Faculty Confront Structural Racism in Health Care
Pilot projects plant the seeds of change
In December 2020, Academic Medicine—the journal of the Association of American Medical Colleges—published “Learning from the Past and Working in the Present to Create an Antiracist Future for Academic Medicine.” The pointed op-ed sounded a clarion call to action.
“The murders of George Floyd, Breonna Taylor, Rayshard Brooks, and others by the police in 2020 sparked demands across the United States and around the world to end systemic racism against Black people,” wrote the coauthors, a subset of the journal’s editorial board who are all members of groups underrepresented in medicine. “These instances of appalling violence occurred during the COVID-19 pandemic, which magnified longstanding health disparities in the Black community. The combination of violence and illness has provided a catalyst for action and an opportunity for change in academic medicine.”
In June 2021, one of those coauthors, Monica Lypson, MD, became vice dean for education at VP&S. She oversees the MD program, including curriculum, financial aid, student affairs, and research. And she has pledged to extend the vision articulated in the Academic Medicine op-ed to foster a diverse and inclusive learning environment not only within the medical school but also across Columbia University Irving Medical Center to promote equitable, high-quality health care for all patients.
Lypson’s efforts will expand on plans laid in the summer of 2020 when CUIMC leadership created a task force to identify actions to move VP&S and Columbia’s other health sciences schools toward the university’s vision of an anti-racist, multicultural, and inclusive institution. The task force was cochaired by Olajide Williams, MD, professor of neurology, and Rafael Lantigua, MD, professor of medicine, and coordinated by Anne Taylor, MD, vice dean for academic affairs in VP&S and senior vice president for faculty affairs and career development at CUIMC.
Many of the action items identified by the task force extend and amplify isolated efforts already underway at a smaller scale in individual departments and programs across VP&S. In October 2020, Columbia’s Office of the Vice Provost for Faculty Advancement awarded funds to 57 pilot projects across the university conceived to dismantle structural racism; 26 of those initiatives involve VP&S faculty. The projects aim to increase recruitment of underrepresented minorities in medicine, expand access to health care, retain minority talent, and update the curriculum to address structural racism. Several of the projects tackle specific clinical issues, such as race-based reporting on kidney function, health access and quality for Black patients with liver disease, mental health issues in the Black community, and racial disparities in telemedicine access for orthopedic health care during the pandemic.
“Naming structural racism is not enough,” says Lypson. “If change is to happen, it takes more than statements. It takes long-term, sustained action and significant funding. These pilot grants awarded to VP&S faculty provide the monetary resources to encourage collaboration, dialogue, and action to create systemic change at the medical school and honor the longstanding commitment of many of our faculty to confront the impact of racism on health care.”
Columbia patients represent myriad countries and cultures. Some need health care providers who can communicate in languages other than English. Others worry about how they will be able to afford care. Few of their doctors have lived through such challenges themselves. As an inpatient family medicine hospitalist at the 200-bed Allen Hospital, Himabindu Ekanadham, MD, who speaks both Spanish and Telugu, the official language of the Indian states of Andhra Pradesh and Telangana, has had ample opportunity to witness the chasm in lived experience between patients and health care professionals.
In the aftermath of George Floyd’s death and the first COVID-19 wave—during which patients and staff at the Allen were particularly hard hit—Ekanadham grew frustrated with the messages of shock and disappointment shared in the news and among her colleagues, friends, and family. “I felt like it wasn’t enough,” says the assistant professor of medicine in the Center for Family and Community Medicine. “Saying that racism is wrong wasn’t changing much for our patients or the community we are in.” So, Ekanadham, who has twice won the American Academy of Family Physicians’ Exemplary Teaching Award and was her residency program’s physician teacher of the year in 2018, launched a monthly video call for the Center for Family and Community Medicine that was open to all faculty, residents, and staff to brainstorm actions they could take with the support and presence of department leadership.
When the opportunity for grant funding arose, Ekanadham and seven colleagues proposed “Addressing Racism Through Education, Intentional Recruitment, and Advocacy” to implement strategies they had identified in their video calls to improve representation and inclusion in the family medicine residency program at NewYork-Presbyterian and retain trainees who match to the program.
“Historically in medicine, there is a huge amount of exclusion of various groups of people because of structural racism and resources that are not equitably allocated in terms of higher education and advancement opportunities. It’s set up that the people who make it into medical school and later on into residency are already isolated into these higher groups of privilege, which tend to be comprised of people who are white,” says Ekanadham. “Working in an urban, underserved community, there’s a stark difference between us doctors and the patients we care for in terms of what we look like, our lived experiences, and the language(s) we speak. This is a big problem because data shows that patients feel more connected to and trust physicians who look like and speak the same language as them. There is a premise here that part of healing involves relatability, which translates into a richer form of empathy.”
The “Addressing Racism Through Education, Intentional Recruitment, and Advocacy” project has three main goals: to educate family medicine faculty and residents on the pervasiveness of racism and how it affects their peers and patients; to form an admissions committee that will help increase the recruitment and retention of underrepresented applicants; and to create a community medicine advocacy track within the family medicine residency program, through which participants will gain skills in physician advocacy and community engagement.
Already, the admissions committee has implemented a host of process innovations. During recruitment, the committee has de-emphasized parts of applications that have historically been included but have little to do with clinical acumen and instead have served as tools of exclusion. Furthermore, greater attention was paid to the relevant experience an applicant could bring to the residency program—community organizing skills, for example, or a passion for lobbying for change within government. The committee also communicated its goals of equity and inclusion to residency applicants and solicited their feedback, which is now being analyzed. As the demographics of incoming residents shift, the project PIs are focused on ensuring residents’ success within the program, which “necessitates active efforts towards creating a culture of mentorship that is predicated on mutual respect and brings out the full healing capacity of every trainee,” says Ekanadham. “Mentorship is key. We need to recognize what each resident has to offer. We have to pay attention to their driving passions, gifts, and skills and nurture them. Only then can we have hopes of retaining residents as faculty who will do the same for residents in the subsequent years to come.”
A space to process racial trauma
Jean-Marie Alves-Bradford, MD, came to VP&S in 2000 as a postgraduate trainee in psychiatry and joined the faculty in 2004. Now an associate clinical professor of psychiatry and director of the Washington Heights Community Service, Alves-Bradford traces her leadership role in diversity, equity, and inclusion work at VP&S to 2012, when she joined the task force that would become the Department of Psychiatry’s Faculty Affairs Committee of Diversity and Inclusion. Alves-Bradford served as co-chair for six years, and when Jeffrey A. Lieberman, MD, psychiatry chair, established the Office of Equity, Diversity & Inclusion to formalize the committee’s work, he appointed Alves-Bradford its founding director. In that role she works with department leaders to create policies, programs, and opportunities that support an inclusive and equitable environment and serves as ombudsman for the department on issues related to equity, diversity, and inclusion.
With funds provided by the provost’s office, Alves-Bradford has joined forces with Hetty Cunningham, MD, associate professor of pediatrics, and Hilda Hutcherson, MD, senior associate dean for diversity and multicultural affairs, to develop interactive workshops designed to foster healing and agency among medical students who have experienced racism. “It’s already challenging to be a med student—you’re learning a lot, changing a lot, and the hours and schedule are challenging, and then students who are underrepresented in medicine have additional challenges of dealing with racism and a system that doesn’t always see them equally,” says Alves-Bradford. “So we created spaces for them to have time to process and heal.”
Through the workshops, participants learn about existing systems of privilege and oppression, share their personal experiences of racism, adopt effective practices for stopping acts of racism as they come up in daily life, and practice resilience strategies that will serve as tools to cope with racial trauma. The workshops, which began in March 2021, occur over two 90-minute Zoom sessions. Each workshop is co-facilitated by either two VP&S faculty members or a faculty member and a graduate student from Columbia’s School of Social Work. The workshop content was created by Alves-Bradford and Cunningham with two 2021 VP&S graduates, Lauren Fields and Taiwo Alonge.
The first participants were medical students who identify as underrepresented in medicine—Black, Hispanic, and Native American. “We wanted to start with that group of students because they tend to experience more microaggressions,” says Alves-Bradford. “We wanted to provide them with tools of how to respond and cope.” Alves-Bradford received the Apgar Academy of Medical Educators’ Vanneck-Bailey Award for 2021-2022 to create a longitudinal curriculum on bias response throughout all four years of medical school. The Provost Innovative Course Design Award will support development and implementation of a longitudinal curriculum of allyship, upstander, and advocacy skills for all medical students throughout their four years.
A continuous commitment
While Black, Latino, and Native American people comprise 33% of the U.S. population, they make up only 14% of the students entering medical school. As Lypson and her coauthors note in their Academic Medicine op-ed, people who experience racism have historically shouldered the bulk of the labor to bring about change. The work of anti-racism in health care, however, requires a collective commitment. “Each member of the academic medicine community should readily acknowledge that it is not only the system that must change but also the individuals who exist within it,” they wrote. “We must all develop new ways of thinking, seeing, and behaving to do our part to mitigate systemic racism.”
In that vein, many of the VP&S projects funded by the provost’s office invite white health care providers and medical students to confront the legacy of racism—with initiatives that target provider bias and advance health equity in maternal care, address inequities in liver transplant evaluation, design anti-racist case studies, and develop anti-racist policies to combat childhood obesity.
The provost’s office awarded only one year of funding, but many of the faculty expect to pursue other funding sources to sustain their efforts in years to come. In the meantime, they see the awards as affirmation for work they have long crammed into evening and weekend hours. “Money is what speaks within this country,” says Ekanadham. “Financially appreciating this work on a level that we appreciate other type of projects and research is really important. By putting money towards it, institutions show what is important to them.”
This article originally appeared in the 2020-2021 Annual Report for the Columbia University Vagelos College of Physicians & Surgeons.
Photos by Jorg Meyer.