inDEPTH: Diversity & Inclusion in Medicine

Chase T. M, Anderson, MD, MS, Child and Adolescent Psychiatrist, The University of California, San Francisco

I remember sitting in class in medical school approximately 9 years ago as we learned facts related to cardiology. Each lecture would begin the same way and you could portend exactly what would happen based on previous instances: as we learned about physiology before moving onto pathophysiology, there would always come a point when the lecturer would speak about the diseases encountered and the racial breakdown. Somehow, Black people were at least 90% of the time listed as being at higher risk of the disease or having worse outcomes.

In those lectures, we never discussed deeply why this occurred—it was often mentioned as a statement of fact and then we’d move on to the next slide. That was it. I even remember a lecturer saying “the Blacks” instead of “Black people” or “individuals who are Black” before the statistic that we were worse off was tossed out casually as a fact to learn for an exam. In my recollection, rarely did a lecturer speak about why African-American people had higher rates of diseases, poorer outcomes, and often a worse prognosis.

I remember sitting there as an African-American, gay, medical student while experiencing discrimination from my classmates and administrators. Part of me wondered if mayhap Black people had higher rates of heart disease because of what was done to us by society, not simply genetics, as I sat there with my heart pounding from simply being around classmates who had made medical school a living nightmare. I wondered if Black people were predisposed to worsened outcomes because of simply being born with the skin color we had in a country where racism was subversive, overt, and woven into everything.

I certainly wasn’t going to ask those sorts of questions, though, especially when I knew that would bring further ire and scorn from certain classmates. We now have so much more understanding of our why, but honestly, we had this answer years and years ago. It’s simply that more people are listening now to the fact that racism, systemic oppression, and a multitude of other factors contribute to why minoritized people in America often suffer worse health outcomes.

The fact that discrimination causes worsened outcomes has been noted across the board for medical illnesses. Prior to the pandemic, Black people, Hispanic people, and people who identify as American Indian and Alaska Native experienced worse health outcomes. These outcomes worsened during the pandemic. Black and American Indian/Alaska Native people are more likely to die during or after pregnancy. Patients of color are often noted to receive inferior healthcare because of physician biases, which can be reinforced throughout, and by, medical education.

These facts also apply to psychiatric outcomes for minoritized people. African-American adults receive prescription medications in lower rates compared with White adults, even with being noted to have severe psychological distress. Minoritized people are less likely to receive treatment when diagnosed with a mental health disorder, and the suicide rate in Black youths is rising faster than in any other racial/ethnic group. The Trevor Project noted that LGBTQ+ youth reported that political events—such as the anti-trans bills being forced through in legislature throughout the country—negatively impacted their mental health.

For The Wall Street Journal to say that “woke politics is about to infect medical education” with statistics around racism and discrimination already proven simply reinforces that the Association of American Medical Colleges is on the right track by naming the need to teach future doctors about diversity, equity, inclusion, and how discrimination affects patients and communities.

Of note, even in writing these statistics and data, I am simply rewriting what has been written before. We have the data. We have had the data for a long time. What we need is action while we deepen and further nuance and finesse our studies. What we need is action where this information is woven into medical training curriculum.

To ask one person—one physician—to extol fully what diversity, equity, and inclusion in medicine should entail is an impossible task. As well, what can be done and needs to be done to write these inequities has been written about by scholars, physicians, and minds who have made this their life’s work.

Instead, I ask a few questions that came to mind when reading the WSJ article and which I’ve pondered since I began medical training:

• If we don’t change how medical education works, aren’t we simply training people to become healthcare workers who continue to enact discrimination against vulnerable patients and perpetuate the system that causes these outcomes?
• If those in medical training treat their classmates in discriminatory ways, what will they do to patients who can’t speak up for themselves?
• If we don’t change the system of medicine and make it truly inclusive, how else will we ever see the heights medicine should reach but has continued to fall short of?
• Is it “woke” to truly care about the whole person and the environment that has made them who they are? Or is it simply being the humans we could and should become?
• What could our medical system look like if we truly valued the full breadth of humanity?

Just a few questions, some rhetorical and some not, by a child and adolescent psychiatrist who continues to hope and believe that we can create a better world inside and outside of medicine.

Joanna Turner, Bisgrove, MD, FAAFP, Family Physician, Assistant Professor of Family Medicine, Rush University Medical Center

The recent AAMC updated guidelines for medical schools to incorporate more evidence-based concepts on diversity, equity, and inclusion into medical education is long overdue, as multiple studies show the link between health disparities and shorter lifespan for all people, even those who are privileged and don’t face disparities. However, the heavy focus on racism as the end-all, be-all health disparity in the Wall Street Journal, above, and in other publications misses a critical component of health disparities: while racism is a significant factor, it is far from the only issue driving health disparities.

Take ableism, which is heavily present in all of society. Ableism is the catch-all term used to describe how our society generally doesn’t try to change to better accommodate those with disabilities. That hurts us all. For example, practical approaches to disability inclusion include simple things like curb cuts, which allow not just people with wheelchairs and walkers to safely cross the street but also people pushing strollers, carts, and any wheeled device. Additionally, the COVID-19 pandemic has precipitated a crisis of disability, with 19% of people who had COVID reporting persistent long-COVID symptoms and millions of US workers currently disabled due to long-COVID, plus the need to wear masks and socially distance affecting people with hearing loss and communication disorders. There are meaningful and reasonable solutions to overcoming the barrier posed by masks (use one with a clear window so the hearing impaired can read lips, allow and fund for assistive listening devices when needed), but these solutions are not widely accepted because, in my experience, people just don’t think about the need for it. For workers disabled by COVID, companies need to adopt policies that allow them to work even with their current disability, as having that many people out of the workforce is likely a major reason for our country’s current labor shortage, an established driver of historic inflation. Moreover, just like COVID did more harm to long-marginalized communities, a higher percentage of the Black and Native American populations are disabled, and people of color who are disabled bear what is known as a “double burden” from the intersectional nature of disability and race. These are just a few examples of why ableism in society must be addressed.

Regarding ableism in medicine, research suggests that more than 80% of physicians view patients with disabilities in a highly negative fashion. This has significant consequences for patient care, as people with disabilities are far less likely to receive the full spectrum of healthcare benefits, including preventative medicine and screenings, that their able-bodied peers typically receive without question.

As someone who has been hard of hearing since birth, I’ve experienced these disparities intimately. I have constantly had to advocate for reasonable accommodations during my education and now as both a physician and patient. My lifelong need for self-advocacy turned me into an advocate for others. However, it gets exhausting constantly educating others about the things I need to be successful, and I am well aware that my efforts don’t come close to helping the millions of people in this country who are unable to advocate for themselves.

Moreover, evidence suggests that when students are exposed to others different from themselves, they develop significant empathy and are more in tune to what patients need. This is critical for people with disabilities, as they represent more than 26% of the population according to most recent estimates, and this number has grown since the beginning of the COVID-19 pandemic. With approximately 3% of current physicians identified as having a disability, the gap in care for patients with disabilities is enormous if diversity, equity, and inclusion (DEI) is not included in medical education.

There is so much that needs to be done to close the health disparity gap for millions of people across the United States. Until recently, fighting back against ableism was barely mentioned, but it needs to be central to all discussions of DEI. As noted above, it affects medicine and society in profound ways. If ableism continues to be ignored, we will never achieve full diversity, equity, and inclusion for our patients or ourselves.