COMMENTARY

Unequal Treatment: Teaching About Racism During Medical Education

Kenneth W. Lin, MD, MPH

Disclosures

June 20, 2016

Editorial Collaboration

Medscape &

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I'm Dr Kenny Lin, a family physician at Georgetown University School of Medicine, and I blog at Common Sense Family Doctor.

Every time I turn on the news these days, it seems that there are new stories about incidents either caused by or linked to racism:

  • unarmed black men being shot and killed by police officers;

  • complaints about contaminated water being ignored in a predominantly African American city;

  • dark-skinned men being forced off airplanes for speaking in foreign languages or, heaven forbid, doing advanced math;

  • a presidential candidate comparing Mexican immigrants to criminals and rapists.

In contrast to the popular culture, I would like to believe that medicine is color-blind, but there's abundant evidence that it is not. In 2003, the Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care[1] highlighted research showing that US racial and ethnic minorities are less likely to receive necessary tests and procedures, and that they experience a lower quality of health services than whites, even after controlling for income, insurance status, and illness severity. Few disagree that this is a problem. The question is what our profession can do about it.

Traditionally, medical education has portrayed race as an immutable biological risk factor rather than a quality that is highly dependent on social and political context. This oversimplified approach to race runs the risk of reinforcing medical students' existing negative biases and discouraging outnumbered students of color from challenging racial stereotypes.

Last year, a medical student at Brown University described this "silent curriculum" in an article in the Journal of the American Medical Association.[2] She wrote, "In textbooks, I saw what psoriasis and drug-related rashes look like on white skin, but what syphilis looks like on black skin. While practicing the medical interview, I was told that Latinos may say yes to all review of system complaints and that cultural competence meant minimizing some of their concerns." She continued, "I watched a young white teenager receive extended opiates for a post-lumbar puncture headache because she looked like a good kid, yet witnessed scrub nurses make fun of a Latino gunshot survivor for crying out in pain."

More recently, a Latino psychiatrist related to how it felt to stand outside an upscale restaurant and be repeatedly mistaken for a valet, and to be summoned brusquely by a surgery attending on rounds with the word "interpreter."[3] A black family medicine physician described how a prejudiced male patient metaphorically stripped away her white coat and made her feel that she needed to justify her professional qualifications in order to receive permission to treat him.[4]

Here at Georgetown, where I am director of a first-year course in population health and policy, we are trying to change the way we teach about race and inequality. Not only do we teach students about the existence of health disparities, but we also have lectures and small group discussions about individual, structural, and internalized racism. We teach students that skin color is important, not only because it may be associated with specific diseases, but because it puts patients at risk of being treated differently by those in positions of power, especially by physicians. We explore practical strategies for overcoming implicit bias so that doctors' subconscious attitudes toward peoples' physical appearances will not compromise the healthcare they provide.

Finally, we treat race as a social rather than a genetic determinant of health. In doing so, we are following the path taken by Brown University, whose students and faculty took a hard look at their preclinical curriculum and made significant changes that they outlined in a paper published in Academic Medicine.[5]

I hope that other medical schools are moving in this direction as well. Talking frankly about race and racism might make us temporarily uncomfortable, but we can't address the problem of unequal treatment if we pretend that it doesn't exist.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.

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