The curriculum must challenge assumptions and unconscious bias.
In fall 2014, Professor of Medical Science and Africana Studies Lundy Braun, PhD, offered an elective on race, health, and structural inequality to medical students. We examined the faulty biological basis of race—the fact that genetic differences are far higher within than between racial groups—and how the biomedical framing of race contributes to physician bias, which in turn perpetuates racialized health disparities.
This exploration stood in stark contrast to what we were learning in our preclinical lectures. For example, we were taught that African-American patients have a significantly higher risk of developing childhood asthma, with several lecturers naming genetic factors as the cause of this disparity. Social factors that disproportionately affect African-American communities, including disparities in health care access or housing inequality, were rarely mentioned—even though these factors contribute more substantially to the higher prevalence and poorer health outcomes of African-American children with asthma.
Frustrated by this disconnect, students wrote a letter to the Medical School administration questioning the reliance on race as a biological construct. The letter urged a rethinking of preclinical education, specifically an integration between social and scientific portrayals of race. In the national context of fall 2014, with Ferguson in flames and the growing Black Lives Matter movement, the importance of translating what we were learning into action felt urgent. While the tradition of student activism at the Warren Alpert Medical School around health disparities is strong and precedes these efforts by decades, what was missing was an institutional commitment.
To further investigate our observations on the use of race in medical education, we sampled basic science lecture slides from the required preclinical curriculum and found that race was almost always presented as a biologically salient factor (96 percent), while only 4 percent of slides contextualized race by examining social differences. Furthermore, an informal survey of all Warren Alpert medical students demonstrated overwhelming peer support for reform of the current approach to race in medicine. After we presented our findings, the administration established a task force chaired by Associate Dean for Medical Education Allan R. Tunkel, MD, PhD; we began an ongoing collaboration with the faculty of the Office of Medical Education; and we continued organizing with other students (now formalized under the name Against Racism in Medicine). We also published our findings in Academic Medicine, joining the conversation around medical racism at institutions across the country.
The collaboration among faculty, administrators, and students in the Race in Medicine Task Force has begun to produce concrete and longitudinal curricular changes that are impacting the preclinical and clinical years. For example, a first-year lecture on radiation science introduced the idea that people with darker skin have evolved a pattern of melanin pigment distinct from those with lighter skin and that this difference was produced by differences in environments and geographies, not inherent genetic differences. These changes in content are not driven by an administrative mandate, but instead by ongoing conversations between the faculty lecturer, the Office of Medical Education, outside experts, and students.
The preclinical curriculum is further reinforced through systems-specific lectures and small group sessions in the Doctoring course. One especially effective session, “Race Correction of Pulmonary Function Tests: Why History Matters,” was led by Professor Braun during the pulmonary block. The lecture equipped students with background on spirometry and clinical lung function tests, illuminating the historical basis for race corrections, including its role in justifying the enslavement of blacks in the antebellum South. It provided rich material for discussion and continued dialogue even outside the lecture hall.
These advances come at an opportune time as medical institutions across the country rethink and reformulate how they teach about race in medical education. The Race in Medicine Task Force’s vision aligns neatly with national goals to incorporate health equity and advocacy training into physician training. It also coincides with Brown’s renewed commitment to diversity and inclusion, as articulated in Pathways to Diversity and Inclusion: An Action Plan for Brown University, and the Warren Alpert Medical School’s long-standing position as the nation’s trailblazer in education innovation. Educational reform around race and inequity fundamentally improves the quality of medical education for all students, and has the added potential to promote physician leaders with the skills to meaningfully reduce health disparities.
Just the Beginning
As the task force looks to the opportunities ahead, it is important to reflect on new and continued challenges. Task force members—especially the often heroic faculty of the Office of Medical Education—have proved to be dedicated and focused on implementable changes. While instruction around race and health inequities at the Medical School has been deliberate and well intentioned, curricular reforms thus far remain sporadic and moderately effective. The bulk of curricular changes have focused on first- and second-year medical education, despite abundant evidence that the clinical years have a greater impact on students and their future professional practice. Though further efforts on longitudinal coordination across all four years are underway, these small changes do not, on their own, add up to the rigorous, systemic curricular reform that is needed.
Significant controversy around the conversation on race in medicine persists. The proposed modifications to lecture content, while evidence based, sometimes run at odds with conventional medical wisdom and may not reflect the lecturer’s own beliefs around race, or clinical practice witnessed by students on the wards. This further underlines the need for robust faculty development that prioritizes critical thought around a controversial topic and developing skills around unconscious bias and structural competency—instead of a simple replacement of dogma.
A final limitation of the current reform efforts is the lack of assessment. While we are proud and grateful for the immediate impact these collaborative efforts have generated, we cannot predict the long-term effects and efficacy without data. A recent query to the Office of Alumni Affairs yielded no information on what proportion of Brown medical alumni go on to work in underserved communities, which could be one way to measure the success of our initiatives. Another measure is the Medical School’s commitment to faculty and student diversity. At institutions across the country, it is clear that attracting, recruiting, and retaining faculty, students, and administrators of color is key to addressing health disparities. Brown is far behind the curve on diversity, with one black male medical student in the current first-year class and 1.65 percent of the clinical faculty identifying as black or African-American.
These ambitious goals require real financial and administrative commitment. As we progress in our own professional development and imagine how to best care for all our patients, we remain cautiously hopeful about the current direction toward change and look forward to continued collaboration.
Alumni interested in these reform efforts or who have more information on their work in under-resourced communities may contact the authors at against-racism-in-medicine@googlegroups.com.
