A Black woman whose kidneys only function at 15 percent of normal wishes to be evaluated for a kidney transplant. Although this is very reasonable, before 2021, many physicians would have said, “I’m sorry, but your kidney function is not bad enough to be referred for a transplant.”
This is because the kidney function calculator used before 2021 overestimates kidney function for Black people, making her kidney function seem “too good” to meet the cut-off for a transplant referral. Recognizing that this calculator was inequitable, the medical community—comprising medical trainees, kidney doctors, patients, and others—advocated for a new calculator that provides the same estimate of kidney function for an individual patient, regardless of their race. The story of eliminating race-based estimates of kidney function is an example of why we need leaders in diversity, equity, and inclusion (DEI).
Medicine is a complex and ever-evolving field. To ensure that physicians provide competent, compassionate, and current medical care, medical education must adapt to the needs of learners and patients. The Association of American Medical Colleges (AAMC), a non-profit organization founded in 1876, develops competency-based evaluations to help medical schools ensure their learners receive high-quality training. Recently, the AAMC released new competency-based guidelines for DEI. Unfortunately, the guidelines received harsh and unwarranted criticism.
Developed to address persistent health disparities in the United States, the new AAMC DEI guidelines build on decades of evidence and national reports calling for the need to incorporate cultural competency and health equity in medical training. The criteria help evaluate where trainees stand across 24 distinct DEI knowledge categories. They employ a 3-tier system to determine if a trainee’s knowledge fits within the expectations of 1) a recent medical school graduate, 2) a physician newly entering independent practice, or 3) a DEI leader/teacher. We wholeheartedly welcome the new AAMC DEI guidelines, which help reliably measure and evaluate how DEI is incorporated into medical training.
Health outcomes are profoundly influenced by social determinants of health such as a patient’s gender, race, socioeconomic status, insurance, financial and housing security, as well as systemic factors such as bias and discrimination. These data are not in question.
Patients from racial and ethnic minority backgrounds experience higher rates of infant mortality, diabetes, chronic kidney disease, breast cancer, and many other medical conditions. LGBTQ+ individuals also experience worse health outcomes compared to heterosexual and cisgender patients. Physicians who understand the unique challenges faced by specific patients may provide more informed and competent care. In fact, patients report better experiences working with physicians of similar race/ethnicity. As the U.S. becomes increasingly diverse, we must look beyond biochemistry and include competence in DEI as part of modern medical training. Addressing these disparities requires medical school curricula to expand from a narrow historical focus on disease pathophysiology and treatment to include a deeper understanding of how social determinants such as systemic bias, discrimination, health policy, and individual patient factors affect health outcomes.
Prior opinion pieces have suggested that teaching about social determinants, bias, and racism in medicine will lower standards for medical education. This is a false equivalency and a dangerous narrative. Medical education is continuously updated based on new data. When data demonstrate the effectiveness of new life-saving drugs, there is no argument about whether to include these drugs in medical training. Similarly, when data demonstrate the glaring inequities in health care, there should be no argument about the need to include these data in medical training.
Original medical school curricula were developed at a time when gender and racial discrimination led to a predominantly white male physician workforce. While curricula have been updated over time to reflect advances in the pathophysiology of disease, curricula must also be updated regularly in the area of culturally competent care. To refuse to acknowledge the need for competency in DEI implies acceptance of—and satisfaction with—prior practices that have contributed to inequities. Curricula need to evolve to incorporate the perspectives of a growing diversity of learners, which now comprise 56 percent women, 12 percent Hispanic, and 11 percent Black trainees.
The new AAMC DEI guidelines will help prepare medical schools to train the next generation of physicians: physicians equipped with an understanding of how diseases mechanistically affect patients and how to identify and address health inequities to ensure their patients can achieve their best health.
Our priority as medical educators should be to train a diverse group of physicians that can address the biologic and societal aspects of their patients’ health care needs. Training physicians who are competent in DEI issues adds to, rather than takes away from, the ability to provide competent and compassionate medical care. To those who say that medical education has “gone woke,” we say, “It’s about time!”
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