The complex roots of bias, discrimination, and health inequity are entangled within our social tapestry. The causes and devastating consequences of racialized medicine have aggravated the suffering of disenfranchised groups. This reality poses painful challenges for health care professionals. In this article, we (1) highlight factors impeding meaningful equity,1 diversity,2 and inclusion2 (EDI) education in graduate medical education (GME); (2) identify resources and guidelines in structuring EDI education; and (3) suggest how accrediting bodies, sponsoring institutions (SIs), training programs, and specialty organizations can be credible models demonstrating holistic integration of EDI. We believe that interdisciplinary collaboration across these entities will deepen the GME community's endeavors toward health equity—empowering trainees, administrators, and faculty to become change agents.
Publication of the Report of the SI2025 Task Force3 by the Accreditation Council for Graduate Medical Education (ACGME) sharpened our perspectives on EDI education. SI2025 describes pervasive neoliberalism as “a way to do business” within the health care system. Neoliberalism posits that profitability is the primary aim of large companies, including those in health care. The report, with phrases like “strong business interest” and “market trends,” predicts (1) corporate priorities threatening the medical profession's mission of public service to address community needs; (2) persistent, multifactorial health care disparities; and (3) corporate health systems' failure to serve rural and urban populations. Considering that a racially diverse population will outnumber Whites by midcentury,4 these predictions illuminate a reality in which much of the population remains disenfranchised by the health care system. These signals demand heightened action by the GME community.
Research identifies systematized transformation, accountability, and sustainability as key elements in promoting meaningful EDI.5 One way that SIs and programs are guided toward accountability and sustainability is through the ACGME and specialty-specific requirements. ACGME Common Program Requirements (CPRs) reference EDI in many categories (provided as online supplementary data). Furthermore, the Clinical Learning Environment Review (CLER) visit requires that trainees are involved in addressing health care disparities at the clinical site of training.6
These CPR and CLER components may have motivated SIs and programs to integrate EDI into the educational program, leveraging accreditation as an essential vehicle for institutional change.7 However, many requirements will benefit from additional scaffolding. Substantial and sustainable EDI education will require standards, theoretical frameworks, pedagogical practices, and evaluation within the constructs of the competency-based medical education model. GME leaders must spearhead interdisciplinary collaboration to respond to shared needs. Below, we outline a series of 5 observed challenges and suggestions for mitigation.
Challenge 1: Misperception That EDI Is a Stand-Alone Domain
Suggestion: Expand EDI Requirements Across Accreditation Domains
CPR incorporation of EDI within multiple categories as discussed reinforces that EDI work does not stand alone. The ACGME can further expand references to EDI within the domains of trainee and faculty assessments as well as other relevant areas to ensure that EDI content permeates all core competencies. However, this expansion should not obviate the need for a distinct EDI category within the CPRs. The expanded references should join a distinct, separate EDI category within the CPRs to enhance integration of EDI content through training.
Challenge 2: Misperception That EDI Training Is Optional or Can Be Added Sporadically
Suggestion: Outline a Common EDI Curriculum for Specialty Adaptation
Most current GME EDI training remains sporadic or optional8 —often a “special” topic delivered in fragmented ways (eg, guest speakers, orientation session, short-term, international immersion trip). Experts have called for delivery of a universal curriculum addressing core EDI skills, knowledge, and behaviors in all specialties.8,9 This shared EDI curriculum should be visibly rooted in GME core competencies (particularly patient care) and should not assume effective training during medical school. The curriculum should include the history of racialized medicine and social and political factors systematically exacerbating health inequities. Each specialty should then supplement this with unique information and/or skills relative to their own patient populations and social determinants within communities served.
Challenge 3: A Lack of Constructs Against Which EDI Curriculum and Evaluations Can Be Mapped
Suggestion: Craft Cross-Specialty Common EDI Milestones
The GME community has already collaborated across specialties (Milestones 2.0), with interdisciplinary groups “harmonizing” subcompetencies and milestones for 4 core competencies: professionalism, practice-based learning and improvement, interpersonal and communication skills, and systems-based practice. The themes of these subcompetencies apply across all specialties.
EDI is also relevant across specialties. Most specialty Milestones include 1 or 2 EDI descriptor(s), offering only basic language (eg, “cultural diversity” or “socioeconomic status”). Such limitation risks oversimplification of EDI concepts and hindrance of nuanced understanding of health inequities. Table 1 provides potential common EDI Milestones for GME.
Challenge 4: Few Faculty Members Are Experts on Pedagogical Practices Promoting EDI
Suggestion: Highlight Pedagogical Practices to Foster Effective Implementation of EDI Education
GME education leaders must compile and distribute resources on critical and anti-racist pedagogy to improve instructional quality—this is a key target for centralized faculty development. Critical pedagogy and anti-racist pedagogy, rooted in critical theory, are pedagogical approaches or paradigms that encourage questioning of social structures, power, and oppression.10,11 Faculty skilled in teaching practices founded on critical pedagogy and anti-racist pedagogy will foster the development of critical consciousness in trainees, particularly if examples of critical pedagogy are offered with respect to the core competencies. Select resources referencing critical pedagogy are outlined in Table 2.
Challenge 5: EDI Education Is Only Credible if Accompanied by Equitable and Inclusive GME Processes and Operations
Suggestion: Enculturate EDI as Core Values Within Daily Operations, Administration, and Sponsored Projects
The GME community must nurture hidden curriculum that promotes EDI in order to reinforce direct EDI education as previously suggested. Modeling EDI within daily organizational operations and administration (provided as online supplementary data) reifies and bolsters accountable, sustainable, and inclusive EDI learning experiences.5
As the above outlined structures are made available, SIs and programs will have concrete resources for creating, implementing, evaluating, and reflecting on key content and outcomes. These challenges cannot be fully addressed in a brief period. Yet interdisciplinary collaboration is highly feasible, considering the work the AAMC (eg, Core Entrustable Professional Activities for Entering Residency12 ) and the ACGME (eg, Milestones 2.0) have already engaged. The GME community must continue its work of consensus building and develop an initial timeline for elevating awareness, collecting resources, and thoughtfully planning implementation. We offer these perspectives as a roadmap toward 2025, by which time we hope all health care professionals will be “educated to address the needs of patients from a variety of backgrounds”3 and “prepared to address ongoing disparities in health care.”3 We believe that a GME community that is willing to examine itself and forge meaningful collaborations will become a driving force in dismantling health inequity.
References
Editor's Note: The online version of this article contains equity, diversity, and inclusion (EDI) related standards in ACGME Common Program Requirements and examples of EDI hidden curriculum within graduate medical education operations, administrations, and sponsored projects.
