Biologic Essentialism and the Need for Educational Reform
A professional and ethical medical education should equip trainees with the knowledge and skills necessary to advance health equity. While American medical schools have increased implementation of Social Determinants of Health (SDOH) teaching, few of these curricula critically engage with the social injustices that engineer institutional inequities.Reference Sharma, Pinto and Kumagai 1 For example, students learn that patients of color have poorer diets, causing disparities in chronic disease. They, however, are not taught the unjust realities of neighborhood segregation, food deserts, and urban design that limit nutrition, economic mobility, healthcare access, and housing.Reference Cummins and Macintyre 2 SDOH models focus students’ attention on the behavioral, biological, educational, and financial impoverishment of marginalized populations, without asking learners to consider what social powers mar-ginalize them.Reference Simis, Madden, Cacciatore and Yeo 3 Students leave the classroom without robust understanding of race or inequity, and therefore advance in training unable to articulate and challenge the causes of unequal conditions at a time when racial inequity is rampant in society. 4
Notions of genetic racial determinism in medicine and science continue to imply the existence of inborn racial differences and characteristics.Reference Vyas, Eisenstein and Jones 5 These concepts of Bio-Essentialism — such as ideas that Black skin is thicker, and that the efficiency of respiratory or renal systems differ by raceReference Ryn, Hardeman and Phelan 6 — are inaccurateReference Fuentes, Ackermann and Athreya 7 and harmful.Reference Andreychik and Gill 8 Such essentialist thinking correlates with greater dehumanization and discrimination against ethnic out-groups.Reference Plaks, Malahy, Sedlins and Shoda 9 They also engender apathy towards injustice and decrease support for interventions that seek to redress inequity.Reference Williams and Eberhardt 10
Of great concern then, is the fact that medical students are frequently confronted with teaching that mobilize misconceptions of racial biology.Reference Braun 11 Because biomedicine continually reifies genetic notions of race, medical trainees are particularly and constantly exposed to bio-essentialist teaching.Reference Donovan 12 This leaves students with less ability to humanize patients, control implicit biases, and challenge social inequities.Reference Donovan 13
The emphasis on genetic race, rather than institutional racism, is at the heart of the matter. If the major detriments of bio-essentialism reside in its incorrect maintenance that racial inequalities can be explained by physiologic difference and its talent at casting people of color as unworthy of compassion and support, then the replacement pedagogy offered as a solution should reverse these faculties explicitly. Instruction that is rigorously attentive to the depths of racial inequity, dedicated to structural competency, and able to inspire action and allegiance to health equity is needed. Critical Race Theory (CRT) is necessary for moral medical education.
The emphasis on genetic race, rather than institutional racism, is at the heart of the matter. If the major detriments of bio-essentialism reside in its incorrect maintenance that racial inequalities can be explained by physiologic difference and its talent at casting people of color as unworthy of compassion and support, then the replacement pedagogy offered as a solution should reverse these faculties explicitly. Instruction that is rigorously attentive to the depths of racial inequity, dedicated to structural competency, and able to inspire action and allegiance to health equity is needed.Reference Metzl and Hansen 14 Critical Race Theory (CRT) is necessary for moral medical education.Reference Tsai and Crawford-Roberts 15
Critical Race Theory
Critical Race Theory (CRT) is a theoretical framework built from legal scholarship that interrogates relationships between racial identity, power, and racial inequity.Reference Bridges 16 In direct opposition to bio-essentialist theory, CRT teaches that race is not a genetic variable, but a political construction that directs power and resources towards some and away from others.Reference Delgado and Stefancic 17 In part by rejecting ahistoricism, CRT argues that racial categorization is enforced to support racial hierarchy and identifies how racism operates within major institutions. When applied to the medical field, it helps learners locate and address racial inequities embedded in healthcare, physician education, and medical research.Reference Hatch 18
CRT’s iterative methodology questions power dynamics embedded in social and institutional relationships, which is important because learners cannot comprehend racial inequity or pursue sustainable health justice interventions without understanding racial privilege.Reference Kumagai and Lypson 19 Though traditional medical education may erase this reflexivity by opining identity is irrelevant to medicine, CRT unequivocally names reflexivity and critical consciousness as crucial to the ability to humanize patients, care for communities, and challenge health inequities.Reference Sharma 20 Additionally, CRT emphasizes the narratives and epistemologies of those most harmed by inequity to direct attention towards the experiences of patients who have historically been excluded from machines of knowledge production. 21 This allows a whole-patient view that expands empathy and circumvents the dehumanization biological racism engenders. 22 Lastly, while bio-essentialism diminishes support for measures that redress health inequity, CRT requires active commitment to social justice.Reference Ford and Airhihenbuwa 23 Thus, because CRT develops in learners action-oriented praxis, understanding of social structures of oppression, and reflexivity that can cultivate greater empathy, it is a pedagogical intervention uniquely equipped to improve current pitfalls of medical education.Reference Hooks 24
Application and Design of a Critical Race Theory-Based Course
Students at the Warren Alpert Medical School of Brown University designed and implemented a “Health Systems of Oppression” (née Healthcare for the Underserved) elective to challenge deterministic notions of racial biology and address the lack of structurally-competent medical education. As many scholars before, course leaders identified a need to teach student-doctors accurate conceptions of race and prepare them to intervene at the level of institutions where health inequity originates.Reference Westerhaus 25 Though the course sought to address Health Systems of Oppression broadly, for the purposes and scope of this paper I focus on its relevance to racial injustice.
1. Active Student Participation
Classic didactic methods of preclinical medical education involve hours of PowerPoint-driven lectures and multiple-choice assessments.Reference Toste-son 26 In these instances, instructors are cast as bearers of knowledge. By implication, students are not permitted to challenge or question knowledge production.Reference Freire 27 In juxtaposition, contemporary educational theory documents the importance of active student participation in promoting critical perspectives.Reference Kiraly 28 Since bio-essentialist notions are already accepted in standardized clinical teaching, 29 and because conversations on racism and identity often entail conflict, emotions, and opinions, course leaders believed it was necessary to pursue pedagogical models that addressed power dynamics inherent to formal lecture-based learning.Reference Boatright-Horowitz and Soeung 30 To allow for genuine and energetic discussion, we sought to create a non-hierarchical, “flat” learning environment where the contestation disavowed in didactics was welcome.
Critical thinking skills requires content and practice, so course leaders integrated interactive workshops, reflective exercises, and activities into each session.Reference Willingham 31 Instead of relying on passive educational “banking,” the course intentionally encouraged debate and dialogic learning by actively critiquing perspectives mobilized by teachers and students.Reference Kumagai 32 Following constructivist educational theory, students were responsible for generating course content.Reference Astin 33 They were asked to learn and present material on health inequity to their peers, moderate discussions, and formulate individual arguments on controversies relating to race and racism.
2. Multidisciplinary Contextualization and Diversity of Perspective
To vigorously contextualize racial health inequities with a diversity of insights, course leaders drew from pertinent history, legal rulings, patient narratives, and public policy in addition to biomedical knowledge. 34 Scholarly work regarding the built neighborhood, colonialism, global trade politics, gender studies, and environmental justice, for example, were included to support a multidisciplinary approach to understanding racial inequity.
Following CRT tenets of “Centering” and “Counter-storytelling,” course leaders also made an explicit commitment to look beyond traditional medical authorities. Building critical consciousness requires learners to listen carefully to people who have been barred from creating biomedical scholarship, as well as acknowledge humility that physicians are not the experts on the experiences of patients.Reference Brayboy 35 The course syllabus included the testimonies of marginalized people and personal illness narratives.
CRT celebrates mutual aid, not charity. The medical field’s approach to vulnerable groups has historically been paternalistic: researchers from elite institutions insert themselves into communities to conduct studies and often fail to listen to effected stakeholders during the delivery of services.Reference Israel, Schulz and Parker 36 Course leaders sought to disrupt the elitist model by physically taking the class to community organizing spaces.Reference Diversi and Finley 37 Additionally, course leaders invited local activists and compensated them for their time. These included advocates from anti-racist organizations, housing and incarceration initiatives, and a domestic violence and sex workers’ rights group. These leaders were invited in concordance with Black radical traditions of the Black Panther Party, wherein community organizers are explicitly recognized as knowledge producers and experts.Reference Nelson 38 These instructors were able to define the particular wishes and experiences of their communities, as well as guide medical students in constructing sustainable and equitable partnerships between local populations and medical systems.
3. Action-Oriented Work
Given CRT’s requirement that leaners actively seek to further health equity, a CRT-based health justice course would be incomplete without tangible action. 39 Course time was spent practicing verbal and writing skills required for advocacy outside the classroom. Students practiced articulating evidence and arguing on health justice topics, including role-plays of difficult situations that might arise on the wards. Students were tasked with creating phrases that would help them maximize engagement and efficacy during health justice discussions with peers, superiors, as well as family. Time was also dedicated to coordinating institutional activism. Students organized and wrote a comprehensive, ten-year Diversity and Inclusion Plan for the medical school. As a final assignment, students were tasked with proposing a possible solution for a self-identified health inequity.
Course Evaluation
Quantitative and qualitative methods were employed to evaluate course impact on learners. As course leaders were unable to identify existing validated instruments that measured student knowledge, attitudes, and commitment regarding health equity, a cross-sectional survey was designed in accordance with recommendations published by the Society of General Internal Medicine (SGIM) Health Disparities Task Force.Reference Smith, Betancourt and Wynia 40 Feedback from content experts in health disparities research was solicited and incorporated, and the survey was piloted among a convenience sample of medical students (n=5) to ensure readability and comprehension. Students who opted to enroll in the CRT-based elective after it was advertised to first-year medical students completed pre-course (n=15) and post-course (n=9) surveys. These results were compared to data garnered from a control group of first year medical students who completed pre-course (n=39) and post-course (n=23) surveys at the same time points (September 2015, and February 2016, respectively) but did not attend any sessions of the CRT-based course. These students were recruited by emailing an online survey link to the first-year medical student listserv, with survey reminders emailed weekly with a cap of data collection at one month. Demographic information was not collected to protect anonymity and encourage involvement. The Brown University Institutional Review Board deemed this study exempt from review.
Course-enrolled students (n=12) also participated in 45-minute, semi-structured, post-course group interviews wherein course leaders solicited feedback and sought to learn how students’ perspectives and goals were influenced throughout the course. The four course-leaders (three men and one woman), who were second-year medical students at the same institution at the time of data collection, randomly divided course enrollees into groups of four for an in-person, group interview conducted without any other faculty or unenrolled medical students present. These interviews were recorded, transcribed, and analyzed using grounded theory methodology to identify themes expressed by students.Reference Strauss and Corbin 41
Results of Quantitative Data
Students who enrolled in the course reported a perceived increase in knowledge and skills relevant to health equity after engaging in the course (Table 1). As seen in Figure 1 , there were significant increases in the percentage of students who chose “Agree” or “Strongly Agree” to a number of statements, including comfort discussing issues of health inequity (67 to 100%), ability to articulate issues of health inequity (67 to 89%), ability to critically analyze and address issues of health justice (40 to 100%), and ability to advocate for medically underserved populations (33 to 56%). Learners also conveyed an increased recognition of and ability to address implicit biases (67 to 89%) and commitment to social justice work (53 to 89%).
Survey Data Results
Percent of Medical Students who “Agree” or “Strongly Agree” with Statements Regarding Perceived Skills and Career Intentions at the Beginning and End of First Year of Medical School (Pre and Post Intervention)
Though course leaders were pleased to find positive metrics in students enrolled in the course, perhaps more concerning and deserving of analysis were the survey results obtained from medical students who did not enroll in the course. For this control group, reported comfort in discussion of health inequity fell from 64 to 48%, ability to articulate issues of health inequity fell from 46 to 26%, and ability to analyze and address issues of health justice fell from 44 to 26%. At the beginning of their first year of medical school, 100% of surveyed students agreed with the statement, “Physicians can take measures to reduce healthcare disparities and I intend to adopt these measures in my own future practice.” Approximately six months later in the post-survey, a 100% of course enrollees confirmed continued agreement, while only 78% of control group students did. ( Figure 1 .) While the reasons for this decreased commitment cannot be ascertained, this leads us to question what negative impacts standard medical education has on the commitment, skills, and capacity of medical students with regards to health justice.
Results of Qualitative Data
From post-course focus groups, course leaders derived seven common themes that are discussed below. Themes, with representative student quotations, can be found in Figure 2 .
Common Themes from Qualitative Data Analysis
Advantages of a Peer-Led Format
In Pedagogy of the Oppressed, Paolo Freire writes: “Only dialogue, which requires critical thinking, is also capable of generating critical thinking. Without dialogue, there is no communication, and without communication, there can be no true education.” 42 If a significant part of developing critical consciousness is the ability to create dialogue, and dialogue is suppressed in hierarchical learning environments, we believe this course was successful in large part due to a peer-led class structure that helped create an open, equitable learning environment. In comparison to professor-led settings, students endorsed that the peer-peer structure of the course allowed them to share personal narratives, as well as challenge opinions and explore disagreement more directly and confidently. Students expressed that this structure generated more complex and candid discussions in comparison to previous medical school experiences.
Community Building, Leadership, Role-Modeling
Students expressed the importance of seeing senior medical students and practicing physicians care deeply about health justice. This engendered a sense of hope, support, validation, and inspiration. Learning about the history of physician activism and having models for ethical community partnerships provided reassurance that social justice is integral to medical professionalism.
Critical Framework Filled a Gap in Medical Education on Race and Health Inequity
Students felt the course’s interdisciplinary perspectives added to their ability to critically appraise issues of race and racial inequality, as well as understand why genetic notions of race are problematic. Multiple students referenced how the course offered important historical background on race-specific clinical adjustments — like those used in equations for calculating kidney function or algorithms recommending treatment for high blood pressure — which had been presented in required lectures without further contextualization. 43 As another example, students noted how class discussions that situated ideas of “healthy choices” within histories of redlining, food access, and highway construction helped shift culpability away from patients. Many students felt that such critical analysis was absent from standard curricula, and that the elective offered space, content, and instruction necessary for them to reach better comprehension about race and racism. Students felt that their peers would benefit from similar education, and that aspects of the CRT-based course should be required in physician training.
Increased Ability to Advocate and Engage in Activism
In both quantitative and qualitative data analysis, students who enrolled in the elective endorsed feeling more equipped to articulate issues and arguments about health justice, not only for themselves, but to peers and faculty members. They felt class content helped solidify concepts and evidence that they could draw on in future discussions and initiatives for social change. Students also expressed greater willingness and confidence to engage in health justice discussions, even in situations where they had to “talk up” the professional hierarchy scale. Of note, the writing of a cohesive Diversity and Inclusion Plan for the medical school led to collaboration with the University President and University Provost, and resulted in new faculty hiring and the establishment of a paid Office of Diversity and Multicultural Affairs (ODMA) fellowship to legitimize and support continued student labor. These represent further evidence that CRT-guided curricula leads to action. Students maintained that the class offered meaningful, energizing, and productive lessons on knowledge production, curricular reform, bi-directional community outreach, and concrete verbal and written advocacy skills.
Reflexivity on Identity and Privilege Makes Students Better Doctors
Learners start to build “Critical Consciousness” about racial identity when they become aware of the power dynamics they inherit personally and professionally. In a class activity, students were asked to write personal descriptors that limited their access to privilege, as well as ways their identities were implicated in the oppression of others. Students wrote about the ability “to ignore the plight of others who are oppressed by the social structures that give me privilege,” the chance and confidence to “speak for others, and potentially over others,” and the power to use service to frame “people as problems to fix, not people to respect.” Students expressed that recognizing these power dynamics equipped them to be better physicians.
Personal Accountability Leads to Actionable Empowerment
Students reported that by engaging with reflexivity and the pervasiveness of racism, they were more able to implicate themselves as part of the structures of oppression they were striving to dismantle. Several students stated that they felt more cognizant of the ways contemporary medical practices — including their own trained behaviors — contribute to health inequities. By learning about their complicity in creating inequity, students verbalized coming to understand that they could help undo inequity by recognizing and adapting these problematic behaviors. Learners reported this helped combat feelings of powerlessness and hopelessness. Indeed, acknowledgement of their complicity left them feeling more compelled, empowered, and equipped to act. Students reported that the elective increased feelings of agency and responsibility, and added to their perception that they were capable of creating positive change.
Increased Empathy for Marginalized Patients Made Vulnerable by Health Injustice
For students, discovering personal accountability required engaging critically with patient-centered frameworks and deconstructing paternalistic medical authority. Many verbalized intentional changes in language — such as striking “noncompliant” from their vocabularies — and concomitantly a greater ability and willingness to empathize with the social situations that patients face in pursuing health. Students found that discussions of racial inequity that meaningfully addressed structures of oppression — such as those caused by racial segregation and limited food access — were effective as departures from explanations often-mobilized in SDOH curricula that attributed racial disparities to racialized distrust of the medical system or poor dietary choices predicated on “cultural norms.” Students reported that this granted them greater access to compassion and empathy.
Limitations
Course leaders are aware that there are shortcomings in collected qualitative and quantitative data that makes these data less easily generalizable. This study evaluated one student-led CRT course and utilized a convenience sample of first-year medical students from the same medical school. As such, the study population may not be representative of the preclinical medical student population as a whole. The course enrollment was small and self-selecting; on average, 9 to 12 students attended class sessions and it is likely these students had a pre-existing awareness and/or interest in health inequities. Second, the measures used in the present study were not psycho-metrically validated; thus, we cannot comment on their reliability, validity, or internal consistency. Note, the decision to develop our own survey measures was driven by the dearth of publicly available, standardized measures in this area. Third, since this is a cross-sectional study, we are unable to assess how medical students’ knowledge, attitudes, and commitment to health equity change over the course of a four-year medical education — a key piece of information that is critical to curriculum development efforts. Additionally, while students expressed a greater commitment to combating health inequity, there is no assessment on the impact these knowledge and attitudes might have on patient care and outcomes. This is an area ripe for future research. Fourth, that these data were self-reported makes them subject to social desirability bias. However, the decision to administer the survey online and collect limited identifying information was made to minimize this and other response biases (e.g., interviewer bias). Finally, the survey consisted of only closed-ended questions; use of open-ended questions or interviews may have permitted a more nuanced understanding of student perceptions. Nonetheless, whereas open-ended interviews can provide useful data, such approaches, by definition, are unable to offer the kind of standardized information provided here. Our study focuses on a topic that is highly rele vant to physician research and practice — namely, the identification that critical and ethical medical education can heighten the commitment and skillset needed to enhance health justice.
Discussion
Contemporary Medical Education: Not Only a Path to Nowhere
Ideas that racial groups reflect different biological “types” of humans contradict scientific consensus and engender miscomprehension by attributing racial health disparities to internal racial deficits in physiology.Reference Shim 44 Because ideas of genetic determinism are entrenched in medical research and practice, associated harms will continue to propagate unless lessons on bio-essentialism are actively disrupted. 45 In order to advance moral science and clinical care, medical education requires an intervention that can contest and critically examine notions of genetic race and racial inequity respectively.
In 2018, Sharma et al. argued that because US medical schools engage superficially with SDOH and neglect critical concepts of health inequity, they are on “a path to nowhere.” 46 Since survey data showed reductions rather than static levels of skill and commitment to health equity, however, the concern for current curricula is heightened. Not only might they plot a “road to nowhere” — not only are they ineffective interventions that fail to elicit progress — but contemporary medical education may actually reinforce unethical and oppressive ideologies that directly undermine health justice. Indeed, current physician training could be characterized as an intervention that reduces the dedication, skills, and capacity of students to empathize with patients of color and pursue measures of racial equity. This is supported by existing scholarship that demonstrates that trainees graduate medical school with reduced empathy, respect for patient consent, and compassion for homeless patients.Reference Ubel, Jepson and Silver-Isenstadt 47 Medicine has the power to undermine equity or support social justice in its training ground. It must be careful to do the right thing.
Looking Forward: Critical Race Theory and Structural Empathy as a Bridge to Somewhere
“I feel like it also motivates me to ask more questions about social background … now I understand really why we’re asking and feel more motivated to take all of that seriously. Yeah I think that’s empathy, a different kind of empathy.”
Racial essentialism robs patients of agency, humanity, and story. By ignoring contexts of structural injustice when discussing racial health inequities, race-based medicine interprets bodies of color as immutably deficient or abnormal, which also adds to the burden of racist stigma.Reference Martin 48 Students are left with less ability to humanize patients, control implicit biases, and challenge social inequities.Reference Condit 49
Educators can improve medical pedagogy and advance health justice in the 21st century by following the tenets of Critical Race Theory, which articulate to physician trainees that the root causes of racial inequality stem not from genetic difference, but structural oppression. This necessarily implicates the prominence of historical power systems, which facilitate the reflexivity required for critical consciousness. 50 These perspectives transfer culpability and causation of health inequities from individual behaviors and biology to unequal systems. Furthermore, it leads to empathy and empowerment, inspires comprehension of personal and professional accountability in machinations that support everyday inequity, and produces learners who are motivated and able to combat health injustice. These results mirror the successful consciousness-building other CRT-based courses have been found to provide to learners, albeit previous analyses on CRT have been conducted in arenas outside of medical education.Reference Ford 51
To add to the existing discussion on Structural Competency, 52 I propose that CRT pedagogy in medical education also promotes the development of Structural Empathy — a principle I seek to frame as not only the compassionate understanding that disease, risk, safety and inequity are constructed within larger socio-medico-historical contexts of power, but the further mobilization of this knowledge in clinical interactions to humanize patient experiences and promote health justice at large. By concentrating on the genes and choices of vulnerable populations, standard medical and SDOH curricula can unwittingly teach students to blame marginalized patients for adverse health outcomes, which may fail to engender empathy — or even discourage empathy — for those facing structural violence.Reference Stone 53 As anyone who has faced burnout in the medical field knows, it is so much harder for a physician to find kindness and generosity for patients when they are frustrated at the situation — when they blame people for “doing it to themselves” or for being “non-compliant,” or “frequent-flyers.”
Doctors shouldn’t be angry at patients for being sick. They should be furious at the health injustices that make their patients ill. This empathy and indignation can empower physicians to act, but it won’t spark if medical professionals are blind to how institutional inequities contribute to systemic disease. In accordance, and in juxtaposition to existing medical curricula, CRT offers a critical education that helps generate not only the knowledge required to under-stand injustice, but the empathy needed to commit to health justice, as well as the skills and community relationships to push back against inequity firmly and effectively. All three are important. After all, it doesn’t matter if a trainee has comprehension without the ability to enact change, nor do knowledge and skill matter if a student doesn’t care enough to use them. I believe that Structural Empathy is an important bridge between theory and praxis, as it represents the ability to marshal critical, conscious, and caring medical education into justice-oriented medical practice.
Conclusion
Ideas of bio-essentialism run rampant in medical education, and they work to reduce and dehumanize people of color in a healthcare system that already produces unequal treatment.Reference Betancourt and King 54 Critical Race Theory-based pedagogy — and the Structural Empathy it can engender — is a balm that both disrupts and soothes current problems in physician training. More research, on the implementation of CRT curricula in physician training, as well as its effect on patient outcomes, is ultimately needed. However, evidence demonstrates that CRT contextualizes medicine using critical interdisciplinary perspectives, forces trainees to think reflexively to intensify the humanity of their patients, and allows the field to access and grow Structural Empathy. This is what inspires and equips physicians to act for health justice. We urge medical training institutions, educators, and students to mobilize higher engagement with the tenets of CRT in order to advance the equity, care, and health of racial and ethnic minorities in the 21st century.
Note
The author has no conflicts to disclose.
Acknowledgements
Many thanks to my course co-leaders, Josh Johnson, Bryan Leyva, Alexandre Boulos, and Joseph Rabatin, as well as course leaders for the Health Systems of Oppression elective, new and old. This manuscript benefited from the generous comments and advice of Professors Osagie Obasogie, Lundy Braun, Steve Rougas, and Paul George, as well as my brilliant colleagues Cameron Donald, Ria Pal, and Radhika Rajan. The Warren Alpert Medical School’s Office of Medical Education supported the implementation of this course and the ensuing investigation. Lastly, I wish to express great and sincere gratitude to the activists who continue to labor — often thanklessly — in order to make medicine a better place for trainees and patients alike.
