I start my day pre-charting my patients in the work room. I glance at the cupboard covered with a resident-made infographic on the racial-ethnic disparities in pediatric diabetic ketoacidosis management. This is just the first of a stream of daily reminders that not all patients experience equitable health care and that I am in a position to change this reality.
My morning continues with pre-rounding. I use the video interpreter to communicate with my non-English speaking family and patients; I am reminded by my program that this should be the first of three minimum times I use an interpreter that day to ensure each family is adequately informed about the plan of care. During rounds, my senior resident asks if I have equity concerns regarding the care of my patient. Over a lunch conference, I learn that white children are more likely to receive IV fluid resucitation for gastroenteritis than their non-white counterparts. Later that afternoon, my senior resident prints an article for the resident team on why the race-based calculation for estimated glomerular filtration rate for Black patients leads to delayed diagnosis and treatment, as well as worse health outcomes. As I sign out my patients at the end of the day, I eliminate labels that carry bias in my description of patients and their caregivers.
I am not surprised to learn on a typical day of my pediatric residency that significant health inequities exist and that clinicians must be equipped with the knowledge and skills to help rectify them. I am, however, profoundly struck by their ubiquitous presence in my current teaching curriculum compared to their virtual absence in all medical education I received prior to the start of residency.
My time as a medical student was eerily devoid of teaching on topics such as health equity, racism in medicine, social determinants of health, diversity, inclusion, and culturally humble care. During my pulmonary rotation, I never learned that for an illness as common as pediatric asthma, children of color have a greater incidence of morbidity and mortality than their white counterparts, or about the role I have as a physician to combat this phenomenon. My clinical skills practice lacked culturally, racially, and linguistically diverse standardized patients and simulations, and thus failed to reflect the variety of genders, sexual orientations, ethnicities, cultures, and religions that accurately reflect the makeup of the U.S. patient population. Culturally sensitive care was never a graded clinical competency in any stage of my medical training.
During my medical training, efforts to hold teaching sessions and conversations about the aforementioned topics were spearheaded by medical students rather than administration and faculty. These events included discussions about racism and bias against medical providers, intersectionality in medicine, and how to provide more culturally sensitive care. Such crucial topics should be a standard part of required medical school curriculum, not the initiative of medical students to champion as one-off optional events that only a limited number of students will engage in and benefit from.
As a resident, I am grateful to be surrounded by an abundance of teaching on how I can combat my own biases and be part of creating a just health care system. And yet, I am simultaneously overcome with both grief and concern that I am now catching up on what should have been incorporated into both my didactic and clinical teaching curriculum as a medical student. My current teaching environment’s emphasis on health equity and anti-racist medicine was unfortunately a foreign experience for me. Only upon graduation from medical school could I see the profound lack of structured learning I received about these fundamental topics and skills, which are the key to cultivating physicians who will implement anti-racist and equitable health care systems, policies, and individual practices. Furthermore, I am lucky to attend a residency program that uniquely elevates such teaching topics. Even in residency, many physicians continue to learn and cement their medical practice without an emphasis on combating health inequities and personal biases.
The four years of medical school represent key, formative years in the shaping of foundational medical knowledge and eventual medical practice. A medical education that lacks a diverse and inclusive curriculum squanders the opportunity to make the practice of equitable medical care for matriculating physicians second nature. As medical trainees and beyond, only if we are consistently educated about health inequities and the driving forces that allow them to exist, while also equipping ourselves with the skills to confront and change them, can equitable health care become common practice. This process must start, at the very least, with one’s induction into the medical profession, and continue every day after.
How would you improve medical education? Share your thoughts in the comments below.
Sara is a Los Angeles native in her first year of pediatrics training at Seattle Children's Hospital in Seattle, WA. She enjoys reading, hiking, taco trucks, chai, and her cat, Tibby. She is a 2020–2021 Doximity Op-Med Fellow.