The role of medical education in perpetuating health care disparities

Black bodies are dying, and medical schools are partially to blame.  Never did I imagine that I would come to the realization that as a medical student; I was being trained and conditioned to identify and treat conditions predominately in white people.  It is time for medical institutions to address how medical school curriculums, which use whiteness as a scale to define normal, contributes to increased rates of mortality and morbidity in Black communities.

In my first two years of medical school, our curriculum focused on training us to be able to compile a comprehensive differential diagnosis based on presenting symptoms.   During one of our practice sessions, we received a list of symptoms, and I shouted, “Kawasaki‘s disease.”   As my classmates smirked (because my answer was a zebra), the ER attending, who is overseeing our discussion said something that I will never forget, “you will not diagnose something that is never on your differential.”

Now that I’ve completed my didactic years of medical school, I have become vividly aware of how I am being trained to diagnose and treat conditions in white bodies, Black and brown bodies are an afterthought.  This was a heartbreaking realization to come to, seeing that my medical school is located in Chicago, an urban area, and our patient population is predominantly Black and brown.

I first began to realize this fundamental flaw in my medical education when we began to learn how to write histories of present illness (HPI’s).  We had been taught repeatedly not to include racial or ethnic identifiers because their inclusion can lead to bias.  Despite that warning, and research confirming potential for bias, my school continues this practice.  However, these identifiers are only used when a clinical case involves a person of color. Examples of cases I received in my first two years of medical school are: a Black single mother of four with colon cancer, a Black Dominican family with sickle cell disease, and a Latina with an epidural hematoma from an incident of domestic violence in the presence of her young child.

These very stereotypical cases teach student doctors early in our careers to typecast people of color, drastically narrowing our differential diagnosis when interacting with these patients. This narrowed differential can lead to delays in diagnosis, which research shows contributes to increased morbidity and mortality in Black people.   Additionally, by only identifying race and ethnicity when wanting students to think of people of color, by contrast, it can be assumed that every other clinical case that we study is of a white person. Effectively expanding how we think of differential diagnosis when working with white patients.  This inherently white supremacist form of medical education is fundamentally teaching us how to treat and care for white bodies; while Black and brown bodies continue to be supplemental to our education.

My suspicions were confirmed when we spent a week studying dermatology. I must have seen at least 100 slides with various skin conditions, and out of those 100 slides, I saw around three on Black skin. When I asked our professor, a dermatology attending, how I could identify a particular skin condition on a Black person, she told me that it was a great question.  She then proceeded to inform me that I would have a better understanding if I did a dermatology residency.

What this incident taught me was that learning about skin conditions on white people is expected to be basic knowledge for all doctors, whereas identifying those same conditions on Black bodies for some reason requires specialized training.  Meaning that out of my class of 200 students, the only people who will be trained to identify basic dermatologic conditions on Black bodies are possibly five students who match into a dermatology residency.  White should not be the standard by which medical education is taught.  Black bodies should not be an afterthought.  Why are medical institutions comfortable with graduating classes of ophthalmologists, internists, family medicine practitioners, and obstetricians that cannot identify basic skin conditions on Black people? This speaks to a health care system that knowingly or unknowingly values white bodies above all else.   I could give countless more examples of how Black bodies in our education are “othered” or “supplemental.”

Sadly, before we know it, we are another generation of doctors who “miss” diagnosis in Black bodies, when the reality is that we are not being trained to identify them, to begin with.  This underlying sentiment of white supremacy in our medical education does a disservice to every single Black patient that we will serve throughout our long medical careers.

This ingrained limited differential diagnosis for Black patients can help to explain why Black people are forced to beg their physicians to believe their symptoms, when their condition strays from the “norm.”  It can also help to explain why Black people are required to get second, third, and fourth opinions; because doctors are not being trained in medical school to treat Black bodies.

Despite the fact that my medical school, like others around the country, are trying to revamp their curriculums, the damage has already been done.  Cohorts upon cohorts have been graduated without basic competencies of how to treat anyone that is not white.  In school, we often learn about the social determinates of health and how they affect both morbidity and mortality in communities of color.  It is time to acknowledge how medical school curriculums that emphasize whiteness and neglect to adequately address how health conditions affect Black bodies continue to perpetuate health care inequities.

The author is an anonymous medical student.

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