Resolution: F-20-2: ANTI-RACISM AND IMPLICIT BIAS EDUCATION IN OSTEOPATHIC MEDICAL CURRICULUM

[Valerie Lile]

1  WHEREAS, medical racism is defined as prejudice and discrimination in the healthcare system due to race¹
2  resulting in pervasive racial health disparities that harm Black, Indigenous, and People of Color (BIPOC) in
3  medical practices;² and implicit bias refers to the attitudes or stereotypes that affect our understanding,
4  actions, and decision in an unconscious manner and implicit biases have been shown to contribute to
5  BIPOC-related health disparities³; and
6  WHEREAS, health disparities have complicated roots, including White privilege, Eurocentrism, medically
7  inaccurate beliefs, explicit racism, lack of access to insurance and care, mistrust of the medical system,
8  socially sanctioned, implicitly racist ideology, and unconscious biases held by doctors. Evidence-based anti-
9  racism education early in physicians’ training is vital to improving these disparities ^4,5,6,7; and
10  WHEREAS, due to false biological beliefs, physicians are more likely to underestimate the pain of Black
11  patients (47%) relative to non-Black patients (33.5%). Surprisingly, 22.43% of medical students and
12  residents endorsed false biological beliefs about Black patients (i.e., “Blacks have thicker skin than Whites”
13  was endorsed by 25% of residents);⁸ leading to Black patients in the emergency room being 17% less likely
14  to receive analgesics for similar reports of pain as white patients; and
15  WHEREAS, medical students and residents who endorsed false biological beliefs underestimated the pain
16  of their Black patients by at least a half scale point lower resulting in at least a 15% less accurate treatment
17  recommendation as compared to those who endorsed no false beliefs (with a further 15% drop in accuracy
18  with each additional half a scale point reduction in pain assessment). This has resulted in racial bias in pain
19  assessment and treatment in current practice,⁸ highlighting the need for updated clinically accurate training to
20  combat racial disparities; and
21  WHEREAS, Black patients were less likely to trust their physicians⁹ and to receive lipid-lowering
22  medication (9% less), the recommended intensity of statin therapy(10.6% less)¹⁰, antiplatelet therapy other
23  than aspirin (24% less), angiogram (29% less), and bypass surgery or angioplasty (45% less)¹¹ as compared
24  to white patients; and
25  WHEREAS, Black patients are disproportionately transferred to lower‐quality hospitals [when suffering
26  from acute myocardial infarction], are more likely to be served by facilities with less capacity to perform
27  needed interventions (even when in closer proximity to high-quality hospitals), and have a 1.52x greater
28  odds (P = 0.01) of mortality as compared to White patients even when considered low surgical risk. These
29  physician decisions are a manifestation of their implicit bias, which research has shown can be mitigated
30  through anti-racism training^{14,7,10,12,13;} and
31  WHEREAS, physicians of all ethnic groups showed an implicit preference for white people (even when
32  explicit bias was denied) except for Black physicians, who did not show any racial preference and have
33  better outcomes when treating black patients.Physicians with higher pro-white bias have worse perceptions
34  of their Black patients, deliver lower quality care, and make medical decisions that adversely affect Black
35  patients^5,6,7,14; and
36  WHEREAS, Black men have been shown to have better health outcomes when treated by a physician of
37  their own race, thereby underscoring the importance of educating a diverse cohort of future physicians to
38  serve marginalized and underrepresented communities¹⁴; and
1  WHEREAS, the American Heart Association recognizes that “Hospital administrators should ensure that
2  the physicians and providers caring for patients are well trained, culturally competent, and adequately
3  equipped. The current lack of diversity among staff should be considered as a marker of hospital quality that
4  must be recognized, measured, and tracked until improvements are made.” This underscores the importance
5  of anti-racism training in medical education as well as the need for increasing diversity among medical
6  students¹⁵; and
7  WHEREAS, the Journal of Academic Medicine recognizes the current gap in, and need for, appropriate
8  faculty training on anti-racism and health inequities in Academic Health Centers to effectively deliver anti-
9  racism education to medical trainees. Such training should include “how to conduct interracial dialogues on
10  race, racism, oppression, and the invisibility of privilege”¹⁶; and
11  WHEREAS, the Commission on Osteopathic College Accreditation (COCA) does not currently have anti-
12  racism curriculum requirements for medical schools¹⁷; and
13  WHEREAS, anti-racism educational interventions are effective in changing attitudes about racism and
14  health inequities among health clinicians^14,7,10,13. Institutions recognize the need for increased diversity,
15  implementation of anti-racist medical curricula, and the allocation of faculty training resources for effective
16  curriculum delivery^15,16,18; and
17  WHEREAS, SOMA policy S-19-23 already recommends integration of training programs in cultural
18  humility and bias awareness for students, faculty and staff¹⁹; and
19  WHEREAS, AOA policy H433-A/15 states, “racial and ethnic healthcare disparities caused by problems
20  with access to, and utilization of, quality care may be alleviated through improvements in the cultural
21  competency skills of physicians”²⁰; now, therefore be it
22  RESOLVED, that SOMA advocates to the COCA to create and enforce quality standards for anti-racism
23  and implicit bias education as a part of the osteopathic medical accreditation process to mitigate the effects
24  of implicit bias and racism in osteopathic medicine; and, be it further
25  RESOLVED, that SOMA advocates to the COCA to mandate faculty anti-racism training to ensure
26  effective anti-racism curriculum delivery; and, be it further
27  RESOLVED, that SOMA and the AOA recognize implicit bias and racism as social determinants of health
28  that are pervasive in current medical practice and adversely affect health outcomes of BIPOC and make the
29  elimination of racial and ethnic disparities in health care an issue of highest priority.

Relevant Existing Policies SOMA Policy: S-19-23

AOA Policy: H433-A/15, H406-A/19, H409-A/16

References

1. Encyclopedia of Race and Racism. Encyclopedia.com. 11 Aug. 2020 . Encyclopedia.com. https://encyclopedia.com/social-sciences/encyclopedias-almanacs-transcripts-and-maps/medical-racism. Published September 12, 2020. Accessed September 12, 2020.
2. Samantha Artiga Follow @SArtiga2 on Twitter KOF@_KOon T. Disparities in Health and Health Care: Five Key Questions and Answers. KFF. https://kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/. Published April 1, 2020. Accessed September 12, 2020.
3. Devine, P. G., et al. (2012). “Long-term reduction in implicit race bias: A prejudice habit- breaking intervention.” J Exp Soc Psychol 48(6): 1267-1278.
4. Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Introduction and Literature Review. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. https://www.ncbi.nlm.nih.gov/books/NBK220344/. Published January 1, 1970. Accessed September 13,
5. Chapman EN, Kaatz A, Carnes M. Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities. Journal of General Internal Medicine. 2013;28(11):1504-1510. doi:10.1007/s11606-013-2441-1
6. Understanding and Addressing Racial Disparities in Health Care. https://cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/00summerpg75.pdf. Accessed September 13, 2020.
7. Geiger HJ. Race and health care–an American dilemma?. N Engl J Med. 1996;335(11):815-816. doi:10.1056/NEJM199609123351110
8. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. PNAS. https://pnas.org/content/113/16/4296. Published April 19, 2016. Accessed September 13, 2020.
9. Armstrong, K., et al. (2007). “Racial/ethnic differences in physician distrust in the United States.” Am J Public Health 97(7): 1283-1289.
10. Black patients less likely to receive statins. Healio. https://www.com/news/cardiology/20180613/black-patients-less-likely-to-receive-statins. Accessed September 13, 2020.
11. Differences remain in heart attack treatments for black patients. heart.org. https://www.heart.org/en/news/2018/09/20/differences-remain-in-heart-attack-treatments-for-black-patients. Accessed September 13, 2020.
12. Khera R, Vaughan-Sarrazin M, Rosenthal GE, Girotra S. Racial Disparities in Outcomes After Cardiac Surgery: the Role of Hospital Quality. Current Cardiology Reports. 2015;17(5). doi:10.1007/s11886-015-0587-7
13. White-Davis T;Edgoose J;Brown Speights JS;Fraser K;Ring JM;Guh J;Saba GW; Addressing Racism in Medical Education An Interactive Training Module. Family medicine. https://pubmed.ncbi.nlm.nih.gov/29762795/?from_term=educational interventions that reduce racism among health providers&from_pos=1. Accessed September 13, 2020.
14. Torres N. Research: Having a Black Doctor Led Black Men to Receive More-Effective Care. Harvard Business Review. https://hbr.org/2018/08/research-having-a-black-doctor-led-black-men-to-receive-more-effective-care. Published August 10, 2018. Accessed September 13,
15. Johnson MD A, Johnson A, Amber Johnson University of Pittsburgh School of Medicine, Johnson Cto: A, Popescu I. Understanding Why Black Patients Have Worse Coronary Heart Disease Outcomes: Does the Answer Lie in Knowing Where Patients Seek Care? Journal of the American Heart Association. https://www.ahajournals.org/doi/full/10.1161/JAHA.119.014706. Published November 30, 2019. Accessed September 13,
16. Acosta is associate vice chancellor. Breaking the Silence: Time to Talk About Race and Racism : Academic Medicine. LWW. https://journals.lww.com/academicmedicine/Fulltext/2017/03000/Breaking_the_Silence Ti me_to_Talk_About_Race_and.15.aspx. Accessed September 13, 2020.
17. Accreditation Standards. American Osteopathic Association. https://osteopathic.org/accreditation/standards/. Published March 2, 2020. Accessed September 13, 2020.
18. Smith WR, University FVC, Betancourt JR, et al. Recommendations for Teaching about Racial and Ethnic Disparities in Health and Health Care. Annals of Internal Medicine. https://www.acorg/doi/10.7326/0003-4819-147-9-200711060-00010. Accessed September 13, 2020.
19. Student Osteopathic Medical Association. (2019). SOMA Past Resolutions Archive [PDF file]. Retrieved from https://studentdo.org/soma-policy-database/.
20. American Osteopathic Association. (2019). AOA Policy Compendium [PDF file]. Retrieved from https://osteopathic.org/wp-content/uploads/2019-Policy-Compendium.pdf

Submitted by:

Azaria Lewis, OMSII, WesternU College of Osteopathic Medicine of the Pacific
Toni Davis, OMSII, WesternU College of Osteopathic Medicine of the Pacific
Mary Unanyan, OMSII, WesternU College of Osteopathic Medicine of the Pacific
Chardonnay Ward, OMSII, WesternU College of Osteopathic Medicine of the Pacific
Christelle Salomon, OMSII, WesternU College of Osteopathic Medicine of the Pacific
Suria Markus, OMSII, WesternU College of Osteopathic Medicine of the Pacific
Emerald Chiang, OMSII, WesternU College of Osteopathic Medicine of the Pacific
Edie Waskel, OMSIV, WesternU College of Osteopathic Medicine of the Pacific
Gilbert Hernandez, OMSIII, WesternU College of Osteopathic Medicine of the Pacific
Brian Diep, OMSIII, WesternU College of Osteopathic Medicine of the Pacific

Action Taken:
Date:
Effective Time Period: Ongoing

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