Understanding the effects of implicit racial bias on medical students

An overview of implicit racial bias in medical education.

Introduction

The field of research studying implicit racial bias in the healthcare and medical sectors is continuing to grow. While there is significant research examining implicit bias among healthcare professionals, the field has yet to produce many studies focusing on the specific effects on medical students experiencing that bias. 

Black, Latino, Indigenous, and Pacific Islander representation within the medical field remain lower than the general population, which ultimately results in adverse patient experiences and health outcomes for those minoritized patient groups.  

The authors offer three primary justifications for the importance of diving deeper into the role of implicit racial bias in medical education, citing the negative impact of implicit bias on:

1. Minoritized students’ mental health and academic performance,
2. Professional development of qualified minority healthcare professionals, and
3. Perpetuation of continued racial inequities in health outcomes. 

Olivia Rochelle Joseph is a PhD candidate at the University of Leeds School of Psychology. Stuart W. Flint is an Associate Professor at the University of Leeds School of Psychology. Rianna Raymond-Williams is a PhD candidate at the Glasgow Caledonian University School of Health and Life Sciences. Rossby Awadzi is a medical doctor for the United Kingdom National Health Service. Judith Johnson is an Associate Professor at the University of Leeds School of Psychology.

Methods and Findings

The authors begin with a narrative literature review of existing research published between 1995 and 2021. This covers the effects of implicit racial bias on medical education, contributors to bias, and possible solutions. 

Key findings on the causes and effects of implicit racial bias:

• Students’ implicit racial biases are consistent over time and may increase with healthcare education. Yet, longitudinal studies specifically assessing healthcare students’ implicit racial bias are extremely limited, which makes it challenging to understand the perceptions and effects of implicit racial bias across time or geographies.
• Peers, educators, clinical environments, and educational environments were all identified as sources of implicit racial bias within the medical education system. 
• Minoritized students are likely affected by interactions with other healthcare students and educators whose biases reflect those of the general population.  In turn, these students are victims of negative stereotypes, which leads to them altering their behaviors to counter negative stereotypes and enduring heightened pressure to demonstrate academic abilities. 
• Implicit racial biases shape educators’ lecture materials, clinical assessments, recommendation letters, and award distribution.
• Senior healthcare professionals propagate unconscious biases, which also leads to students of color’s disproportionate stress relative to their white peers. As a result, minoritized students report lower levels of social support, harmful educational environments, and higher rates of racial discrimination as a result of their race.

Effective interventions to address implicit racial bias in healthcare education include:

• Raise awareness of implicit racial bias
  “On an institutional level, recommended interventions include developing a commitment to auditing current practices and processes to identify and eliminate biased language, ideology, and misrepresentations of race, allocation of adequate resources to build capacity amongst staff, enforcement of accountability, and implementing transparent reporting systems for students and faculty to report experiences of bias.”
• Teaching bias mitigation strategies
  “At the organizational level, the author proposed the development of an inclusion strategy to show commitment to reducing bias, from hiring and retaining diverse faculty to admissions and assessment committees.”
• Reduce misrepresentation of race in the curriculum
  The authors highlight a successful implementation of a multi-stage approach comprised of “asking first-year medical students to engage with materials about implicit bias (e.g., books and film), encouraging students to take the IAT to identify personal biases, and engaging in open discussions with peers and faculty.”
• Organizational commitment to recruit and retain diverse staff
  The authors point to a study recommending “assessing the use of language in recruitment materials, considering where job opportunities are advertised, improving faculty reviewing processes to recognize talent within the diverse staff and provide clear information, mentoring, and support regarding formal processes for promotion.” They add that it is equally important to implement an effective inclusion strategy along with efforts to increase diversity.
• Creating trusting spaces
  “Many studies indicate the importance of informal networks and support groups and suggest faculty should help students to benefit from interracial communication by allocating diverse peers for group work.”

Conclusions

The authors highlight that medical students experience the effects of implicit racial bias, but the effects remain unclear. Hence, they conclude that more research should be conducted into the specific consequences of implicit bias on the well-being and academic progression of medical students of color. The authors also recommend conducting more longitudinal studies to understand the effects of different interventions and techniques across time and place. Lastly, they highlight the need for both interventions that target various contributing factors of racial bias and high-quality corresponding studies that assess the efficacy of these interventions. 

A Systematic Review of Global Anti-Racism Interventions in Healthcare

Introduction

Racism in healthcare settings is a persistent and complex problem for both healthcare delivery and access to health services. Over the past decade, several publications demonstrate the experiences of racism faced by minoritized patients such as the enduring racist assumptions about pain tolerance of Black people, the low propensity for screening Black women for cervical cancer, and the chronic undertreatment of fractures for Black people in emergency rooms. These studies indicate a need for interventions to address racism in the healthcare setting because of its negative effects on patient care.

In the years following the murder of George Floyd, many health organizations declared anti-racism commitments and shifted their core values in an attempt to reform hospital-based interventions to implement antiracist change. To date, however, there remains a gap in providing a systematic review of these efforts to understand which interventions actually worked. In this paper, authors conducted an international systematic review for anti-racist interventions in healthcare to: (1) increase understanding of these efforts for the sector and (2) analyze the anti-racist interventions’ potential to influence policy and patient care.
Nadha Hassen is a Toronto-based doctoral candidate at York University that works on antiracism and community-centered interventions.  Aisha Lofters is a family physician and researcher at Women’s College Hospital and the University of Toronto. Sinit Michael is a policy analyst for Canada’s parliamentary relations office and at the time of publication was part of St. Michael’s Hospital’s Knowledge Translation Program. Aminta Mall is part of the Faculty of Medicine at the University of Toronto. Andrew Pinto is the founder and director of The Upstream Lab and is a public health, preventive medicine specialist, and family physician at St. Michael’s Hospital. Julia Rackal is a journalist and family physician at St. Michael’s Academic Family Health Team in Toronto.

Methods and Findings

The authors relied on several search engines to sample the literature landscape to include keywords such as “race”, “racism”, “drivers”, and “cultural competency”, which resulted in 3587 citations (excluding duplicates). Each paper was then screened by at least 2 team members. For inclusion into the systematic review, articles required focus on the development and implementation of antiracist interventions within the following care settings: (1)  outpatient care (out of the hospital, in the clinic setting, etc.) and (2)  public health practitioners providing individual patient care.

Analyzing AntiRacism Interventions 

The authors then examined the interventions three ways: (1) determining if the intervention was a true anti-racism intervention, (2) distinguishing the level of racism the intervention sought to address, and (3) classifying the focus of the intervention. 

First, the authors used Calliste and Dei’s definition of a true anti-racism intervention, which is interpreted as an “action oriented, educational and/or political strategy for systemic and political change that addresses issues of racism and interlocking systems of social oppression”. Secondly, the authors used Camara Jones’ framework for the levels of racism (institutionalized, personally mediated, and internalized) to delineate the levels of racism each intervention sought to address. Lastly, the Social Ecological Model (SEM), was used to analyze the focus of the intervention; SEM allowed the authors to determine if the intervention operated at the individual, interpersonal, community, organization, or policy levels.

Types of Anti-Racism Interventions 

The literature review provides readers with an understanding of the typical focus of an anti-racism intervention at each SEM level:   

·  Individual level: ex. cultural competency training (addressing concepts related to racism, implicit bias, stereotype, or prejudice)

·  Interpersonal level: ex. develop and implement guidelines on how to address racist or prejudicial comments in psychotherapy

·  Community level: ex. meaningfully engage Aboriginal/Indigenous and racialized communities at multiple levels and make these relationships sustainable

·  Organizational level: ex. “Develop a strategic leadership committee, consultation group, team charged with monitoring and addressing policies and practices, resource allocations, relational structures, organizational norms and values, and individual skills and attitudes and implementing action plans that work towards anti-racist strategic goals.”·  Policy level: “Recruit, retain, and promote Black, Indigenous and people of color at all levels of the academic ladder in mainstream admission and promotion policy and in the healthcare workforce.”

Overview of the Literature

The authors used 37 peer reviewed articles in their review:12 empirical studies and 25 theoretical or conceptual papers. The majority of the papers were written by authors in the United States (51%) followed by Canada, the United Kingdom, Australia, and New Zealand, respectively. Additionally, most of the data targeted Indigenous (Aboriginal and Torres Strait Islander people, Maori, First Nations, Inuit, and Metis/Native Americans) and Black patient populations.

Suggested strategies for creating anti-racist programs:

·  Define the problems and set clear goals and objectives

·  Incorporate explicit and shared anti-racism language

·  Establish leadership buy in and commitment

·  Invest dedicated funding and resources

·  Bring in the right support and expertise (i.e. community leaders and subject matter experts) 

·  Establish ongoing, meaningful community and patient partnerships

Suggested strategies for the implementation and evaluation of anti-racism programs: 

·  Use a multi-level, long-term approach (i.e. targeting two levels such as community and organizational intervention, then ensuring the effort is sustainable) 

·  Embed racial equity policies and procedures in hiring, retention, and promotion practices  Hiring, retention, and promotion)

·  Link mandatory anti-racism work (including staff education and training) to broader systems of power, hierarchy, and dominance·  Incorporate opportunities for pause and reflection within a cyclical, process improvement practice  reflect mechanisms in a cyclical process

Conclusions

The authors describe the paucity of research related to the implementation and evaluation of anti-racist efforts in the outpatient clinical setting while simultaneously recognizing the scarcity of these interventions. The authors also acknowledge the lack of institutional and societal level policies and practices focused on anti-racism in the healthcare setting. Overall, the authors’ work demonstrates the scientific imperative for anti-racist interventions in medical care and the need for more widespread reporting of these efforts to advance a more standard application of these practices from a global perspective.