A Call for Critical Race Theory in Medical Education
(This article of mine appeared in the Spring issue of the Journal of the National Medical Student Association. You can access the whole journal here: http://jsnma.org/2014/04/the-spring-edition-of-the-2014-journal-of-the-student-national-medical-association-is-here/)
(This article of mine appeared in the Spring issue of the Journal of the National Medical Student Association. You can access the whole journal here: http://jsnma.org/2014/04/the-spring-edition-of-the-2014-journal-of-the-student-national-medical-association-is-here/)
Despite ballooning increases in annual health spending, advances in medical science, and increased attention towards the elimination of racial and ethnic health disparities over the past decade, many troubling inequities in health outcomes have persisted (RWJF, 8). Medical schools have attempted to address racial/ethnic health disparities through curricular changes to teach “cultural competence,” which has been shown to improve medical students’ attitudes towards caring for diverse populations over the short term, as well as increased patient satisfaction and perceived quality of care (Brach and Fraser, 2000; Betancourt et al., 2013; Beach et al., 2005; Paez et al., 2009).
However, it is unclear whether current interventions actually translate into improved equity in health care delivery and/or enduring attitudinal changes over time for medical professionals. For example, five years after the Liaison Committee on Medical Education (LCME) changed its guidelines on cultural competency accreditation standards for medical schools, first-year residents who had just graduated were reporting that they didn’t feel prepared to care for diverse populations (Weissman et al., 2005). Furthermore, it’s unknown whether these clinical-level changes, even if effective, contribute to broader-scale health disparities reduction.
Critical Race Theory (CRT) as a compelling alternative framework for teaching medical students about health disparities that may help address gaps in current methods. CRT was first developed in the mid-1970s as an offshoot of Critical Legal Studies to respond to the persistence of racial inequity despite breakthrough legal advances such as Brown v. Board of Education (Crenshaw et al. 1995; Delgado & Stefanic, 2001). The framework emphasizes the “historical, contextual, political, or other social considerations” that define and construct race, as well as the dynamic ways racism is perpetuated through institutions and policies (Ford & Airhihenbuwa, 2010, p. S31; Delgado & Stefanic, 2001).
This initiative was started at Harvard Medical School in
the fall of 2010 with the goal of making changes to the
medical school and residency curriculum. With SNMA
chapter co-sponsorship, students have already hosted
class-wide town hall forums, and have several ideas
in place, such as with getting a third year intersession module as well as a residency training module.
CRT analyses in education have focused primarily on five tenets (Solorzano, 1998). When applied to medical education, these tenets suggest that a CRT-informed medical education would:
1. “Center” race conceptually as a key determinant for understanding health disparities.
2. Challenge the dominant biomedical model as a “master narrative” in medical education that marginalizes the impact of social, political, and historical processes on health.
3. Emphasize the importance of medical students and health providers engaging in social justice work to combat health disparities.
4. Privilege the voices of people of color and value their knowledge of racism, gained through their experiences.
5. Incorporate multidisciplinary perspectives from histories of science, sociology, anthropology, and public health.
Although few medical schools incorporate a comprehensive, CRT-informed framework throughout their curriculum, there are some promising examples taking place. In the U.S., physicians and social scientists have teamed together to promote the incorporation of “structural competency” as a core competency in medical education, proposing a five-step conceptual model that emphasizes an understanding how historical, social, and political forces, including racism and oppression, contribute to health (Metzl, 2012; Metzl and Hansen, forthcoming). Initial integration of these types of standards is occurring at the residency level in the form of systems- based practices (Englander et al., 2013, p.1092). At Harvard Medical School, students formed the Race in the Curriculum Working Group and, with the support of our school’s SNMA chapter, worked with faculty to integrate a deeper analysis of race as a social determinant into the first-year curriculum.
in place, such as with getting a third year intersession module as well as a residency training module.
CRT analyses in education have focused primarily on five tenets (Solorzano, 1998). When applied to medical education, these tenets suggest that a CRT-informed medical education would:
1. “Center” race conceptually as a key determinant for understanding health disparities.
2. Challenge the dominant biomedical model as a “master narrative” in medical education that marginalizes the impact of social, political, and historical processes on health.
3. Emphasize the importance of medical students and health providers engaging in social justice work to combat health disparities.
4. Privilege the voices of people of color and value their knowledge of racism, gained through their experiences.
5. Incorporate multidisciplinary perspectives from histories of science, sociology, anthropology, and public health.
Although few medical schools incorporate a comprehensive, CRT-informed framework throughout their curriculum, there are some promising examples taking place. In the U.S., physicians and social scientists have teamed together to promote the incorporation of “structural competency” as a core competency in medical education, proposing a five-step conceptual model that emphasizes an understanding how historical, social, and political forces, including racism and oppression, contribute to health (Metzl, 2012; Metzl and Hansen, forthcoming). Initial integration of these types of standards is occurring at the residency level in the form of systems- based practices (Englander et al., 2013, p.1092). At Harvard Medical School, students formed the Race in the Curriculum Working Group and, with the support of our school’s SNMA chapter, worked with faculty to integrate a deeper analysis of race as a social determinant into the first-year curriculum.
Even as these interdisciplinary initiatives move forward
within medical schools, CRT will remain useful as a
unique methodology and framework for grounding
health disparities and their manifestations within the
context of race, racism, and power. In fact, Florida
Atlantic University already lists CRT as one of 12 topics
included in the social science portion of their integrated
medical sciences curriculum (FAU, 2013). Other
schools could benefit from similar moves to explicitly
incorporate CRT.
To be clear, the argument for CRT isn’t meant to discount the valiant efforts of physicians, researchers, and patients pushing for cultural competency to be included in medical curricula. In fact, the amount of change that has occurred just in the past decade in this arena is quite impressive. Nevertheless, it does seem that a CRT framework could help strengthen certain aspects of the cultural competency frameworks that are currently being deployed.
The incorporation of CRT into medical curricula will require action by various stakeholders. More specifically, the following recommendations should be considered:
References:
To be clear, the argument for CRT isn’t meant to discount the valiant efforts of physicians, researchers, and patients pushing for cultural competency to be included in medical curricula. In fact, the amount of change that has occurred just in the past decade in this arena is quite impressive. Nevertheless, it does seem that a CRT framework could help strengthen certain aspects of the cultural competency frameworks that are currently being deployed.
The incorporation of CRT into medical curricula will require action by various stakeholders. More specifically, the following recommendations should be considered:
-
Medical school faculty and administrators should incorporate a CRT
perspective as one of the components of the LCME guideline for
“socioeconomic subjects.”
-
LCME requirements should be strengthened to include specific guidelines
requiring a variety of socioeconomic subjects (i.e. critical understanding of
race, ecosocial model, etc.)
-
Medical school administrators should allocate more resources and faculty
time for CRT programming and teacher training.
-
Medical students should agitate and push for a health disparities
curriculum that incorporates critical perspectives to ensure they get a full
and comprehensive understanding of the issue.
References:
1. Beach, M.C., Price, E.G., Gary, T.L., Robinson, K.A., Gozu, A., Palacio,
A., Smarth, C., Jenckes, M.W., Feuerstein, C., Bass, E.B., Powe,
N.R., Cooper, L.A. (2005). Cultural competence: A systematic review
of health care provider educational interventions. Medical Care. Vol.
43, 356 –373.
2. Betancourt, J., Green, A., Carrillo, J.E., Ananeh-Firempong, O.A. (2003). Defining Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Health Care. Public Health Reports. Vol. 118, 293-302.
3. Brach, C. & Fraser, I. (2000). Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. Vol. 57, Suppl 1, 181 217.
4. Crenshaw, K., Gotanda, N., Peller, G., & Thomas, K. (Eds.) (1995). Critical Race Theory: The key writings that formed the movement (pp. xiii-xxxii). New York, NY: The New Press.
5. Delgado, R., & Stefancic, J. (2001). Critical Race Theory: An introduction (pp. 1-35). New York, NY: New York University Press.
6. Englander, R., Cameron, T., Ballard, A., Dodge, J., Bull, J., Aschenbrener, C. (2013) Toward a Common Taxonomy of Competency Domains for the Health Professions and Competencies for Physicians. Academic Medicine; 88:1088-1094.
7. Florida Atlantic University (FAU) (2013). About Integrated Medical Science in the Charles E. Schmidt College of Medicine. Accessed on 10/19/13 http://med.fau.edu/research/about integratedmed.php
8. Ford, C.L. & Airhihenbuwa, C.O. (2010) Critical Race Theory, Race Equity, and Public Health: Toward Antiracism Praxis. American Journal of Public Health, Vol 100, No S1.
9. Metzl, J. (2012). Structural Competency. American Quarterly, 64 (2):213-218.
10. Metzl, J.M. & Hansen, H.H. “Structural Competency: theorizing a new medical engagement with stigma and inequality.” Social Science & Medicine [forthcoming].
11. Paez,K.A.,Allen,J.K.,Beach,M.C.,Carson,K.A.,Cooper,L.A. (2009) Physician cultural competence and patient ratings of the patient–physician relationship. Journal of General Internal Medicine Volume 24, Pages 495–498.
12. Robert Wood Johnson Foundation (RWJF), Commission to Build a Health America. (2009). Beyond Health Care: New Directions to a Healthier America. New York: Ideas On Purpose.
13. Solórzano, D. G. (1998) Critical race theory, race and gender microaggressions, and the experience of Chicana and Chicano scholars. Qualitative Studies in Education, 11(1), 121-136
14. Weissman,J.,Betancourt,J.,Campbell,E.,Park,E.,Kim,M., Clarridge, B., Blumenthal, D. Lee, K., Maina, A. (2005). Resident Physicians’ Preparedness to Provide Cross-Cultural Care. JAMA, Vol 294, No. 9. 1058-1067.
2. Betancourt, J., Green, A., Carrillo, J.E., Ananeh-Firempong, O.A. (2003). Defining Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Health Care. Public Health Reports. Vol. 118, 293-302.
3. Brach, C. & Fraser, I. (2000). Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. Vol. 57, Suppl 1, 181 217.
4. Crenshaw, K., Gotanda, N., Peller, G., & Thomas, K. (Eds.) (1995). Critical Race Theory: The key writings that formed the movement (pp. xiii-xxxii). New York, NY: The New Press.
5. Delgado, R., & Stefancic, J. (2001). Critical Race Theory: An introduction (pp. 1-35). New York, NY: New York University Press.
6. Englander, R., Cameron, T., Ballard, A., Dodge, J., Bull, J., Aschenbrener, C. (2013) Toward a Common Taxonomy of Competency Domains for the Health Professions and Competencies for Physicians. Academic Medicine; 88:1088-1094.
7. Florida Atlantic University (FAU) (2013). About Integrated Medical Science in the Charles E. Schmidt College of Medicine. Accessed on 10/19/13 http://med.fau.edu/research/about integratedmed.php
8. Ford, C.L. & Airhihenbuwa, C.O. (2010) Critical Race Theory, Race Equity, and Public Health: Toward Antiracism Praxis. American Journal of Public Health, Vol 100, No S1.
9. Metzl, J. (2012). Structural Competency. American Quarterly, 64 (2):213-218.
10. Metzl, J.M. & Hansen, H.H. “Structural Competency: theorizing a new medical engagement with stigma and inequality.” Social Science & Medicine [forthcoming].
11. Paez,K.A.,Allen,J.K.,Beach,M.C.,Carson,K.A.,Cooper,L.A. (2009) Physician cultural competence and patient ratings of the patient–physician relationship. Journal of General Internal Medicine Volume 24, Pages 495–498.
12. Robert Wood Johnson Foundation (RWJF), Commission to Build a Health America. (2009). Beyond Health Care: New Directions to a Healthier America. New York: Ideas On Purpose.
13. Solórzano, D. G. (1998) Critical race theory, race and gender microaggressions, and the experience of Chicana and Chicano scholars. Qualitative Studies in Education, 11(1), 121-136
14. Weissman,J.,Betancourt,J.,Campbell,E.,Park,E.,Kim,M., Clarridge, B., Blumenthal, D. Lee, K., Maina, A. (2005). Resident Physicians’ Preparedness to Provide Cross-Cultural Care. JAMA, Vol 294, No. 9. 1058-1067.
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