Reimagining Graduate Medical Education (GME)
My interaction with education and medicine has been a love-hate kind of relationship.
As a child refugee, my first encounter with racism was during elementary school. My fifth-grade class was split into three distinct classes: one for all the Black students; the other two were for the white and Asian students. The class with Black students had a few descriptive labels such as: "the difficult class," "the class of students with attitude," "the challenging class." Despite being studious and disciplined, as a Black child I was placed in the "challenging" class. Our class was hardly given the learning opportunities to engage in educational competitions, and we had the most detentions compared to the other fifth graders. This was my first introduction into racialized education. Even as a child, I never really felt that my white teachers were interested in my education. My parents, being educators from Uganda, had a level of understanding of the racism embedded in childhood education in North America. They tried to advocate for improvements in that school without success. Eventually, I was transferred to another school district as I transitioned to middle school.
In addition to facing racism in education, as a child I recall the many frustrations and disappointments my parents had experienced while navigating the Canadian healthcare system as immigrants. My father had told me on several occasions he never truly felt that the healthcare system was meant for our survival and longevity as Black people. Among other things, my mother always felt there was no advocate for the health of Black individuals.
As I grew older, I became more cognizant of the experiences immigrants of color go through when it comes to accessing healthcare services. My parents' words about the healthcare system echo in my mind constantly. My interest in becoming a doctor was sparked and then nurtured by not only my own family's experiences of racial biases but also witnessing other immigrants of color go through the same predicament that my family went through.
Fast forward to the present, and as a Black Muslim female family medicine resident physician in the U.S.A., I know that medicine has historically racialized Black and Brown bodies, and to some degree it continues to do so. I've had many moments of "double consciousness" that W. E. B. Du Bois described very eloquently in his book, The Souls of Black Folk (1), where I'm conflicted with the double consciousness of being a physician and a Black woman: the physician who wants to offer care to her patients but, at the same time, trying to reconcile with the dark history of medicine in the U.S.A. that experimented on Black female bodies.
This double consciousness is most evident during my clinical decision-making. For instance, when using the estimated glomerular filtration rate (eGFR) to estimate renal function, we are taught that serum creatinine is influenced by physiologic variables such as muscle mass (i.e., higher in African-Americans) (2). This is problematic because it is a damaging myth (supported by the medical field), which validated the institution of slavery (i.e., Black people were better suited for the conditions of hard labor because of "more" muscle mass) (2). In addition, the race-adjusted eGFR literally reduces Black patients' access to kidney transplantation, for which racial disparities are substantial (2). Renal function measurement scenario is one of the many instances where I tend to experience moments of "double consciousness" whenever I have such discussions with my Black patients. The reality is that the field of medicine is riddled with clinical decision-making that uses racist tools to make diagnoses and determine treatment options for patients that create more disparities. By way of illustration, the spirometer was racialized by Samuel Cartwight, among others, based on President Thomas Jefferson's interpretive framework from his "Notes on the State of Virginia" (3,4). In Jefferson's works he had elucidated that the negro had a deficiency in pulmonary function (3,4).
Navigating through medical education, like how my parents navigated through the healthcare system, for me has been filled with daily overt racism and microaggressions. In my quest to reconcile with my double consciousness, I was fortunate to be one of the first family medicine residents to go through the newly minted Local-Global Health rotation offered by a Federally Qualified Health Center (FQHC) in downtown Minneapolis, affiliated with the University of Minnesota, that serves a diverse racial and immigrant population.
Unlike my previous core rotations, this particular elective rotation exposed me to faculty that were willing to have the difficult discussions regarding the role of white supremacy and privilege in causing unfair housing laws and limited access to healthcare services to Black, Indeginous people of color (BIPOC). I had relevant discussions with faculty about the impact of racism on chronic illnesses like hypertension and diabetes mellitus.
Sadly, like in most medical academic institutions, these discussions of racism and its effects on the health of our patients are always considered "electives" and not part of the core curriculum. Furthermore, few white residents rarely engage in such rotations, yet they account for most of the trainees in GME training. Even before the killings of Breonna Taylor, Ahmaud Arbery, George Floyd, and many before them, I knew that family medicine GME training failed to acknowledge the dark history of medicine on Black and Indigenous lives in didactics and clinical encounters. In addition, GME training has not prioritized the understanding of racism as a risk factor instead of race in medical education.
With the current global and domestic realization of the dual pandemic of systemic racism and COVID-19, there has finally been some engagement from academic institutions to reflect on their role in causing health disparities among minorities. I acknowledge that there are few GME programs that have established some form of antiracism curriculum (5,6,7). However, there hasn't been a major shift in family medicine training in Minnesota or nationally to teach about the impact of white supremacy and white privilege on the health of Black and Indigenous lives in our CORE curriculum. Furthermore, a distinction must be drawn between antiracism and health equity curriculums; one should not be a substitute for the other.
Currently, I feel that family medicine GME training fails to acknowledge the white supremacist foundation of medicine through all its teaching methods, including but not limited to didactics and clinical encounters with patients. I believe this is because the dominant white culture has not been willing to engage in relevant discussions about systematic racism and white supremacy.
Faculty of family medicine need to understand that residents of color have various unique experiences on racism garnered over time while navigating through dominant white spaces in medical education, which could be resourceful in creating change. It is no surprise that physicians like me are so passionate about medical education requiring mandatory core curriculum on racism. Family medicine GME needs to have serious discussions about the historical impact of slavery and continued systemic racism on the health of patients of color. In my opinion, understanding racism as a risk factor for poor health in a Black patient is just as important as understanding that smoking is a strong risk factor for developing lung cancer.
I love the field of family medicine — so much so that my criticisms of the field are meant to stimulate radical change in training. As family medicine physicians, we pride ourselves on being the first-line doctors for our community members. However, I feel that if our CORE training continues to focus only on clinical skills without being trained about the systemic injustices of medicine faced by our Black and Brown patients, we will continue to perpetuate white supremacist ideas in our practice. If we are to improve the health outcomes of Black and Brown lives, family medicine needs to reimagine and recreate our GME training. Residents need to be trained to have honest discussions about systemic racism with their peers and their patients as a core competency. Urgent and robust antiracism curricula need to be supported financially and in academic associations. An American Council of Graduate Medical Education (ACGME) milestone on understanding systemic racism needs to be created so the above can be implemented in our training.
If family medicine is to achieve its objectives for all people regardless of their race, religion, or color, we need to acknowledge the dark history of medicine in our curricula, as a first step, and how systemic racism is the most important social determinant of health of a Black person.
1. Du Bois, W. E. B. (1903). The Souls of Black folk. Oxford University Press.
2. Eneanya, Nwamaka Denise, Wei Yang, and Peter Philip Reese. "Reconsidering the Consequences of Using Race to Estimate Kidney Function." JAMA (2019).
3. Washington, Harriet A. Medical apartheid: The dark history of medical experimentation on Black Americans from colonial times to the present. Doubleday Books, 2006.
4. Lujan, Heidi L., and Stephen E. DiCarlo. "Science reflects history as society influences science: brief history of "race,""race correction," and the spirometer." Advances in physiology education (2018). https://journals.physiology.org/doi/full/10.1152/advan.00196.2017
5. Guh, Jessica, Collette Harris, Patricia Martinez, Frederick Chen, and L. Paul Gianutsos. "Antiracism in residency: a multimethod intervention to increase racial
diversity in a community-based residency program." Family medicine 51, no. 1 (2019): 37-40. https://journals.stfm.org/familymedicine/2019/january/chen-2018-0328/
6. Brown University Family Medicine Residency Program Health Equity Curriculum: https://www.brown.edu/academics/medical/about/departments/family-medicine/education/residency-program/diversity-and-inclusion
7. University of Virginia Family Medicine Residency Program Health Equity Curriculum: https://med.virginia.edu/family-medicine/education/family-medicine-residency-pro