COMMENTARY

Doctors Should Learn to Fight Injustice, Not Just Pandemics

Alexa Mieses Malchuk, MD, MPH

Disclosures

June 02, 2020

As protests erupt around the country in response to police violence and the death of George Floyd, we doctors have a clear role to play. This, even as Stanley Goldfarb, MD, former associate dean at the University of Pennsylvania, recently argued that medical education should disabuse physicians of the idea that they can solve poverty and racism.

Goldfarb advocates for better emergency preparedness, public health, and epidemiology training for medical students. Where I disagree is with his argument that medical schools abandon education about the social determinants of health.

These mass demonstrations, set against the backdrop of an ongoing pandemic, are sobering reminders of the need for increased training in this area, not a reason to abandon it.

COVID-19 Spotlights Disparities

The acts of racism, murder, and violence that are dominating headlines directly affect the well-being of our patients, peers, and colleagues. Although we are not policymakers, these events are a reminder that we must be educated about injustice and inequities so that we may better serve those in our care.

Look no further than the coronavirus crisis. COVID-19 disproportionately affects people of color. Nationally, Black people are 2.6 times more likely than their white counterparts to die from COVID-19. In North Carolina, where I live, Black people comprise 35% of laboratory-confirmed cases of COVID-19 and 34% of deaths , although they represent only 22% of the population. In New York City as well, Black people make up 22% of the population but account for 28% of COVID-19 deaths. Similar trends can be seen among Hispanic and Latino populations at national and state levels.

Sadly, none of this is surprising. Blacks and Latinos are disproportionately affected by countless diseases, including high blood pressure, diabetes, and obesity. As a young child growing up in an ethnically diverse but medically underserved area of Queens, New York, some of the first words I learned to read were on fast-food signs. These signs paved the way from my home to the clinic I would visit with my mother, who has diabetes. It wasn't until I was much older that I learned what social determinants of health were, let alone how food deserts affect people's ability to control something like diabetes.

As a college student, I worked with Gay Men's Health Crisis, the world's first and leading provider of HIV/AIDS prevention, care, and advocacy. There, I witnessed firsthand how women of color are still being infected with HIV at high rates, despite the progress seen among their white counterparts.

In residency, I began volunteering with the Durham Department of Public Health. I saw how race, poverty, and other social factors actively hurt the patients in my care. In 2017, I helped prepare the department's community health assessment on racial and ethnic disparities and saw the same things reflected in the wider statistics I compiled. A Racial Equity Task Force grew from that assessment. My colleagues and I in that group work to integrate antiracist principles into public health, as well as data collection and reporting processes.

All doctors have stories and experiences like these—moments when abstract ideas about how race, income, and environment can potentially affect people become tangible, as they see the visible harm to the health of their patients. This may be nothing new, but it is still not consistently taught in medical education, and the efficacy of the instruction that does occur varies widely. In 2018, a review of the Accreditation Council for Graduate Medical Education residency program requirements revealed that only family medicine programs actually required residents to assess the impacts of these factors on health.

Although the Liaison Committee on Medical Education has requested that schools create specific curricula regarding health disparities, the guidelines do not detail what should be included or provide benchmarks for monitoring success. As a result, we do not currently have consistent curricula. We have no widely identified or adopted best practices. We are not educating students about these important issues as thoroughly or as effectively as we should be.

The rising disproportionate body count during the COVID-19 crisis only makes the need for this education more urgent, not less.

The Argument for Integrating Social Justice and Health Equity

The recent violent clashes between police and the public over issues directly related to racism and injustice underscore the important role that physicians play beyond providing direct clinical care. Many of us became physicians to improve the health of our communities. I became a family physician specifically for this reason. Knowing about the sensitivity and specificity of a diagnostic test or the inner workings of clinical trials is important for a physician, as Goldfarb outlines. Yet, in isolation, this knowledge is insufficient.

A few institutions and medical specialties have distinguished themselves as leaders in education about health inequities. Family medicine as a medical specialty was born out of a movement toward social responsibility in 1969, with patient advocacy expressly written into its mission. This is why research continues to single out family medicine as a leader in this training.

In addition, residency programs such as the University of California San Francisco general medicine program and Montefiore Medical Center's social medicine program have social justice in their core training tenets. My own alma mater, the Icahn School of Medicine at Mount Sinai, launched a Racism and Bias Initiative in 2015. As described on its website, the objective is "to explicitly address and undo racism and bias in all areas of medical school and center racial justice, health equity, and underrepresented voices and experiences of our medical education colleagues."

Currently, at the University of North Carolina–Chapel Hill School of Medicine, I teach medical students and residents while caring for patients in the clinic and hospital, and I also serve as the co-director of curricular innovation for health equity. In this role, I have reviewed my own institution's curriculum and curricula for medical schools around the country. I have also discussed the status of health equity education with colleagues, leaders in medical education, and outspoken medical students.

I have consistently heard a strong desire for more rigorous training in these areas. As one scholar wrote, the current instruction treats social determinants of health as "facts to be known rather than as conditions to be challenged and changed.'" Coursework related to these issues is too often provided as separate instruction rather than seamlessly integrated into the organ system–based medical curriculum.

What I Hope Is Next for Inequity Education

George Floyd, Ahmaud Arbery, and Breonna Taylor are the most recent victims in a long history of structural racism and violence. I know my patients feel the effects of those factors too. For physicians to address issues like these with those in our care, we require adequate and integrative education.

Instead of separate instruction, principles of social justice and health equity should permeate the whole of medical education and training. Devoting time to this education isn't a sacrifice that takes away from biomedical education. Learning about health disparities, social justice, and health inequity is biomedical education. Furthermore, these universal principles do not belong in one medical specialty any more than another.

When students learn about antihypertensive medications in medical school pharmacology, they should learn about racial bias that spawned misperceptions that are still widely accepted. When students learn about the nephron and acute versus chronic kidney disease, they should learn about racist distortions that led to an estimated glomerular filtration rate that is different for Black people than for other racial groups. When students learn that being Black is a risk factor for sexually transmitted infections, they should have a discussion about the ways in which structural racism limits sexual and reproductive health.

We should ensure that students, residents, faculty, and staff mirror the patients we serve, that everyone has a voice, and that all are made to feel genuinely included. COVID-19 is simply the latest spotlight to illuminate long-standing health disparities in the United States. My hope is that this discussion lasts long after the pandemic has dissipated and translates into action.

My apologies to Dr Goldfarb, but epidemiology, emergency preparedness, public health, and health equity are not in any way mutually exclusive. Beyond diagnosis and treatment of disease, physicians are responsible for the health of their communities and advancing the field. From developing a pipeline for getting more minorities to graduate from college and into medical school, to devising ways to retain and support minority faculty in medical schools, we can do better. We should do better. We must do better.

The recent protests have reminded me of my privilege as a physician. My knowledge and skills can help me effect change in my community. I have been fortunate to learn about issues of injustice from my role models and mentors, and I have been trained to wield this power for the good of the community. I want the medical students I teach and all those in training to have the same opportunity.

We must end the false division between medical education and social justice. As physicians, we alone cannot solve the problems of poverty, food insecurity, and racism. But we should learn about these problems, and our instruction about them should be deeper and better. We should be trained to advocate for our patients and work to improve the health of our whole community, not just part of it.

Alexa Mieses Malchuk, MD, MPH, was born and raised in Queens, New York. Social justice is what drew her to family medicine. As an academic physician at the University of North Carolina–Chapel Hill, she practices inpatient and outpatient medicine and serves as a medical educator for students and residents.

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