What Medical Schools Can Do to Fix Systemic Issues in Health Care
Minnesota consistently ranks as one of the healthiest states in the nation, often taking the top spot. And as the home to the world's first Mayo Clinic, Minnesota is known worldwide for its innovative solutions in health care. However, as the conversation around racial disparities and social inequities has risen to the forefront, research shows that Minnesota's portrayal as the home to healthy residents only paints half the picture.
Census data shows that Minnesota's population is more than 80% white and just 7% Black. Despite this vast difference in population size, Minnesota's Black community is overrepresented in chronic health issues when compared to their white counterparts.
Black men in Minnesota have a higher mortality rate from cardiovascular disease than white men. Black women die of breast cancer at a 24% higher rate than white women, although their incidence rates - how frequent a disease occurs in a population - are 22% lower. The difference in health outcomes between white Minnesotans and Minnesotans of color is so pervasive that it can be pinned down to a zip code.
And the COVID-19 pandemic has exposed more healthcare inequities. According to state data, Black and Hispanic Minnesotans are testing positive at higher rates than the overall population. When adjusted for age, Black and Asian residents have the highest COVID death rates.
These racial disparities in health are not unique to Minnesota, and are indicative of a systemic issue that is plaguing the nation.
To address these inequities, universities and healthcare institutions have begun to redefine their roles in training and educating healthcare professionals.
One such institution is the University of Minnesota's medical school — the leading producer of physicians in the state which manages several hospitals and clinics across Minnesota.
University students and faculty at several medical schools have called on their administrations to create programs that address racial inequities that have caused disparities in health, pointing to inequality in care, racial bias among physicians and the lack of representation found in their study material.
Making a Change in How Race is Addressed in the Classroom
Constructing a racially and culturally inclusive curriculum has become a focal point for medical schools across the country as the classroom serves as the introduction to medicine for students. What students learn in their first few courses in medical school may influence their practice for years.
To change their approach to educating future physicians, the University of Minnesota Medical School recruited Dr. Ana Núñez to head their inaugural office of Diversity, Equity, and Inclusion (DEI). Dr. Núñez serves as a Vice Dean in the medical school and was brought on after last summer's civil unrest sparked by the Minneapolis police murder of George Floyd.
"One of the things that actually impressed me about coming here in the first place was how many had actually started doing the work," Dr. Núñez said.
The medical school's curriculum has been a focal point in making institutional changes. Knowing this, administrators have brought medical students in on the process to give their input as they work to reconstruct their education.
"As we talk about curriculum, what really matters is: What are the student's experiences when they come to us," Dr. Núñez said.
"Because that's how you get it right in terms of that engagement piece, because people sitting in a little conference saying, 'This is how we're going to change stuff,' without the voice of the lived folks just never get it right."
Medical students like Sally Jeon and Tegan Carr have worked to fix the medical school's approach to education. Both have served as their class DEI officers and are a part of the UMN Medical Education Reform Student Coalition (MERSC) that formed as a response to the police murder of George Floyd.
"That was the straw that broke the camel's back," Carr said.
Carr helped lead the Task Force for Change, a student group on the medical school's Duluth campus aimed at reforming the medical school's approach to racial inequity, which later coordinated with student groups like White Coats for Black Lives in the Twin Cities. This cooperation would create the MERSC.
Members of this coalition met with the medical school's administration, faculty and staff after sending a letter that listed what changes they'd like to see in response to the nation's racial awakening. Those changes include emphasizing an equity-based curriculum, establishing plans for faculty development in health equity instruction, removing race as a biological indicator in medicine, diversifying their standard patients and strengthening ties with communities of color.
You can read the full list of demands here.
Though medical students want to be a part of this change, their studies and time reserved for clinical work off campus limits how much they can do.
"For me as a first-year coming in, I had a sense that maintaining sort of the momentum of this could be a challenge," UMN medical student Sally Jeon said. "While it is absolutely crucial to have student voices centered through this experience, students cannot do this alone."
That's where school faculty comes in.
Both Jeon and Carr have commended Dr. Núñez and Dr. Mary Owen, director of the Center of American Indian and Minority Health, for doing the work from within the institution that goes beyond school hours. Much of DEI's work in health care or other industries has been seen as a sort of caveat or add-on to the work, but Dr. Núñez believes that it should be integral to how medicine is taught going forward.
"In the course of the year that I've been here, we've sort of built infrastructure," Dr. Núñez said.
All the school's medical departments now have committees and key individuals in DEI roles. Specialists like pediatricians and anesthesiologists must now have some understanding of equity in their practice.
Medical school faculty have also received racial bias and microaggression training to recognize how prejudice can appear in their practice.
"There is no area that is exempt from health disparities," Dr. Núñez said. "Not a one."
Most Patients That Medical Students Serve Are White
To gain an accurate perspective on how they will practice medicine in the future, medical students have asked for more diversity in their material and the patients they encounter while in school. Areas of medicine like dermatology rarely include how skin diseases will show up on people who are not white, for example.
"Students have voiced: How are we supposed to relate to each other and diverse patients if every standardized patient that we see, or community teacher that we interact with, is a white person?" Carr said. "We were only seeing white skin. In our lectures and pathology books. I mean I probably couldn't diagnose Lyme disease on my own skin."
If there was representation or mention of other races, it often came with misinformation which saw race as a biological factor.
"We know that race is a social construct. It is not a biological construct, and a lot of medicine was built in a faulty way — we also know that we can't just eliminate it," Dr. Núñez said. "Because people's lives are different based on who they are, where they live and their access to health."
Black individuals suffer kidney failure at three times the rate of white individuals and represent a third of patients in the U.S. receiving dialysis. For decades, physicians approached illnesses and diseases relating to kidney function with the racist notion that Black individuals have more muscle mass than other races. Muscle mass is relevant because it breaks down into nitrogen that taxes the kidneys, but medical institutions had internalized this racist trope from slavery and incorporated it into their care. The National Kidney Foundation recently announced the removal of race from estimating kidney function.
Since being diagnosed with a chronic illness relating to her kidneys, Carr has experienced the dismissive attitude that harms other patients of color seeking treatment. She said that questions about her race were brought up at the start of many of her doctor's visits.
While change is essential within educational institutions, it's also important to incorporate more racially conscious approaches to public health policy.
Dr. Rachel Hardeman is the director of the Center for Antiracism Research for Health Equity at the University of Minnesota and was named the first Blue Cross Endowed Professor of Health and Racial Equity at the university's School of Public Health. Dr. Hardeman's work aims to collaborate with colleagues across the university on developing curricula, fostering community engagement and developing policy work. Though Dr. Hardeman's conversations with Blue Cross and Blue Shield began before Floyd's murder, she believes there is even more reason to commit to this work now.
"My research, broadly speaking, focuses on the impact of racism on health outcomes and healthcare delivery for Black populations, but specifically for Black moms and babies," Dr. Hardeman said. "Minnesota is often ranked as the healthiest state in the nation, but when you start to pull back the layers and understand a little bit more about what's going on here, we actually start to fall towards the bottom of the list when we look at health outcomes by race."
Seeing those disparities in health outcomes firsthand when her grandmother's health deteriorated, Dr. Hardeman decided to pursue a career in health to help close that disparity and to provide everyone with high-quality care.
Black maternal and infant mortality rates are some of the most significant examples of health disparities between Black and white individuals.
"What we know when it comes to public health is that infant mortality is a critical marker for community health and wellbeing," Hardeman said. "Black women are four times more likely to experience maternal mortality (meaning death during pregnancy, childbirth, or year following childbirth) in comparison to their white counterparts despite their socioeconomic status."
And the U.S., Dr. Hardeman stated, is the only industrialized nation that has a rising maternal mortality rate.
"Even when you adjust for education and income level, you're still seeing these disparities," Dr. Foster said. "A lot of time when you talk about solutions, they want to point to social determinants of health and resources are crucial in achieving health equity."
The history of malpractice and mistreatment of Black women is rife in medical history. One offender was the "Father of Modern Gynecology," James Marion Sims, who experimented on many female slaves without anesthesia. For some people, the treatment of Black women in that era parallel how they are treated today.
"While folks can say, 'That's in our past, that's our history.' We haven't actually sat down and reconciled with that history and really struggled with what that means on how implicit bias and racism show up in current clinical encounters," Dr. Hardeman said.
Dr. Foster said that other issues within health care appear when looking at the cross-section of race and gender.
"Black women were typically offered hysterectomy as the only option or it was presented as the best option," Dr. Foster explained. "I know many women who had their uteruses removed in their 30s or 20s because of a few benign tumors.
Dr. Hardeman recently received an appropriation from the state to develop an antiracism training curriculum for perinatal care providers in Minnesota. This preventative care is provided in the form of checkups, nutrition assistance, and monitoring any biological changes. The Dignity in Pregnancy and Childbirth Act aims to reduce these racial disparities impacting Black mothers and babies and has allocated nearly $300,000 to the Center for Antiracism Research and Health Equity.
States across the country have begun to implement similar changes which focus on creating implicit bias and antiracism training while expanding in areas such as midwifery.