Anti-Racism, Inequity, and Implicit Bias in Health Care

Academic Medicine is committed to assisting medical schools and teaching hospitals, their faculty and trainees, and the public in dismantling racism. This collection previously published Academic Medicine articles (2016-Present) was curated with the intent to help readers engage in necessary conversations about race and to inform strategies to eliminate structural racism in their institutions.

Increasingly, the U.S. population is older and more diverse, and in the next two decades, racial and ethnic minorities will compose 42% of older adults. Without intervention, existing racial and ethnic health disparities among minority older adults are likely to be exacerbated. The pressing need to address these health disparities is perhaps most evident in Alzheimer disease (AD), which increases in prevalence with age and is disproportionately more prevalent among African American and Hispanic/Latino individuals.

The concept of race is often taught in health professions education with a clear biologic underpinning despite the significant debate in the literature as to whether race is a social or biologic construct. In response, the authors provide several evidence-based steps to guide discussions around race in clinical settings, while also hopefully limiting the use of bias and racism in the practice of medicine.

Designed for physicians and other health care professionals, "Advancing Health Equity: A Guide to Language, Narrative and Concepts" provides guidance and promotes a deeper understanding of equity-focused, person-first language and why it matters.

The authors conclude that "health professions must continue to engage with the complex social and structural determinants of health that intersect with politics and law. Addressing the health effects of structural racism cannot be accomplished through clinical, educational, or research activities alone; social advocacy and activism are required to employ antiracist policies targeting specific health inequities."

The authors argue that before any curriculum on race and racism can be developed for students in the health professions, and before faculty members can begin facilitating conversations about race and racism, faculty must receive proper training through intense and introspective faculty development.

This paper proposes the following recommendations for guiding efforts to mitigate the adverse effects associated with the use of race in medical education: emphasize the need for incoming students to be familiar with how race can influence health outcomes; provide opportunities to hold open conversations about race in medicine among medical school faculty, students, and staff; craft and implement protocols that address and correct the inappropriate use of race in medical school classes and course materials; and encourage a large cultural shift within the field of medicine.

This article introduces Critical Race Theory to the public health community, highlights key Critical Race Theory characteristics (race consciousness, emphases on contemporary societal dynamics and socially marginalized groups, and praxis between research and practice) and describes Critical Race Theory's contribution to a study on racism and HIV testing among African Americans.

Clinician bias contributes to healthcare disparities, and the language used to describe a patient may reflect that bias. The objective of this study is to assess whether stigmatizing language written in a patient medical record is associated with a subsequent physician-in-training’s attitudes towards the patient and clinical decision-making.

This article discusses the lessons learned in significantly restructuring the cultural competency instruction for medical students at the authors' institution, focusing on achieving greater health equity through caring for vulnerable populations and acknowledging and addressing bias and stereotyping.

Microaggressions and their impact have been documented in minority college students; however, little is known about the experience of medical students. This study reports the prevalence and understanding of microaggressions among medical students at the University of Florida College of Medicine , while gaining insights into experiences of medical students dealing with microaggressions.

Growing recognition of the deleterious effects of racism on health has led to calls for increased education on racism for health care professionals. As part of a larger curriculum on health equity and social justice, we developed a new educational session on racism for first-year medical students consisting of a lecture followed by a case-based small-group discussion.

The authors developed a longitudinal case conference curriculum called Health Equity Rounds (HER) to discuss and address the impact of structural racism and implicit bias on patient care. The curriculum engaged participants across training levels and disciplines on these topics utilizing case-based discussion, evidence-based exercises, and two relevant conceptual frameworks.

Despite mounting evidence that race is not a reliable proxy for genetic difference, the belief that it is has become embedded, sometimes insidiously, within medical practice. One subtle insertion of race into medicine involves diagnostic algorithms and practice guidelines that adjust or “correct” their outputs on the basis of a patient’s race or ethnicity. By embedding race into the basic data and decisions of health care, these algorithms propagate race-based medicine.

Relying on a close reading of more than 4,000 medicals student theses, this essay explores the evolving medical approaches to race and environment in the early national and antebellum United States and highlights the role that medical school pedagogy played in disseminating and elaborating racial theory. Specifically, it considers the influence of racial science on medical concepts of the relationship of bodies to climates.

Report produced by the Institute of Medicine (U.S.) in 2012.

As part of an educational continuous quality improvement process at the University of California, San Francisco, School of Medicine, the authors examined data for the classes of 2013–2016 to determine whether differences existed between underrepresented in medicine (UIM) and non-UIM students’ clinical performance and honor society membership—all of which influence residency selection and academic career choices. This analysis demonstrated differences that consistently favored not-UIM students. Whereas the size and magnitude of differences in clerkship director ratings were small, UIM students received approximately half as many honors grades as not-UIM students and were three times less likely to be selected for honor society membership.

Microaggressions are connected to broader conceptualizations of the impact of implicit bias and systems of inequity. The body of evidence supporting the need for more-open discussions in medical education about race, racism, and their impact on health disparities continues to grow. To discuss the intent and impact of microaggressions in health care settings and how we might go about responding to them, the authors developed a workshop for third-year undergraduate medical students within a longitudinal undergraduate medical education diversity and inclusion curriculum.

Sociologist James M. Thomas examines how public and scientific accounts of racism draw upon medical and psychological models, and how this contributes to our understandings of racism as a medical, rather than social, problem.

The Race and Medicine collection reflects NEJM’s commitment to understanding and combating racism as a public health and human rights crisis. This includes efforts to educate the medical community about systemic racism, to support physicians and aspiring physicians who are Black, Indigenous, and people of color, and ultimately to improve the care and lives of patients who are Black, Indigenous, and people of color.

The authors of this letter urge the director of NIH to lead education efforts directed at both scientists and the public about the nature of human genetic diversity and the ongoing need and obligation to confront racism in science in order to begin to address the misuse of racial measures in scientific and clinical practice.

Despite racism’s alarming impact on health and the wealth of scholarship that outlines its ill effects, preeminent scholars and the journals that publish them routinely fail to interrogate racism as a critical driver of racial health inequities. As a consequence, the bar to publish on racial health inequities has become exceedingly low. There is no uniform practice regarding the use of race as a study variable and little to no expectation that authors examine racism as a cause of residual health inequities among racial groups.

This article uses the White counselor-client of color counseling dyad to illustrate how racial microaggressions impair the development of a therapeutic alliance. Suggestions regarding education, training, and research in the helping professions are discussed.

Microaggressions, which are categorized as microassaults, microinsults, microinvalidations, and environmental microaggressions, are indirect expressions of prejudice that contribute to the maintenance of existing power structures and may limit the hiring, promotion, and retention of women and underrepresented minorities. The primary goal of this communication is to help readers understand microaggressions and their effect. We also provide suggestions for how recipients or bystanders may respond to microaggressions.

From the author: "During my medical training thus far, Trayvon Martin lost his life, Michael Brown was left to die in the streets of Ferguson, Missouri, and Eric Garner was choked by officers as he repeated 11 times that he could not breathe. But these events were rarely mentioned in the lecture hall, my small-group sessions, or morning rounds. Was I supposed to ignore their implications for the lives of my patients, and for my role as their caregiver?"

This paper describes a shift in medical education away from pedagogic approaches to stigma and inequalities that emphasize cross-cultural understandings of individual patients, toward attention to forces that influence health outcomes at levels above individual interactions.

This essay uses three historical case studies to illustrate how extraclinical stigma, socioeconomic factors, and politics can shape diagnostic and treatment disparities. It then explores how attention to structure helps explain the role of race in clinical encounters, and draws some lessons for medical education that take account of structure.

Amid the historic convergence of the coronavirus disease 2019 (COVID-19) pandemic and antiracist activism in the US, JAMA spoke with Chicago public health official, Linda Rae Murray, MD, MPH. In the Juneteenth conversation, Murray said the pandemic glaringly exposed health inequities and systemic racism.

Medicine largely frames racial health disparities in terms of biological difference and individual behavior, despite evidence that social and structural factors generate and perpetuate most health issues. This article was written by four medical students and graduate student researchers who witness these harms every day in their textbooks, classrooms, clinics, and communities.

Ethnicity & Disease is an international journal that exclusively publishes information on the causal and associative relationships in the etiology of common illnesses through the study of ethnic patterns of disease. Topics include ethnic differentials in disease rates; impact of migration on health status; social and ethnic factors related to health care access and health; and metabolic epidemiology.

Ethnicity & Health is an international academic journal designed to meet the world-wide interest in the health of ethnic groups. It embraces original papers from the full range of disciplines concerned with investigating the relationship between ’ethnicity’ and ’health’ (including medicine and nursing, public health, epidemiology, social sciences, population sciences, and statistics). The journal also covers issues of culture, religion, gender, class, migration, lifestyle and racism, in so far as they relate to health and its anthropological and social aspects.

Health and Human Rights is an online, open-access publication, supported by the FXB Harvard School of Public Health, the Dornsife School of Public Health, Drexel University, and Harvard Health and Human Rights Consortium. The journal provides an inclusive forum for action-oriented dialogue among human rights practitioners and endeavors to increase access to human rights knowledge in the health field by linking an expanded community of readers and contributors.

Medical Humanities presents the international conversation around medicine and its engagement with the humanities and arts, social sciences, health policy, medical education, patient experience and the public at large. Medical Humanities is an official journal of the Institute of Medical Ethics.