Evaluating the impact of an educational intervention on the history of racism in America for teaching structural competency to medical academicians
PMCID: PMC11157923
PMID:
Abstract
Background A challenge facing many Academic Health Centers (AHCs) attempting to revise health professions education to include the impact of racism as a social and structural determinant of health (SSDoH) is a lack of broad faculty expertise to reinforce and avoid undermining learning modules addressing this topic. To encourage an institutional culture that is in line with new anti-racism instruction, we developed a six-part educational series on the history of racism in America and its impact on contemporary health inequities for teaching structural competency to health professions academicians. Methods We developed a six-hour elective continuing education (CE) series for faculty and staff with the following objectives: (1) describe and discuss race as a social construct; (2) describe and discuss the decolonization of the health sciences and health care; (3) describe and discuss the history of systemic racism and structural violence from a socio-ecological perspective; and (4) describe and discuss reconciliation and repair in biomedicine. The series was spread over a six-month period and each monthly lecture was followed one week later by an open discussion debriefing session. Attendees were assessed on their understanding of each objective before and after each series segment. Results We found significant increases in knowledge and understanding of each objective as the series progressed. Attendees reported that the series helped them grapple with their discomfort in a constructive manner. Self-selected attendees were overwhelmingly women (81.8%), indicating a greater willingness to engage with this material than men. Conclusions The series provides a model for AHCs looking to promote anti-racism and structural competency among their faculty and staff. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-024-05626-5.
Full Text
The primary cause of health inequity in the United States is structural racism [1]. Stark inequities in morbidity and mortality among minoritized populations have persisted for generations. In 1899, W.E.B. Du Bois was the first to note that social conditions determined by the experience of racism and discrimination, not genetics, were the primary determinants of ill health of Black residents in Philadelphia, leading to their higher mortality rates [2]. The COVID-19 pandemic amplified and exacerbated the health inequities that have plagued marginalized communities for over a century [3–5]. The Black Lives Matter movement, brought to a crescendo with the brutal public murder of George Floyd, prompted many Academic Health Centers (AHCs) in the U.S., including associated schools of medicine, nursing and health professions, to increase their anti-racism efforts in the face of one of the most glaring examples of structural violence in America: the systemic killing of unarmed Black persons by police. These included efforts to eliminate bias from teaching materials and clinical algorithms, and mandated training in unconscious bias and other forms of discrimination [6]. Other academic institutions issued anti-racism statements or held community conversations to process the traumatic effect of structural racism [7]. Academic organizations were closely scrutinized for compliance with accreditation standards regarding diversity and many were found lacking [8].
Like many campuses, The University of Kansas Medical Center (KUMC) held community conversations and town hall meetings to discuss the legacies of racism at AHCs. University leadership instructed all departments to audit their curricula and remove instances of outdated race-based medicine and review their anti-racism instruction (including racism as a major structural determinant of health in the US). Initial efforts across the institution were disjointed, using non-standardized criteria to review curricula, and relying upon faculty with varying levels of content expertise in this area. To coordinate our efforts and improve implementation across the institution, KUMC adopted The REPAIR Project. The REPAIR Project (REPAiring Institutional Racism) is designed to address anti-Black racism and augment Black, Indigenous and People of Color (BIPOC) voices and presence in science and medicine. The project addresses racism in medicine and health professions as an educational problem by providing a theoretical framework for coordinating and implementing social justice and anti-racism curriculum throughout the medical center. The REPAIR framework began at the University of California at San Francisco [9] and is now being implemented at KUMC and Johns Hopkins School of Medicine as well.
We undertook the challenge of “repair” with the acknowledgement of social theory in Indigenous studies that troubles the concept of repair [10] in contexts where the material conditions for returning to a pre-harm status may no longer exist, especially in situations in which the harms committed led to losses of life. This acknowledgment includes insights from critical disability studies scholars who have long-critiqued distinct but interrelated concepts such as repair, rehabilitation, and cure [11, 12] in biomedical contexts. Each activity, training, and learning module developed under the REPAIR framework is designed to meet one or more of four pillars within the theoretical framework. These pillars also guide the development of new research, inform institutional policies and practices, and enhance community engagement. They are:
As we began developing and rolling out new evidence-based curricular content around racism as a major structural determinant of health as part of REPAIR, initial student feedback revealed that it was not uniformly implemented by all instructors. Students reported that some preceptors lacked the expertise in structural competency [13] to adequately facilitate class discussions around the new topics, some undermined the new instruction by re-iterating some of the non-evidenced-based racial folklore [14] that permeates Western medicine, and some eschewed discussing the new content altogether.
Though many academic institutions have implemented DEI programming and training over the past few years, published research looking at implementation and effectiveness is scarce [15]. This evaluative study of the series is meant to help fill the gap in implementation and effectiveness research pertaining to similar efforts. In this paper, we describe the educational program, explain the challenges to intervention and how they were overcome, report its outcomes, and offer suggestions for next steps in dismantling racism in academic health institutions.
The Civil War (delivered by David Roediger [16]).
Responses to the four primary assessment questions were summarized (Figs. 2, 3 and 4, and 5) for each of the six sessions and the post-series poll, by calculating the percentage of respondents (vertical axis) who selected either strongly disagree, disagree, neutral, agree, or strongly agree, and representing this longitudinally (horizontal axis) from the first session to the post-series poll. The mode of the responses is shown as a clustered bar chart (Fig. 6), with the mode (horizontal axis) grouped by question and session date.
The series enjoyed 273 unique participants who attended one or more sessions as they were delivered live, averaging 92 persons per session. A further 134 participants watched recorded versions of one or more sessions online. Of the persons who attended the live streaming, 160 people attended only one session, 50 people attended only two sessions, 16 people attended only three sessions, 19 people attended only four sessions, 11 people attended only five sessions, and 17 people attended all six sessions (Fig. 1). The average number of sessions attended was 2 out of 6. We are unable to determine the amount of overlap between persons who attended the sessions live and those who watched recorded versions.
Overwhelmingly, participants identified as female. Self-identified gender data was available for 258 participants, and of those, 211 (81.8%) identified as female, 46 (17.8%) identified as male, 1 (0.4%) identified as “other,” and there were 15 (5.8%) persons for whom no data was available (see Table 1).
There were 213 participants for whom racial/ethnic data could be collected. Of those, 133 (62.4%) identified as White; 38 (17.8%) identified as Black/African American; 20 (9.4%) identified as Asian [including 9 (4.2%) who identified as Indian, 6 (2.8%) Middle Eastern, and 5 (2.3%) Southeast Asians or Pacific Islanders]; 19 (8.9%) identified as Latinx/Hispanic; and 1 (0.5%) who identified as American Indian/Alaskan/Hawaiian Native). The gender gap skewing heavily toward women was present for every racial and ethnic group save for persons who identified as Middle Eastern, who were evenly split between males and females (Table 1).
The series drew attendees from across the health center and the surrounding community. Affiliation data was available for 210 (76.9%) participants. Of those, 59 (28%) were university administration/staff (including 2 members of executive leadership); 47 (22.4%) were clinical faculty; 37 (17.6%) were community members not affiliated with KUMC or any other AHC; 26 (12.4%) were research faculty; 14 (6.7%) were nurses; 27 (5.5%) were students (including 12 medical students, 6 (2.9%) post-docs, 6 (2.9%) graduate students; and 3 (1.4%) undergraduates) (Table 1).
The response rates for each of the six pre-assessments were 53.5%, 51.1%, 57.1%, 60.9%, 52.2%, and 51.3% respectively, with an average response rate of 54.4%. Out of the 273 attendees who were emailed and asked to complete a post-assessment, 80 did so, for a response rate of 29.3%. Our assessments revealed that attendees of this series demonstrated appreciable increased understanding of all four series objectives over the course of the series. Out of the four objectives, the first (“I can describe and discuss race as a social construct”) had the highest pre-series understanding, with 68.5% of respondents indicating that they either agreed or strongly agreed at session 1 and only 10.9% reporting that they disagreed or strongly disagreed (see Fig. 2). By contrast, the fourth objective for the series, (“I can describe and discuss: reconciliation and repair in biomedicine”) had the lowest pre-series understanding, with 62% of respondents reporting that they either disagreed or strongly disagreed at session 1 while only 13% reported that they agreed or strongly agreed (see Fig. 5).
Overall, objectives two (“I can describe and discuss: Decolonization of the Health Sciences and health care”) and four (“I can describe and discuss: reconciliation and repair in biomedicine”) had more participants who were unfamiliar with the concepts pre-series than who were familiar (see Figs. 3 and 5, and 6). For objective two, 47.8% of respondents indicated that they either disagreed or strongly disagreed at session one. This percentage was reduced to just 6.5% at the post-series poll following session six. We saw a similar degree of reduction in disagreement with objective four, from 62% at session 1 down to only 11.5% at the post-series poll following session six.
For objective three, “I can describe and discuss: The history of systemic racism and structural violence from a socio-ecological perspective,” most respondents (65.3%) polled before session one expressed either neutral or slight agreement, while only 6.5% of respondents expressed strong agreement. However, by the end of session six, strong agreement responses rose to 45.5% (see Fig. 4).
Participants responded to three optional open-ended questions during the post-series poll (Table 2). Many participants commented on the depth of the content delivered and the unexpected value of learning history to inform healthcare. Many other attendees commented on how the series helped them grapple with their discomfort around the topic of racism in a constructive manner. For some participants, the series sparked a plan to share what they learned with others and to change their behavior. Still, some patients had questions about how they could directly take action against racism.
Generally, female employees of KUMC outnumber males by a ratio of 3:2. However, female series attendees outnumbered males by a ratio of almost 5:1. Employees of the health center are also approximately 72% White. This means that both women and Black, Indigenous and People of Color (BIPOC) individuals (n = 80 or 37.6%) were over-represented as series attendees, though women were much more so. This is consistent with a 2022 Women in the Workplace Report which found that women are leading the charge for a more inclusive workplace and are two times as likely to invest time and energy in DEI activities, compared to their male counterparts [17]. White men accounted for only 9% of total attendees. Compared to their numbers on campus, they were the most underrepresented of any gender/racial group. Given that attendance was voluntary, this may indicate a general disinterest among White males in DEI educational programming, and a need to conduct greater targeted outreach for that population.
The number of participants who were pleasantly surprised at the historical nature of the series is an indication of how integral history of medicine scholarship is to the development of an anti-racist and structurally competent biomedical workforce (when it doesn’t neglect the central role that racism and the concept of race played in the production of biomedical knowledge). It also demonstrates that there is an appetite for more of this type of learning on a medical campus. Unfortunately, it is also a commentary on how often teaching the history of medicine to students and faculty gets neglected in many AHCs [18].
Sections
"[{\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"CR1\", \"CR2\", \"CR3\", \"CR5\", \"CR6\", \"CR7\", \"CR8\"], \"section\": \"Background\", \"text\": \"The primary cause of health inequity in the United States is structural racism [1]. Stark inequities in morbidity and mortality among minoritized populations have persisted for generations. In 1899, W.E.B. Du Bois was the first to note that social conditions determined by the experience of racism and discrimination, not genetics, were the primary determinants of ill health of Black residents in Philadelphia, leading to their higher mortality rates [2]. The COVID-19 pandemic amplified and exacerbated the health inequities that have plagued marginalized communities for over a century [3\\u20135]. The Black Lives Matter movement, brought to a crescendo with the brutal public murder of George Floyd, prompted many Academic Health Centers (AHCs) in the U.S., including associated schools of medicine, nursing and health professions, to increase their anti-racism efforts in the face of one of the most glaring examples of structural violence in America: the systemic killing of unarmed Black persons by police. These included efforts to eliminate bias from teaching materials and clinical algorithms, and mandated training in unconscious bias and other forms of discrimination [6]. Other academic institutions issued anti-racism statements or held community conversations to process the traumatic effect of structural racism [7]. Academic organizations were closely scrutinized for compliance with accreditation standards regarding diversity and many were found lacking [8]. \"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"CR9\"], \"section\": \"Background\", \"text\": \"Like many campuses, The University of Kansas Medical Center (KUMC) held community conversations and town hall meetings to discuss the legacies of racism at AHCs. University leadership instructed all departments to audit their curricula and remove instances of outdated race-based medicine and review their anti-racism instruction (including racism as a major structural determinant of health in the US). Initial efforts across the institution were disjointed, using non-standardized criteria to review curricula, and relying upon faculty with varying levels of content expertise in this area. To coordinate our efforts and improve implementation across the institution, KUMC adopted The REPAIR Project. The REPAIR Project (REPAiring Institutional Racism) is designed to address anti-Black racism and augment Black, Indigenous and People of Color (BIPOC) voices and presence in science and medicine. The project addresses racism in medicine and health professions as an educational problem by providing a theoretical framework for coordinating and implementing social justice and anti-racism curriculum throughout the medical center. The REPAIR framework began at the University of California at San Francisco [9] and is now being implemented at KUMC and Johns Hopkins School of Medicine as well.\"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"CR10\", \"CR11\", \"CR12\"], \"section\": \"Background\", \"text\": \"We undertook the challenge of \\u201crepair\\u201d with the acknowledgement of social theory in Indigenous studies that troubles the concept of repair [10] in contexts where the material conditions for returning to a pre-harm status may no longer exist, especially in situations in which the harms committed led to losses of life. This acknowledgment includes insights from critical disability studies scholars who have long-critiqued distinct but interrelated concepts such as repair, rehabilitation, and cure [11, 12] in biomedical contexts. Each activity, training, and learning module developed under the REPAIR framework is designed to meet one or more of four pillars within the theoretical framework. These pillars also guide the development of new research, inform institutional policies and practices, and enhance community engagement. They are:\"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"CR13\", \"CR14\"], \"section\": \"Background\", \"text\": \"As we began developing and rolling out new evidence-based curricular content around racism as a major structural determinant of health as part of REPAIR, initial student feedback revealed that it was not uniformly implemented by all instructors. Students reported that some preceptors lacked the expertise in structural competency [13] to adequately facilitate class discussions around the new topics, some undermined the new instruction by re-iterating some of the non-evidenced-based racial folklore [14] that permeates Western medicine, and some eschewed discussing the new content altogether.\"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"CR15\"], \"section\": \"Background\", \"text\": \"Though many academic institutions have implemented DEI programming and training over the past few years, published research looking at implementation and effectiveness is scarce [15]. This evaluative study of the series is meant to help fill the gap in implementation and effectiveness research pertaining to similar efforts. In this paper, we describe the educational program, explain the challenges to intervention and how they were overcome, report its outcomes, and offer suggestions for next steps in dismantling racism in academic health institutions.\"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"CR16\"], \"section\": \"\", \"text\": \"The Civil War (delivered by David Roediger [16]).\"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"Fig2\", \"Fig3\", \"Fig4\", \"Fig5\", \"Fig6\"], \"section\": \"Statistical analysis\", \"text\": \"Responses to the four primary assessment questions were summarized (Figs.\\u00a02, 3 and 4, and 5) for each of the six sessions and the post-series poll, by calculating the percentage of respondents (vertical axis) who selected either strongly disagree, disagree, neutral, agree, or strongly agree, and representing this longitudinally (horizontal axis) from the first session to the post-series poll. The mode of the responses is shown as a clustered bar chart (Fig.\\u00a06), with the mode (horizontal axis) grouped by question and session date.\"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"Fig1\"], \"section\": \"Participants\", \"text\": \"The series enjoyed 273 unique participants who attended one or more sessions as they were delivered live, averaging 92 persons per session. A further 134 participants watched recorded versions of one or more sessions online. Of the persons who attended the live streaming, 160 people attended only one session, 50 people attended only two sessions, 16 people attended only three sessions, 19 people attended only four sessions, 11 people attended only five sessions, and 17 people attended all six sessions (Fig.\\u00a01). The average number of sessions attended was 2 out of 6. We are unable to determine the amount of overlap between persons who attended the sessions live and those who watched recorded versions.\"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"Tab1\"], \"section\": \"Participants\", \"text\": \"Overwhelmingly, participants identified as female. Self-identified gender data was available for 258 participants, and of those, 211 (81.8%) identified as female, 46 (17.8%) identified as male, 1 (0.4%) identified as \\u201cother,\\u201d and there were 15 (5.8%) persons for whom no data was available (see Table\\u00a01).\"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"Tab1\"], \"section\": \"Participants\", \"text\": \"There were 213 participants for whom racial/ethnic data could be collected. Of those, 133 (62.4%) identified as White; 38 (17.8%) identified as Black/African American; 20 (9.4%) identified as Asian [including 9 (4.2%) who identified as Indian, 6 (2.8%) Middle Eastern, and 5 (2.3%) Southeast Asians or Pacific Islanders]; 19 (8.9%) identified as Latinx/Hispanic; and 1 (0.5%) who identified as American Indian/Alaskan/Hawaiian Native). The gender gap skewing heavily toward women was present for every racial and ethnic group save for persons who identified as Middle Eastern, who were evenly split between males and females (Table\\u00a01).\"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"Tab1\"], \"section\": \"Participants\", \"text\": \"The series drew attendees from across the health center and the surrounding community. Affiliation data was available for 210 (76.9%) participants. Of those, 59 (28%) were university administration/staff (including 2 members of executive leadership); 47 (22.4%) were clinical faculty; 37 (17.6%) were community members not affiliated with KUMC or any other AHC; 26 (12.4%) were research faculty; 14 (6.7%) were nurses; 27 (5.5%) were students (including 12 medical students, 6 (2.9%) post-docs, 6 (2.9%) graduate students; and 3 (1.4%) undergraduates) (Table\\u00a01).\"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"Fig2\", \"Fig5\"], \"section\": \"Participants\", \"text\": \"The response rates for each of the six pre-assessments were 53.5%, 51.1%, 57.1%, 60.9%, 52.2%, and 51.3% respectively, with an average response rate of 54.4%. Out of the 273 attendees who were emailed and asked to complete a post-assessment, 80 did so, for a response rate of 29.3%. Our assessments revealed that attendees of this series demonstrated appreciable increased understanding of all four series objectives over the course of the series. Out of the four objectives, the first (\\u201cI can describe and discuss race as a social construct\\u201d) had the highest pre-series understanding, with 68.5% of respondents indicating that they either agreed or strongly agreed at session 1 and only 10.9% reporting that they disagreed or strongly disagreed (see Fig.\\u00a02). By contrast, the fourth objective for the series, (\\u201cI can describe and discuss: reconciliation and repair in biomedicine\\u201d) had the lowest pre-series understanding, with 62% of respondents reporting that they either disagreed or strongly disagreed at session 1 while only 13% reported that they agreed or strongly agreed (see Fig.\\u00a05).\"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"Fig3\", \"Fig5\", \"Fig6\"], \"section\": \"Participants\", \"text\": \"Overall, objectives two (\\u201cI can describe and discuss: Decolonization of the Health Sciences and health care\\u201d) and four (\\u201cI can describe and discuss: reconciliation and repair in biomedicine\\u201d) had more participants who were unfamiliar with the concepts pre-series than who were familiar (see Figs.\\u00a03 and 5, and 6). For objective two, 47.8% of respondents indicated that they either disagreed or strongly disagreed at session one. This percentage was reduced to just 6.5% at the post-series poll following session six. We saw a similar degree of reduction in disagreement with objective four, from 62% at session 1 down to only 11.5% at the post-series poll following session six.\"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"Fig4\"], \"section\": \"Participants\", \"text\": \"For objective three, \\u201cI can describe and discuss: The history of systemic racism and structural violence from a socio-ecological perspective,\\u201d most respondents (65.3%) polled before session one expressed either neutral or slight agreement, while only 6.5% of respondents expressed strong agreement. However, by the end of session six, strong agreement responses rose to 45.5% (see Fig.\\u00a04).\"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"Tab2\"], \"section\": \"Participants\", \"text\": \"Participants responded to three optional open-ended questions during the post-series poll (Table\\u00a02). Many participants commented on the depth of the content delivered and the unexpected value of learning history to inform healthcare. Many other attendees commented on how the series helped them grapple with their discomfort around the topic of racism in a constructive manner. For some participants, the series sparked a plan to share what they learned with others and to change their behavior. Still, some patients had questions about how they could directly take action against racism.\"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"CR17\"], \"section\": \"Discussion\", \"text\": \"Generally, female employees of KUMC outnumber males by a ratio of 3:2. However, female series attendees outnumbered males by a ratio of almost 5:1. Employees of the health center are also approximately 72% White. This means that both women and Black, Indigenous and People of Color (BIPOC) individuals (n\\u2009=\\u200980 or 37.6%) were over-represented as series attendees, though women were much more so. This is consistent with a 2022 Women in the Workplace Report which found that women are leading the charge for a more inclusive workplace and are two times as likely to invest time and energy in DEI activities, compared to their male counterparts [17]. White men accounted for only 9% of total attendees. Compared to their numbers on campus, they were the most underrepresented of any gender/racial group. Given that attendance was voluntary, this may indicate a general disinterest among White males in DEI educational programming, and a need to conduct greater targeted outreach for that population.\"}, {\"pmc\": \"PMC11157923\", \"pmid\": \"\", \"reference_ids\": [\"CR18\"], \"section\": \"Discussion\", \"text\": \"The number of participants who were pleasantly surprised at the historical nature of the series is an indication of how integral history of medicine scholarship is to the development of an anti-racist and structurally competent biomedical workforce (when it doesn\\u2019t neglect the central role that racism and the concept of race played in the production of biomedical knowledge). It also demonstrates that there is an appetite for more of this type of learning on a medical campus. Unfortunately, it is also a commentary on how often teaching the history of medicine to students and faculty gets neglected in many AHCs [18]. \"}]"
Metadata
"{\"issue-copyright-statement\": \"\\u00a9 BioMed Central Ltd., part of Springer Nature 2024\"}"