In order to create a more just and equitable medical culture for racial and ethnic minorities, all stakeholders in the medical system must acknowledge and learn lessons from past and ongoing mistakes toward minorities. The Federation of State Medical Boards (FSMB), in its leadership position, can influence state medical boards to recognize systemic racism and take steps to combat racism and promote racial diversity. This article reviews current and historical examples of medical racism toward Black or African Americans that are largely invisible to the white community; offers ethical guidelines to ensure fairness; provides guidelines for medical boards to reduce implicit bias in disciplinary proceedings; and suggests educational approaches to increase understanding and empathy for the experience of Black physicians and Black patients in the medical system. Eight fundamental questions, outlined in this article, provide a road map for the FSMB and medical boards to increase racial diversity and reduce inequity
“Racism in all of its forms is a public health issue.”1
Washington Medical Commission
Racism is a deeply ingrained feature that impacts a wide range of American institutions, including those in the medical profession. In order for regulatory organizations to take meaningful action in addressing racial inequity, they must candidly assess the current environment within which health care is delivered in the United States. Addressing eight fundamental questions, outlined in this article, can provide a road map for medical boards to increase diversity and reduce inequity.
We, as a medical community, have a responsibility to work towards equitable care for all. Where better to start than with the things over which we have some control? How can we begin to make amends for the racial inequities in our society through our regulatory boards and systems? In order to create a more just and equitable medical culture for racial and ethnic minorities, all players in the medical system must acknowledge and learn lessons from past and ongoing mistakes toward minorities. The Federation of State Medical Boards (FSMB), in its leadership position, can influence state medical boards to recognize systemic racism and take steps to create systems that embrace racial diversity.
Creating diversity in the membership of regulatory bodies will be a step toward building trust among ethnic and racial minorities. State medical boards can take actions that will reduce bias in disciplinary proceedings. Educational programs can inform physicians and others in the medical system about the history of racism so that they understand and empathize with the experience of Black people in the United States and through self-reflection and self-analysis make changes that promote diversity, equity and inclusion.
What is Racism?
There are no uniformly agreed upon definitions of racism and related terms. According to the American Medical Association (AMA) Manual of Style Committee:2
Terms and categories used to define and describe race and ethnicity have changed with time based on sociocultural shifts and greater awareness of the role of racism in society… Although race and ethnicity have no biological meaning, the terms have important, albeit contested, social meanings. Neglecting to report race and ethnicity in health and medical research [and health initiatives and policies] disregards the reality of social stratification, injustices, and inequities and implications for population health… Terminology, usage, and word choice are critically important, especially when describing people and when discussing race and ethnicity.
The Committee accepts the definition of terms offered by the Centers for Disease Control and Prevention (CDC) as follows: 3
Racism is a “system of structuring opportunity and assigning value based on the social interpretation of how one looks…(“race”), that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and undermines realization of the full potential of our whole society through the waste of human resources.”
Three levels of racism are defined as follows:4
Institutionalized racism (also referred to as systemic and structural racism): “Structures, policies, practices, and norms resulting in differential access to the goods, services, and opportunities of society by ‘race’ (e.g., how major systems — the economy, politics, education, criminal justice, health, etc. — perpetuate unfair advantage).”
Personally-mediated racism: “Prejudice and discrimination, where prejudice is differential assumptions about the abilities, motives, and intents of others by ‘race,’ and discrimination is deferential actions towards others by ‘race.’ These can be either intentional or unintentional.” (Unintentional prejudice referred to as implicit bias is defined below in this article.)
Internalized racism: The power of culture to affect attitudes should not be underestimated. The prejudiced attitude of the dominant white culture that views Black people as inferior can result in “Acceptance by members of the stigmatized ‘races’ [e.g., Black individuals] of negative messages about their own abilities and intrinsic worth.”
White supremacy is at the root of racism. It is the belief and idea purporting natural superiority of the white race over other racial groups. Over the centuries, it has taken many forms and levels of acceptance within societal institutions — political, legal, scientific, medical, and religious. According to the Challenging White Supremacy Workshop Catalyst Project: “White Supremacy is an historically based, institutionally perpetuated system of exploitation and oppression of continents, nations, and people of color by white peoples and nations of the European continent, for the purpose of maintaining and defending a system of wealth, power and privilege.”5
In her article “White Privilege: Unpacking the Invisible Knapsack,”6 Peggy McIntosh discusses “whiteness” as a racial identity. She describes white privilege as “an invisible package of unearned assets”— culturally unacknowledged. White people enjoy unearned skin privilege and have been conditioned into oblivion about its existence. White people are culturally conditioned into a mindset that “their lives are morally neutral, normative, and average, and also ideal, so that when we work to benefit others, this is seen as work which will allow ‘them’ to be more like ‘us.’”
According to McIntosh, racism is “invisible systems conferring dominance” to the white majority. It is a “myth that all democratic choice is equally available to all.” She lists twenty-six examples of cultural advantages automatically conferred on her by virtue of being white. Concretizing how their privilege plays out in real life helps white people see it, and explicitly acknowledging it validates what Black people experience throughout their lives.
Is There Racism in the Medical Establishment?
Some physicians disavow the presence of racism in medicine and among physicians. A recent case in point is the controversial 2021 Journal of the American Medical Association (JAMA) podcast and tweet that stated, “No physician is racist, so how can there be structural racism in health care?”7 However, extensive literature and evidence-based studies strongly support the existence of structural racism in medicine and its adverse impact on health. Prestigious medical organizations, including the AMA, admit to their own record of racism as well as to racism in the medical profession as a whole. The AMA, for example, has adopted a formal policy recognizing racism as a public health threat and committing to actively work on dismantling racist policies and practices across all of health care — making clear that “a proactive approach to prevent, or identify and eliminate racism is crucial…”8 Following the 2021 JAMA podcast and tweet, the editor in chief of JAMA issued an apology and later resigned, and the AMA’s CEO declared “we are deeply disturbed — and angered — by a recent JAMA podcast that questioned the existence of structural racism and the affiliated tweet…”9
The historical record, omitted in the education of physicians, includes abundant evidence of longstanding issues of medical racism. Although there are general themes and principles regarding disparities that apply to all minorities, this article focuses on Black or African Americans as a specific example — well documented by Harriet Washington in her 2008 book “Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present.”10
Recently, racial disparities are evident in the high morbidity and mortality among minority groups from COVID-19. More generally, and historically, data show that Black patients receive less care than white patients regarding many medical conditions. According to CDC data,11 compared to the white population, racial and ethnic minorities in the United States experience higher illness and death across a wide range of health conditions: diabetes, hypertension, obesity, asthma and heart disease. The United States has the highest maternal and infant mortality rates among comparable developed countries. African American women are dying from preventable pregnancy-related complications at three to four times the rate of non-Hispanic white women. The death rate for Black infants is twice that of infants born to non-Hispanic white mothers. The 2015 Kelly Report documents in great detail the health disparities in America,12 and little, if anything, has changed over time.
Systemic racism is also reflected in the fact that there are disproportionately fewer Black physicians than white physicians in the United States. Although more than 13% of the U.S. population self-identify as Black or African American,13 only 5% of physicians so self-identify.14 This disparity exists for a variety of reasons. On the supply side, for example, there is a long history of medical schools actively excluding and discriminating against Black students. In 2009, the Liaison Committee on Medical Education introduced pro-diversity accreditation guidelines. Data show that from 2002 to 2017 Black and other ethnic minority applicants and matriculants to medical schools of both sexes were underrepresented, with a significant trend toward decreased representation for Black female applicants from 2002 to 2012.15 This decline in Black male medical school applicants and matriculants to medical schools occurred in spite of more Black men graduating from college. Without Black medical students, you can’t have Black physicians.
In order to understand and empathize with the experience of Black physicians, it is important to hear their voices. Following medical school, Black physicians may experience job-related discrimination. Typically, systemic or institutional protections are lacking, and they may be left to endure humiliating, hurtful acts of discrimination on their own, without collegial or institutional support. Damon Tweedy, MD, in his book, “Black Man in a White Coat,”16 relayed his experience as a Black physician, beginning with medical school, describing what it is like for Black patients to live in a medical system that only looks at them through a white lens — a lens of discrimination.
In an article published by the Association of American Medical Colleges, Kali Cyrus, a Black female academic physician, explained why “I gave up my dream of leading diversity efforts in medicine”:17
“[Despite many accomplishments,] I often felt overwhelmed and unsupported…I felt terribly alone. So few of my colleagues shared my identites: I’m a Black, queer woman, and many of them were White men… As long as the culture discouraged asking for help, didn’t fully value those who focus on innovative diversity education, and failed to provide sufficient support to minority faculty, I would never feel truly safe. I knew members of my medical community appreciated my work, but unless they intended to use their privilege to prevent Black and brown faculty from leaving, it was not worth it to stay… Meanwhile, I find myself hoping for progress in academic medicine, though I’m not completely optimistic. Senior physician-leaders of most academic communities continue to look the same, unlike the rest of the United States, which is becoming increasingly diverse… But, medical schools and teaching hospitals need to do much more to create a culture of inclusivity at every level across the entire institution.”
What Relevance Does Racism Have to State Medical Boards and the FSMB?
Racial and ethnic minority individuals are typically underrepresented in the power structure of medical organizations, including regulatory organizations. Their voices are often not solicited. This absence of their voices undermines trust. Given the historical record of discrimination and even exploitation and abuse of Black people and the relative absence of Black people in the controlling organizations and power structures, can racial and ethnic minority physicians who are under investigation trust that they will be dealt with fairly? Also, can racial and minority complainants trust that investigation of their issues will acknowledge racism when it occurs? Even further, do racial and ethnic minority individuals avoid making complaints because of mistrust that their complaints will be dealt with fairly? Are topics of racial and ethnic bias adequately addressed in the medical education process, including continuing education? Is there bias against Black individuals in medical school admission, internship and residency processes? Is there bias in qualifying test instruments? Unless these types of issues are addressed and realistic data generated, important questions remain unanswered, and discrimination remains invisible and perpetuated.
What is Implicit Bias?
Bias represents a preferential, rather than neutral, attitude or belief toward a person or group of people. Although bias can be positive, bias typically implies a negative attitude or belief. It can manifest verbally or non-verbally through acts of commission or omission.
When bias is unconscious or outside of conscious awareness, it is referred to as “implicit bias.” It affects communications and actions toward others. Even the most well-intentioned individuals can harbor subconscious negative stereotypes and assumptions about race and ethnicity.
Bias can be expressed by any of the stakeholders in the medical system, including providers and institutions — medical schools, postgraduate training programs, professional medical organizations, hospitals and other health care delivery organizations, insurers, accrediting bodies, medical boards, regulatory entities and legislators.
What Effect Does Bias Have on Patient Care?
For several decades, inequities in health for racial and ethnic minorities have been documented in great detail at the national level. Racial prejudice and discrimination, complexly caused and manifested at many levels, have resulted in inequities, and they continue to be barriers to implementing change. The following are a few examples of government sponsored reports documenting ethnic and racial disparities in health care:
In 1985, the U.S. Department of Health and Human Services Office of Minority Health released the Report of the Secretary’s Task Force on Black and Minority Health (the Heckler Report). 18 The eight-volume report recommended a national agenda for improving minority health.
In 2003, the Institute of Medicine, mandated by Congress, published a report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.”19 Its multidisciplinary panel of experts concluded that, even when access-to-care barriers are controlled for, racial and ethnic minorities received worse health care than non-minorities: “Stereotyping, biases [both explicit and implicit] and uncertainty on the part of healthcare providers can all contribute to unequal treatment.” The report noted that white clinicians who did not believe they are prejudiced “typically demonstrate unconscious implicit negative racial attitudes and stereotypes.” The report stirred controversy in the medical community and prompted additional research documenting disparities in health care.
In 2018, fifteen years after the Institute of Medicine study, the National Healthcare Quality and Disparities Report documented that Black and other racial and ethnic minorities continued to receive poorer care than white patients on 40% of the quality measures, with little to no improvement from decades past.20
Although racial and ethnic disparities in health care for many conditions have been well documented, uncovering the reasons for the disparities can be difficult. The reasons are complex and can relate to any of the following: evaluating individual patient-doctor relationships based on race concordance versus discordance because of the low percentage of Black physicians; Black patients’ mistrust of the medical establishment to safeguard their best interests and protect them from exploitation; and systemic issues, such as insufficient numbers of Black physicians and racism in the larger culture in which we live. Much needed research can be hampered and limited by these and other factors, such as the difficulty of finding funding resources, small sample-sizes that make it difficult to control for variables, and differences in research study designs and methodologies that make it difficult to compare findings and reach firm conclusions.
Despite these limitations, there are studies worthy of note that document the impact of both conscious and implicit bias on the care of ethnic and racial minorities.
The attitudes and behaviors of health care providers have been identified as two of many factors that contribute to health disparities. In a systematic review,21 authors Chloë FitzGerald and Samia Hurst found that “Implicit biases have been identified as one possible factor in healthcare disparities and our review reveals that they are likely to have a negative impact on patients from stigmatized groups.”
Implicit bias in pain assessment and management has been the subject of several studies. Racial minorities and women are less likely to receive accurate diagnoses and appropriate pain management, leading to worse clinical outcomes. 22 In a study by Hoffman et al.,23 half of a sample of white medical students and residents endorsed false beliefs about biological differences based on race (Black compared to white). Participants who endorsed these beliefs rated the pain of Black patients as lower than white patients and made less accurate treatment recommendations. The authors cite other studies that show that “relative to white patients, black patients are less likely to be given pain medications, and, if given pain medications, they receive lower quantities.”24 Additional research to uncover the cause of racially based false beliefs could help point to remedies.
Another factor that affects disparities in health care is Black patient underutilization of medical services because of mistrust of the white medical establishment. The Conference on Addressing Medical Mistrust in Black Communities published an extensive bibliography of “Reviews, Definitions, and Context and Origins of General Medical Mistrust.”25 Mistrust has been fueled by a long history of neglect, exploitation, and abuse of Black people by the white medical establishment, which is discussed in Appendix I of this article. Mistrust of the medical profession is further reinforced when discrimination and abuses occur as part of American culture — in law enforcement practices, the criminal justice system and voter suppression.
Despite extensive published documentation of racial and ethnic disparities in health care, change has been slow in correcting racism in medicine. With recent heightened public awareness through the news media focused on police brutality, inequities in the criminal justice system and voter suppression, there is increased momentum to support positive change in all institutions of our society, including in medicine.
How Effective is Implicit Bias Training?
Bias, whether implicit or explicit, is a habit that can be overcome with motivation, awareness and effort. Because implicit bias is unconscious, individuals need to be trained to recognize it in themselves, and institutions need to be restructured to include minority individuals and their perspectives.
Implicit bias training is one type of cultural competency training. Implicit bias training includes experiential and educational components, helping participants identify their own biases and recognize the negative impact those biases can have on others. It is in the nature of human beings to develop biases. No one is immune to biases, even those who hold to egalitarian goals of fairness and equality. Stating this as part of training can help reduce defensiveness.
Effective training requires ongoing participation in training sessions, data collection and assessments to determine effectiveness. Many medical schools and hospitals have incorporated cultural competency into their training.
There are mixed opinions about the effectiveness of cultural competence programs. One systematic review of the literature26 found that: “Cultural competence training is an effective intervention that enables healthcare providers to give culturally competent care that increases satisfaction of patients from minority groups.” Another systematic review, by Renzaho et al.,27 concluded: “Although the programs may increase practitioner knowledge and awareness, there is no evidence that this translates to improved patient health.” However, there is a problem in evaluating such contradictory conclusions due to the “lack of patient health outcome measures in the majority of studies.”28 The authors also found that participants undertaking training may have differing values and attitudes that affect their receptivity to learning and making changes. The spectrum can range from those who hold humanistic values and are receptive to learning to those who hold deeply ingrained white supremacist values. The authors acknowledged: “More research is, thus, required to properly examine the impact, if any, of CC [cultural competence] PCC [patient-centered care] models on health outcomes.”29 When devising and evaluating educational programs, there is likely no one-size-fits-all approach, given the range of receptivity versus resistance among participants.
A good example of positive results from implicit bias training comes from the experience of the Ohio State University College of Medicine (OSUCOM). The admissions committee members were aided in recognizing their implicit bias and that translated into acceptance of greater numbers of racial and ethnic minority students. Results from the Implicit Association Test (IAT) revealed that all groups within the admissions committee displayed significant levels of implicit white preference, with men and faculty having the largest bias and women and students less bias. Most survey respondents thought the IAT might be helpful in reducing bias. Approximately half were conscious of their individual bias results when interviewing candidates in the next admissions cycle, and approximately 20% reported that knowledge of their IAT results impacted their decisions in the subsequent admissions cycle. A summary of OSUCOM’s IAT activity noted: “The class that matriculated following the IAT exercise was the most diverse in the OSUCOM’s history.”30
Requiring organizations to self-evaluate bias at an institutional level can help them apply the best findings and interventions to create inclusive cultures. This has been the experience of the Washington Medical Commission, a state medical board whose efforts are noted below. The American Surgical Association has published organizational survey and self-assessment tools that can be useful to any organization. (See details in Appendix II.)
What Steps are Regulatory Bodies Taking to Address Implicit Bias and Racism?
Increasingly, regulatory bodies are recognizing the need to proactively address racism in order to ensure adequate care to minorities. According to the Washington Medical Commission, key steps in addressing racism in regulatory organizations include the following:31
Accept that there is a problem.
Acknowledge our role in continuing the systems that produce these outcomes.
Use our position and privilege to change the systems to serve all people.
As with medical error, we should recognize and apologize when our efforts to effect positive change do not have the desired impacts.
In 2020, the Commission published a formal statement: “Racism in all of its forms is a public health issue.”32 The Commission acknowledged its own role in a system that has produced biased outcomes, and it committed to using its position of authority and privilege to change its system to serve all people. Dismantling racism requires remedies at all levels of the organization, which the Commission addressed through a series of action steps:
All commissioners now receive implicit bias training.
The Commission created a multidisciplinary Health Equity Advisory Committee comprised of clinicians, faculty, administrators, students, community and system leaders. This Committee is tasked with reviewing the Medical Commission’s policies and procedures to ensure equity for all patients regardless of race, ethnicity, language, religion, age, spiritual practice, sexual orientation and gender identity.
The principle of equity has also been applied to staff hiring processes.
The Commission seeks to address systemic racism in the health care system, from medical school and residency to practice, including patient safety.
The Commission established a Healthcare Disparities Workgroup with a specific focus on maternal mortality, breast cancer, heart disease, and pain assessment, noting that data show a disproportion of morbidity and mortality from these conditions among persons of color.
To minimize the effect of implicit bias in disciplinary actions, the Commission has incorporated policies and methods to make its disciplinary proceedings fair and equitable — without bias toward individual physicians because of race and other demographics.
The Commission has instituted practices that level the playing field in addressing complaints against practitioners. Complaint summary documents that come before the Commission no longer list the complainant’s name, the name of the physician against whom the complaint is filed, or any other information that may introduce bias into the complaint review process.
With these actions, the Washington Medical Commission has not only acknowledged the need for decisions to be fair, based on merit and without bias, but it has also taken steps to ensure equity. The Commission’s work is laudable and can serve as a role model for other regulatory bodies to make changes.
Examples of actions taken by other states include the following:
Beginning in 2022, Michigan will require any new medical health care provider to undergo implicit bias training as a condition of medical licensure.33 In Michigan, reported cases of COVID-19 have been three times higher among the Black population than among white people. Although 14% of Michigan’s population is Black, 40% of confirmed deaths were among Black patients. The Michigan Coronavirus Task Force on Racial Disparities recognizes that “By providing awareness to health care workers on how to recognize and mitigate implicit bias, we can help them carry out their mission of providing the best health care to every patient they serve.”34
California law stipulates that a physician “is required to demonstrate satisfaction of continuing education requirements, including cultural and linguistic competency in the practice of medicine.” As of January 2022, the curriculum of all continuing medical education (CME) must include “specified instruction in the understanding of implicit bias in medical treatment.”35
Noting disparities in health care among population groups, the Oregon Medical Board published “Cultural Competency: A Practical Guide for Medical Professionals.” The Board encourages physicians “to provide care that is increasingly culturally responsive.”36 Beginning in July 2021, cultural competency continuing education became a condition of re-licensure (Oregon HB 2011). Also, Oregon requires health professional regulatory boards to “establish programs to increase the representation of people of color and bilingual people on the boards in in the professions that they regulate…” 37
By taking actions such as these, state boards are increasingly making explicit public demonstrations of their commitment to reducing inequity. Such actions can carry significant weight in helping raise awareness and can influence other organizations to take similar steps. Examples of public commitments by others, aimed at admitting to issues of racial inequity and improving conditions, are included in Appendix II.
What Can Regulatory Bodies Do to Promote Diversity Within Their Own Membership?
A concerted system-wide effort to combat racism and promote diversity is necessary in order to create a more just and equitable medical culture for minorities. Regulatory bodies, as one part of a larger medical system, need to embrace diversity in their power structures and in their dealings with racial and ethnic minority physicians and health care workers. Organizations — and their leaders — that have the most power and influence must lead by example to root out negative racial biases; i.e., not only “do as I say,” but also “do as I do.”
Eight Guiding Questions
The following eight questions are important for regulatory bodies, including the FSMB and medical boards, to address as they seek to embrace diversity and include racial and ethnic minority voices in their organizations:
Are members of racial and ethnic minority groups represented on the medical board?
Are members of racial and ethnic minority groups represented among staff and investigators of the medical board?
Does the board require ongoing training about diversity, cultural competence and implicit bias for board members, staff and investigators?
Does the board require ongoing training about diversity, cultural competence and implicit bias as a requirement for licensees?
Do the board’s mission statement and website embrace fairness and justice toward ethnic and racial minorities and their issues?
Do the board’s regulations, policies and procedures consider the needs of racial and ethnic minority groups?
Does the board influence lawmakers to enact legislation that addresses racial and ethnic minority needs?
Are there mechanisms in place to measure disciplinary disparity outcomes and the effectiveness of efforts to achieve fair outcomes?
What Role Can the FSMB Play in Influencing State Medical Boards to Embrace a Diversity Agenda?
The FSMB can play a leadership role, alone and in collaboration with other stakeholders, to influence state medical and osteopathic boards to promote diversity, equity and inclusion of Black physicians, physician assistants and other health providers in the medical profession. This is consistent with the FSMB’s mission to lead, assist and support state boards in providing physicians and other health care professionals with continuing medical education activities that bear on medical regulation, licensure, discipline, advocacy and policy in order to promote public health, safety and welfare. It should be noted that the FSMB launched a new, formal Workgroup on Diversity, Equity and Inclusion in Medical Regulation and Patient Care in 2021.
Examples of questions and issues that could be addressed as the medical regulatory community advances a diversity agenda include the following:
What impediments exist that discourage Black individuals from applying to medical schools and entering the medical profession?
What needs to occur so that Black physicians are respected and included as equal members of the profession, not marginalized or discouraged from meaningful participation? What can be done to protect them from acts of discrimination?
What can be done to promote more Black physicians to positions of influence and authority in medical organizations and establishments?
What policies and procedures can be developed so as not to discriminate against Black physicians in disciplinary proceedings?
What can be done to ensure that Black patients are treated fairly and with respect and to protect them from exploitation?
What are the best ways to help white physicians understand and empathize with the experiences of Black physicians and Black patients?
What are the best ways to develop cultural competency? For example, how can programs such as implicit bias training programs most effectively address racism among physicians, taking into account the range of attitudes from overt prejudice to pro-diversity?
What are the best ways to measure the effectiveness of such programs and to utilize results to improve program content and delivery?
What Ethical Principles Can Guide Corrective Practices?
Moving forward, important ethical principles can guide our system toward diversity, equity and inclusion for all persons regardless of race, ethnicity, religion, sex and other factors.
Living the age-old principle of the “Golden Rule”— treating all people the way you want to be treated, with dignity, kindness and fairness — is a good place for all of us to start.
We can empathize with situations faced by racial and ethnic minorities. One way to do so is by learning the history of racism and its impact on attitudes and values of both Black people and white people in the present. According to Thomas Jefferson, “No people who are ignorant [uninformed] can be truly free.”
We can embrace diversity, thinking about how we all are different from each other in some ways. This includes valuing our differences and accepting our shared humanity. In so many ways, we are the same. Inside, we all have feelings and basic survival needs.
We should all make an effort to practice democracy and its emphasis on liberty and justice for everyone. The society in which we live should ensure inclusion of all its members, not just in words but also in real actions.
At every turn, the effort must be made to include ethnic and racial minority voices. Understand racial and ethnic minority issues and needs from the viewpoint of minorities. Include the voices of racial and ethnic minority individuals at the decision-making table.
These guidelines are consistent with accepted medical sources and authorities. The Hippocratic Oath asks practitioners to never harm others because life is sacred, to soothe the pain of anyone who is in need and to never betray them or risk their well-being. The guidelines are consistent with Accreditation Council for Graduate Medical Education (ACGME) Core Competencies that expect physician residents to demonstrate patient care that is compassionate; effective interpersonal and communication skills with others across a broad range of socioeconomic and cultural backgrounds; professionalism in the form of compassion, integrity, and respect for others and sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion and other factors. Violation of these ethics is obvious when reviewing the history of racial relations in medicine.
Living according to these virtues is easier said than done. Relinquishing the status quo in favor of diversity can be challenging for those already in positions of power. White supremacy is alive and well in many segments of American society, and it does not support application of these ethical principles to Black and other minority groups. Trust is easily broken and difficult to earn, especially when it has been repeatedly undermined since the founding of America. Gaining the trust of racial and ethnic minorities requires more than lip-service but real action that embraces these ethical guidelines and is sustained over time.
Summary and Conclusions
Racism is a deeply ingrained feature that impacts a wide range of American institutions, including the medical establishment. Corrective efforts need to address diversity, equity and inclusion for Black physicians and Black patients — both as individuals as well as communities. Eight questions are posed for the FSMB and medical board self-assessments to uncover racist practices and promote positive changes within their organizations. In addition, the FSMB can assist medical boards to create a medical culture that encourages Black individuals to enter the profession, rather than one that discriminates against them. The recent launch of the FSMB’s Workgroup on Diversity, Equity and Inclusion in Medical Regulation and Patient Care is an encouraging step towards promoting an agenda of racial and ethnic diversity.
Rooting out racism is the right thing to do. It is a call for action — now. Doing so is a matter of conscience. Although recognition of disparities in health care has been well documented, constructive change has been slow to occur. Some medical boards that have already begun to institute constructive change can serve as role models to help others ensure fairness in their regulatory activities. Positive steps are being taken, but there is much more work to be done.
On the one hand, expecting quick, easy solutions to longstanding, complex, deeply ingrained systemic problems is unrealistic. On the other hand, delays and small changes can be frustrating to those who bear the brunt of discrimination. Small steps that seem positive to the white majority can be experienced as token efforts to the Black community.
According to Ortega and Roby, “Ending structural racism and inequities in the U.S. health care system has proved to be a challenge. What has become clear is that there needs to be much more intensified and multifaceted approaches that by necessity will require a much larger and committed investment in research, training, clinic[al] practice, and community engagement.”38
Preface: Why is History Important?
Knowledge of this history is essential for understanding and creating positive change. Otherwise, as noted by George Santayana, “Those who cannot remember the past are condemned to repeat it.” Knowing one’s heritage is part of one’s identity. Knowing another person’s heritage — family and racial identities — allows us to understand and empathize with them. Systems that minimize, distort and deny history undermine that process. Omitting factual history about racism makes it difficult for white people to understand their white privilege and the oppression of Black people as individuals and as a group. Without factual information, it is difficult for white people to empathize with the experiences of Black people — to appreciate that the Black voice is largely absent in the medical profession; to recognize exploitation of Black people in government-sponsored medical experiments; to appreciate Black people’s distrust of the white medical establishment and the reasons for it. Omitting the historical record can result in Black people feeling ignored, discounted and unprotected from ongoing abuses.
The appendices included here are intended to provide some details about racism in the medical community and efforts to address that racism.
There is a need to include information about racial and ethnic racism and how bias can impact the medical education curriculum and continuing education processes used by medical boards. Because racial and ethnic minority group perspectives and needs have not traditionally been part of their education and training, health care professionals are relatively uninformed about those perspectives and needs. Those who are uninformed can develop biases that negatively affect patient care. Although some physicians may be influenced by humanistic concerns of fairness alone, they can be enlightened by knowing the history of Black/white race relations. The appendices provide examples of factual information that should be included in the educational curriculum in order to inform physicians about the nature and extent of medical racism.
Appendix I: Historical Examples of Racism in The Medical Profession
The following are just a few examples of discrimination and abuse of Black people by the medical profession.
Racial theories of disease. In 1851 prior to the Civil War, Dr. Samuel Cartwright, under the aegis of the Medical Association of Louisiana, published his theories about diseases peculiar to the “negro race,” both enslaved and free. His work reflects the deep-seated belief that Black people were, by nature, inferior and best kept in slavery — a culturally sanctioned viewpoint shared by many lay and well-educated whites, especially in the south. According to Cartwright, “drapetomania” was a mental disease that caused slaves to run away and become free; it manifested as “rascality,” a disease that made slaves commit petty offenses. “Dysaesthesia aethiopica” made slaves “insensible and indifferent to punishment.” In the case of slaves becoming “sulky and dissatisfied without cause”— a warning sign of imminent flight — Cartwright prescribed “whipping the devil out of them” as a “preventive measure.” As a remedy for this mental disease, doctors made running away a physical impossibility by prescribing the removal of both big toes.39
Cartwright’s pseudoscience served as a foundation for scientific racism. The impact at the time and its subsequent legacy should not be underestimated. According to Nancy Krieger,40 “Exemplifying the political salience of scientific racism was the inclusion of an essay by Cartwright in the first print edition of the infamous U.S. Supreme Court 1857 Dred Scott decision, which declared that Black Americans ‘had no right which the white man was bound to respect...’” Over a half century later, the third edition (1914) of Thomas Lathrop Stedman’s Practical Medical Dictionary defined “Vagabondage, dromomania; an uncontrollable or insane impulsion to wander.”41
Tuskegee medical experiment. The U.S. government-sponsored Tuskegee medical experiment (from 1932 to 1972) studied the natural course of untreated syphilis in poor Black males without informing them of their diagnosis and withholding treatments, including in the era of penicillin. Failure to treat them resulted in unnecessary suffering, premature death and unwittingly infecting others.42 When questioned, the government officials and the physicians conducting the study attempted to cover over the abuses and rationalized the study. None of the physicians were ever disciplined or sanctioned for their involvement. This experiment significantly contributes to the distrust that Black people have of the medical profession and their reluctance to seek medical care. It is important to note the Tuskegee experiment on Black individuals is just one of many abuses of Black people in medicine. Harriet Washington references misuse of Black people for surgical experiments, plutonium radiation experiments of African Americans, research on Black prisoners and research targeting young African Americans.43
The eugenics movement. The eugenics movement during the twentieth century fostered racist practices in the United States. Racial disparities in illnesses were considered to be due to the biological inferiority of the Black race, without consideration of sociocultural determinants that shape health and illness. Many prominent individuals endorsed the idea of improving the human population by selecting for those with “superior” traits and reducing the reproduction of those with “negative” traits.
Influenced by eugenics ideas, the government (U.S. and state) sponsored involuntary medical sterilization of “undesirables,” mainly involving persons of color. Thirty-two states passed eugenic-sterilization laws during the twentieth century, and between 60,000 and 70,000 people were sterilized under them.44
Eugenics practices in the United States began prior to those of Nazi Germany, and they continued after the post-WWII Nuremberg Tribunal that condemned Nazi physician involvement in involuntary experimentation on human beings as crimes against humanity. The 1947 Nuremberg Code, spearheaded by the United Sates, was put forth as a standard to protect human subjects. The ethical principles about the use of humans in experiments that arose in the course of the Tribunal proceedings are laudable, but they have not been followed by the U.S. government in its treatment of Black and other racial and ethnic minority citizens in the United States. Racist eugenics policies and actions help explain why many Black patients mistrust a medical system dominated by whites.
The Flexner Report. Standards set by the Flexner Report (1910) resulted in the closing of many medical training institutions for Black people.45 In the latter part of the nineteenth century and early twentieth century, Black physicians helped to establish institutions where Black patients could obtain medical care and Black people could be trained to become physicians. The values expressed in the report were not only in line with the “separate but equal” 1896 decision of the Supreme Court (Plessy v. Ferguson) that legitimated segregation but also supported an elitist white superiority agenda consistent with mainstream values of the day, especially in the south. The Flexner Report recommendations were intended to elevate the medical profession by setting high-quality standards for the education and training of physicians. Meeting these standards required costly resources that most Black training facilities could not meet. The report proposed “development of the requisite number of properly supported institutions and the speedy demise of all others.”46 As a result, only Howard University College of Medicine and Meharry Medical College continued to exist. The other Black medical schools became defunct. Some white schools in the north admitted Black students but few in number, and Black students were denied admission to many other schools. Despite the establishment of two additional Black medical schools — Charles R. Drew Medical School (founded in 1966) and Moorehouse School of Medicine (founded in 1975) — the legacy of the Flexner Report continues up to the present with an underrepresentation of Black physicians in the medical profession and a too-common attitude of prejudice toward Black physicians who are in the profession.
AMA membership exclusions. Through its policies and practices, the American Medical Association excluded Black physicians from its membership for many years. In 1895, Black physicians formed their own medical organization, the National Medical Association.
These are just a few examples of medical racism. Harriet Washington provides abundant examples in her book “Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present.”47
Appendix II: Examples of Efforts to Address Racism in the Medical Profession
Credit is due to those entities that acknowledge their role in racism and offer to do better in the future. Some examples include the following:
Tuskegee apology. In 1997, President Clinton issued a formal apology acknowledging the government’s betrayal of the Black men who were subjects in the Tuskegee experiment. “The United States government did something that was wrong — deeply, profoundly, morally wrong,” he said. President Clinton proposed measures to protect African Americans from future abuses.48
Reparations for sterilizations. Some states passed legislation to pay reparations to victims of forced sterilizations. For example, North Carolina and Virginia paid monies to some of the surviving victims of eugenics sterilization programs.49 In contrast, California has not offered reparations, despite approximately 20,000 sterilizations having been conducted in the state. In 2014, California banned coerced sterilizations as means of birth control in prisons.50
Cultural competency. The U.S. Department of Health and Human Services has published core concepts and principles of cultural and linguistic competence in health care. “Think Cultural Health” is a program that provides information to health care professionals.51 There is a separate program for behavioral health professionals.
National Institute on Minority Health and Health Disparities. In 2010, the National Institute on Minority Health and Health Disparities (NCMHD) was designated as an institute of the National Institutes of Health (NIH) with a charge to eliminate inequities in health and health care.
AMA apology and new focus on equity. In 2008, Dr. Ronald Davis, as President of the American Medical Association (AMA), formally apologized for more than a century of AMA policies that excluded African American physicians from the AMA. The AMA pledged to “do everything in our power to right the wrongs that were done by our organization to African-American physicians and their families and their patients.”52 The AMA pledged to make changes to include Black physicians as equals.
The AMA House of Delegates has prioritized the elimination of racial and ethnic disparities as of top importance. Launched in 2019, the new AMA Center for Health Equity has a mandate to embed health equity across the organization so that equity becomes a part of the AMA’s practice, process, action, innovation and organizational performance and outcomes.
AAMC and NMA partnership. In August 2020, the Association of American Medical Colleges (AAMC) and the National Medical Association (NMA) announced a joint effort to convene an Action Collaborative that will address the lack of representation of African Americans in medicine.53
ACGME Equity Matters. In 2021, the Accreditation Council for Graduate Medical Education (ACGME) announced “ACGME Equity Matters,” a new initiative that introduces a framework for continuous learning and process improvement in the areas of diversity, equity and inclusion and anti-racism practices. The initiative aims to drive change within graduate medical education by increasing physician workforce diversity and building safe and inclusive learning environments, while promoting health equity by addressing racial disparities in health care and overall population health.54
Academic efforts. Academic institutions, prestigious journals and professional associations have taken strong stands to promote diversity, equity and inclusion. For example, the American Surgical Association produced a handbook titled “Ensuring Equity, Diversity, and Inclusion in Academic Surgery.”55 The handbook “identifies issues and challenges and develops a set of solutions and benchmarks to aid the academic surgical community in achieving these goals.” According to the Association, “Surgery must identify areas for improvement and work iteratively to address and correct past deficiencies. This requires honest and ongoing identification and correction of implicit and explicit biases. Increasing diversity in our departments, residencies, and universities will improve patient care, enhance productivity, augment community connections, and achieve our most fundamental ambition — doing good for our patients.” The 77-page document includes useful resource-assessment tools in its appendices:
Employee/Faculty/Staff Survey to Evaluate Diversity
Organizational Diversity, Inclusion, and Equity — A Self-Assessment Tool
Tool for Recognizing Microaggressions and the Messages They Send
Negative Acts Questionnaire