Health Disparities Are Not Accidental: Medicine’s Legacy of Structural Racism
Health disparities persist in the United States, functioning as a direct outcome of structural racism, which is embedded within medicine and its pathways: the educational system. To unveil these disparities, an analysis of the entry process, biases, policy, and anti-racist approaches to change the system is a step toward a more equitable field of medicine and pool of future physicians.
This gateway mentioned above is guarded by the MCAT, which often acts as a precursor to medical school acceptance and a core metric to admissions committees. In a 2013 study from Pennsylvania State University, College of Medicine, it was found that Black and Latino examinees’ mean MCAT scores were lower than their white counterparts, and while there was no direct evidence of bias derived from the MCAT exam itself, it was an indicator that structural and socio-economic barriers affect outcomes.
While cultural competence started to be formally integrated into medical education in 2015 through the addition of the Psychological, Social, and Biological Foundations of Behavior sections through AAMC initiatives, additional work still needs to be done, especially prior to taking the exam itself.
In a recent multi-institutional study of undergraduate medical-based curriculum, it was found that educators regularly pathologized race, rather than a social and political construct, which led to untrue notions about biological importance (Amutah et al., 2021). Additionally, one of the analyzed lectures presented a complex topic: “race-and-ethnicity-adjusted life expectancy,” without explaining how race and ethnicity affect one's life expectancy (Polanco Walters et al., 2020).
Centuries of structural and interpersonal racism and bias have persisted throughout not only our educational systems but also our government programs, contributing to continued disparities in higher education and the healthcare workforce.
On an economic level, government assistance programs from the Federal Housing Administration loan program and Social Security intentionally prevented BIPOC communities from receiving proper benefits, which trickled into patient care. This effect leads to sustained economic disadvantages and a higher concentration of BIPOC communities in lower-income neighborhoods, which have inadequate access to quality schools.
On a physician-to-patient level, a 2019 cohort study on the association of racial bias among resident physicians found that of the 3,392 second-year residents who self-identified as non-Black, their own symptoms of burnout resulted in outward bias (both explicit and implicit) toward Black patients (Dyrbye et al., 2019).
Additionally, Dovidio and Fiske (2011) found that, in general, physicians with higher rates of implicit bias toward Black patients resulted in an association with lower health outcomes for these patients, from greater distrust to being less likely to follow treatment recommendations.
Though studies suggest that BIPOC residents themselves actually present as being less burned out, Davis (2021) plausibly suggests that BIPOC residents have acquired certain protective factors that mitigate burnout in residency, and in turn acquire higher levels of resiliency that act as a protective factor.
Furthermore, Serafini (2020) provides that the lived experience of racism carried into residency, which necessitates mental flexibility for “sheer survival," though other factors could include under-reporting from fear of identification or protection from further marginalization.
According to the latest data from the AAMC on varieties in race/ethnicity, 63.9% of physicians are white, while only 5.7% are Black, 20.6% are Asian, 6.9% are Hispanic, 1.3% are multiple races or non-Hispanic, 0.3% are American Indian or Alaska native, and 0.1% are native Hawaiian or other Pacific Islander.
In a 2023 CNN article, Michael Dill, the director of the Association of American Medical Colleges, says the historical exclusion of Black people in medicine and the institutional racism within society are reasons why the 5.7% statistic does not reflect the communities they serve, as an estimated 12% of the U.S. population is Black.
The American Medical Association (AMA), issued an apology in 2008, a direct outcome of the JAMA paper published by independent experts, detailing how historically the AMA worked to close down African American medical schools; although the original 2008 apology leads to a “page not found” on the AMA website now, with evidence of the initial apology as ProPublica interviewed one of the authors of a recent JAMA article.
Additionally, overpolicing in communities of color has a direct impact on BIPOC communities' engagement in physical activity, where middle-class Black men who live in predominantly white neighborhoods report reduced physical levels of activity, which correlates with increased all-cause mortality, cardiovascular disease mortality, and risk of metabolic disorders, including hypertension and diabetes mellitus.
Not only is there an overarching knowledge gap in medical curricula, but also in how medical students at large understand the toll of structural racism, as estimates show there are over 70,000 excess deaths of Black individuals in the U.S. yearly, which contributes to the mentioned health inequalities (Benjamins et al., 2021).
We can’t undo systemic racism against BIPOC communities overnight, but academic medicine can evolve and take an anti-racist approach
As a white woman whose undergraduate career was centered around journalism, reporting from not only a fact-based fabric, but also a solutions-oriented one is vital to what I believe is journalism in its truest form: impact-driven.
When I stumbled upon a 2021 NIH journal article on ‘fixing’ the leak in the pipeline of Black physicians, I thought about how some things can’t be simply fixed by new policies, attitudes, and evolutions of systems; some things are simply woven into the fabric of our country, and thus, not issue that takes a simple fix to be solved.
Although the article presents valuable points, findings, and solutions on a curriculum and faculty level, the end goal of “fixing” is not only outdated but also ignorant of the systemic racism in our healthcare system. Racism in medicine needs to be confronted from the inside, by making intentional reforms in medical education, clinical practices, and by institutions taking accountability.
When it comes to how medical students are taught, making antiracism education a standard part of all residency and fellowship programs is a vital foundation. Including scholarly work produced by BIPOC in the classroom, from discussions, seminars, and assigned readings paired with class discussions that don’t just provide a synopsis, but an examination of the influence of structural racism on healthcare, is a start.
Cultural Competence is a vital skill that can follow the foundations mentioned prior, and is integrated into one of the AAMC’s preprofessional 15 core competencies for entering medical students. Cultural competence in this sense may be demonstrated by having experience working within medically underserved communities or interacting effectively with patients from different backgrounds.
In a 2024 study analyzing what core competencies make up an anti-racist physician, researchers designed, implemented, and evaluated the effects of a course designed to introduce upstander skills for addressing anti-Blackness amongst second-year medical students.
The study found that through constructed patient cases that illustrate scenarios of anti-Black racism in medicine, the pre- and post-assessment surveys found that 97% of the students rated the course as effective and improved from pre to post survey exam (Williams et al., 2024).
This leads to the often unspoken norms and interactions that shape training environments, such as having a standard, equitable procedure to guide your practice, including the normalization of having open conversations in clinical cases with discussions about racism.
These goals mustn’t stop there or only lie within students, as having a diverse applicant pool for hiring faculty, adding minority voices to selection processes, and setting aside DEI committees for schools helps to ensure that institutional support continues. Health disparities are not accidental — and neither should be the solutions, competencies, courses, and metrics to entry into medical school. Close the gap.