Introduction

Race is a social construct that carries no scientific basis. Racism is the more problematic concept in which people are mistreated, exploited, or oppressed due to perceived hierarchies within this social construct based on phenotypic discrepancies.1 While racism impacts all aspects of society, health care represents an area where racism can manifest both directly and indirectly to impact medical outcomes. One ideal entry point for addressing racial health disparities in medicine is starting with the education of medical students, who represent the future of the health care workforce. In a commentary about racism in medicine, child psychiatrist Dr Amanda Calhoun stated: “…if medical education does not educate us about racism, we cannot be fully prepared to combat it”.2

There are numerous examples of how racist ideologies could translate to racial health disparities. Regarding medical students and trainees in particular, a 2016 study at the University of Virginia demonstrated that medical students and residents carried racist beliefs, with over half of participants believing that Black people had thicker skin than White people. This resulted in participants giving lower ratings for Black patients’ pain, which adversely impacted treatment recommendations.3

While this pivotal study illuminated how racist ideology could impact clinical care, it is not a new or isolated phenomenon. The historical concept of “medical superbodies,” as discussed by Diedre Owens in her book “Medical Bondage,” dates as far back as the transatlantic slave trade. Black enslaved women were masculinized and were not perceived to experience pain.4 More modern-day examples of this persistent falsehood include data demonstrating that Black pediatric patients are less likely to receive analgesia for appendicitis5 and that Black patients are less likely to receive pain medications compared with White patients.6,7 Such findings highlight that racism is not simply a belief in racial superiority and inferiority but also represents a physical manifestation of those beliefs that lead to harm and poor medical outcomes. The disparity is not a single event noted in a group of people at a particular institution but represents a systemic, pervasive, historically rooted, and longstanding institution that is embedded into every aspect of society.

There is an overwhelming and urgent need for positive change. Education of the new generation of health care providers represents a critical approach to addressing racial health disparities. This article explores how teaching about the history of racism in our nation can be accomplished through medical education. We review prior anti-racist education initiatives across institutions, address current challenges in the national landscape, and evaluate the outcomes of a pilot curriculum at a single medical school.

Teaching About Racism In Medical Education

Training in diversity, equity, and inclusion (DEI) was formally introduced into medical education in 2000 by the Liaison Committee on Medical Education (LCME). The Association of American Medical Colleges (AAMC) developed tools initially focused on the concept of “cultural competency,”8,9 in which providers were required to demonstrate an understanding of people of diverse backgrounds in relation to their intersection with the health care system. However, this approach has since metamorphosed to encompass the myriad dimensions of culture, acknowledge the complexity of various socio-demographic classifications, and challenge the concept of being “competent” in a particular culture.10 There has been a shift to address broader issues within the scope of DEI, but there are still few existing interventions that directly address systemic racism within the health care setting and its impact on health disparities.11

While DEI curricula have been spearheaded in medical institutions across the country, some notable initiatives in medical schools and residency training programs have included the following:

A study group of 3 faculty members and 29 medical students was formed at one institution to review current teaching materials and provide feedback on cultural competency training. This involved didactics, case-based learning objectives, facilitator scripts with clinical cases, and student reflections focusing on diversity and inclusion in the health care setting.12 A longitudinal, mandatory discussion-based curriculum was developed and implemented at 2 university-based pediatric residency programs. This curriculum consisted of 3 one-hour lectures focusing on implicit bias, historical trauma, and structural racism. Through pre-surveys and post-surveys, the study demonstrated a modest decrease in racial preferences among pediatric residents.13 While implicit and explicit bias decreased, findings were not statistically significant. Furthermore, the results showed an unexpected decrease in empathy. An anti-racist curriculum was implemented at a pediatric residency program in Pittsburgh, Pennsylvania. Through 7 educational sessions, the curriculum goals included understanding structural racism, appreciating the history that influenced the local patient population, promoting behaviors that address disparities, and encouraging anti-racist practices among trainees.14 Pre-surveys and post-surveys demonstrated significant increases in awareness in areas such as health care, housing, and employment. There were also statistically significant increases in self-reported clinical skills and individual advocacy behaviors. An optional mini-lecture on racism in medicine was spearheaded by students at Harvard Medical School as a response to the ongoing dialogue (and eventual removal from the electronic medical record) of the race correction factor for the estimated glomerular filtration rate (eGFR). The popularity of this lecture resulted in a small-group session on race and the eventual incorporation of the mini-lecture into the medical school curriculum.15 The Differences Matter Initiative was a $9.6 million project piloted by the University of California San Francisco (UCSF) School of Medicine in response to student demonstrations by White Coats for Black Lives.16 This initiative included educating the incoming medical student body about racism and racial health disparities. There are also 2 separate 3-week courses focused on structural competency, social science, public health, and topics on race. Furthermore, medical students at UCSF have spearheaded efforts to review the course, which led to changes in improved compensation of teachers in areas of social science and race theory, enhanced discussion of structural violence, and increased rigor of the course in comparison to other preclinical courses.15 Georgetown University School of Medicine implemented an anti-racism program for incoming medical students to learn about the intersection between structural racism and racial health disparities. This summer curriculum, through the leadership of the institution’s Racial Justice Committee for Change (RJCC), utilizes “Fatal Invention: How Science, Politics, and Big Business Re-Create Race in the Twenty-first Century” by Dorothy Roberts as a framework for discussing anti-racism and cultural humility.17 The University of Missouri-Kansas City School of Medicine leads an anti-racism and cultural bias program that is integrated into the medical school curriculum. Before medical school clerkships, students engage in a variety of workshops involving cultural self-awareness/cultural sensibility, implicit bias, white fragility, and microaggressions.18

There are also larger national efforts regarding racism in medical education. The AAMC houses an Anti-racism Education Collection through MedEdPORTAL, which provides anti-racist education resources to health care professionals through toolkits and peer-reviewed articles. This repository contains featured topics such as equipping medical students to address microaggressions, anti-bias workshops to reduce stigmatizing language, and implicit bias identification and management.19

Amidst these efforts, there has been significant opposition to DEI initiatives in medicine and in other institutions of higher education. In 2020, an executive order was issued under former President Donald Trump to eliminate “divisive concepts” and initiatives supporting these concepts (such as those that include race, gender, and ethnicity),20 although this was later rescinded by President Joseph Biden in 2021.21 However, nationwide DEI efforts continue to be under attack. Introduced in 2024, the Embracing anti-Discrimination, Unbiased Curricula, and Advancing Truth in Education (EDUCATE) Act is aimed at eliminating race-based mandates in medical schools. The bill would make medical schools that support policies or initiatives related to DEI ineligible for federal funding, which includes “providing a course of instruction for students solely on the basis of race, color, or ethnicity…”.22

While the AAMC has formally expressed their opposition to the EDUCATE Act,23 there are numerous other nationwide initiatives aimed at banning DEI efforts. In 2024, the state of Utah implemented a bill prohibiting DEI programs in universities,24,25 along with Florida— in which funding of DEI programs in public colleges and universities is prohibited.26 Other states including Mississippi, Oklahoma, Tennessee, Alabama, and Iowa have also passed laws banning or limiting certain trainings or education that contribute to perceived “divisive concepts” on the topics of race, ethnicity, or gender.27,28 Universities in the state of Texas were reported to have laid off dozens of DEI employees in an effort to comply with Senate Bill 17, which bans DEI offices and trainings at public universities.29

This legislation jeopardizes the knowledge base, empathy, and capability of the upcoming physician workforce to provide quality care to diverse communities.8 Equally concerning is the attempt at erasure— in which entire histories are intentionally dismissed when they, in fact, play an enormous role in the way that racial health disparities are observed and understood today. To effectively reverse these disparities, medical education must actively engage in discussions about the history of racism in medicine and its persistent legacy that is still observed in modern medicine. Furthermore, while most approaches appear to utilize broad strokes when addressing racism, there are fewer approaches that more tangibly evaluate the historical context of racism through the lens of a single major medical pathology or issue. This was the impetus for which the pilot curriculum in this manuscript was developed.

A Single Institution Approach To Discussing Racism In Ob/gyn

This project represents a novel curriculum that educates students on the history of racism in the field of obstetrics and gynecology (OB/GYN) in the United States. The curriculum is not an exhaustive review of all racist practices and events in the history of OB/GYN but instead presents the history of racism through the lens of one of the most pressing racial health disparities of our time in OB/GYN— Black maternal mortality. The goal of this pilot curriculum was to focus on a single health topic to create a framework for discussing the larger impact of racism and how history permeates into current racial health disparities. A pilot curriculum at the University of Michigan Medical School in Ann Arbor, Michigan, was developed through the Department of Obstetrics and Gynecology, which was reviewed and edited by multiple departmental faculty. This curriculum was then integrated into a pre-existing course focused on health systems science for pre-clerkship medical students. This course was mandatory for all medical students.

The curriculum was rooted in a conceptual framework developed by Brown-Jeffy and Cooper,30 representing a fusion of culturally relevant pedagogies based on prior frameworks described by Gay, Ladson-Billings, and Nieto.31–34 While this framework was modified to be applicable to the medical student context, the core teaching is maintained in critical race theory, recognizing that systemic racism exists and has impacted (and continues to play a central role in) current racial health disparities. The Brown-Jeffy and Cooper Culturally Relevant Pedagogy is based on 5 major tenants,30 which we adapted to the context of medical education:

Identity and achievement: Appreciating diversity in identity and perspective Equity and excellence: Integration of multicultural content into the curriculum Student-teacher relationship: Creating a caring and respectful learning environment Teaching the whole person: Interacting with students in a way that acknowledges the complex interaction between race and culture Academic appropriateness: Identifying the cultural impact of race at this level of the medical student’s academic career.

The learning objectives were as follows: (1) identify factors that led to the creation of OB/GYN as a discipline, (2) recognize how structural determinants of health contribute to maternal health disparities, (3) discuss the state of maternal health outcomes, and (4) discuss strategies for addressing racial inequities related to maternal health outcomes. The curriculum consisted of an interactive didactic, small group break-out discussions, and then a final large group discussion (total of 2 hours). Based on the aforementioned pedagogy, the didactic included key concepts such as (but not limited to) those outlined in Fig. 1,4,35–46 spanning from the transatlantic slave trade to the current state of Black maternal health.

FIGURE 1:

Key didactic concepts of racism in OB/GYN curriculum.

Following the didactic, students were assigned small groups for discussion with the following prompts:

What are your feelings after this lecture? Were there things that you didn’t understand or that didn’t make sense? What was most poignant for you? What links do you see between the past and present? What constitutes informed consent? Can we judge historical characters by today’s standards? How will this knowledge impact the care that you provide to patients both as a medical student and future physician? Have you ever experienced/witnessed care in which historical bias may have played a role?

The class then returned together for a large group debrief and closing discussion for 30 minutes to further explore these questions and other topics that arose in small groups.

To evaluate the curriculum, a convenience sample of students was invited to complete an optional 11-question post-session survey. Through Likert rating scale and qualitative open-ended questions, the survey was aimed at evaluating students' understanding of the 4 course objectives and soliciting their feedback regarding the session as a whole. A 1-proportion Z test was performed to assess the significance of a positive response to the question, “Do you feel like your participation in this session will lead to positive change in your own practice and future patient outcomes?” as this was determined to be our most important question to assess impact. Students' perceptions of the possible areas of positive change (personal competency, performance, and patient outcomes) were also explored. This study was reviewed and exempted by the University of Michigan Institutional Review Board (HUM00199667).

Student Feedback Demonstrates Perceived Positive Impact Of The Session

The pilot curriculum was delivered on 3 occasions between January 2021 and December 2022 for 3 separate first-year pre-clerkship medical student cohorts totalling 510 students. All students participated in the pilot curriculum. For all 3 sessions combined, a convenience sample of 254 students was invited to complete the post-session survey in accordance with the academic policy to reduce the survey burden on students. Of those 254 students, 197 completed the survey (77.6% overall response rate). Of note, for the first, second, and third sessions, the survey response rates were 91.7%, 81.2%, and 60.0%, respectively. Not all questions were answered by all respondents. The first 2 sessions were conducted entirely virtually as per medical school guidelines regarding COVID-19, and the last session was conducted in-person without a virtual option.

Demographic data is shown in Fig. 2. The majority of the respondents identified as female (65.3%) and non-Hispanic White (61.0%). Out of all total participants, the following represented the breakdown of students’ ability to address curriculum objectives:

Objective 1- Identify factors that led to the creation of OB/GYN as a discipline: 49.0% strongly agree, 35.9% agree, 10.9% neutral, 4.2% disagree, and 0% strongly disagree (n=195) Objective 2- Recognize how structural determinants of health contribute to maternal racial health disparities: 62.1% strongly agree, 31.8% agree, 5.1% neutral, 1.0% disagree, and 0% strongly disagree (n=195) Objective 3- Discuss the state of maternal health outcomes: 54.9% strongly agree, 37.9% agree, 6.2% neutral, 1.0% disagree, and 0% strongly disagree (n=195) Objective 4- Discuss strategies for addressing racial inequities related to maternal health outcomes: 57.9% strongly agree, 36.9% agree, 4.1% neutral, 1.0% disagree, and 0% strongly disagree (n=192) FIGURE 2:

Demographic data of respondents.

Regarding our primary impact question, “Do you feel like your participation in this session will lead to positive change in your own practice and future patient outcomes?” 177 of 189 total responded affirmatively (93.7%, P<0.01). If the student responded “yes”, the follow-up questions were asked regarding where they expect to see the changes: in competency, performance, or patient outcomes. Students were invited to provide multiple responses in whichever category they felt was applicable, which are summarized based on gender identity (Fig. 3) and race and ethnicity (Fig. 4). Improvement in personal competency resulting in positive future change was the metric rated the highest across race, ethnicity, and gender identity (75.0%–100%). After further stratification, though, fewer students (as low as 49.9% among those identifying as female) believed that their participation in the curriculum would specifically improve patient outcomes, although this metric was as high as 83.3% among Asian students.

FIGURE 3:

Survey responses based on gender identity.

FIGURE 4:

Survey responses based on race and ethnicity.

Session ratings were also collected. A total of 58.5%, 25.9%, 10.9%, 4.1%, and 0.5% found the course to be excellent, very good, good, fair, or poor, respectively (n=193). Regarding the instructor, 72.3%, 17.3%, 7.9%, 2.1%, and 0.5% found them to be excellent, very good, good, fair, or poor, respectively (n=191). All students were invited to submit feedback regarding strengths or areas for improvement for the session. Key points and those that were repeated by more than 1 student were included. Comments were grouped into common themes.

Student evaluations regarding the strengths of the pilot program were numerous, as outlined in Fig. 5. Multiple students communicated that they were grateful for the lecture and perceived the didactic to be the best of their medical school experience, with some requesting more lectures be given on this topic. Some comments pointed to the effectiveness of teaching history through both the lens of the past while simultaneously exploring links to current racial health disparities. Importantly, some commented on how this lecture impacts care, challenging students to reflect more deeply on what their approach would be for patients of color and to make “conscious” decisions as medical practitioners.

FIGURE 5:

Student evaluation of pilot project strengths.

Student evaluation also included areas of improvement, as outlined in Fig. 6. Many students expressed the need for trigger warnings and debriefs, given the heavy and charged nature of the topics discussed. While some students provided positive feedback regarding the course structure (didactic, small, and large group sessions), others found this framework to be challenging. Some comments included the need for greater student participation in the larger group or questioned the utility of the large group discussion altogether. Other issues included the observation that some students (particularly Black students) may have felt more pressure to speak given the subject content, highlighting the need for small group moderators. Finally, there were numerous comments on students’ desire to gain a clearer understanding of how to translate historical knowledge into tangible action items. There was also a recommendation to expand the discussion to cover other disadvantaged groups.

FIGURE 6:

Student evaluation of pilot project areas of improvement.

Discussion

Teaching medical students about the history of racism in medicine is of critical importance, and is being jeopardized by recent state and federal policy. This article highlights findings from a pilot project teaching medical students about the history of racism in OB/GYN and how historical events relate to current racial health disparities. Overall, the majority of students found the course to be either very good or excellent, with some noting that it was the best course in their medical school education thus far. Students generally perceived that the information learned in this course would have a positive impact on their future clinical practice, encouraging some to reflect further on how they treated patients of color. These findings support the feasibility of a race curriculum in medical school education and demonstrate its overall acceptability to medical students. Furthermore, this study suggests that a race curriculum could contribute to students' perceived positive change in future practice, particularly in the area of personal competency.

The pilot reinforces a more recently proposed framework for teaching anti-racism in the clinical learning environment using the acronym REACT: “reflecting on implicit biases, educating ourselves on historical and current forms of structural racism, assessing the use of race-based algorithms and asking how racism is impacting a clinical interaction, calling out behaviors that perpetuate racism, and treating everyone with dignity and respect”.47 Our curriculum expands upon some of the elements of this proposed framework by empowering students to reflect on their own biases by highlighting a tool (the VBAC calculator) that was universally and routinely used by OB/GYN practitioners, providing education regarding the history of birthing among enslaved people and the gynecologic experimentation on Black enslaved women, and exploring instances in which the use of racist medical practices were challenged (such as the race component of the VBAC calculator).

While feedback from the course generally showed that the curriculum was well-received by medical students, there are potential areas of improvement. Racism, slavery, and health disparities are academically and emotionally dense topics that may be challenging for some learners to process. Many students expressed the need for trigger warnings. We did integrate this into subsequent sessions and provided warnings before the beginning of the didactic. Furthermore, some students expressed the need for a debriefing session following the didactic and small group. A debriefing session was offered at the conclusion of the third session in response to this feedback, with one student in attendance.

Small group facilitators were challenging to procure based on the large class sizes. However, it is critical that facilitators be integrated into future sessions for several reasons. Some students expressed that the small group was more informative than the larger final group session, which suggests that the small groups could be a more suitable environment for students to expand their understanding of the topic material and engage in discussion. Such dialogue could be further enhanced with trained facilitators. There was also feedback that some students (namely Black students) may have felt the need to direct the conversation simply due to their race and the nature of the topic. A facilitator would help to pivot group dialogues away from any one person and redirect them back to the larger group.

Another limitation of the curriculum involved the disconnect between the historical and current racial health disparities, and its intersection with the students' future clinical practice. While examples of local and national initiatives to combat Black maternal mortality were discussed, some students still expressed feelings of powerlessness in the context of systemic racism. Although many were receptive to the information and believed this curriculum would positively impact their future practice, some remained uncertain about their personal role in addressing health disparities. This finding was reflective in lower scores for the “improvement in patient outcomes” metric as well as in comments from the qualitative feedback. While large-scale systemic change is undoubtedly necessary, the overarching aim of the curriculum was to empower students with the understanding that they themselves are a part of that systemic change and that their individual actions can impact health disparities cumulatively on a broader scale. This concept could be better elucidated in subsequent sessions. Direct application of anti-racist clinical practice is a ripe area for further elaboration of this curriculum. Future directions could include case presentations to help medical students better conceptualize how bias can manifest in the health care setting, allowing them opportunities to discuss real-life clinical scenarios and explore their responses. As the didactic and discussion are already 2 hours in length, adding this component may require additional sessions.

While race education is critical at all stages and should be encouraged along the breadth of the medical education continuum, it could be that practical knowledge of racism in medicine could play a more prominent role at the time in which medical students are more directly interfacing with patients (ie, during clinical clerkships) as opposed to their first year of medical school (as were the students in this cohort). However, this is an area that is understudied and may warrant further research. Future directions could include both short- and long-term follow-up with medical students to identify if and how the curriculum may have longitudinally impacted their approach to patient care. Similarly, it could be valuable to observe any differences in the receptiveness and impact of an anti-racism curriculum between medical student students during their clinical sciences versus clerkship years. Evaluating the optimal timing and reach of a race curriculum enables a more tangible, sustainable translation from the classroom to the bedside.

It is imperative that medical schools prioritize the integration of anti-racist curriculum to better identify, understand, and reverse modern-day racial health disparities. Racist theology remains deeply rooted and interwoven into the medical system, such that significant, positive, and sustainable change cannot be expected by passive means. This pilot demonstrates that a race curriculum concerning the history of OB/GYN is feasible and acceptable to medical students. Furthermore, it suggests that the information learned could translate to positive change. A larger national discussion of the universal integration of such a curriculum should be considered to reach the entirety of the nation’s future health care leaders, for which this pilot curriculum (among others) could serve as an additional blueprint. This is particularly important in the current national landscape in which anti-racist education is being extinguished. There is an urgent need for purposeful didactics on health care disparities and how it relates to the history of racism to better educate and equip our future practitioners to care for diverse communities.

Acknowledgements

The authors thank Sarah Block and Dr Ashley Hesson for their contributions to this article.

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