Addressing racism in medicine: Experts call on colleagues to turn talk into action
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Inequities across all facets of health care — from clinical research to patient outcomes — are not new.
What is new is that more Americans are thinking critically about racism, and several organizations are voicing their anti-racism stances.
“Conversations such as these have opened the window for real and actionable change. As physicians, we frequently see evidence of health inequities in practice, and people often cite race as the reason for the inequities experienced by people from disadvantaged communities — but really, racism is the source,” Frinny Polanco Walters, MD, fellow in the department of adolescent and young adult medicine at Boston Children’s Hospital, told Healio. “Given the longstanding history of police brutality in the U.S., along with the recent killings of innocent Black people — including, but certainly not limited to, George Floyd, Breonna Taylor, Ahmaud Arbery, Eric Garner and Freddie Gray — and the resultant worldwide protests, the Black Lives Matter movement has gained a lot of attention as of late.”
In a commentary published in August in Nature Medicine, Polanco Walters, Adjoa Anyane-Yeboa, MD, MPH, gastroenterology physician at Massachusetts General Hospital, and Alden M. Landry, MD, MPH, emergency medicine physician at Beth Israel Deaconess Medical Center and assistant dean for Office of Diversity, Inclusion and Community Partnership at Harvard Medical School, aimed to illustrate how racism and police brutality affect the lives of Black patients, as well as to help physicians learn how to discuss racism with their patients and provide physicians and organizations with guidance to work toward health equity.
The ‘elephant in the room’
Racial and ethnic disparities exist across every field of medicine, and one cannot promote the health and well-being of all without addressing the “elephant in the room” of racism and devaluation of Black lives, experts wrote in the commentary.
For example, in gastroenterology, such disparities are evident in colorectal cancer, which is the second leading cause of cancer death in the U.S. and is preventable with screening. Yet, Black people have the highest rates of colorectal cancer incidence and mortality, Anyane-Yeboa said.
“In pediatrics, children and adolescents from racial and ethnic minority backgrounds across the U.S. have higher rates of poor health, mortality and disability,” Polanco Walters added. “It is well-documented that racial and ethnic minority children and adolescents are disproportionally affected by chronic diseases, including asthma and obesity.”
One way to help eliminate these disparities is to address the social determinants of health — the conditions of the places where people reside, learn, work and play. In addition, the focus should be on equity, not equality, as individuals may require different resources and tailored services to live their healthiest lives possible.
‘Black people need us now’
The experts outlined several key steps to take toward achieving equity and racial justice in medical training, as well as to address racism in the clinical setting.
First, medical schools, residency and fellowship programs should develop curricula on health equity and combating racism that teach trainees about the social determinants of health, policy and advocacy.
“Medical institutions should provide ongoing training on implicit bias and develop an anti-racism culture where all individuals are educated on how to best address patients’ needs with the goal of eliminating these disparities,” Anyane-Yeboa told Healio. “It is important to recognize that implicit bias and anti-racism training is just a start, and one session in isolation will unlikely lead to measurable change.”
Second, diversity among faculty and students in training programs should be increased. According to data from the American Association of Medical Colleges, the number of Black matriculants in U.S. medical schools remains at an all-time low.
“Institutions must also make an effort to have diverse leadership in their departments, diversity in their faculty and trainees, early mentorship, pipeline programs for trainees from underrepresented backgrounds, and sponsorship and career advancement opportunities for minority faculty,” Anyane-Yeboa said. “The work toward anti-racism, leading unconscious bias efforts, and advancing diversity and inclusion should not be led by minority faculty alone. For change to happen, there needs to be buy-in from the top and support at all levels.”
Racism should also be addressed at the patient-care level and implicit bias and anti-racism education should be provided, according to the commentary.
Finally, the experts suggested physicians engage in self-reflection by asking themselves: What did your family tell you about Black people growing up? Has that changed? Are you afraid of Black men? How many Black patients do you care for? Do you give them the same respect and time that you give your white patients?
“All individuals in the medical community should self-reflect on their own biases and whether they provide all patients with the care they need to achieve optimal health, regardless of their background,” Polanco Walters said.
Beyond training and patient care, the experts added that physicians should not only discuss with patients the dangers that Black people face, but also contact legislators, organize conferences to discuss how to better serve the Black community, and compel the judicial branches of government to develop fair and more equitable justice for those who kill Black people.
“As health care providers, we must use our platform to speak up. Black people need us now,” they wrote.
Polanco Walters and colleagues articulated their points well, particularly with regard to training, Christopher Lathan, MD, MS, MPH, oncologist and assistant professor of medicine at Dana-Farber Cancer Institute, said during an interview with Healio.
“I empathize greatly with the need to diversify training — we need to think about how we train individuals about structural inequity in medicine, and we need to integrate this into the minds of those who are most present with our patients and integrate it all the way through medical training,” Lathan said. “If we do not train clinicians appropriately, then how can we expect them to build clinical trials or think about the research in the way we want them to? We need accountability. There is a lot of talk, but are we really following through?”
Targeting cancer disparities
In 2001, NCI established the Center to Reduce Cancer Health Disparities (CRCHD) to address and eliminate cancer health disparities while increasing workforce diversity in cancer research.
During the last 2 decades, CRCHD has developed research, training and community outreach activities in response to these goals through various programs, including:
- Continuing Umbrella of Research Experiences (CURE);
- Partnerships to Advance Cancer Health Equity;
- Special Populations Networks;
- Community Networks Program (CNP) and CNP Centers; and
- Patients Navigation Research Program.
“CRCHD, through its CURE and now its Intramural CURE programs, has been fully dedicated to training the next generation of competitive researchers from backgrounds typically underrepresented in the cancer and cancer health disparities research fields,” Sanya A. Springfield, PhD, director of the CRCHD, and colleagues wrote in a paper published in June in Journal of the National Medical Association. “Today, CRCHD leads NCI’s efforts in supporting research training and career development experiences beginning as early as middle school and continuing through to tenured track appointments. ... Moving forward, the CRCHD will continue its steadfast efforts to move us closer to the day when diversity is a given and disparities no longer exist.”
Still, across all cancer centers, especially NCI-designated centers, patients with fewer resources and immigrants remain underrepresented, according to Lathan.
“There is a clear disconnect between the patient population that is served at these incredible institutions where incredible discoveries are being made and the more vulnerable patient populations,” Lathan said. “Also, cancer care in general does not accommodate for issues plaguing our lower-resource patients. We treat cancer almost like it is a white middle-class disease — we expect all patients to stop working, to find someone to drive them to their treatment appointments and that their fight against their cancer will be their number one priority. However, not all patients are able to do this, and we need to be aware of this.”
Addressing disparities in cancer care may require a “rethink” of the oncology community’s role, Lathan added.
“As oncologists, we do a good job at treating our patients, but how do we help individuals get diagnosed and how do we help prevent cancer? How are we thinking about survivorship for patients in poorer communities? There is an opportunity for cancer centers to invest in patient navigation and to invest in relationships with local providers and community clinics. There needs to be a diversifying of what cancer survivorship can mean for our underrepresented patient populations,” Lathan said. “The oncology community should change the way it thinks about recruiting for clinical trials and also focus on diversifying the individuals who work in the oncology field.”
References:
- Polanco Walters F, et al. Nat Med. 2020;doi:10.1038/s41591-020-0984-3.
- Springfield SA, et al. J Natl Med Assoc. 2020;doi:10.1016/j.jnma.2020.06.001.
For more information:
Adjoa Anyane-Yeboa, MD, MPH, can be reached at Harvard Medical School, 25 Shattuck St., Boston, MA 02115; email: adjoa.anyaneyeboa@gmail.com.
Christopher Lathan, MD, MS, MPH, can be reached at Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA 02115; email: christopher_lathan@dfci.harvard.edu.
Frinny Polanco Walters, MD, can be reached at Boston Children’s Hospital, 300 Longwood Ave., Mailstop 306, Boston, MA 02115; email: frinny.polancowalters@childrens.harvard.edu.
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