A qualitative study to explore experiences of anti-racism teaching in medical residency programs across the United States and subsequent creation of the SPOC (Support - Pipeline - Outcomes - Community) Model to guide future curricula design

Abstract

Background

Racism contributes to health disparities and is a serious threat to public health. Teaching physicians about racism, how to address it in medical practice, and developing high quality and sustainable curricula are essential to combating racism.

Objective

This study aimed to (1) describe the experience of racism and anti-racism teaching in residency programs, and elicit recommendations from key informants, and (2) use these data and formative research to develop recommendations for other residencies creating, implementing, and evaluating anti-racism curricula in their own programs.

Methods

From May to July 2023, 20 faculty and residents were recruited via convenience sampling for key informant interviews conducted via Microsoft Teams. Interviews were audio recorded, transcribed, and coded. An initial list of themes was developed using theoretical frameworks, and then refined using a grounded-theory approach. A brief online optional anonymous demographic survey was sent to participants in August of 2023. 

Results

Eighty percent (20/25) of participants approached were interviewed. Seventy-five percent (15/20) answered a brief optional demographic survey. Seven themes emerged: (1) Racism in medicine is ubiquitous; (2) Anti-racism teaching in medicine varies widely; (3) Sustainability strategies should be multifaceted and include recruitment, resource allocation, and outcome measures; (4) Resources are widely available and accessible if one knows where to look; (5) Outcomes and metrics of success should include resident- faculty-, patient- community-, and system-focused outcomes; (6) Curricular strategies should be multilayered, longitudinal, and woven into the curriculum; and (7) Self-reflection and discomfort are necessary parts of the process. 

Conclusions

This study is one of the first to qualitatively examine perspectives of key stakeholders invested in anti-racism teaching for residents. The Support - Pipeline - Outcomes - Community (SPOC) Model, that was developed using information collected during this study, can be used in the future as a guide for others working to design and implement sustainable and high quality anti-racism curricula for residents.

Introduction

There is no question that racism contributes to differences in health outcomes between different populations and is, therefore, a serious threat to public health [1]. Inequities among different racial groups in the United States are well documented [1,2,3]. Teaching physicians about racism, learning how to address it within the practice of medicine, and developing sustainable and high quality curricula to do so are key.

Published literature describing anti-racism curricula in residency programs and particularly in primary care programs is growing but still lacking in many respects including data on how to ensure the sustainability and quality of such programs [4, 5]. Curricula that have been described in the peer-reviewed literature include those describing curricular strategies such as lecture series, longitudinal experiences, increasing resident/student knowledge, improving attitudes, decreasing implicit bias, and increasing diversity of residents and staff [6,7,8,9,10,11].

Although health disparities teaching is now required in family medicine residency programs, it is unclear if and how anti-racism teaching, specifically, is taking place and whether it is effective [12]. Of the small number of social determinants of health post-graduate medical education curricula that exist and are described in the literature, the vast majority do not focus on sustainability or continuous quality improvement efforts [13, 14]. Most reports focus on descriptions of the curricula, evaluation of the curricula and/or residents, and faculty perceptions of and experiences with the curriculum [12]. Similarly, there is a dearth of qualitative research exploring program directors’ and residents’ perspectives of racism and anti-racism teaching in various programs. Finally, few studies have included descriptions of patient-oriented outcomes, which is understandable given the difficulty in demonstrating causation. For example, it is difficult (but not impossible [15]) to design a study that provides evidence that medical students or residents who were included in a curriculum designed to improve empathy, actually went on to care for patients who lived longer due to their chronic diseases being better controlled because of improvements in their providers’ empathy skills [16, 17].

This study aimed to use qualitative data gathered via key informant interviews and formative research to explore approaches to developing a sustainable, and high quality anti-racism curriculum for residency programs in the U.S. Findings from the interviews were used to inform development of a model that programs can utilize as a roadmap or guide when creating, implementing, evaluating, and sustaining and high quality anti-racism curricula in their own programs.

Methods

Conceptual framework and model development

The Consolidated Framework for Sustainability Model [4] and Deming’s Theory of Quality Improvement [18] were used to guide the creation of the interview questions and probes. A modified grounded theory approach was used to create an initial list of themes, which was then built upon as the transcripts were coded. Using the Consolidated Framework for Implementation Research (CFIR) [19, 20], the themes and sub-themes were then organized to develop a model for development of anti-racism curricula for physicians in training.

Instrument development

A semi-structured interview guide was developed based on the research aims and the theoretical frameworks described above. Questions were designed to elicit participants' perceptions and experiences with racism in medicine, anti-racism teaching in medicine, and curricular development for residency programs. A brief optional, anonymous demographics survey was emailed to participants to complete after the interviews. The in-depth interview guide is shown in Table 1.

Table 1 Questions from in-depth key informant interviews designed to capture experiences of racism in medicine, anti-racism teaching in medicine, and elicit recommendations for strategies to improve and sustain anti-racism curricula

Sampling and recruitment

A convenience sampling technique was used for recruitment. Participants included faculty and prior residents from across the U.S. from multiple specialties, who had either thought about or been involved in designing, implementing, and evaluating anti-racism curricula in their own institutions. We included not only faculty but also residents and former residents who had been the recipients of such efforts or lack therof. Subjects were recruited via emails, texts, or in person conversations. Participants were chosen based on prior knowledge or pre-existing interest, experience, and/or expertise in the area of study, and the lead author’s or colleagues recommendations. Participants were invited to interview until theoretical redundancy was reached. Inclusion criteria were (1) adults age 18 years or older who (2) worked at a residency program, were current residents, or had previously been a resident in a residency program in the U.S. No incentives were provided. Participation was voluntary. Verbal informed consent was obtained from participants prior to involvement in the study. A concerted effort was made to ensure that at a minimum half of all participants were those who identified as under-represented minorities.

Data collection and analysis

The lead author with expertise in public health, clinical care, and medical education utilized the in-depth interview guide to conduct, record, and transcribe the interviews via Microsoft Teams from May to July 2023. Interviews lasted on average approximately 40 minutes (range 20 minutes to 2.5 hours). Transcriptions were de-identified and saved in Microsoft Word and then collated and coded in Microsoft Excel. A brief online optional anonymous demographic survey was sent in August of 2023 to participants who completed the interviews. Data from the in-depth interviews were analyzed using coding and thematic analysis. AMG developed the initial list of questions and themes; JB, MS, and MV reviewed and provided feedback. AMG then conducted and transcribed the interviews using the updated questions. Prompts were updated to include subthemes that arose during previous interviews. Coding was initially conducted by AMG with review and adjustment by MS and JB. Themes, sub-themes, and representative quotes were initially compiled by AMG with input and adjustment based on feedback from MS, JB, DT, and AT. AMG developed the SPOC model (described below) and refined it based on feedback from all of the other authors. The final list of themes and the model were reviewed, updated, and approved by all authors.

Results

Of 25 potential participants approached, 20 (80%) completed in-depth interviews and 15 of those 20 (75%) completed an additional optional post interview brief demographic survey between May and August of 2023. Interview participants included faculty, current residents, and program directors. Participants included people who self-identified as persons of color, as well as those who self-identified as being part of other minority communities (e.g., religious minorities and sexual minorities). Geographic location of participants also varied but included participants from the East Coast, South, Mid-west, and Western U.S. Details of the demographics for those participants who opted to answer the brief demographic survey questions are shown below in Table 2.

Table 2 Demographics of respondents to in-depth interviews discussing anti-racism curricula for physicians in training, who opted to also complete the brief post-interview, anonymous, online survey

Seven major themes emerged from the interviews and within each major theme, a number of sub-themes emerged. The major themes that emerged were: (1) Racism in medicine is ubiquitous; (2) Anti-racism teaching in medicine varies widely; (3) Sustainability strategies should be multifaceted and include recruitment, resources allocation, and outcome measures; (4) Resources are widely available and accessible if one knows where to find them; (5) Outcomes and metrics of success should include resident- faculty-, patient-, community-, and system-focused outcomes; (6) Curricular strategies should be multilayered, longitudinal, and woven into the curriculum; and (7) Self-reflection and discomfort are necessary parts of the process. 

Major theme 1: experiences of racism in medicine are ubiquitous

Subthemes included in the first major theme regarding ubiquitous experiences of racism in medicine highlighted that everyone has either witnessed and/or experienced racism directed at themselves, their colleagues, and/or their patients. Some have experienced extensive racism and had little recourse. One respondent noted, “I can say that at all stages of my training I experienced racism,” while another recalled, “One of the attendings … asked me about my visa status...” (from someone who was born and raised in the US). Another noted, “I frequently got mistaken for [the one other dark-skinned person in the program]” Another subtheme was that outright racism was not uncommon and ranged from use of the “N word,” to assuming a physician was someone on staff with lesser training such as a student, environmental services staff, transport staff, nurse, or tech. One participant recalled, “One of my attendings … would always wear a suit and he was the only black attending that I can recall in the ICU ... A lot of the other attendings would wear scrubs … and when he was asked by one of my co residents... ‘why do you always wear suits, including on weekends?’, he said, ‘So that people take me seriously.’” Another subtheme was that racism exists on a spectrum ranging from micro-aggressions (in written word, spoken word, and actions and gestures) to structural and systemic racism such as policies and social/cultural “norms.” One respondent noted, “I had an attending who would joke about me being from Africa and [ask] if I swing trees or have pet lions.” Another subtheme that emerged was that racism exists in the medical system in multiple forms including but not limited to race-based medicine and calculators to expectations of outcomes based on race to misguided attempts to address racism. Highlighted here was also the point that racist policies instituted by local, state, or federal government (such as restrictions on use of the words equity and diversity) all the way down to racist clinic policies (such as allowing physicians to refuse to see patients who arrive >10 min late) exist and contribute to the problem. To illustrate this, one responded noted, “There are a lot of things [we could do to improve care for our under-represented minority patients, for example], if patients arrive late, you can accommodate [because] you know they obviously have struggles... a lot of the time [they have] transportation issues or [other barriers] we just don’t know [about].” Several people discussed discrimination based on other characteristics (e.g. sexuality, religion, etc.) and the importance of considering intersectionality in such curricula. Tokenism was also mentioned, and it was noted that often people of color are pushed into equity and anti-racism work even when they may prefer to focus on other things. When they are interested in doing this work, they are often poorly compensated. One participant recalled, “I’ve had promotions announced [and then] people comment that it was smart of my boss to [promote me] because [they could now] ‘check the diversity box.’”

Major theme 2: experience of teaching anti-racism in medicine are variable

Multiple subthemes were elucidated as part of the second major theme exploring experiences of teaching anti-racism in medicine. Multiple participants said they had little to no anti-racism teaching in their own training. Some reported they had a minimal amount, but it was named something else such as “social determinants of health” or “cultural competency.” One participant recalled: “I can remember maybe once or twice where there was some discussion within dermatology specifically about different appearances of rashes on darker skin, and that was the extent of it, though. There was absolutely no discussion of racism specifically or its impacts on health.” Another recalled, “My medical school and residency both had lectures and seminars on cultural competency, [but] I can’t remember anything... like an antiracist curriculum at any point.” One subtheme that emerged here was that the tone for anti-racism teaching is set from the top. System leaders, chairs, faculty/program directors must be an example and set the tone for anti-racism action and teaching. One respondent noted, “I really try to model my own style around those [attendings] that I came to respect very highly … to be able to confront the [racism] issues directly.” Many respondents reported at least attempting to engage in teaching anti-racism in their current practice. Some had very developed curricula; several even reported enacting other anti-racism measures focused on recruitment and retention efforts, and redesigning activities that previously perpetrated implicit bias (such as interview selection rubrics, orientation activities, and even morbidity and mortality (M&M) presentations). Representative quotes describing development of such curricular improvements to address racism included: “The ambulatory attending rounds were not infrequently centered around issues of race and implicit bias.” And “We received a grant ...to create a virtual reality application intended to teach providers about social determinants of health and Health Equity, which is to say also … about racism... I led a team that created [the] exercise ...[that] dropped the user into [an] … under-resourced neighborhood and has them follow a family through six different scenes [describes each scenario]. [Learners are then] assigned to look for help assets and health risks within the setting.” Participants reported in their current programs, having a number of activities aimed at educating residents about equity including didactics, interactive sessions, case-based learning poverty simulations, outside consultants, and support groups for underrepresented minorities (URMs). Finally, a few respondents noted that their programs really emphasized collaboration with the community and having community representation.

Major theme 3: sustainability considerations for anti-racism curricula should focus on recruitment & retention, resources, and systemic changes

Subthemes noted within the third major theme of sustainability efforts included the importance of integrating anti-racism outcome measures into credentialing, accreditation, and other metrics needed for individual or program success (such USMLE, MCAT, specialty board exam questions, ACGME core competency, and hospital equity scores tied to grant funding). Representative quotes highlighted the importance of having “measurable outcomes in the population that residents treat, [including things like] satisfaction scores.” One respondent said, “Every ACGME accredited program has specific milestones that … are connected to EIDA... I would like to see that happen on a specialty-specific basis. I would like to see that at the ACGME level, it’s happening through the clinical learning environment review. Healthcare disparities are there as part of healthcare quality but don’t really have teeth behind them. So, to make it an ACGME requirement, to really add in that language in the different core competencies, would be something that could be really powerful.” Another commented, “I think there should be anti-racist and implicit bias [criteria included in] how medical students are evaluated. … [and] when you apply to medical school, it should be part of the screening... it ought to be as important as all the other things that you screen for.” Another subtheme that emerged in the sustainability category highlighted the importance of ensuring all lecture topics covered during residency include teaching points on equity and anti-racism. One respondent said anti-racism should be “...more integrated in every topic, every talk... if we’re talking about communication, [we mention] cultural humility. If we’re talking about heart failure, [we note] healthcare disparities in this area. So it is really woven into everything that we’re doing instead of set aside as its own topic.” Ensuring dedicated staff, with protected and compensated time, are in charge of leading the effort, while also ensuring buy-in and an ownership feeling by all, was another subtheme articulated. Participants said, “[You] not only need funding, but [also] to have a strong commitment.” And that “having that ownership and pride from the people higher up is paramount.” The significance of finding and ensuring ongoing and permanent resources and support are present and sharing training opportunities across the system was also highlighted. Interviewees noted, “[Programs should capitalize on] any ways in which you can combine forces, because obviously these concepts are transdisciplinary, so there’s no need for each program to recreate the wheel and there’s power in numbers if multiple programs in the same institution can have a shared curriculum.” And “Many of our educational leaders have become trainers as well of those programs. So not only are they receiving the training, but they’re providing the training so that there’s some built-in model where we have local expertise.” Ensuring URM are recruited, supported, and promoted to leadership positions, and providing extra mentoring and support for URM, was another subtheme that emerged. One participant noted, “…it’s not just limited to finding someone who was previously not going to get in or get selected and bringing [that person into your program] … [this can’t undo] the decades or centuries of suppression … it is more likely that people from those groups are going to have struggles and those struggles need to be supported as well. So we had systems for making sure we provide [support].” Another subtheme that emerged was promoting STEM in local communities to encourage kids from URM groups to be interested in medicine. One interviewee commented, “One of the structural things that is currently being done... is to make sure that when we are looking at hiring program directors, assistant program directors, or core faculty, that we are thinking about diversity, and if we don’t have representation from groups historically underrepresented in medicine, then we’re probably not trying hard enough to sponsor and mentor faculty members to aspire to those roles.” The importance of continuous quality improvement efforts was also highlighted. Finally, it was noted that changing the mindset from “We are doing this to help URM,” to “We are doing this to make us all better,” was noted to be very important.

Major theme 4: tools for curriculum building are abundant if you know where to find them

Subthemes in the fourth major theme focused on different types of resources and strategies available to build curricula and included: books & podcasts and having residents present on a topic they learned about listening or reading, using problem and case-based learning (e.g., Cases that explain topics such as the roots of health care disparities or unfair consequences/discipline for similar actions in white residents vs. URM), using online simulations and other tools, inviting speakers, having pre-recorded lectures, having paid expert consultants who may be URM themselves, inviting speakers from the community or creating a community medicine rotation, shadowing other staff in clinic or hospital, didactics, and having colleagues share their own experiences. One respondent noted, “Having small groups [where] people just like you ... [including] leaders [can openly] discuss … experiences [during] residency, [including those involving] racism, or homophobia, [etc.,] ... getting people’s personal perspective... allow[ing] people to be comfortable, [especially for some white residents/students who] might be sheltered … it might open their eyes [or allow them to realize] colleagues … have experienced all these horrible things .... I think would be really useful because in a sense... talking about personal experiences [will help people understand] … then you won’t have those people who [say] ‘racism doesn’t exist’ or ‘it doesn’t happen anymore.’ When you hear about it firsthand from your colleagues. I think that really makes a huge statement.”

Major theme 5: outcome measures should be multilayered and include resident, faculty, patient, community, and system metrics

Subthemes in this major theme about outcomes, highlighted the importance of using varied metrics to measure curriculum success. One technique mentioned use of resident pre-post surveys/tests/interviews (to measure knowledge, attitudes, and beliefs). Use of the Kirkpatrick Model for curriculum development, was also mentioned. Respondents also commented on specific strategies used in their own programs: “[To capture] people’s perceptions of the talk itself, whether they intend to change their practice ... surveys are offered right after the talk is given, by email.” Another noted, “Residents take the implicit bias test every so often,” and another noted use of a “test or quiz … to reflect whatever knowledge was gained during that portion of the curriculum,” and yet another commented on the usefulness of “a group discussion .. making sure that they’re applying the correct knowledge and guidelines to patients.” One respondent also suggested, “Assess … residents of color. How comfortable [are] they … with the curriculum and ... how comfortable are they addressing their [program leadership] if there are issues, or if they’re being discriminated against. How confident are they about [being able to successfully] seek help [or] discuss those issues [with program staff, faculty, or leadership]?” Demographics tracking (such as the percent of URM students considered for interviews, the percent matched, the percent that go on to become faculty, and the percent that pursue fellowship) was also emphasized as an important metric. One respondent commented, “The first thing is … keeping track of … how many [URM] residents we had in our program,” and another noted the importance of “whether or not the number of URM residents and faculty had increased over the years to have ... racial concordance to match our patient population,” and yet another suggested tracking “...how many residents of color have we admitted... how many of them have [completed the] program...” One participant said, “...if your intern classes every year have a high representation of black male residents, but those residents are all not completing the program, then that’s obviously a problem.” Another suggested, “Track the number of residents who self-identify as underrepresented in medicine who applied to our programs, who interview at our programs, and who get ranked.” Another subtheme in this area included tracking patient-oriented outcomes such as use of patient surveys, and measuring patient access to care, and patient health outcomes. One participant advised looking at measures such as “[Are] patients not showing up for follow up visits? [Adhering to] medications? [Are] patients actually connected with care? [Do they] trust in the care that they’re receiving or trust the doctors that they have?... If ... not … why?” Another suggested “seeing if your community feels that we are doing everything in our power to make sure that people are treated equally and fairly,” and a third suggested, “[Look at URM patients compared to white patients. Are they] getting their screenings? [Having] improvements in their A1C?” Tracking system resources and funding allocation and hiring equity outcome experts as consultants were other subthemes that emerged.

Major theme 6: curricular strategies should be multipronged, include integration, and be longitudinal

Subthemes surrounding curricular design strategies highlighted that integration into all other parts of the curriculum should occur, that longitudinal integration was needed, and that it was important to provide evidence and data, when available, to support teaching. It was noted that there is a vast literature on the health effects of racism and it is important for educators to use it to teach residents. Incorporating personal stories of experiences of racism in the medical system faced by patients as well as medical professionals was also suggested. An anti-racism journal club was recommended by several participants. Having a safe space for discussion and also a venue to provide anonymous feedback without fear of retribution was noted as an important curricular strategy. One respondent suggested, “[Have an] anonymous comment box where people can feel free to speak up about topics without having their name associated with [their comments],” while another pointed to the importance of “developing openness in your program that allows for the residents and other team members and patients - the full community at the residency program - to be able to share perspectives.” A broad range of “what not to do” recommendations were made and comments in this subtheme included: “You can’t just hire one tokenized black person with no budget, no protected time, no equitable advancement, or promotion [potential],” and when discussing a part of residency where residents would visit a poor neighborhood adjacent to the hospital one responded noted that they “... don’t know if the word is voyeuristic, but it initially had been very problematic in the sense that it just felt more like [we were] touring this place as opposed to actually learning about the history and integrating ourselves [into the community].” And (referring to the online system-wide required ‘bias’ courses) another noted, “… at least from my experience, most people just check them off or don’t really pay that much attention.” And “…required training course that you do online that you have [to complete to get] your hospital privileges or clinic privileges, like … an EHR training, and I felt that was really useless because most of the time people just very quickly click through them…” Another commented: “We implement systems, and nobody really cares about any form of evaluation..“ Finally, it was emphasized that programs must come up with unbiased ways to deal with “concerns” raised about residents of color to ensure all concerns were dealth with fairly. Finally recognizing that URM residents might not always feel safe speaking out when they have questions, was noted as an important step in creating an effective learning environment.

Major theme 7: self-reflection, discomfort, engagement are all necessary

The final major theme around introspection and advocacy encompassed a number of subthemes including (1) a need to address and advocate for change on a social level and in society at large, not just in medicine, (2) recognizing that many of the murders that occur are traumatic for URM residents, and (3) addressing potentially unrecognized or uncomfortable issues such as white fragility, and ensuring each person engaging in this work should start by critically examining their own beliefs and biases. Another point that was noted was that strategies that work for programs based in urban academic centers, might not work for more rural programs. Likewise, programs with many IMGs might need to consider a slightly different approach from programs with mostly US medical graduates. One participant (from a program with many IMGs) said, “... I have talked about colonialism and how we also can translate that to how our black population in the US has been treated historically, but not everyone seems to have that same connection ... I have had residents tell me ‘I grew up in [X country], no one has anything. Everyone suffers. Poverty is everywhere’ .... Many of them have told me ‘When I come to the US, I assume this is the best health care system in the world ... so why isn’t this patient taking their meds?’ So much of our curriculum content is geared towards US grads - I find it doesn’t always fit what I need for my [residents].”

A full list of themes, sub-themes, and additional select representative quotes are shown in Table 3 below.

Table 3 Themes, sub-themes, and selected quotes from in-depth key informant interviews describing experiences of racism in medicine, anti-racism teaching in medicine, and strategies to improve and sustain anti-racism curricula

Specific resources such as books, book lists, articles, simulation websites, consultants, podcasts, and other tools were collected during the course of this study, and can be found here: https://www.medicalantiracismcurriculum.com/.

Model development

To develop a visual guide for programs designing sustainable anti-racism curricula in the future, the Consolidated Framework for Implementation Research (CFIR) [19,20,21] was used to organize themes and sub-themes derived from key informant interviews, and guide creation of the SPOC (Support – Pipeline – Outcomes – Community) Model (see Fig. 1) - pronounced “spoke”. Using the CFIR domains that would influence success of such curricula, the team contextualized themes and sub-themes derived from interviews, to design the model as an actionable guide. These CFIR domains considered included: the outer setting (e.g. society as a whole, policies and laws, and the hospital system), innovation (e.g. the curriculum structure, strategies, and resources), inner setting (e.g. university or college and program including resources and available funding), individuals (e.g. the teachers, learners, champions, and those the curriculum affects such as the patients), and the implementation process (e.g. what measured outcomes will strongly influence how successful the curricula are).

Fig. 1

The SPOC (Support – Pipeline – Outcomes – Community) Model for creating sustainable anti-racism curricula for physicians in training

Integrating the reorganized themes and subthemes into the CFIR domains, we included as the four inner spokes of the model: (1) Support, (2) Pipeline, (3) Outcomes, and (4) Community. Within the first spoke of ‘Support’, programs must ensure that resources for the curriculum are secured, that funding is present for the activities that the curriculum will include, and finally that dedicated staff are identified, and importantly, compensated for their time spent building and maintaining the curriculum. As part of the second spoke, ‘Pipeline’, programs must ensure that recruitment, retention, and promotion of traditionally under-represented minorities in medicine occurs within their program. Within the third spoke of ‘Outcomes’, it is imperative that outcomes focused on residents, the program and institution itself, and last, but likely most importantly, on patients are agreed upon, tracked, and utilized to measure program success. If these metrics are not improving over time, the curriculum must be adjusted. Finally, the last spoke, ‘Community’, involves inclusion of the community the program serves in program planning and evaluation (e.g., community action boards), integration of the program into the community (e.g. community based rotations), and participation in community activities by residents and faculty (e.g., involvement in STEM programs at local schools).

Discussion

Summary of findings

This study employed in-depth interviews with key informants, formative research, and existing theoretical frameworks, to determine strategies for creating sustainable, effective, and continuously improving anti-racism curricula for medical residents. Findings highlight the need for focusing on ensuring the four key elements of (1) Support (2) Pipeline (3) Outcomes and (4) Community. The SPOC model can be used as a roadmap for future anti-racism curriculum design and implementation.

Key messages

One of the key messages of this work is that 'what gets measured gets done', and can be used to hold people accountable, which is essential if anti-racism work is to be successful. Including outcome and accountability measures tied to credentialing and accreditation is necessary to ensure long-term goals are met and continuous quality improvement occurs. Recruitment and retention of underrepresented minorities into programs and leadership positions is also necessary and, along with resource allocation and availability, is essential to long-term sustainability of anti-racism curricula. Community involvement is also key.

Limitations and strengths

Findings from this study are subject to serveral limitaitons. The formative and qualitative nature of the work potentially limits the generalizability of the findings. In addition, this work may be limited by regional or system restrictions (for example prohibition of the use of the term “diversity” in programs in Florida). Moreover, individual program sustainability will depend on individual funding and resource availability which may vary from program to program. Finally, only 15 of the 20 participants opted to answer the optional demographic survey, limiting our ability to analyze complete demographic data for our study sample.

The strength of this work is rooted in the breadth and depth of experience represented by the participants as well as the research team itself which consisted of a diverse group of clinical, psychology, and public health practitioners, faculty, and educators. Team members included those who identified as URM. Multiple members also have extensive experience in adult learning, direct patient care to populations which are vulnerable, and teaching and curriculum building for adult learners in the areas of equity, social determinants of health, gender studies, and trauma informed care. The research team also included members with expertise in use of theoretical frameworks.

Conclusions

This work is one of the first to qualitatively examine the experiences and perspectives of key stakeholders involved or invested in creating and advancing anti-racism curricula. It highlights the importance of considering sustainability factors when creating, implementing, and evaluating anti-racism curricula for physicians in training.

Next steps

Next steps for research in this area should focus on examining measurable and meaningful outcomes of anti-racism curricula to identify what strategies and approaches are most effective in bringing about the desired downstream effects for residents, programs, health care systems, communities, and the health care system as a whole.

Policy makers and academic medical residency leaders can access and use this work to drive recommendations for future policies aimed to support and advance anti-racism teaching in physician training programs specifically: (1) Implementation of credentialing designed to promote integration of anti-racism teaching and (2) Implementation of academic hospital system outcome metrics aimed at measuring equity that are tied to accreditation. Policy makers should also recognize that some regional policies might be impeding this work in specific parts of the country, and advocacy efforts to change such policies at the local and national level will be needed to ensure this work can be done effectively.

Community participation is a key to success. Programs undertaking this work should involve the communities they serve in each step of the process. Establishing a community action board may be an effective manner in which to accomplish community involvement, but other methods can also be used.

Available tools for future work

Along with specific curriculum tools (https://www.medicalantiracismcurriculum.com/), the SPOC Model can assist teachers and learners who are interested in designing, implementing, and evaluating their own anti-racism curricula. This model may support future residency programs’ efforts to ensure sustainability and continuous quality improvement components are built into curricula, and resultant downstream improvements in health outcomes and community involvement occurs.