The Unacceptable Pace of Progress in Health Disparities Education in Residency Programs

The National Academy of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,¹ made front-page news when released in March 2002. That was 18 years ago. Even before the National Academy of Medicine report, the 2000 Healthy People 2010 campaign² highlighted and set targets for reduction of health disparities. That was 20 years ago. The American Medical Association was committed to disparities reductions by 2004 if not earlier. Most importantly, the Accreditation Council for Graduate Medical Education (ACGME) began requiring health disparities education for residents since at least 2004. Therefore, one would expect that after 2 decades of national focus on health disparities and 15 years of required curricula, nearly all internal medicine residency programs would include a disparities curriculum. However, this is not the case.

As the study by Dupras et al³ makes clear, fewer than half (40%) of all internal medicine program directors report any health disparities curriculum. In addition, merely 16% thought their curriculum very good. With a median of only 6 hours of training devoted to the topic during 3 years, a lack of curricular depth or rigor is not surprising. To be sure, there has been some measure of progress: in 2012, only 17% of internal medicine program directors reported delivering a health disparities curriculum. This snail’s pace of progress is not a function of how program directors are queried. Other national studies,⁴ working with different data sets and questions that are more specific to disadvantaged populations, also found that only approximately half of residency programs have incorporated relevant teaching about disparities into their standard curricula. Medical schools are doing somewhat better—approximately 66% reported mandatory training in the social determinants of health for first-year students in 2019.⁵ Medical students need more training during their clinical years when they perceive health care disparities and are troubled by not knowing how to respond.⁶ However, residency is when trainees become physicians; it is simply unacceptable that teaching about health and health care disparities is not universal in internal medicine residencies in 2020.

It will take an all-of-medicine approach to accelerate this pace and create the extensive curricular change needed to train all internal medicine residents to recognize and avoid health care disparities and to mitigate the individual consequences of adverse social determinants of health. Some residencies will choose to go beyond the individual and teach their trainees principles of population health and of advocacy that can modify the social determinants of health.⁷ However, at a minimum, all residents should be trained to care effectively and equitably for their individual patients irrespective of their race, ethnicity, or preferred language. An all-of-medicine approach starts with residency directors and academic departments and then moves beyond academic medical centers, given that there are multiple external stakeholders and all should mobilize.

The study by Dupras et al³ includes helpful data summarizing the perspective of program directors. The program directors report a lack of (1) curricular time, (2) faculty training, (3) faculty interest in health disparities education, and (4) institutional support for health disparities reduction projects. These barriers are readily addressable. Lack of curricular time reflects educational priorities—it is past time to change those, and department chairs can guide program directors who seem unwilling. Lack of faculty interest is addressable by intentional hiring of new faculty eager to teach these issues. Faculty development is cited frequently as a formidable barrier in health disparities education.^8,9 However, with an all-of-medicine approach, faculty development is certainly possible: the American College of Physicians and the Society of General Internal Medicine can sponsor high-quality faculty training programs at their annual meetings. Foundations interested in medical training can step up and fund robust train-the-trainer faculty development programs to reach beyond the usual conference attendees. Medical centers and medical schools can fund groups of faculty to attend these programs and achieve a critical mass of interested and knowledgeable educators at a given institution. Academic internists are used to incorporating new knowledge about diseases and treatments into their clinical practice and their teaching. Knowledge and skills related to health disparities are not more elusive, or much more difficult, than learning about new diabetes medications.

Moving to additional stakeholders in internal medicine training beyond program directors and academic faculty, the American Board of Internal Medicine should incorporate the assessment of health disparities knowledge into its examinations. Assessment drives teaching and motivates learners. The professional associations of internal medicine chairs (Alliance for Academic Internal Medicine) and internal medicine program directors (Association of Program Directors in Internal Medicine) should survey and support their members to navigate common barriers to curriculum incorporation. The ACGME might also need to step up its guidance to program directors and perhaps the consequences of nonprogress.

There are additional stakeholders from outside internal medicine. Professional groups such as the American Heart Association are well aware of health and health care disparities. Can they make themselves heard on resident training? The ACGME specifically requires program directors to work with local data, yet many program directors report having no access to data stratified by race and ethnicity from their medical centers. Is it not past time for the National Quality Forum and others to heavily encourage reporting of key quality metrics by race, ethnicity, and language?

The disparate impact of coronavirus disease 2019 on minority communities is an ongoing crisis. It was also predictable and avoidable.¹⁰ Transforming society to reduce the prevalence of chronic diseases or to ensure universal access to health care will require a massive effort across multiple social sectors. Put simply, although it is certainly possible, reducing disparities in health will be very hard. In contrast, ensuring that the next generation of internists is trained in health and health care disparities is quite simple. We just need to get on with it.

Published: August 10, 2020. doi:10.1001/jamanetworkopen.2020.13097

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Fernandez A. JAMA Network Open.

Corresponding Author: Alicia Fernandez, MD, Department of Medicine, University of California, San Francisco, UCSF Box 1364, 1001 Potrero Ave, San Francisco, CA 94143 (alicia.fernandez@ucsf.edu).

Conflict of Interest Disclosures: Dr Fernandez reported being a member of the board of directors of the American Board of Internal Medicine.

Disclaimer: This invited commentary reflects the individual views of Dr Fernandez and not those of the American Board of Internal Medicine.