allowed experts to gather extensive data and present that exploring the impact of race and ethnicity on health and health outcomes. Even after correcting for socioeconomic and health care access factors, the report found that racial minorities were less likely than whites to receive needed services, including clinically necessary procedures. Moreover, the report found that our decisions as physicians are influenced by race and racial stereotypes, and this data isn't new. This is a report from 2003.

So as we come back to this chart, if we consider not just mortality ratios and health outcomes, but other aspects of life, when we compare Black and white Americans in every single sector, Black Americans have a higher likelihood of a bad outcome. We call this something different in each of these sectors. In health we call it health disparities. We call it the achievement gap in education. Or disproportional disparate sentencing in criminal legal systems and disproportionality in the child welfare system. We call it redlining when we talk about homeownership, financing and we talk about under-utilization of minority enterprises in other aspects of our finance system.

But what I'll offer you is that the end result, right now, our current status quo is that white folks in America have better outcomes across every sector. And I'll say that the Racial Equity Institute has data demonstrating this in every state across the country, in many county-level outcomes as well, and the pattern never changes.

So, how do we explain this and understand this? I want to talk to you about fish. This is an analogy that I'll use, it's inspired by the work of epidemiologist-physician Camara Phyllis Jones, but also was presented by Joyce, James, and Baylor back in 2013. So in medicine, when somebody dies unexpectedly, we look to the autopsy report right? For the sake of analogy, let's say you walk past a lake and you find a dead fish. We might ask, why did this fish die? What was wrong with it? Maybe it ate poorly. Maybe it didn't exercise. Maybe it smoked and that's why it died and to answer those questions, we dissect the fish. But if we walk past that lake, and you find that half the fish in the lake are dying, our frame might shift.

So what's wrong with the lake? we might ask. We'd still probably think about the fish. Why did those ones die? And also the others. Maybe they have better genetics. Maybe those surviving fish took better care of themselves, so they were eating well and avoiding, harmful behavior, but even so, there's a lot of fish dying, so we probably would test the lake water to see if there's something in that particular lake that's poisoning half the fish.

What if you realize that what's happening in your lake is also happening in all the lakes in the whole country? Now we'd have to look to the groundwater to find the toxin. Because if we realize that this is happening, we can't just fix fish and put them back into that poisoned water. Helping individuals, no matter how much, won't solve the underlying problem. I particularly love this metaphor for systemic racism because like the poisoned groundwater, the problem can go unnoticed unless you intentionally start to look for it. So let's look for it. We'll talk about some manifestations of racism in medicine next.

This is a busy figure, but it's a framework that I find helpful when thinking about how racism and other root causes of inequities operate to produce inequitable health outcomes. When we think about where racism manifests and how to address these systems of oppression, I find it helpful to come back to this to consider whether an initiative is really purifying lakes or addressing groundwater, or whether I'm just fixing fish.

And allow for you the idea that diagnosis determines treatment, right? We know this in medicine. If you make the wrong diagnosis, you're going to almost inevitably treat incorrectly. We can't fix what we don't see. So, we'll start by talking about interpersonal colorblind racism, and then we'll move on to thinking about some of the institutional and structural ways in which it's baked into our systems.

Interpersonal racism in what I'll call its old-fashioned form, is not invisible, right? It's blunt. It's easy to recognize, and in most parts of American society, it's become unacceptable to the point where the risk of social ostracization limits the use of racialized slurs and overtly racist remarks. We know that some of that has changed in recent years, but nevertheless, you know, we've heard this and we know that there is social risk in being overtly racist.

I want to bring your attention to the more subtle and arguably more powerful or self-sustaining version of interpersonal racism that predominates in the 21st century. This is what Eduardo Bonilla Silva calls colorblind racism and I'll offer you this framework. It's how many of us, particularly in this sort of post Civil Rights era, understand and explain racial inequities that persist in our society. The 4 central frameworks include abstract liberalism, which is using abstract ideas like equal opportunity or individual choice as explanations for persistent and marked racial inequities. Using the naturalization framework, we can explain away racial phenomena by suggesting their natural occurrence is right. The idea that people just gravitate towards each other and are attracted to people of their own race as an explanation for neighborhood segregation, for example. Cultural racism is a framework that attributes racial differences to cultural practices. For example, a particular racial group just doesn't care about education as much as another. Lastly, minimization allows for statements like “it's better now than it was in the past,” which may be true but dismisses and thus normalizes ongoing racial inequity as part of the status quo. And so some of the more covert manifestations of this colorblind racism perpetuate inequity through our everyday, seemingly nonracial interactions. Some of these stem from what's called what's been called unconscious or implicit bias and we'll talk about that in a little bit. Those automatic associations we make in our everyday lives.

Microaggressions are another manifestation and many of the statements that we've all heard and which almost all of us have made at some points, have a disproportionate impact on people who are marginalized or have some aspect of their identity that is socially marginalized.

We'll dig into this a little bit more as well.

I want to share with you Daniel Kahneman's model for how our brains work. Thinking about our system, one or system two brains as he terms them. System one brains the way that we think we're using them are effortless. It's implicit, it's fast, it's pattern recognition and associations, and it happens unconsciously. Our system two brain takes work. It's explicit. This is where we use reason. It's slow and sometimes a lazy process. You use logic a little bit more consciously, and these processes take intentional effort.

And so if I pulled all of you, if we're in a room together and ask you how much of your time you spend using your system two brain, most people would respond somewhere in that maybe 10% to 15% of the time. In reality, we know again from neuroscience, that it's only 2% to 5% of our thinking. That is actually done with our system two brain. The vast majority of our brain's use is done in the system one framework. It's firmly in charge of how we think, and so I want to talk a little bit about unconscious or implicit bias, which is how our system one brain operates.

This bias is the consolation of unconscious attitudes and stereotypes that influence our way of thinking and our behavior without our awareness. And these unconscious beliefs are most at play when we find ourselves in high-stress, time-pressured situations when operating with incomplete information.

And that sounds a lot like my clinical job, basically, every time I'm in the emergency department. Importantly, it's often divergent from how our system two brains think, and we are just as susceptible as physicians to using these heuristics. Our system one brains both in our clinical work and outside of it.

Implicit association tests were developed to measure implicit preferences by bypassing the conscious processing to evaluate how system one brains operate. You get presented with a times dual categorization task, where you are instructed to rapidly categorize a photo or a word by pressing a lefthand key or a righthand key, and they've been validated as a means of evaluating our unconscious preferences, for example, with regard to race or gender.

And so how does this operate at work? I want to share this conceptual framework for how our biases can affect patient care. This is offered by Blair et al in their 2011 paper, and each of the aspects in this framework, I'll just say are supported by extensive research, both into the sociology field and in medicine. So, consider as an example a white male clinician who is caring for an elderly Black patient who has poorly controlled hypertension. Without realizing that his unconscious biases are affecting his assumptions, the physician feels like the patient is a little bit uncooperative. Or maybe she just doesn't prioritize her health, and she'll probably be noncompliant with a more intensive antihypertensive regimen. The clinician might evenly erroneously “remember” that this patient can't afford the pharmacy copay, which in this particular patient case is untrue and as a result of these unexamined beliefs and assumptions, the physician chooses not to change the patient's medication, believing that he's acted in a way that is in the best interests of that patient's situation.

The physician's decision-making process, however, was distorted by those unconscious or implicit biases. This figure also highlights the patient's perceptions of the clinician, which can influence their interaction and in turn, their ability to or their interest in listening to the physician's advice, and many studies have demonstrated that people, including physicians with higher degrees of unconscious racial biases, have more negative interpersonal interactions with people of color, which in turn of course can influence the patient again, and their sense of trustworthiness and physician's trustworthiness in the eyes of their patients.

Then we'll underscore here that our unconscious biases are the result of the society in which we live, right? They're based on messaging that we absorb from the media, from our teachers, from our families and friends. Based on facial expressions, small gestures, or offhand comments. As Professor Mohammed has highlighted, our brains didn't end up with blind spots on their own. We've all been taught early in life with whom to play, where to go to school, what neighborhood to let them wear to work, and even where to shop based on the risk of criminal victimization and other aspects of the ways in which Black people are portrayed in our society. And so again, I want to turn to some of the other covert ways in which this shows up in our interpersonal interactions.

Microaggressions are another way of this racism in our groundwater manifests. It's a term that was first coined by Dr Chester Pierce in 1970, was popularized by the work of Derald Wing Sue. And microaggressions while seemingly small and innocuous, or innocent can trigger anger and depression and lower work productivity as well as poor problem-solving skills whether intentional or not like regressions, make work in school hostile unless validating causing an erosion of confidence and achievement in students and trainees and in our colleagues. Links to again borrow the words of Dr Jones, this manifestation of racism harms us by sapping the strength of the whole society through the waste of human resources. Whether it's through personal or secondhand experience, most of us are aware of raises a context for microaggressions statements, like the ones that are portrayed on the screen can be heard in many of our workplaces and in our social interactions.

These can affect all of us, though whether it's in the context of being misgendered and making assumptions about someone's sexuality or someone's religion without knowing what religious beliefs, they have. And they can affect each of us in different ways based on our own social identities, it's important to recognize that the impact of microaggressions is dissociated from the intent.

So a statement like, “wow, you're so articulate” may be intended as I'm giving you a compliment, but when heard by a person of color can feel like “I don't expect people of your race to be well spoken” or “people of your race normally aren't well spoken”. And I liken this to telling somebody like, “oh, your breath smells so good today”, right? Like implying that that is a shock it would obviously connote that you didn't think that they were going to be how they show up in most of their life. So saying to them like “you don't look like you speak Spanish” might be intended to open a conversation about someone's background, or say that you couldn't tell their race or ethnicity or wonder where they might have studied abroad. But really it makes a note to someone who is Latino or Latina that Spanish speakers are all dark complexioned or that Hispanic people all look alike.

A question like “where are you from?” is one that really gets at the heart of the difference between intent and impact and also highlights the ways in which the impact differs between people. When somebody asks me where are you from, I say I'm from Philadelphia, right? Not a big deal, not a microaggression when it happens to me, but to a person of color or someone whose social identity is otherwise marginalized in this country, it can signal or make them feel like the speaker thinks you're not American or you don't belong in some way.

So, what's the impact of these things, of our unconscious biases, and of microaggressions? Particularly with microaggressions, I want to highlight this in the context of medical training. This qualitative study of 27 minority resident physicians found that participants described 3 major themes in their experience, a daily barrage of microaggressions, and bias. They felt that they were tasked as race and ethnicity ambassadors, representatives of their social group, and they also highlighted many challenges negotiating their professional and personal identity while being seen as an other.

The impact of unconscious bias microaggressions in the workplace is often easier to grasp for people who have at least one aspect of their social identity that places them in the minority. So for example, women in medicine, and particularly in specialties, where there are still stark gender disparities, are familiar with being mistaken for a nurse or being called diminutives like “sweetheart” by you know, patients or even colleagues.

Now that you've heard a smattering of microaggressions, I'd like to point out that just going through life, not hearing them is a privilege and an emotional advantage, right? We know that when we address these and we understand that our colleagues experience these, that we can influence and shape the culture in which we work. But for those of us who've gone through life without hearing and feeling them, we have an emotional edge, right? We don't have to deal with the baggage with the harm that is caused by these statements. And just like my father's childhood and mine was unfairly advantaged because the education that my grandfather received and the neighborhood where they were allowed to live and where I was allowed to live, we've gone through the world with many people may most of our time, with people giving us the benefit of the doubt and that again kind of privilege, it gives us an advantage.

The recent increased attention to unconscious bias has led to some of the emerging evidence about how to mitigate its harmful effects, and so I'll again turn to Daniel Kahneman's book here. We know that awareness of the effects of racism and the other forms of oppression can help us change our patterns of thinking. There's some evidence that increased awareness of unconscious biases helps mitigate their effect. We can also consider multiple perspectives when thinking and trying to use our system two brains more effectively. We can make incremental decisions rather than snap judgments. We can use frameworks and theories to help us. Things like a specified treatment plan for pain management and other through decision trees can help to shape our behaviors in ways that produce more equitable outcomes. We can use probability and statistics rather than impressions or hunches. There's also new data that suggests that knowledge of racism predicts bystander intervention when a racial microaggression or racist policy are noted. The authors of this paper underscore that when we understand and explicitly name and teach about the impact of racism, rather than just rates, as a cause of poor health outcomes, we can increase our ability to address racism in multiple contexts, both interpersonally and institutionally.

And so, I now want to turn from interpersonal manifestations of racism to some of the more hidden ways in which racism operates in our society. Rather than asking if racism is affecting patient care or patient experience or treatments or outcomes, I'll challenge you to instead start from the understanding that it's in our groundwater. This allows us to begin by asking how and not whether racism is operating in our workplaces and in our society at large, because again, diagnosis determines treatment. If we're treating the symptoms but not the underlying disease, we're never going to get folks healthy.

So, let's talk about institutional racism. It's a term first coined in 1967 by Stokely Carmichael and Charles Hamilton in Black Power: The politics of Liberation. Carmichael and Hamilton wrote that while individual racism is often identifiable because of its overt nature, institutional racism is less perceptible because of its less overt far more subtle nature. It includes discriminatory treatment, unfair policies and practices, and inequitable opportunities, which originate from the operation of established and respected forces in society and thus receive far less public condemnation than individual races.

So, we might think about institutional racism as something like a racist policy. For example, at Grady Hospital just a few decades ago, all Black patients were treated only in one tower of the hospital while white patients were treated in the other tower and people in the community still remember this. Occasionally, you'll still hear Grady referred to as “the Gradys”, which is a consequence of these dual segregated racial and racialized systems of care.

Much more recently, we identified racial inequities and specialized heart failure care at the Brigham where I trained. Residents who are working on both general medicine and cardiology services observed the Black and brown patients with who presented to the emergency department with congestive heart failure were disproportionately admitted to general medicine while their white counterparts were admitted disproportionately to the cardiology service. When we looked at the data, it became apparent that even after we controlled for comorbid illnesses, insurance, socio-demographic factors other than race, neighborhood wealth, and the type of heart failure, valvular disease, etc., this racial inequity persisted, and moreover, it translated into worse outcomes. There were higher rates of 30-day readmission, lower rates of cardiology clinic follow-up for our Black and Latinx patients because having an in-network cardiologist was a strong and the strongest predictor of being admitted to the cardiology service this led to a vicious and self-perpetuating cycle. These findings lead us to work to address this at assistance level both to ensure equity in admission service and to improve the quality of heart failure care on the general medicine service.

It's important to recognize that addressing structural manifestations of racism improves care not just for marginalized and minoritized patients, but for everyone who receives care in that system. And one of the only examples of institution-level reparations that I'm aware of, our study, also led to the development and implementation of a program that preferentially allows Black patients to be admitted to the cardiology service when they present to the ED with CHF until the historical imbalance has been correct.

So, Bram Wispelwey and Michelle Morse, two of my coauthors, in that heart failure study that I just discussed, laid out this framework and other concrete strategies that institutions can take to live up to their anti-racism pledges in publication that they put out last year, which garnered some national media attention, and so the Healing ARC is a framework that aims for institutional accountability. We go for a broad education on racism and its clinical manifestations, as well as redress for patients with input from impacted communities. And it takes reparative and restorative justice approach, so the acknowledgment aspect of this means that the institution voices ownership and responsibility for inequities of the to the communities that were impacted and there's research that backs up this approach, right? People know that harm is happening, and so when the institution explicitly acknowledges that this is happening, it doesn't actually harm the institution's reputation any further because the people who were being harmed already knew it. They might not have known the numbers. They might not have known the specific manifestations, but people know that this is happening in our institutions. The redress portion of this means that there's a compensatory step that's taken to address patients and communities that were harmed by institutional racism.

So, in the Brigham's case, this example that I was just mentioning, there's a new popup alert for patients who self-identify as Black or Latinx when they present to the emergency department with heart failure. If an ED doctor enters a bed request to admit them to the general medicine service, they get a new BPA, says patients from a racial or ethnic group historically inequitable access to the cardiology service., consider changing the admission to cardiology unless extreme census or overriding clinical reasons mean they should be admitted to general medicine.

The closure piece of the Healing ARC framework means that we explore community oversight as a means of ensuring fair restitution for inequities. In this effort, the Brigham team is meeting with community leaders and health activists, and the reparative justice framework is used to acknowledge historical and current institutional racism within heart failure care with deep engagements to consider redress and create closure.

So, I'll turn now to systemic racism. It's even larger scale. This is like the big P policy, not the small P institutional policy. And think about the ways in which racism operates behind the scenes to produce widespread racial inequities. So, systemic racism is characterized by discrimination in the social, economic, and political systems of housing, education, employment, earnings, benefit, credit, media, healthcare, and criminal justice as well as I'm sure others.

So, we'll focus on the health care sector to look at the ways that racial discrimination is baked into our system. For a last example here of how racism manifests in contemporary medical care, I'll ask you to consider with me the inclusion of race in clinical algorithms. Inclusion of race in clinical decision-making frameworks exemplifies the covert way in which racial essentialism—that idea that race is biological is a biologic reality or genetic reality—and the way that that concept and framework has infiltrated and continues to support research in medicine today. There are so many examples that are beautifully summarized in this New England Journal article by Josh Hawley Gas and her colleagues. But I'll highlight three here, so the vaginal birth after Cesarian risk calculator predicts a lower likelihood of successful VBAC for Black and Latino women, which can decrease the likelihood of an obstetrician offering a trial of labor for women of color.

The fracture risk assessment tool reports 10-year major osteoporotic fracture risk as markedly lower for a Black or Hispanic woman compared to a white woman with identical characteristics. This may delay treatment of osteoporosis among people of color.

And interestingly, though, the formula used behind the scenes for the Fraxel is proprietary, so we can't see how it was derived, there's no similar race correction in other countries with racially heterogeneous populations. I'm sure there's a third example, sort of the better known one, which is that both the [unintelligible] and the equations that were used to calculate bGFR previously incorporated a race correction which raised the patient's bGFR for by a factor of 15% to 20% if they're Black. This suggested better renal function for the same creatinine level, which in some cases delayed referral to nephrology or listing for transplant. The National Kidney Foundation and the American Society for Nephrology task force that they put together to study this recommended the removal of the race correction and presented a race-neutral formula for calculations last year which has been implemented in many institutions across the country now.

I want to be clear about why the inclusion of race-based corrections in each of these equations is problematic. First, from a pragmatic standpoint, it's not clear in any of these cases how Black is Black enough to use the adjusted algorithm? If a patient is half Black, is that sufficient? What about a quarter? One drop? More importantly though, is the premise on which these algorithms were developed. It's not that the equations are technically incorrect. The curves likely do fit better when we when these tools or these algorithms incorporate race as an adjustment. I like this quote from Lawrence Bobo, the Dean of Social Science, at Harvard because the problem with incorporating race into clinical algorithms is the underlying premise, the idea that race could even be a contributing factor to help kidneys, reproductive organs, or bones function. We don't make adjustments in our clinical algorithms or in any of our studies based on the color of someone's hair or based on the color of shirt that they were wearing when they enrolled in the study, and doing so based on the color of someone's skin or their attributed race is just as scientifically preposterous. It's a reflection of the profound extent to which false racial beliefs about racial essentialism have permeated medicine.

I want to highlight a key distinction here to help underscore why it's deeply harmful and inappropriate to incorporate race into algorithms while simultaneously being beneficial to take conscious consideration of race when making an admission decision. The key difference is in the ways that we use race versus the consideration of racism, and the ways that that creates or reduces racial health inequities those downstream outcomes in our health system. So, when race is ill-defined and presumed to have biologic underpinnings, we end up with science that links race with biology and specific disease states. This reinforces racial essentialism and creates health care workers and trains us to believe or to implicitly understand that some races are inherently diseased. That then, in turn, influences the way we care for our patients, layering additional interpersonal harms on historically marginalized and minoritized people and supporting racial health and equity.

However, when we look at race consciousness and then we define race as a power construct and a social invention, we can frame shift. We can study the effects of racism, its consequences on health, and we can train clinicians who are quick to understand and address the structural barriers that interfere with achieving excellent health. We think, and we hope, that that will then create the opportunity for us to reduce racial health inequities in our society.

I hope as you consider this point again, you'll realize we don't need to just address ourselves, right? Our unconscious thoughts and our patterns and assumptions that we make in our social interactions are important, yes, but we also need to address our systems and the groundwater that permeates our whole society.

So, this work is challenging. It's deeply uncomfortable to wake up to the realization that you may be part of an unjust system. And this can be particularly true for white folks and people who are further on in their life or their careers. Negative feelings like defensiveness or denial or guilt are almost inevitable when thinking about this work, and they may have arisen for you in part of this presentation. But my goal at the end of this is really not to make people feel guilty because feeling bad about things doesn't actually help anyone, neither yourself, nor the rest of society. To the extent that you can channel that into motivation such that it would inspire you to learn more or change behavior, then that might be productive, but I've found it more useful to think about anti-racism work as just part of my responsibility as a member of society because I want my children to live in a just world where they have the opportunity to learn from and work alongside people who have the resources and opportunities to live up to their full potential.

That sense of responsibility helps me channel some of those negative feelings that inevitably come up when doing this work, like that it's never enough, or that it's an insurmountable challenge, into more concrete behaviors chipping away at the system one conversation at a time, one presentation at a time, one intervention at a time at the programmatic level. We need many people in this work to work for organizational and societal change because it's something that we all have a stake in and so I'll offer thoughts on what you might do.

The first is really to learn more, to broaden your input. Follow people of color on Twitter and other social media platforms. Listen to books if you don't have time to read them or if you find that more accessible for you. I listen on my commutes. If you're new to these concepts, I'll offer you some books you can start with Ijeoma Oluo's, So You Want to Talk About Race and ibram Kendi's How to be an Anti-Racist. They're both excellent foundational works in this space.

Harriet Washington's Medical Apartheid should, in my opinion, be required reading for every medical student, but because I'm not yet in charge of the world, I can't make it so, and so I would encourage you to read it. Dana Bowen Matthews' book Just Medicine explores more deeply how our unconscious biases inform and shape our actions in medicine. And for a deeper dive in understanding the contemporary face of racism in post-Civil Rights America, I'd encourage you to delve into Eduardo Bonilla Silva's book, Racism Without Racists, which I mentioned before.

Another broad-based and incredibly approachable book that I'd highly recommend is Heather Mcgee's book, The Sum of Us, which is really one of the best I've read in years, and Isabel Wilkerson's second book, Caste provides a different framework for thinking about how racism operates in our society, and it profoundly, honestly changed the way that I think about the ways that race shapes our individual and community actions here in the US.

As you as you start to learn more and more frequently, notice the manifestations of racial inequity around you, I'd encourage you to also try to hold each other accountable. Challenge those racist ideas where you see them. You can say things like I'm concerned about what you just said or what makes you say that or offer something that you learned. I recently learned that this thing is not true or that this framework or explanation for the way that the system is operating may be based on things that I hadn't previously understood. You can find ways to talk to your colleagues about race and racism by calling them into the conversation rather than calling them out.

I've learned from experience occasionally the hard way that calling someone racist almost never helps. We all have some degree of internalized prejudice and racism because we all operate and exist in a highly racialized society. There are many other ways to deepen your understanding and your skills and leadership strategies to advance racial justice and proceeded penalty and still offer you a few additional resources. Happy to continue the conversation as well.

The American Medical Association's Ed Hub offers free content, much of which is available with CME credit to deepen your understanding of these concepts through interactive modules and amazing videos, conversations with national experts discussing a variety of topics related to equity in the health ecosystem. Throughout the year will also be expanding our health equity Education Center offerings to include more content on addressing racism in medicine with modules to help organizational leaders as well to push upstream to address some of the structural drivers and root causes of inequities.

The Institute for Healthcare Improvement also offers some really extraordinary resources for organizational change, as well as tools for individual education and skill building. Many of their courses are also free open access.

Policylink, in collaboration with FSG and Just Capital, created an incredibly practical and straightforward CEO blueprint for racial equity, so if you have a key leadership role in your organization their recommendations could be adapted for use by leaders in the health care space as well.

REI, which I've mentioned before on the Groundwater Institute, offer more in-depth training opportunities and facilitated workshops as well. I've deeply appreciated their work that I've had the opportunity to see through my own experience as a learner in their workshops.

And then lastly, the VU Medical Groups Office for Equity, Vitality, and Inclusion developed an excellent, process driven guide for department level analysis of policy. In structures that may support or hinder progress towards racial equity among faculty groups. We found that very useful in my own department for structuring our process of self-reflection and identifying some opportunities for policy change.

Other ways to get more educated include some more focused and intentional strategies, so there are many institutions, including my own, that are investing in health equity fellowships to train the next generation of leaders who will advance equity in our systems, and so those are things you may seek out or encourage your institution to offer.

I'll also mention the medical justice and advocacy fellowship, which is a one-year fellowship at the American Medical Association in conjunction with the Satcher Health Leadership Institute at the Morehouse School of Medicine launched last year. Our first cohort of Fellows had the opportunity to attend the American Medical Association's house of delegates meeting just earlier this month in Chicago. It was amazing to meet them and to hear what they've learned. It's a one year experience that can overlap with residency, fellowship, or a faculty position. It is stipended. There's some in-person learning and a lot of virtual learning as well with some really amazing community building to help physicians understand how they can use their voice to advance equity in many different levels.

There are probably also local anti-racism organizations around you. Many of these groups have been offering training opportunities for decades, and you can probably find them by Googling them. For example, White People Challenging Racism is a great foundational course for folks for white folks in particular who are looking to learn more, and that's offered at the Cambridge Center for Adult Education in the Boston area. I don't know if they have virtual offerings, but there may be opportunities like this from local community groups around you.

And so, while, education is clearly a prerequisite to understanding why and how systems need to be changed, we're not going to read or probably talk our way out of our racially stratified society. Transforming our health care system and our country into a just and equitable place requires action and policy change to sustain it.

So we'll again bring you back to this framework of the ways that we can think about upstream versus downstream actions, and encourage you to take action that addresses your lakes and even the groundwater, rather than trying to just fix fish in your clinical roles. You can push upstream through place-based and institution-based equity-focused anchor mission strategies by identifying opportunities to center community and historically marginalized voices as you design interventions. You can consider how your own decisions, whether at work or in the community, and at home, may be supporting false racial ideologies or beliefs. You can think about how the decisions of your organization may also be supporting those, and what different choices might be made.

Sometimes creating change just starts with asking a simple question of why did we design it this way. So considering if you have a role in clinical medicine, creating structures that might link patients to resources to address social determinants of health based on the needs of the local community.

Departmental and other leadership roles can allow you to evaluate pay equity and opportunities for advancement and inclusion by race, and there are other resources, some of which I've mentioned, including that core tool and policy links documents, which can support you in that process.

If you have a role in quality and safety work, you can ask whether your department's quality and safety processes explicitly address equity, so is our data is stratified to ensure patient care and outcomes are equitable. Again, we can't fix what we don't see.

The American Medical Association Peer Network to advance equity through quality and safety, which launched in January, is helping health systems embed equity into the DNA of their organizational operations in this way, and more of those resources will be available for other health systems after this pilot cohort experience is completed over the next 6 to 12.

You could also think about the ways in which this might affect you and your health systems through your work at home, right? Where do you invest your time, your money, your influence? Think about the ways in which local housing and zoning policies can help support neighborhood integration and other strategies that address some of those upstream drivers of health.

So as we close out and we'll turn to some questions, I want to just remind you that this work is really about improving the health and lives of everyone in this country, allowing every individual to experience their full potential.

I love this quote from Miller Watson said “If you come here to help me, you're wasting your time. But if you've come because your liberation is bound up with mine, then let us work together.”

So I invite you to join us in this work. I'm happy to take any questions and I thank you for your interest and your attention. Thank you.

Video Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.0 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

1.0 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

1.0 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and

1.0 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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