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June 30, 2020

Academic Medicine and Black Lives Matter: Time for Deep Listening

Author Affiliations
  • 1Northwestern University, Feinberg School of Medicine, Division of Cardiology/Department of Medicine, Chicago, Illinois
JAMA. Published online June 30, 2020. doi:10.1001/jama.2020.12532

Echoes of “medicine as the noble profession” continue to resonate, now 35 years since my legendary Chair of Medicine imbued me with this guiding ethos. Nobility in medicine is not obsolete; the selflessness, courage, self-sacrifice, and altruism on gallant display in the response to COVID-19 reassures that at its core, this ethic of egalitarian service remains intact and deeply established in the DNA of physicians worldwide, including the ranks of academic medicine. But now, a new test of this nobility has emerged.

The killings of George Floyd, Breonna Taylor, Ahmaud Arbery, Rayshard Brooks, Tony McDade, and others have placed racism, especially anti-Black racism, as an ever-present painful reality in the collective social conscience and have vigorously galvanized Black Lives Matter. Academic medicine has not been immune from the influence of this intensely spirited movement. #WhiteCoatsforBlackLives and #ShutdownSTEM are highly visible exhortations to raise awareness of racism on the campuses of academic medical centers. Accompanying statements acknowledge that science needs to “look in the mirror” and make space for people of color to lead laboratories that publish great science and produce influential scientists.1 As one accomplished Black scientist queried: “How much creativity are we leaving on the table?”1 These symbolic efforts and pensive statements have recently been joined by poignant student-generated protestation statements received by leadership of major academic medical centers with the expectation of explicit action focused on racial equity in academic medicine. This groundswell chorus arguing for change cannot be quieted. Leaders in academic medicine are committed to respond; as a former Black medical student 38 years prior, I am emboldened to applaud.

These statements and actions mirror what is noted in the broader society: today’s protests are unlike those of the 1960s or any prior moment of remonstration; not a race but a generation is expressing concern and seeking both a response and a set of intentional actions to expunge racism from medicine. Yet, before proceeding, important questions are necessary; is focusing on academic medical centers an indirect consequence of the universality of concerns in US society? Has academic medicine been caught up in the fury of the moment? Or is there a pressing question of racism in academic medicine?

As Cooper has asserted, health care systems that include academic medicine are a microcosm of society. Social movements and questions of social justice permeate discovery science and education.2 Williams and others have defined racism as “an organized social system in which the dominant racial group, based on an ideology of inferiority, categorizes and ranks people into social groups called ‘races’ and uses its power to devalue, disempower, and differentially allocate valued societal resources and opportunities to groups defined as inferior.”3 This definition is an eloquent statement but requires a personal firsthand translation. As a child, racism makes you feel lost and afraid; as a young adult, racism leaves you on the outside looking in; as a young aspiring professional, racism makes you start at the back, work twice as hard, for half as much; and as a mature adult, racism makes your soul grieve. Williams and Cooper have strongly suggested that cultural racism leading to disinvestment in marginalized communities drives (adverse) social determinants of health and subsequent health disparities.4 The multiple dimensions of racism—cultural, institutional, personal—complicate the discussion and obfuscate responses, but the concern is real and the need to respond is compelling. Several truisms confirm this concern and require active engagement of academic medicine in the attainment of racial equity.

The first truism is that racism is present in academic medicine. Consider the biographies and histories of Daniel Hale Williams, the Tuskegee study, Henrietta Lacks, Charles Drew, and many others that highlight contemptible segregation, bias, and racism throughout the history of medicine. These are not regrettable past deeds of only historical consequence, but milestone events that remain consequential. History, per se, defines culture and culture defines behavior. What exists today as the infrastructure for scientific discovery and medicine reflects structural racism that has evolved from a biased, stained, and oppressive history against Black individuals. If for no other reason than atonement, not for the many people who have been affected by racism in academic medicine, but for the many generations that have been aggrieved by structural racism in medicine, addressing racial equity is a just cause for academic medicine. It is absolutely the right thing to do.

The second truism is that academic medical centers exercise an outsized influence in the practice of medicine. The patients cared for in academic centers in the US reflect a disproportionately small percentage of patients receiving care across the nation. Yet the majority of physicians in practice today receive training from academic medical centers or the aligned affiliates. Thus there is a responsibility to provide not only the biology but also the sociology of medicine. Those who argue that the ills of society have no place in medical education are abjectly wrong; for proof, simply walk the corridor of a COVID-19 unit. Medical students and early career physicians inculcate lessons learned both academically and experientially as foundational pillars in the practice of medicine. Nothing will change in the practice of medicine if that change is not initiated, promulgated, and sustained by academic medicine and championed by the leaders of academic medicine. A new rumble needs to be heard in the alcoves of academic medicine.

The third truism is that what works is simply not clear. In the haste to achieve racial equity in medicine, many are rushing to embrace the same strategies: implicit bias testing; bias mitigation seminars; cluster hiring of diverse faculty members; eliminating any evidence of race-based medicine from curricula; hiring of chief diversity officers; no longer reporting race in research reports. Yet, where is the evidence that such strategies achieve the desired goal? What is the cost to already stressed budgets, and overworked faculty, and are these efforts sustainable? If there were guidelines to inform how best to achieve racial equity in academic medicine, what would be the class of recommendation and the level of evidence? The evidentiary basis for effective strategies to attain racial equity is disappointingly thin arguing for pause before widespread implementation.

But it is precisely because of the paucity of data that academic medicine must be responsive. Academic medicine owns the responsibility of evidence generation, but in this domain has failed miserably. As Carnethon et al have asserted, academic medicine has also failed the investigators who intend to study disparities and racial equity.5 Considering the health-related consequences of racism in medicine, number of lives lost, and annual health care expenditures, how can this persistent evidence void be allowed to continue? The absence of evidence to achieve racial equity should not be bemoaned and the absence of talented Black clinicians and scientists to diversify faculties should not be cited if academic medicine has been unwilling to execute the science and commit to the training.

The fourth truism is that within the ranks of academic medicine new leaders are identified, mentored, and then vested in new roles of leadership for hospitals, medical schools, and large health care entities. Leadership matters. Culture change, especially of this magnitude, is a top-down process. Budgets, as authenticated and established by leadership, represent a moral contract with the communities that institutions serve. Policy, as it directly affects education, research, and health care delivery, determines how high-priority functions are actualized. Mission, as the guardian of purpose of an academic medical center, establishes the rules of engagement and the metrics of success. When Black persons are not in leadership positions, not in the C-suite, and not even candidates to enter leadership training, the likelihood that budgets, policy, or mission will ever fully embrace racial equity becomes nil; history will continue to dictate the future.

Given these 4 truisms, an argument evolves validating the engagement of academic medicine in the attainment of racial justice. Academic medicine, and especially the leaders of academic medicine, should harken the construct of Polite et al6 targeting cancer injustice: “…What should no longer be tolerated is the misguided belief that the problem is too difficult to solve, cannot be solved, or that it is due to the affected person’s genes or inaction. Public health evidence to the contrary is too compelling, and condoning such excuses violates fundamental principles of equality.”

I concur; the fundamentals of equality should be respected; the problem is solvable. Listen deeply to the plaintive calls for change; to heed these petitions could be among the finest moments in medicine. All physicians, and particularly those in academic medicine, can and should address racial equality and engage with Black Lives Matter because atonement matters; culture matters; evidence matters; and leadership deeply matters. This is how the problem will be solved.

Medicine is the noble profession but now, perhaps more than ever before, that nobility will be put to the test.

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Article Information

Corresponding Author: Clyde W. Yancy, MD, MSc, Northwestern University, Feinberg School of Medicine, Department of Medicine/Division of Cardiology, 676 N St Clair, Ste 600, Chicago, IL 60611 (cyancy@nm.org).

Published Online: June 30, 2020. doi:10.1001/jama.2020.12532

Conflict of Interest Disclosures: None reported.

References
1.
Thorp  HH.  Time to look in the mirror.   Science. 2020;368(6496):1161. doi:10.1126/science.abd1896PubMedGoogle ScholarCrossref
2.
Cooper  LA, Beach  MC, Williams  DR.  Confronting bias and discrimination in health care: when silence is not golden.   JAMA Intern Med. 2019;179(12):1686-1687. doi:10.1001/jamainternmed.2019.4100 PubMedGoogle ScholarCrossref
3.
Williams  DR, Lawrence  JA, Davis  BA.  Racism and health: evidence and needed research.   Annu Rev Public Health. 2019;40(40):105-125. doi:10.1146/annurev-publhealth-040218-043750 PubMedGoogle ScholarCrossref
4.
Williams  DR, Cooper  LA.  COVID-19 and health equity—a new kind of “herd immunity”.   JAMA. 2020;323(24):2478-2480. doi:10.1001/jama.2020.8051 PubMedGoogle ScholarCrossref
5.
Carnethon  MR, Kershaw  KN, Kandula  NR.  Disparities research, disparities researchers, and health equity.   JAMA. 2019;323(3):211-212. doi:10.1001/jama.2019.19329 PubMedGoogle ScholarCrossref
6.
Polite  BN, Gluck  AR, Brawley  OW.  Ensuring equity and justice in the care and outcomes of patients with cancer.   JAMA. 2019;321(17):1663-1664. doi:10.1001/jama.2019.4266 PubMedGoogle ScholarCrossref
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    5 Comments for this article
    EXPAND ALL
    Addressing Race-Based Score Differences
    James Thompson, MD ABIM ABEM | Retired physician
    With respect to differential race-based outcomes, the most insoluble issue for medicine and other STEM-based pursuits is that, even when adjusted for privilege of background, substantial standardized test score differences exist between self-identified group of "black" students and those self-identifying as "white" or "asian." At some level, STEM pursuits use these scores (SAT; MCAT; placement and certification exams) for ongoing advancement in the various fields.

    The gap is wide and has been highly resistant to efforts to close it. We need to fix it, and we need to find ways to address how we evaluate black students in
    the interim so that the testing score gaps do not prevent their advancement.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Radical Change
    Steven Blaser | None
    I concur with the author on almost all points.

    In his assertion that change occurs from the top down, he fails to acknowledge the situations where radical change occurs from the bottom. Such changes have included the rise of the Protestant sects of Christianity, Marxism, and the rise of popular music.

    History is full of cautionary lessons warning of the need to listen to and react to the forces of change or be left behind. If today's leaders are not responsive others will arise and take their places.
    CONFLICT OF INTEREST: None Reported
    Truth and Reconciliation
    Jacques Drolet, Ph.D. | Private Consultant
    Deep listening is something extremely difficult because it asks for getting out of the boundaries of our paradigm which for some is a betrayal of our reason-based values. However, there are techniques like "truth and reconciliation" that have been used to great effect in the most polarized context. The idea is if eye to eye is of value, there is much work from both sides (if polarized) and from many sides (if multidimensional, which it is...) to move toward a state where the contribution of all is optimized, which should be the goal, acknowledging that it is a dynamic process and that it will ask for re-assessments. Should you want to talk more, see www.idrg.eu.

    Kind regards,

    Jacques
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Academic Medicine
    Nicholas Klokochar, M.D. | Retired
    If racism is present in Academic Medicine then fix the Academic Centers, ie, the faculty that apparently espouses it. Judging the present by the past solves nothing. Turning doctors into social justice warriors may salve Academia's conscience but actually teaches racism by forcing doctors to look at patients by factors other than their illness.
    The goal of Academia is to turn out the best doctors regardless of race, ethnicity, sex or other uncontrollable attributes. Filling quotas does just the opposite. It is reverse discrimination. Fairness and not social justice should be the goal.
    Categorically blaming
    disparate outcomes on racism while ignoring the effects of genetics and personal responsibility is a cop out.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    The Pace of Change in Medicine
    Catalina Lopez, MD | Private Physician
    That academic medicine has been slow to integrate is an understatement. There are many causes and “truism 4” indirectly addresses what may be one of the biggest hurdles to achieving racial equity: unconscious bias in identifying the new leadership. That knot can only be unwound by strong leadership from the top to include the Board Chair of the hospital, the President/CEO, the Department Chair, the Division Chief, and the Program Director. Given that “truism 1” is so widely challenged (hence, not a truism) and that so many people would have to overcome their unconscious bias and system 1 thinking, I see it as a near impossibility that academic medical centers on their own will actually act. Perhaps if their funding were threatened or if financial incentives were rendered for the creation of a more diverse environment will we see change.

    And change we do need to see because there is evidence galore that diversity in medicine has many benefits to the community as well as to the Academy itself. But I am pessimistic. They say that it takes 15-20 years for research evidence to reach clinical practice. I have been following this debate for 30 years and the ending never changes.

    Fernando Lopez, MD, FACP, FACC
    CONFLICT OF INTEREST: None Reported
    READ MORE
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