Moving from Theory to Action: An Anti-Racism Activity for Faculty in Academic Medicine

In recent years, the national spotlight has focused on the impact of racism in the United States with many faculty in academic medicine asking themselves difficult questions and searching for meaningful ways to address structural racism within academia. Most academic centers have diversity, equity and inclusion initiatives and messages of condemnation when overt racial violence flares nationally. Though the acknowledgement of systemic racism is new for many, it has been long recognized, endured and lived by faculty and communities of color.

Discussions of dismantling structural racism intersect at every imbalance of power, status and relationship in society from the macro to micro-levels. An appreciation of the larger historic forces that entrench racism into the DNA of our country, though necessary, can leave many overwhelmed with the task at hand.  The focus of this blog will be what we can do as individuals working within our own spheres of influence within the different missions of academic medicine.

Dr. Taneja and Mr. Catlett from College of the Holy Cross have developed a “How to Write an Anti-Racism Action Plan” Self-Paced guidebook.¹ Aimed at the beginner level and highly transferable to a multitude of disciplines and sectors, the guide contains many great activities and can be found at the following link:  https://www.holycross.edu/anti-racism-guidebook.

An activity I found particularly helpful was assessing “spheres of influence.” After listing the spheres of influence which can include but does not need to be limited to people (self, family, friends), relationships (social, school, work), community (formal or informal), greater society and organizations, they ask us to consider critical 4 questions:

1. What are examples of the verbal and nonverbal messages you received around race, racism, and anti-racism in each of the various spheres?
2. How do you think these individuals or groups developed those perspectives? What life experiences do you think led them to these views?
3. Using these Spheres of Influence, what are the areas where you have expertise where you could meaningfully contribute to change?
4. What strategies, if any, might be effective to use in each sphere of influence that you have?¹

All this work starts at a deeply personal level. It is not comfortable and requires we interrogate where we learned our messages, how we internalized them and became their standard bearer.

The following section will focus on question #4 and how individual faculty can challenge the status quo within the various missions of academic medicine specifically. This is not meant to short circuit the deliberate process of self-discovery or meant to be exhaustive but only to show how others have started to think through navigating an anti-racist approach to their work.

Education Mission

Questions to Ask	Potential Interventions
How are you mitigating bias in the curriculum (GME and UME)?	Utilize Dr. Amy Caruso Brown’s Anti-Bias Checklist2 for individual materials and program/school/university wide
How are you teaching race as a social construct (GME and UME)?	Contextualize race as a social construct3 in medicine complete with history and link to the social determinants of health (SDOH)4 Teach SDOH as a consequence of policy and not natural occurrences Discuss how, why and whether race should be used in calculators in clinical medicine5
How are you training faculty on mitigating their biases and teaching with an anti-racist lens?	Advocate for mandatory faculty development on how to contextualize the use of race in medicine as a social construct Identify and compensate faculty champions to lead these efforts Participate in training efforts and implement new knowledge
If faculty of color are providing most of the training, are they getting adequately compensated and recognized for their time, skills, and perspective?	Advocate for faculty of color to get compensated and recognized with effort for their diversity, equity, and inclusion work. This should not be in addition to their other duties but should replace them6
What is the diversity of the classes, residency programs, faculty, staff, etc? What are the yearly trends?	Track data, monitor for trends, conduct focus groups to understand unmet needs Insist upon the need for diversity in all areas Integrate community members and students on important committees Create and support strong and consistent messaging on the importance of diversity at the institutional level
What are recruitment efforts to increase diversity?	Participate in recruitment Ensure recruitment efforts are reaching diverse populations Participate in fundraising for scholarship programs Link diversity recruitment efforts to department, chair, division metrics and goals
What efforts are underway to decrease bias from the admissions process and promote diversity?	Ensure holistic admissions process that places value on diversity, service, and life experience.7 Interrogate any outside influences of the process such as legacy or donor-related applicants.
What pipeline programs are developed and supported?	Participate in longitudinal mentorship in pipeline programs.8
How are underrepresented minority (URM) students and residents being mentored and supported throughout their education and training?	Develop and participate in mentorship programs Assess unmet needs and how to address these Create formal and informal spaces for networking and socialization
What are the rates of student mistreatment with reports of racism, sexism, homophobia, etc? What are the efforts to improve this?	Disseminate student mistreatment data widely9 Link decreasing rates of mistreatment to faculty, department and division metrics and goals Mitigate individual biases10 Train on bystander interventions Debrief with students after difficult clinical experiences11
What elements of institutional or hospital culture are barriers to students, residents, faculty or staff who are URM to thrive?	Insist upon a 360 comprehensive assessment of the institutional, clinic and/or hospital culture with respect to diversity, equity, and inclusion Conduct focus group interviews with URM students, residents, faculty, and staff to solicit perspectives and unmet needs Develop an action plan with metrics and systems of accountability12
What bias reporting mechanisms have been created?	Develop report, monitor, and intervene on bias events Create transparency around the reporting process and how complaints are handled

Clinical Mission

Questions to Ask	Potential Interventions
What are the differences in patient experience among your patients depending on gender, race, sexual orientation, disability, etc?	Develop reporting mechanisms, reviewing of metrics, feedback to healthcare workers, understanding of underlying factors and creation of interventions.
What are the differences in patient outcomes among your patients depending on gender, race, sexual orientation, disability, etc?	Develop reporting mechanisms, reviewing of metrics, feedback to healthcare workers, understanding of underlying factors and creation of interventions.
What are the differences in patient access to care among your patients depending on gender, race, sexual orientation, disability, etc?	Develop reporting mechanisms, reviewing of metrics, feedback to healthcare workers, understanding of underlying factors and creation of interventions.
Does your patient population resemble the demographics of your community or region?	Ensure your health system is prioritizing access for the community they are serving
What are the barriers to healthcare access in your area and how is the healthcare system addressing this?	Ensure the health system is actively addressing known barriers to accessing care
Does the insurance status of the patient dictate which clinician they can be seen by?	Ensure that the system is set up such that any patient irrespective of insurance status can be seen by any clinician.
How is language used in verbal or written form to reinforce or create bias or stigma in the medical record, clinic, or inpatient service?	Review language utilized in conversation, formal presentations, and the medical record to make appropriate adjustments.13 Train healthcare workers and staff on appropriate language use
What systems are in place to systematically evaluate health disparities based on marginalized status?	Advocate for systems to be in place for the creation of dashboards to create accountability for the health system including the creation of metrics and collaboration with other sectors (public health, housing authority, etc)
What training have health care workers in the clinical space received to provide non-biased and inclusive trauma-informed patient care?	Create and participate in trainings to improve education on non-biased, inclusive trauma-informed care
To what extent are underlying SDOH being assessed with appropriate interventions put into place?	Screen for SDOH, link to appropriate services and adequately fund care coordinators, social workers, and community health workers14 Collaborate with local, state, and regional organizations to provide services Create innovative solutions to SDOH issues (public-private partnerships, grant funding, etc)
To what extent are clinicians advocating for SDOH policies at the state, national or international levels?	Integrate diverse clinician voices into state, national and international policy making framework

Research Mission

Questions to Ask	Potential Interventions
How are diverse research participants recruited, communicated with, and cared for during the duration of the study?	Evaluate recruitment strategies, images on pamphlets, languages utilized, etc Conduct focus groups with diverse participants on how to improve the research participant experience Communicate clearly, effectively and in the way the patient prefers in a non-judgmental and non-biased manner
How are you building trust with communities made marginalized?	Build ongoing sustainable relationships with the community based on their needs and not on the research agenda
How are you using interpreters?	Ensure trained interpreters are utilized in every aspect of research communication
Have all the people associated with the research from the coordinators to the project investigator been trained in non-biased and inclusive trauma-informed care?	Provide training on non-biased, inclusive trauma-informed care Hold the entire research team accountable to living up to these standards
How are you mitigating implicit bias in the design of research trials?	·Vet the design of the research trial with a focus group ·Assess from multiple different perspectives
Are you capturing information about race in your research? If so, how is this being assessed? What is the utility?	Contextualize race as a social construct in medicine Capture self-report race with many options or write-in option available Consider whether you are assessing an association with race or rather of racism15
Will your research be of relevance to diverse populations?	Perform a thought experiment from your research all the way through to the end user. How freely available and accessible will the end product be? Who will have access to it and who will not? Ask and listen to what the community tells you their priorities are and integrate them into your research16
How are discussions about authorship conducted and decisions made?	Follow standard authorship guidelines and discuss beforehand
How diverse is your network of research collaborators, assistants, graduate students, etc?	Outline your research network and determine how diverse it is
How diverse are your mentees? How do mentees gain access to your mentorship? Are you a part of formal mentorship programs?	Consider who your mentees are and how they gained access to you Participate in a mentorship program and offer your longitudinal mentorship Create opportunities for formal and informal networking and socialization
What pipelines programs for research mentorship do you participate in?	Create research pipeline programs and participate in them

Administrative Mission

Questions to Ask	Potential Interventions
What is your involvement in committees, organizations, boards, professional groups, working groups and conferences at the local, regional, and international levels?	Take note of which commitments would be great opportunities for junior faculty and get them involved
Are those spaces as diverse as they can be? Who is missing from the table? Who is present but their voices are silenced or not listened to? Does the composition of those groups preserve the status quo or disrupt it? How can you build a longer table or relinquish your seat to someone else?	Nominate diverse members to join Amplify the voices of those who are silenced or not listened to Call in other members who are not taking seriously the comments of URM faculty Use your influence to change the rules of membership Relinquish your seat to make room for someone new
Do you need leadership positions for career advancement? If you are mid or late career, which leadership positions can you vacate and groom someone else to take over?	Mentor others to take over leadership positions Vacate leadership positions periodically
Are you actively advocating for more diversity, equity, and inclusion?	Judge your effectiveness based on metrics and feedback from mentees
How diverse are your mentees? Who are you providing opportunities for? Who has access to you?	Keep track of your mentees Actively reach out to URM students, residents, faculty to offer access to your mentorship
Do you make recruiting, hiring, promotion, performance evaluation or firing decisions? If so, how do you ensure you are mitigating bias during that process? Have you interrogated the recruiting process?	Ensure diversity within all committees (search, promotion, etc) Discuss individual, group, and institutional biases up front and call each other out Follow a thoughtful interview process and list of vetted interview questions Solicit input from all search committee members prior to larger discussion Focus on skills and value of diverse perspectives Evaluate data on hiring, firing, etc to look for trends Create action plans for targeted recruitment
How is diversity, equity and inclusion baked into every policy that you oversee?	Develop all policies with a diversity, equity, and inclusion lens
How are decisions made? Who gets to decide? How are you getting input from diverse voices, avoiding group think and ensuring inclusion?	Create a thoughtful process to guide decision making, enforce it and reassess effectiveness at creating inclusion

Conclusion

Academic institutions are embedded in systems and structures of power, politics, and hierarchy where structural racism flourish. Though transformations in high level leadership may be needed, individual faculty have a critical role in advocating for change and taking an anti-racist approach to their individual work as well. We can all “start where we are” in the spheres of influence we exert. Building coalitions to push for policy change can create dramatic ripples of change throughout the culture of an institution.

-Premal Patel, MD Community of Practice Member

Dr. Premal Patel is a board-certified Physician and an Associate Professor in the Department of Internal Medicine. She also serves as the Associate Director of the Global Health Education Program at UTMB and is co-coordinator of the Global Health Inter-Professional Core Course.

References:

1. https://www.holycross.edu/anti-racism-guidebook.
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