Overcoming the Challenges of Addressing Race, Culture, and Structural Inequality in Medical Education
A Conversation With Katherine C. Chretien, MD
In 2017, a workgroup task force, made up of medical students and faculty at George Washington University, Texas Christian University, and the University of North Texas Health Science Center, conducted a literature review to identify best practices for teaching and learning about race and culture in medicine. The task force analyzed 63 virtual patient teaching cases presented by Aquifer (formerly MedU), a nonprofit company that provides virtual teaching and learning methods to more than 95% of medical schools throughout the United States.
The virtual patient cases were from courses in family medicine, internal medicine, and pediatrics. The goal of the task force was to understand the challenges and best practices for increasing medical students’ understanding of race and culture and to address the forces that drive the health disparities experienced by patients from marginalized communities in an evidence-based guide for curricula revision of existing teaching cases.
The task force then developed a working summary of the essential competencies for medical students surrounding race and culture, effective teaching and learning strategies, characteristics of ineffective race and culture curricula, and best practices for online learning. The group then distilled its findings into six major themes that describe the common pitfalls in the ways that race and culture were presented in the teaching cases. The six themes included the following:
1. Cases may not distinguish between race as a genetic risk factor and the social or structural causes of racial health disparities.
2. Etiologies of disease centered around individual behaviors and characteristics without any context of upstream factors. Language used to describe patients’ characteristics and behavior prevents understanding the root causes of health disparities and may perpetuate racial and cultural bias.
3. Patient descriptions frequently include reductionist and race essentialist portrayals of non-Western cultures and people of color, which may reinforce stereotypes and lead to racism.
4. Providers ignore or portray a sense of futility in addressing social and structural causes of disease and illness.
5. Cases may lack critical reflection on health disparities and implicit bias in medicine.
6. Cases do not consistently portray minority identities among patients, medical students, and physicians and, therefore, do not reflect the current population of the United States in each of these categories.
Based on its analysis of these six major themes, in 2019, the workgroup published a Race and Culture Guide for Editors of Teaching Cases1 as a tool for medical educators to improve the delivery of critical content about race, culture, structural inequalities, and health disparities through case-based learning. The workgroup’s evidence-based rationale for making case edits include these five conclusions:
1. Students must be exposed to alternative portrayals of minority patients that move beyond reductionist views and exemplify the diversity within minority groups.
2. Medical education must minimize essentialism.
3. Structural competency skills are best learned when demonstrated in practice. The structural context in which patients live should be incorporated into the disease narrative, since this may expose modifiable risk factors different from those associated with the patient’s stereotype.
4. Race itself is not necessarily a biologic risk factor. However, the social context of racism can be a risk factor, which has led to certain health behaviors, disease prevalence, and health outcomes being commonly associated with certain races and cultures.
5. Although it is critical to learn how to understand, model empathy, and effectively communicate with people of different races and cultures, these provider-patient communication tactics should be taught and practiced because they are medically relevant and lead to improved health outcomes, not because a patient is a member of a racial/cultural group for which stereotypes exist. For example, the same questions regarding patients’ health beliefs can and should theoretically be used for minority and nonminority races and cultures.
Katherine C. Chretien, MD
The ASCO Post talked with Katherine C. Chretien, MD, Associate Dean for Student Affairs and Professor of Medicine at George Washington University School of Medicine and Health Sciences, Washington, DC, and a coauthor of the Race and Culture Guide for Editors of Teaching Cases, about how medical schools may reinforce racial or cultural stereotyping and how medical education can be reformed to reduce implicit bias and improve care for minority patients.
Race and Culture: Social Determinants of Health
In your literature review of patient teaching cases, you found that traditional medical education approaches may not adequately address the factors that drive the health disparities experienced by racial and ethnic minorities. Why aren’t medical schools providing better cultural competency training for addressing race and culture as social determinants of health?
The approach to teaching cultural competency in medical education has been evolving over time and, as we have more evidence on the best way to conduct this training, medical schools are implementing evidence-based curricula to adequately reflect the lived experiences of our current and future patients. However, we are still learning how to better equip future physicians to address racial and cultural health disparities in structurally competent ways.
In this environment of racial and social justice, medical schools are extremely invested in improving the way we present race and culture throughout curricular content.
“Medical schools are extremely invested in improving the way we present race and culture throughout curricular content.”— Katherine C. Chretien, MD
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Awareness of Racial or Cultural Stereotyping
How may cultural competence–based curricula inadvertently reinforce racial or cultural stereotyping, and what are the consequences of such cultural stereotyping?
In its time, cultural competence programs in medical training were a good first step in increasing peoples’ sensitivity toward culturally and ethnically diverse patient populations; improving physician-patient communication, patient satisfaction, and clinical outcomes; and reducing health disparities. However, this training can result in reinforcing stereotypes; it often includes lists of preferred words, images, or approaches for treating minority patients and portraying all racial and ethnic groups as having the same values, beliefs, and behaviors based on their culture and so may inadvertently lead to cultural profiling.
Oversimplification of cultural competence programs fails to recognize and acknowledge the heterogeneity within specific racial and ethnic populations, so medical trainees are never taught how to apply knowledge of sociocultural issues on an individual patient level. Making generalized assumptions about minority patients can interfere with their care and may lead to delays or misdiagnoses.
Improving Patient Outcomes
How does structural competency training differ from cultural competency training in medical education?
Structural competency is recognizing and addressing health-related social justice issues that result in health disparity, including structural inequity, structural racism, structural stigma. The framework of structural competency presents a way for medical students to recognize and respond to the impact of upstream, structural factors on patient health and health care; it also empowers providers to think beyond brief patient-provider encounters and improve health outcomes through structural interventions.
For example, after observing that patients were unable to take their medications at prescribed times because of long commutes to grocery stores, medical students in Nashville organized a mobile grocery van to deliver goods to impoverished neighborhoods.2
Sam J. Lubner, MD, FACP
Cultural competence education, as I mentioned previously, strives to improve physician-patient communication and collaboration, thereby reducing health disparities and improving clinical outcomes.
Reducing Implicit Bias in Medical Education
When will you have feedback from the evidence-based Race and Culture Guide for Editors of Teaching Cases you published, and what are the next steps for the race and culture task force?
At George Washington University, the task force on the Use of Race and Ethnicity in Medical Education was formed to develop best practices in teaching about race and ethnicity in the undergraduate medical curriculum. We have now distributed the Race and Culture Guide for Editors of Teaching Cases to all teaching faculty. The task force also recommended including question prompts to evaluate the implementation of the guidelines as part of routine student course evaluations. Other medical schools have expressed interest in revising their case-based curricula using the guide, and that process is underway.
At least now there are guidelines to engage medical students and faculty in responding to the challenges of teaching about race and culture in medical schools. Whether they are fully executed needs to be evaluated. Aquifer has already incorporated edits based on our guidelines into its core virtual patient teaching cases and received excellent feedback from student users. At our institution, there is an antiracism coalition working to address structural racism in medical education and how we can better address the structural and social determinants of health to result in more equitable care.
Raising awareness and acknowledging that we all have implicit bias are the first steps in reforming medical education to minimize its impact on the care we provide to patients. Our guide may also enable medical educators to practice structural humility by reflecting on how they can improve their own approaches to promoting a more diverse and equitable learning environment.
DISCLOSURE: Dr. Chretien is a student engagement lead at the nonprofit organization Aquifer and receives a small stipend for her work.
1. Krishnan A, Rabinowitz M, Ziminsky A, et al: Addressing race, culture, and structural inequality in medical education: A guide for revising teaching cases. Acad Med 94:550-555, 2019.
2. Metzl JM, Hansen H: Structural competency: Theorizing a new medical engagement with stigma and inequality. Soc Sci Med 103:126-133, 2014.