Ep 16. Race and Healthcare: Teaching Med Students

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I am the Senior Associate Dean for Diversity, Equity and Inclusion at the Warren Alpert Medical School of Brown University. This is a new role. It's inaugural. It started almost a year ago, April 1 of 2022, is when I took on this position. And although we had an Office for Diversity for many, many years that was led by an Associate Dean, the original thought process or the original goal of the Office for Diversity was really to help support students who self identified as underrepresented, racially and ethnically, so very specific sort of cohort of underrepresented students, the job of the office was to support them. And oftentimes, what that meant was creating community, connecting students with mentors who are also from historically underrepresented groups. But it was a very insular office, right? It was an office created to help a very specific student population. And there are always going to be limitations with something like that. Because supporting students through a toxic environment can only get you so far. At some point, you have to look at the environment and you have to look at the systems and say, Okay, we've been supporting the students through the toxic system for, you know, a decade. How about, we just changed the system?

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Brilliant, take two steps back]. And so the creation of this position really had that sense in mind. It was, yes, we can continue to support students through an environment like academic medicine, which is not just toxic here at Brown, I would argue it's toxic everywhere around the country.

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Yes, we should continue to do that. And understand that we can't only support students, because students become trainees and trainees become faculty. And so really, we need to support all individuals, including nurses and other individuals who self identify as underrepresented. We need to support this entire community of people. And while we're doing that, we also need to look systemically at how we can change the system, so that we eventually make our job supporting individuals who are historically underrepresented, obsolete, right? Like the goal should be that the system is inclusive enough that everybody feels supported. And no one needs an Office for Diversity because the system is here for everyone. And so in my role, I'm now doing both - like really expanding the support that we provide for individuals who are underrepresented beyond just students, and looking at the system to figure out how we can continue to make it more inclusive, really, for everyone.

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What are some of the steps you're taking on that latter point?

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So as you can imagine, it's a pretty colossal endeavor. Luckily, I'm I don't usually shy away from big challenges. And so part of that a big part of that certainly is education. I think that's where Brown has had strengths for a really long time. We actually began to partner with our own Africana American Studies Department on the undergraduate campus several years back to run courses on racism in medicine.

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And actually, one of the individuals who works in that department Lundy Braun is the is like the sort of expert on pulmonary, the history of pulmonary function tests and why there were different standards for pulmonary function tests for African Americans. And for individuals who are white, she actually sort of spearheaded that research, she spent her her a good deal of her life, lecturing about it, and really tying together how specific events during our time of slavery have trickled down into how we continue to practice medicine. So she teaches two courses here for our students, and also runs an elective course. And we have been doing that for a really, really long time. And so we're trying to expand on some of that initial work where we, you know, it's important for us to talk about the historical nature of much of racism in medicine. But sometimes when we focus a ton on history, people presume that means that it's no longer relevant. It's something that happened in the past, it's not a part of who we are anymore. And so what we're trying to do now is really transition, that historical context, which is critically important, but transition it to practical applications of what you were doing every single day. So how do you as a provider of healthcare question your positionality, your power, the differential outcomes that you see in your patients? How how do you constantly keep that questioning attitude moving forward so that you can utilize the historical context that you learned. But also understand there's so much more to learn, right? Because this is a constantly evolving field. We are we are just now beginning to catch up with the content that we really need to understand in order to practice medicine in a way that's equitable.

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What age medical students, what level of medical students take that course?

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We have a course that we run. So Lundy's course, I'm pretty sure it's for the first year students. But then she runs an an elective course, for the second year students. We have a separate course that actually I teach, called Racism in Medicine, and it just sort of goes through, it's a very broad overview of how racism has impacted much of the much of the medical information that we sort of take for granted that we don't think about, that we don't question. And so I teach that as well, also to the first years.

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And so a ton of the content does come in the first and second years. And that is very convenient. Because the first and second year students as you know, are sitting in classrooms.

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And so a lot of it is didactic up in in the first and second year. So another project that I'm working on right now is the creation of a third year clerkship on racism in medicine.

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Because really, you know, if you think about the model of medical education, we do all this preclinical stuff, right, the first 18 to 24 months of medical school, and then we send our students out into clinical spaces, and we say, now it's time for you to learn the practical application of everything that we taught you.

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But we don't do that with racism, right, like, so, again, it kind of goes back to this, I can teach you a ton of content on racism in medicine, but what I really need you to do is take that content, and make it make a difference. So you know, some of the some of the skill building that we want to teach our students is how to engage in a conversation about race with a family, particularly if you're in a non race-concordant relationship with that family?

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How do you we know that in pediatrics, for example, we know that racism is a significant ace? So how do you engage in a conversation with a family about how racism is impacting them?

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How it might be impacting their children or their other family members? And how do you do that in a way that is helpful and supportive to the patient and helps to see them for who they are. So I think that skill building around the context of the history of racism is our way of saying, Okay, this is how you show up and bring this knowledge into your exam room every single day.

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Is there any kind of self reflection component early on in the first second year or later on third, fourth year, or even into residency where they look back and I don't know how many years you've been doing the program, but you know, have you gotten feedback about it?

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So for the third year clerkship, we're still building it. So we haven't gotten any feedback, but one of the pieces of the clerkship is like self reflection, and it's consistent self reflection that they have to review with with the leader of the clerkship, because you know, I don't need to tell you or this audience that racism is, there's so much about it, that is personal. And individuals come into this work with entirely heterogeneous levels of engagement with racism, right? Like you have someone like myself, I was, I was actually reflecting on this in a group of faculty members, faculty leaders, and I was the only black person in the group.

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And I said, you have people like myself, who for personal and for professional reasons, I think about racism every single day.

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Like, I can't remember 24 hours that have passed, I don't know, in the last two decades of my life, where I have not actively thought about racism, right. So that's one end of the spectrum.

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And then you have individuals who, for personal reasons, and for professional reasons, might not ever consider the impact of racism, or they might only think about it when they're in a conversation, like the one that we're having now or in a training session. So when you have individuals at those two ends of the spectrum, and we definitely have students who are at those two opposite ends of the spectrum, making sure that there's some self reflection to understand how our personal identities and how our own personal histories and experiences influence how we show up in exam rooms for patients is critical, because if we're not examining that, then we're completely missing the boat. Like we're not we're not all coming into this conversation at the same level.

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I actually don't I've been looking for, to find

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Are you aware of anyone else doing programs out if there are other people who are doing it. Because it's like that, and creating clerkships around the idea of like, why reinvent the wheel if people are doing this well, or racism and how often maybe find ways to collaborate, so that one person, you know, one schools approach might be different than the approach that we're taking. And we can learn from one another, from those different approaches. You know, one of the one of the challenges, we have several challenges in rolling this out.

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But one of them is, you know, how do you assess a student who's gone through this clerkship? Like, what does it mean, you know, in every This is school, right. So in everything that we do, our goal is that our students are learning something and growing. And so how do you assess whether someone has, you know, really understood the information that's been shared with them, and that the information has been transformational? Right, like, you know, we have we have simple goals and objectives for the clerkship, which we always have for clerkships, but they don't feel meaningful, right? Like, of course, we want you to understand the impact of racism, yes. But really, I want to transform how you think about your interactions with people.

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That's really hard to measure.

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Yeah, so trying to understand how successful the clerkship is going to be, because we want to measure the outcomes of the clerkship is some place where I get tripped up quite a bit. It's like, how do we think about assessment outside of our traditional measures of assessment, in order to capture what it is that we think is really important about an educational exercise like this?

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That part is a little bit tricky. Yeah, you know, when I was at UFC, I taught a lot of the courses on professionalism.

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And, you know, how do you teach someone to be more professional in their relationships? It's, this is this conversation is making me like, think back to that also, my anxiety is going up a little bit. But I remember we would have the same conversations. And this was back in 2003 2005, we were having these conversations like, well, what does it mean that the student has learned it or not learned it, and we ended up just basing a lot of it on self reflection, if we felt like if they were able to be very self reflective on some of their experiences that they were having that was a very good sign that they're just at least learning that at least they were demonstrating that they learned a skill that over time, then should help them achieve the goals we were trying to teach.

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Yeah, that is

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You know, so I've done a ton as you can imagine, in this role, and just because of my own interest, I've taken a lot of time to learn more about what it means to be anti racist and anti oppressive in an academic environment. And what I have come to understand is just how academia itself is an oppressive environment. And so the tools that we utilize to measure success within academia are oppressive by nature. You know, there's an entire concept of epistemic injustice, which I was not familiar with before I started this work. And the idea is that our entire understanding of higher education is really baked in oppression, right, because the individuals who created structures of higher education were, you know, mainly European, white men. And so the structure that they built was a structure that reflected their values. And so we continue to function within that structure, of course, but it also behooves us to question all of the parts of that system if our goal is to dismantle oppression. And so, you know, you think about assessment, for example, right, like how we assess competency and a big part of assessment in competency in medicine is, you know, standardized tests around medical knowledge. And, you know, I see you nodding your heads, you know exactly where I'm going with this, right. But have we ever demonstrated that individuals who demonstrate a better, sort of, I don't want to say a better grasp, but an a better ability to recreate or reproduce their understanding of medical knowledge on a standardized test. Have we ever demonstrate that those people are better doctors? Provide better care?

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I'm sure not.

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But also that's tricky, because what does better care mean?

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Right So how would you even

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to measure whether we are on the same path?

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begin Right? So it's literally it's like you just start deconstructing all of these things that you've always taken for granted. Like, someone might say better care is better outcomes, right? And I think a lot of individuals think that way. So like, if a patient does well, you have given good care.

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Right, like when you talk to patients, and we, you said this right, before we started this interview, they might say, actually, the relationship that they have with their doctor is the is the sign of the best care, and it's not their outcome, it's their ability to talk to their doctor, confide in their doctor trust what their doctor has to say, and are we measuring any of those things when we're measuring competency in medical school? And do we even know how to measure for another phenotype of individual?

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Because if I don't have a way of measuring how well you communicate, or how well you develop a relationship of trust with another human being, how can I make sure I'm selecting for those people? There's no way for me to do it, I'm looking at your grades, I'm looking at your MCAT score. And then I'm looking at an interview with who? With a lot of other people who are entrenched in our older system who are not asking themselves those questions. And so that system is going to recreate and reproduce the exact type of physician that it's always recreated and reproduced.

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It makes me wonder if the current changes in the college admissions landscape, this is on my mind, because I have one in college and one heading to college soon.

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Makes me wonder if the makeup you know, of, of the more competitive colleges as it's changing so much now, partly because of the pandemic, but also because I think a lot of the schools just glommed on to the pandemic as an excuse to make changes that I think are right, you know, less, less legacy admissions, more diverse admissions, blind test, optional non testing, I love all of that.

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It did not help my white Midwestern children, but I'm cool with that, because I think it's better for the world. But it makes me wonder if then, you know, those students are then going to feed into the medical school system. And it makes me wonder how that's going to change down the line.

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I mean, I'm hopeful that it does change. The problem is, and you know, my, I try not to always think about problems,

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or your job, part of my

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job, the problem is that you can feed all of these diverse individuals with different perspectives and different skill sets into our system. But if we don't fundamentally change our system, we they will either fundamentally change because you adapt to the system that you're in for survival, or you be terrible, right, or you just you're out. And what we have found is that, certainly individuals who are at least of diverse identities, right, when they come into our system, we fail them. And I mean, not like we give them an F, but we do not create environments that are inclusive, we do not create environments that encourage belonging, and we do not create environments that encourage their success. So either they leave, they're dismissed, or they fundamentally try to change who they are in order to survive in the system. And the whole reason why we brought them in, which was for their diverse perspective, their diverse background, and their different way of thinking about things gets lost, because the system itself works to dilute it out.

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Right, like, if you think about medical education, our our medical education system is all about uniformity. We don't have a system. And you could argue that's that's sort of like all of education in the United States, right. But I'm just going to focus on medical education, because that's what that's my area of expertise. We really focus on uniformity.

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We're not trying to celebrate diverse perspectives, like there is a way that you do things, right. We talk about clinical practice guidelines, and we talk about uniformity and outcomes.

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And there's a very specific definition of a doctor that we have in mind. And we try to fit everybody within that definition. Now, I'm not saying that that's fundamentally wrong, because we do have to have standards, right. Like we have to have standards for what we think make a successful physician. And we have to be careful that in the support of those standards, or even in the replication of those standards, what we're not doing is eliminating opportunities for different perspectives and different thoughts and innovation frankly. And I think that's always the danger with any of these large institutions, right? Like you, you say there's a standard for a physician that we want and you create that standard. And that feels like it makes sense. You want someone who has a minimum amount of understanding about, you know, X and a minimum number of years and training around why and a minimum number of patient experiences. Totally makes sense. But what else are we selecting for when we create those systems? There are other aspects that we're selecting for that aim is we dismiss the things that we claim to celebrate. Because if a student comes on a clinical rotation, and is rounding with us, and they say something that is different than what the attending thinks, depending on the psychological safety of that group, the attending might just shut them down. And you know, like medicine is still based in a hierarchy. So how do you encourage innovation and diverse thought, when there's a person in charge, who gets to make all of the decisions, and then their resident and their students, and sadly, then there are nurses, and other members of our interprofessional care team. And we create, we have this hierarchy that we actually worked really hard to maintain.

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But then we say that we really want diversity and innovation and, you know, like, different ways of thought, but those two things don't work together. So one has to be dismantled in order to welcome the other one.

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It's almost a little dizzying, because you have to work forwards and backwards at the same time, like the students are coming in, you have to think about who you're selecting what your makeup is, what your goals are for them right from the start, but at the same time, you need to be at the endpoint and say, well, what, as an institution, are we going to say defines a good doctor who can graduate from here? Do we just want someone with the good test scores? Or do we want somebody who shows empathy in the face of difficulty and pressure and is inclusive of all of their patients? And then you have to say, well, okay, now we have the definition of the doctor that we want, we have to work backwards to create the curriculum. That's very dizzying.

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And it's particularly hard to do, because there's a lot invested in the current definition of doctor.

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Right, so all of the people who were in charge, worked through the current definition of doctor, including myself. And so to question our current definition is to question the identity of all of the people who are in charge. And some people are okay with that. And some people absolutely are not.

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And it really threatens who they are and their core identity. And they're not comfortable with that. Because if I did it one way, if I became a doctor because of this very specific skill set, if I scored awesome on my MCAT, and fantastic on my STEP and blew my board exams out of the water, and published the way I was supposed to, which is what everybody told me to do, then why do we get to change the rules now? Because that's what I did and why and if you're telling me that, what I did is not what makes a good doctor, then you are de facto telling me I'm not a good doctor. People do not like that. And in the end, of course, we're not telling people that they're not good doctors now, because they went through another system. What we're saying is that we have opportunities to bring in other people who can also be good doctors, right? Like it's not a zero sum game. A lot of equity talk is around, we don't all work with one pie, right? Like it's not if I get a slice, you don't get a slice. You are a good doctor, you've accomplished a lot. That doesn't mean that how we define doctor needs to stay the same in order to maintain your value as a human being and as a physician, right?

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Like it's not a pie. This is both and we can bring other people with other skill sets into the space, who can also be exceptional physicians. And that doesn't have to threaten who you are.

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Let me, let's play fantasy for a minute.

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Pretend we live in a world where? Well, this might not be fantasy. I'm not digging you in any way. Let's pretend let's say future instead of fantasy. When you personally develop an incredible curriculum that just works right for everyone around this topic, could you see something like that being able to be plucked out and used at other medical schools? I think just restate my question more clearly. Could you ever see there being a national curriculum for medical students on these ideas that all the schools could use?

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Absolutely.

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Absolutely. And I think that there are some spaces is where we're thinking about this on a more sort of national or even global level. So I'm going to do a little bit, it's not really self promotion, it's like self promotion. But um, the American Board of Pediatrics actually put together a small working group, I want to say about two years ago, and I had a chance to serve on the working group to look at untrustable professional activities. And, you know, you may or may not know, you know, untrustable professional activities are another way that we are trying to get a better sense of the competency of our pediatric trainees, right. It's like and, and we're doing this in pediatrics, but the boards for all of the other specialties are also doing something very similar, right. There's recognition that how we've assessed competency of our physicians is not perfect. And untrustable professional activities are really based in competency based medical education. It's like how do we make sure that the education that we're providing is linked back to the competencies that we want physicians to have, which as we shared in the beginning of this conversation has not always been the case, right? Like how we assess our doctors has not always been linked to the competencies that we actually want them to have as doctors, which is like a crazy concept.

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Sometimes I say that out loud.

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And people look at me like I'm crazy. I'm like, No, seriously, like, we're not, I'm not even kidding, you're not crazy. And so we have 17 untrustable professional activities in pediatrics. And one of them was an untrustable professional activity on like, quality improvement and advocacy. And the working group was actually charged with incorporating anti racism into the into trustable professional activity. So that not only were we calling out what we wanted pediatricians to understand about how race impacts pediatric health outcomes, we also had to call out how those things were going to be assessed. And the EPA is meant not only for residents, the EPA is ultimately meant meant to help to measure the competency of all physicians.

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And so that, to me, is a very sort of global perspective. Like no matter where you trained as a pediatric resident, we the the Board expects you to have some level of competency in how racism impacts your patients, how to measure how racism is impacting your patients, and how to implement systems to help mitigate the impact that racism has on your patients. Which is like kinda revolutionary.

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It is i My mind is working. That's why I'm looking at you blankly I'm like thinking about 100 things at the same time. So is the idea here that if the American Board of Pediatrics comes out and says for example, we expect our physicians to demonstrate competency in terms of racially sensitive relationships with their patients, then that will drive medical schools to be required to teach?

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Well, certainly, because that the board is really looking at the competency of residents, it will at least drive residency education. And we actually do a ton. In addition to just creating the EPA. You know, we also talk about like, here's curriculum that you can utilize to help support what we're saying we want your residents to be able to do, right like we don't want to just put the the requirement out there, we also want to give people the content that they can deliver to their trainees. But is as you can imagine, antiracism in pediatrics is not that different than antiracism in adult medicine or in gynecological care or in surgical medicine, right? But the concepts are the same. How you might execute or assess it might be slightly different based on your specialty. But overall, we're asking you to do the same thing. We're asking you to have an understanding of how racism impacts medicine, we're asking you to have a questioning attitude so that you can interrogate your systems for how racism is impacting your systems. And then we're asking for you to then help to recreate systems or mitigate systems where you're seeing how racism is impacting your patient outcomes. And even though that might change a little bit based on specialty, it's kind of the same thing. And you can pull it back to medical student education as well. Absolutely.

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But you were talking about just the wide variety of preceptors and teachers that you have, who then become responsible to teach this material. I wondered if you have a program in place to teach the teachers?

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Absolutely. We actually do a ton of Faculty Development. Some of it is proactive, some of it is reactive. So I'll explain that a little bit. You know, right now, for example, we we actually this past year, hired outside consultants because we don't have enough people with fluency in how to teach in an anti racist way. We just don't have enough of those people within our institution. So we asked a group to come and help our faculty members, again, understand the complexity of racism, you know, like racism and oppression in general is really complex. People spend their entire lives, studying this writing about it, lecturing on it. And our faculty members are busy people, they're seeing patients, they're teaching. So the ex, we can't have an expectation that they have to would have this level of expertise, just magically. And so we hired some individuals who are doing antiracism workshops with our faculty right now to give them some of that skill set. So that's some of the proactive work that we're doing.

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And then the reactive work that we do, and I think it's important that you have both, is that we also have a system to report what we call curricular opportunities. So when our faculty members are sharing clinical content, particularly in the preclinical years, but also in the clinical years, when they are sharing curricular content that might be based in oppression or might not be inclusive and sensitive to different identities, our students have the ability to report those, and we call them curricular opportunities. Those actually are all reviewed by someone who is incredibly talented here, our Assistant Dean for Diverse Curriculum, Teaching and Learning. She's a PhD and anti racism education, she's not a physician. And she reviews all of the curricular opportunities, and then creates sort of like individual plans for those faculty members based on the report. So sometimes, it's just that the dermatology lecturer did not have enough representation of rashes on different skin tones. And so she goes back to the faculty member, and she says, Here are some resources, can you please, you know, create some more slides so that individuals can see these different pathologies on different skin tone, right? Like that's sort of, that's not hard.

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Sometimes it's in something that a faculty member has said, so the slide is fine, and the content is fine, but how they deliver the content was not inclusive. So one of the other examples that we hear a lot is a faculty member that might speak about prevalence related to race, as opposed to relate it to racism, right, without, so you say that black individuals have a higher into or I'll use another example, you say Native American individuals have a higher incidence of alcoholism, and then you end the conversation, then you move on, without ever really explaining that it's not something inherent to individuals who are American Indian or Native American. It's actually related to racism and systemic racism and systemic oppression that this has happened. So it's like, okay, faculty member, we're going to need you to elaborate a little bit more about why you see the statistical difference and have some more content expertise in how racism has played a role here. So that the takeaway message is not that this is an inherent part of this person's racial biology or whatever, not whatever that is. But that this is really a uh, it takes a lot of work.

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Yeah, I'm so excited. You have that person. I wonder how many schools have someone like that? That role specifically? I mean, I've never heard of it.

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I don't think very many to be honest with you, like I am. I mean, our team, I think I was sharing at the beginning, you know, our office started as this really small office like just to support students of color. So there were a total of 3.5 FTE, right, like for the entire office, in the year that I've been here, we have exploded the office because a lot of work needs to get done.

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And we went from 3.5 FTE to about, we have 12 individuals now in our group, and altogether, they're about nine FTE with like everybody's work.

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And it's, like I said, I feel very, like I feel very, very privileged to be able to do this work in this environment with this level of support. I know not everybody has that. So our goal, of course, is to export as much of this as possible so that even in lower resource settings, we're still getting the students and the trainees and the faculty the education that they need.

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I love it. I'm so glad you're there. I'm so glad you have that job and that you're there. Oh, man makes me feel like it's gonna be okay.

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Pat, it's been so great talking to you. I've learned so much about what you're doing there and wonderful.

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This was a lot of fun. I've been in different interviews before and this really did not feel like an interview. It felt like I was talking to a friend of Barrett so thanks for saying stuff, you know, but um, but I Really appreciate you elevating it on your own platform and bringing such different perspectives to the table and just your general treatment of the of the topic has been amazing so I'm really appreciative of you, thank you.

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You're very welcome!

Ep 16. Race and Healthcare: Teaching Med Students

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