Combating systemic racism has become a focus for many in medicine, but perhaps most intensely for the field's newest members.
Residents across the U.S. have advocated to correct racial inequities in many areas of health care, including their own training. In some cases, they've achieved rapid change. One example is the collective internal medicine residency programs at Yale New Haven Hospital in Connecticut, where chief residents Jana Christian, MD, and Rachel Schrier, MD, led the implementation of multiple anti-bias programs.
These include a new distinction pathway in Race, Bias, and Advocacy in Medicine (RBAM) that allows residents from all three medicine residency programs (traditional, primary care, and medicine-pediatrics) to focus their learning in these areas starting in the second year. It joins pre-existing distinction pathways in education, research, global health, and quality improvement.
In RBAM, residents study the legacy of racism and bias through workshops, readings, and other formats. They create educational materials to be presented during morning report or noon conference, and each participant completes a capstone project, which can entail research or quality improvement related to race, bias, or advocacy. The pathway's activities launched in fall 2020 and it will begin enrolling participants in the 2021 academic year.
Another initiative that the residents developed during the summer of 2020 is the Committee on Anti-racism in Resident Education (CARE), which meets regularly to develop methods to integrate anti-racism teaching into the education that every resident receives.
To learn more about these efforts, ACP Hospitalist recently spoke with Dr. Christian, Dr. Schrier, and Christopher Sankey, MD, FACP, associate residency program director for the traditional internal medicine residency program and a mentor to the residents in developing these programs.
Q: What motivated you to focus on anti-racism as chief residents?
A: Dr. Christian: Being a chief resident is a yearlong position, and for us, that transition began in June 2020. That was only a couple of days after the murder of George Floyd. Our beginning of chief year was marred by that really traumatic, horrific event in the U.S., and it challenged us as new leaders of the residency to consider how to respond to this act and racism in the U.S. broadly, but also specifically, how racism also interacts with the medical system, unfortunately, in medical education and the hospital. It brought us to want to look inwards at how residents can advocate for anti-racism.
Q: Why did you focus your efforts on resident education?
A: Dr. Christian: We wanted to create something that would be highly sustainable. So many efforts come and go. . . . Another point of emphasis that we thought was incredibly important was making something that's highly visible. . . . In a number of major academic medical centers, there is a great emphasis on basic science and clinical research. Those are highly visible careers and pathways to choose. . . . There is usually amazing work being done in the arena of social justice and anti-racism, anti-bias work, but very often it's done in silos that are still incredibly productive, but not necessarily highly visible to a trainee.
Q: What are some examples of changes to the curriculum that have come out of CARE?
A: Dr. Schrier: My favorite is this idea of creating a resident consult service, to “teach up” to faculty on how to talk about race in medicine in their selected field. The most recent example is a lecture on chronic kidney disease given by one of our fellows who . . . collaborated with the resident who was running this effort to research how race and racism has affected the field of nephrology, specifically the role of a race-based calculation of [estimated glomerular filtration rate].
The advantage to this structure is that residents themselves are building a knowledge base on their selected topic and they're teaching up to experts in that field. . . . The CARE is currently working on how to best perform outreach to the community with respect to educating our patients about the coronavirus vaccine. The range of projects is very broad, but the most exciting part is that it's resident-led.
Q: What's this role reversal been like for faculty? Has it been challenging for them to deal with criticism of some longstanding aspects of medical practice?
A: Dr. Sankey: I don't see this as a role reversal at all. This is a growth opportunity for faculty to intentionally consider ways in which race and bias, and structural racism in particular, impact the medical care we provide and how we educate learners in our areas of expertise. We strongly believe that a truly effective anti-racism curriculum is founded on bringing race and bias considerations into the clinical teaching we provide every day. Individual didactics and workshops on diversity, equity, and inclusion are necessary but by no means sufficient. The best way to integrate race and bias into our routine education conferences is to help support faculty to include them. And this has been widely accepted and not perceived as criticism thus far.
Q: What do you think will be key factors in making your efforts successful?
A: Dr. Christian: That it's a combination of mandatory and opt-in opportunities. If you make everything optional, then you're saying that this is optional to learn about. Certainly it's OK to have evening events and allow for people who want to really build a career as a physician advocate or build a career in diversity, equity, and inclusion to have special events and mentorship. But saying this is mandatory for you to know this as an internal medicine physician is crucial.
Dr. Schrier: Mandatory and integrated. . . . Building [anti-racism] into our everyday teaching has been really crucial to success. . . . We're going through a medical case, and it just so happens that racism affected the outcome or that health care disparities affected the outcome. Integrating it into the conversation of a case, in which we're going over the pathophysiology and management of the disease, sends the message that this is within our purview as a physician to address and talk about and dismantle.
Dr. Sankey: It was key that we started by surveying our trainees and found that they were unanimous in wanting more educational opportunities related to race and bias. We also had the support of institutional champions—Dr. Inginia Genao, [FACP,] associate chair for diversity in the department of internal medicine, and Dr. Gary Desir, the chair of the department of internal medicine. They have been strong advocates and clear and consistent voices for the incorporation of equity and diversity into our residency training. Dr. Aba Black has been recently appointed vice chief of diversity for the section of general internal medicine and is the new faculty lead for RBAM.
The timing was also a key factor. Typically, when we would envision the addition of a new learning distinction pathway, we would have to form a committee and a subcommittee and have every experience and educational objective preselected and vetted ahead of time. But during the pandemic, entire medical wards were flipped from non-COVID to COVID in a day, making it feasible to create and implement these important anti-racism opportunities now.
Q: How has work in this area changed during your residency?
A: Dr. Schrier: The other initiative I run is the curriculum on social determinants of health and physician advocacy. This was a curriculum I actually started back in my intern year. It's a six- to eight-hour curriculum targeted at interns. The first year, we started with a debate on whether it is the obligation of the physician to be a physician advocate and strive for societal change. And I remember at the time, it was very controversial, and it was a very good debate. Doing the same debate three years later did not work because everyone was on the same page, which is a testament to how our field is changing.
This year we really wanted to reframe the concept of social determinants of health. Sometimes when we talk about social determinants of health and divorce them from these forces of racism and wealth and inequity that have really caused them, it can naturalize the difference and make it seem like it's intrinsic to certain communities. . . . So what we did was take one health care disparity—increased mortality from COVID-19 in communities of color—and contextualize that in terms of risk factors, in terms of social determinants of health, but more broadly in terms of historical forces that have created these inequities.
Q: How will you ensure that these projects continue after your chief year is over?
A: Dr. Christian: For all these initiatives, we are very lucky to know exactly which residents will be the resident leaders next year. Before any transition will take place, there have been residents who have already been working very closely with us and creating a lot of this content. . . . One thing that Rachel and I are incredibly proud of is that these have been resident-run and -driven activities and initiatives. . . . But we've also gotten just unanimous support from the institution . . . in terms of “yes, go for it,” but just as importantly, they've given us resources in terms of faculty. These faculty members along with the residents secure the ability for this to be a sustainable effort.
Dr. Sankey: The need to hardwire anti-racism education into our medicine residency programs is exactly why it was essential to elevate RBAM to the level of a distinction pathway, alongside the more traditional canon areas of education and research. While we are incredibly fortunate to have the passion, dedication, and vision of gifted chief residents like Jana and Rachel, it is essential that the opportunity for our trainees to acquire necessary knowledge, skills, and attitudes around race, bias, and advocacy remains after they move on. This absolutely cannot be reduced to a passion project.
Q: What advice would you give to residents, faculty, and training programs interested in starting similar initiatives?
A: Dr. Schrier: The biggest piece of advice I would have is just keeping in mind that perfect is the enemy of good. . . . Residents and faculty with very little experience in discussing issues that pertain to race in medicine, that pertain to social justice, or even social determinants of health are just really uncomfortable in starting the conversation, but they can, and in fact have a responsibility, to make change, and the first step is starting a conversation.
Dr. Christian: To talk about things that divide our country can be highly emotional. People can obviously be concerned about offending someone or concerned or embarrassed about what possible blind spots they might have. . . . We have to all agree to be vulnerable, but also all agree to be generous and understanding and to know that we're all just trying to learn.
Because ultimately, even though it's scary, it's our responsibility. Regardless of whether or not you know about racism and how it affects health outcomes, and how structures have been in place to disproportionately advantage some and disadvantage others—you can go through your life not knowing that—but if you're a physician, it's going to affect your patients, either way. And so it really is your responsibility to understand that.