Continuing Education Activity

The United States is a diverse country and a place for people of all backgrounds. However, discrimination against individuals and groups belonging to minority identities persists, leading to negative outcomes for patients and healthcare professionals. Clinicians are responsible for addressing inequity in the medical profession, a part of the American healthcare system. Several decades ago, diversity and discrimination were considered terms within social justice or social movements. However, in recent years, there has been a notable shift in focus within the healthcare field towards understanding and addressing social determinants of health. Remaining cognizant of these cultural shifts is relevant for healthcare community members at all levels to remain productive and contribute within the field.

This activity reviews the concepts of diversity and discrimination and highlights the interprofessional team's role in improving care for patients from diverse backgrounds through medical education. Participating clinicians are equipped with historical milestones, past and present events, and recommendations to inform policy that aims to increase diversity and decrease discrimination within healthcare settings.

Objectives:

• Identify different manifestations of diversity and discrimination, and analyze their impacts on health care.
• Interpret the different levels within the healthcare system on which bias and discrimination occur.
• Evaluate relationships between bias and negative patient outcomes in the healthcare system.
• Implement interprofessional guidance that healthcare systems can adopt to increase diversity and reduce disparities.

Introduction

Diversity is broadly defined as the inclusion of varied attributes or characteristics. In the medical community, diversity often includes healthcare professionals, trainees, educators, researchers, and patients from diverse backgrounds, including race, ethnicity, gender, disability, social class, socioeconomic status, sexual orientation, gender identity, primary spoken language, and geographic region.

Discrimination in health care is defined as negative actions or lack of consideration directed towards an individual or group based on preconceived notions about their identity. Individuals do not have to belong to a marginalized group themselves to experience discrimination against that group. Discrimination can occur based on perceived membership. Furthermore, harm does not need to occur for discrimination to exist. A group may be discriminated against if it consistently receives lower-quality healthcare services compared to another group solely because of their race, ethnicity, gender, disability, social class, socioeconomic status, sexual orientation, gender identity, primary spoken language, or location of residence.

Although discrimination can manifest for various reasons, this activity focuses mainly on gender, ethnicity, and race-based discrimination in the healthcare workforce. Discrimination occurs in all workforce segments, not limited solely to health care. However, health care presents a unique scenario because both care providers and recipients may face discrimination simultaneously, underscoring an inherent power dynamic.[1]

Issues of Concern

The 2 main types of discriminatory acts are macroaggressions and microaggressions. Macroaggressions are more overt and radical forms of discrimination deeply rooted in a society or within a system. Examples of macroaggressions include the forced relocation of Japanese-Americans into internment camps during World War II, laws preventing equal suffrage rights for women, and the Tuskegee study, where Black men were intentionally misled and denied standard treatment for syphilis.

Laws such as Title VII of the Civil Rights Act and the Americans with Disabilities Act (ADA) prohibiting unequal treatment based on race, sex, and disability have decreased overt racism within healthcare settings. In areas where overt racism has declined, awareness of microaggressions has increased. Microaggression can be defined as short, everyday insults or snubs that can be barely perceptible or difficult to define but convey a negative message to individuals because of their identity or affiliation with marginalized groups.[2] Microaggressions, often unintentional and rooted in unconscious biases, can be challenging to identify, easily concealed, and delivered involuntarily through verbal or non-verbal communication.[3][4] Microaggressions are often delivered during one-on-one interactions, whereas macroaggressions are rooted in systems.[5] 

Despite their insidious nature, microaggressions have perceptible negative impacts on the quality of life of oppressed individuals or groups. Increased exposure to microaggressions increases the likelihood of feeling discriminated against. Microaggressions may damage the mental health of oppressed individuals, causing lower self-esteem, poorer self-care, and increasing susceptibility to substance abuse, depression, suicidal ideation, and anxiety.[6][7][8][9] Growing evidence suggests that repeated exposure to microaggressions is associated with a higher incidence of hypertension, increased frequency of hospital admission, and more severe diabetes-specific distress.[10][11]

The killing of George Floyd in 2020 in a succession of incidents of police brutality, in conjunction with the disproportionate burden of COVID-19 in communities of color, has elevated the national consciousness regarding diversity and discrimination.[12] Americans are more aware that structural racism is causing healthcare disparities.[13] Research demonstrates that discrimination and bias exacerbate and create new healthcare disparities.[14] As a result, the national conversation surrounding racism has resulted in the recognition of racism as a public health crisis.[15] As the national discussion surrounding diversity, discrimination, and structural racism continues, several matters have been brought to the forefront, as discussed below.

A Multicultural Society Requires a More Diverse Workforce

As our country's racial and ethnic diversity increases, the need to diversify our healthcare workforce increases. The need to diversify health care has been present since the inception of the first women and individuals of color entering higher medical education.[16] The Flexner report significantly slowed the inclusion of Black physicians in the American medical system.[17][18] Flexner concluded that medical education within African American schools was deficient, resulting in the closure of 5 of 7 African American medical schools.[19] Since then, the ability of Black and Brown clinicians to reach higher workforce levels has increased, but discrimination is still prevalent, intersecting with several marginalized identities. Many years later, when COVID-19 disrupted the American healthcare system, a rise in discrimination towards Asians and Asian Americans necessitated a focus on increasing social support from students to the professional level.[20] Concerning diversity outside of race, individuals belonging to gender-diverse and disabled groups face significant exclusion.[21][22]

Progression From Individual to Structural Racism

Racism is a social construct that emphasizes phenotype. According to the National Museum of African American History & Culture, individual racism, interpersonal racism, institutional racism, and structural racism are delineated. Individual racism is most directly related to the biases that we hold, and interpersonal racism is an expression of these biases between individuals. Institutional racism is reflected in the policies and procedures of an organization. Structural racism is the cumulative effect of these forces across systems and between institutions or organizations. The promotion of health equity and a decrease in health disparities requires addressing individual and interpersonal racism and dismantling institutional and structural racism. However, the complexity of such endeavors should be recognized, given the hundreds of years of history where individual and structural racism have prevailed within health care.[23][24] The decision regarding Dobbs v. Jackson in 2022 that overturned Roe v. Wade reignited the conversation surrounding the relationship between the healthcare system and reproductive health.[25] In 2023, the ruling against affirmative action for college admissions had an unknown impact on higher medical education in the following years.[26] The conversation in many sectors about the potential effects of structural racism, particularly concerning artificial intelligence, is prevalent in 2024.[27]

Bias, Stereotype Threat, and Negative Outcomes

Increasing awareness in the United States involves recognizing that implicit bias contributes to poorer healthcare outcomes for patients of color.[28] Racist behavior negatively impacts patient well-being. In addition, stereotype threat is a psychological state where individuals underperform due to their fear of fulfilling negative stereotypes. The hypothesis is that stereotype threat impairs the performance of minority students on standardized tests such as the Medical College Admission Test (MCAT) and the United States Medical Licensing Examination (USMLE).[29] Stereotype threat has been found to cause psychological harm among students and trainees of color.[30] Several efforts continue to examine the approaches to teaching trainees about healthcare disparities.[31][32]

Clinical Significance

Individual racism is a personal belief in the superiority of one's race over another, often leading to discriminatory behavior driven by implicit and explicit biases. Historically, racist beliefs regarding biological differences between Black and White people were used to justify slavery and medical experimentation on men and women of color. The legacy of this false belief in fundamental and innate biological differences between Black and White people is still present in medical practice, leading to health disparities such as the undertreatment of pain in Black patients.

A research study published in the Proceedings of the National Academy of Sciences of the United States demonstrates the connection between false beliefs about biological differences between Black and White people and racial bias in pain assessment and treatment recommendations. In this 2-part study, medical students and residents endorsed beliefs suggesting biological differences between Black and White patients. These beliefs included that the nerve endings of Black people are less sensitive compared to White people and that the skin of Black people is thicker compared to White people. Furthermore, medical students and residents who held these beliefs rated the pain of Black people lower compared to that of White people and, therefore, made less accurate treatment recommendations.[28] Historically, similar beliefs were endorsed by the Nazis during the Holocaust regarding tolerance of pain levels that led to some of the most brutal documented recollections of medical experimentation based on identity.[33][34][33]

Structural racism is rooted in societal, historical, and cultural norms that support racial group inequality. As an institution, medicine has adopted and implemented practices and policies that promote structural racism. Race-adjusted algorithms are based on the historic racist belief that Black people are physiologically different. For instance, race-corrected estimations of glomerular filtration rate are based on the unscientifically supported belief that Black people are more muscular and have higher creatinine levels. Consequently, this may result in a higher reported estimated glomerular filtration rate, interpreted as a better renal function for anyone identified as Black. As a result, there may be delays in diagnosing renal disease and reduce access to transplantation.[35] 

At a systems level, the failure to identify the health implications of discrimination may result in developing a system promoting health disparities. For example, an algorithmic bias was identified in a medical artificial intelligence program that considered past healthcare costs when predicting clinical risk. Consequently, due to White patients having greater healthcare expenditures compared to Black patients, they were determined to have higher risk scores compared to Black patients. These scores may have led to more referrals for White patients to specialty services, perpetuating both spending discrepancies and race bias in health care.[36] In the United States, maternal mortality rates are disproportionately high, and patients who identify as female face numerous barriers to accessing equitable medical care, ranging from the use of imaging modalities, surgical recommendations, and perception of self-efficacy in decision-making to the final diagnosis, now termed gender-affirming health care.[37] Disability-conscious health care is also emerging in the continued movement toward equity in clinical practice.[38]

The root cause of discrimination based on race, gender, or other identifying social constructs has led to racism, inequality, and inequity concerning the process of patient history intake, evaluation, and diagnostic testing. Within each specialty, the effect of discriminatory beliefs is exhaustive, but some commonalities can be observed. Considering the past pitfalls of experimentation on marginalized groups and restructuring the approach to medical education in the present is the path presented in this activity.

Other Issues

Medical Education on Diversity in Healthcare

This section is intended primarily for healthcare professional educators. However, all educators may benefit from both peer- and self-education.

Preface

The Liaison Committee on Medical Education and the Commission on Osteopathic College Accreditation require medical schools to promote diversity and prohibit discrimination. However, researchers have yet to confirm whether such actions affect health outcomes. A search in PubMed for education studies about diversity for healthcare professionals did not yield results generalizable to the effectiveness of any specific strategy. Before considering healthcare outcomes, an intermediate step is raising the awareness of bias to modify perceptions and behaviors at the student level; research in this area is abundant and described below.

Valuing cultures other than oneself involves a willingness to learn and self-reflect continuously. When discussing the ability of education to change perceptions and behaviors, the terms cultural humility, cultural awareness, and cultural sensitivity are more appropriate compared to cultural competency, as competency implies having attained a finite body of knowledge.[39] The former terms present the knowledge as existing on a continuum that requires progress toward inclusion.

Educational Approaches

Inclusive education emphasizes that healthcare professionals should consider patients in their unique individual contexts and acknowledge that a situation may be experienced differently by different patients. What matters in making informed decisions are an individual's health perspectives, requirements, and experiences, not their ethnicity, race, or social status.[40] A critical skill for all healthcare professionals is to understand patients not by employing any particular label but instead by employing an attitude of curiosity about how each patient’s experiences and context shape their views and behaviors.

Developing a healthcare professional's critical consciousness, defined as a reflective awareness of the self, others, and the world and a commitment to addressing issues of societal relevance in health care, is believed to be an effective approach to education about diversity than teaching facts or emphasizing the use of an individualized approach to patient care.[41] Healthcare professionals should also undergo training in recognizing their own implicit biases and biases of the institutions and systems in which they work. This training includes understanding the composition of the leadership workforce and how decisions are made within their workplaces.

Recent review articles provide general guidance and practical examples for educators.

• In 2007, Smith et al developed recommendations for curricula on health disparities and suggested that the broad goal of such curricula should be to eliminate health disparities.

• In 2016, Dogra et al published a curriculum guide and reviewed examples of education about diversity. They recommended integrating education concerning diversity throughout the curriculum and highlighted the importance of self-reflection in learning and teaching related concepts.

• In 2020, Brottman et al reviewed education models for trainees and professionals in medicine, nursing, pharmacy, dentistry, physical and occupational therapy, public health, audiology, and social work. The interventions studied ranged from 20 minutes to hundreds of hours and included immersion experiences, simulation, discussion, lecture, reflection, educational technology, case-based learning, essays, presentations, readings, and videos. This extensive review determined insufficient evidence to recommend any particular format as a best practice.

  • A multidisciplinary approach incorporating many education modalities typically enhances knowledge retention. Similar to Objective Structured Clinical Examinations (OSCEs), simulations, in particular, may resemble real-life clinical encounters as applicable to situations of discrimination.[42][43]

Despite the lack of large-scale evidence for best practices, many smaller studies focused on particular target populations or particular interventions. Some evidence suggests that multimodal, active learning formats, such as a combination of faculty role modeling, interprofessional rounds, and OSCEs, can yield gains in learners' knowledge, skills, and attitudes.[44] Lectures are useful but have potential pitfalls and should be followed by hands-on practice with feedback and formative evaluation. The discussion format is likely more effective compared to lectures alone in helping learners explore and develop their attitudes on cultural issues.

When education about diversity is integrated longitudinally throughout a curriculum, appointing someone to oversee all curricular modules can maximize cohesion and minimize redundancy. Smith et al proposed that a curriculum committee not assign all teaching roles to faculty persons of minority demographics because that arrangement can imply that issues related to discrimination are only a problem for minorities to navigate rather than the responsibility of all healthcare professionals.[32]

Diversity education is a unique curricular topic. Healthcare team members at all expertise levels, from trainees to experienced clinicians, require the same foundation that builds a skill set. If education is considered a shared responsibility, professionals from diverse backgrounds can engage in mutual learning and collaboration.

Pitfalls

Healthcare professionals have made many false assumptions about the relationship between cultural variables and medical outcomes, unnecessarily reinforcing negative stereotypes. Teaching typical characteristics of minority groups frequently promotes stigmatization without promoting healthcare outcomes. This approach makes culture a proxy that prevents healthcare professionals from noting the person behind the patient. Categorizing patients based on cultural characteristics assumes that culture and its impact on persons' responses are fixed. Healthcare professionals should instead realize that patients have dynamic views that vary based on their immediate contexts and recognize that identity classifications such as gender, age, class, disability, sexuality, race, and ethnicity are multifaceted.

Faculty preparation is crucial for effectively teaching diversity education; educators who are well-intentioned but unprepared can inadvertently promote students' and patients' stereotyping. Microaggressions embedded in curricular content create an unsafe climate for cultural minority students. Emphasizing minority patient characteristics as inconsistent with the privileged majority's norm marginalizes minority patients and paints them as a problematic other.[40]

Finally, educators should realize that they teach a curriculum implicitly or explicitly. While the planned curriculum describes what educators perceive, the experienced curriculum describes what students perceive. What educators teach students unintentionally is the hidden curriculum, described as a set of influences that function at the level of organizational structure and culture.[45] The hidden curriculum can have positive effects, such as when an educator role models cultural humility. The hidden curriculum can also have negative effects, such as using clinical vignettes that promote stereotypes and undermining cultural sensitivity training in other parts of the curriculum.[46] In addition, a lack of diversity among faculty or institutional leaders can project through the hidden curriculum that minorities do not have a role in higher career positions.[31]

Summary

Education regarding diversity is not a time-bound goal but rather a journey. The education should provide learners with the opportunity to become actively engaged in fostering a level of critical awareness of the healthcare provider's position of power and privilege in society.[47] Inclusiveness in a curriculum does not involve adding a few learning activities to the existing curriculum but rather involves a culture shift.[48]

Enhancing Healthcare Team Outcomes

Based on existing literature and the results of several studies, the hypothesis positing an inverse relationship between discrimination and diversity is recognized. The prevailing belief within the medical community is that discrimination decreases and equity increases if the percentage of underrepresented minorities reaches a critical mass. Evidence suggests that although diversity is a goal, it alone does not create equity. Although more than half the pediatricians and gynecologists in the United States are now women, leadership positions within departments remain predominantly occupied by men.[5] Men are likelier to be selected for editorial board membership and achieve status as an associate or full professor, department chair, or medical school dean. Men also earn more at each academic rank.[49] Therefore, diversity does not necessarily impact the distribution of resources within the teaching system.

These results are similar to those found in the nursing profession. The male advantage in nursing has been described as a glass escalator, in which men are put on a fast track and almost pushed to achieve positions that include greater responsibility, higher salaries, and more organizational benefits.[50] Thus, although diversity is necessary and important, equity is needed to decrease disparities and mitigate the impact of discrimination. 

Although increasing diversity may not eliminate all problems related to healthcare disparities and discrimination, we strongly encourage healthcare systems to promote diversity among clinicians. A larger talent pool, including clinicians with heterogeneous customs, experiences, and problem-solving tactics, can create more innovative approaches to systems-based problems. Individuals within a group may best solve healthcare issues that are more prevalent within that group. Diverse viewpoints enhance patient care and clinical research design, which may lead to improved inclusion. 

Numerous studies have shown that increased clinician diversity is associated with improved healthcare quality. Concordant care, defined as a patient and clinician sharing a common attribute such as race, ethnicity, or gender, has been associated with improved quality of care. Race-concordant patient-physician relationships are associated with improved communication, longer patient visits, greater medication adherence, and higher patient satisfaction scores.[51][52] Language and gender-concordant patient-physician relationships have similarly been associated with improved home medication compliance and outcomes.[53][54] Such results suggest that patient-physician concordance may facilitate communication and trust.

Poor access to quality care continues to impact minority and low-income individuals in the United States disproportionately. A potential solution is to focus on recruiting and retaining underrepresented healthcare professionals. Underrepresented minority physicians are more likely to serve in areas with a physician shortage and serve underserved groups, including minorities, low-income individuals, and the uninsured.[55][56][57]

The following measures are encouraged to be considered by healthcare groups and systems to improve the recruitment and retention of employees from underrepresented groups:

• Eliminate financial barriers to higher education for socioeconomically disadvantaged groups by developing scholarships, grants, and tuition assistance.
• Create mentorship and pipeline programs to increase the number of underrepresented minorities in healthcare careers. When possible, these mentorship pairings should align with the race and gender of participants.
• Provide opportunities for coaching and leadership training for healthcare professionals from underrepresented groups.
• Use transparent processes to select committee members and leaders with diverse backgrounds and viewpoints.
• Provide pay transparency and objective measures for promotion and salary increase.

The following actions are encouraged to be considered by healthcare groups and systems to quell discrimination and accelerate the remedy of healthcare disparities:

• Acknowledge that past discrimination and current implicit biases lead to inequities related to race, gender, ethnicity, sexual orientation, and disability, which still exist in healthcare settings. Progress is limited by denying the existence of discrimination and bias.
• Educate healthcare professionals on the impact of health disparities and structural racism on patient outcomes. Equip healthcare trainees and practicing clinicians with tools and resources to confront macroaggressions and microaggressions.
• Create a zero-tolerance policy for harassment and discrimination that includes a safe reporting mechanism for both the victim and the reporter.
• Increase support for research on healthcare disparities.
• Consider diversity as a subject integrated into medical education rather than an adjunct.

Review Questions

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References

1.

Mansh M, Garcia G, Lunn MR. From patients to providers: changing the culture in medicine toward sexual and gender minorities. Acad Med. 2015 May;90(5):574-80. [PubMed: 25650825]

2.

Barber S, Gronholm PC, Ahuja S, Rüsch N, Thornicroft G. Microaggressions towards people affected by mental health problems: a scoping review. Epidemiol Psychiatr Sci. 2019 Dec 16;29:e82. [PMC free article: PMC8061293] [PubMed: 31839013]

3.

Young K, Punnett A, Suleman S. A Little Hurts a Lot: Exploring the Impact of Microaggressions in Pediatric Medical Education. Pediatrics. 2020 Jul;146(1) [PubMed: 32493709]

4.

Elliott AM, Alexander SC, Mescher CA, Mohan D, Barnato AE. Differences in Physicians' Verbal and Nonverbal Communication With Black and White Patients at the End of Life. J Pain Symptom Manage. 2016 Jan;51(1):1-8. [PMC free article: PMC4698224] [PubMed: 26297851]

5.

Torres MB, Salles A, Cochran A. Recognizing and Reacting to Microaggressions in Medicine and Surgery. JAMA Surg. 2019 Sep 01;154(9):868-872. [PubMed: 31290954]

6.

Cruz D, Rodriguez Y, Mastropaolo C. Perceived microaggressions in health care: A measurement study. PLoS One. 2019;14(2):e0211620. [PMC free article: PMC6363167] [PubMed: 30721264]

7.

Torres-Harding S, Torres L, Yeo E. Depression and perceived stress as mediators between racial microaggressions and somatic symptoms in college students of color. Am J Orthopsychiatry. 2020;90(1):125-135. [PubMed: 30843707]

8.

Hollingsworth DW, Cole AB, O'Keefe VM, Tucker RP, Story CR, Wingate LR. Experiencing racial microaggressions influences suicide ideation through perceived burdensomeness in African Americans. J Couns Psychol. 2017 Jan;64(1):104-111. [PubMed: 27854440]

9.

Dickerson DL, Brown RA, Klein DJ, Agniel D, Johnson C, D'Amico EJ. Overt Perceived Discrimination and Racial Microaggressions and their Association with Health Risk Behaviors among a Sample of Urban American Indian/Alaska Native Adolescents. J Racial Ethn Health Disparities. 2019 Aug;6(4):733-742. [PMC free article: PMC6661006] [PubMed: 30788812]

10.

Sittner KJ, Greenfield BL, Walls ML. Microaggressions, diabetes distress, and self-care behaviors in a sample of American Indian adults with type 2 diabetes. J Behav Med. 2018 Feb;41(1):122-129. [PMC free article: PMC6005388] [PubMed: 29116568]

11.

Orom H, Sharma C, Homish GG, Underwood W, Homish DL. Racial Discrimination and Stigma Consciousness Are Associated with Higher Blood Pressure and Hypertension in Minority Men. J Racial Ethn Health Disparities. 2016 Oct 31; [PMC free article: PMC5411333] [PubMed: 27800597]

12.

Hennein R, Tineo P, Bonumwezi J, Gorman H, Nguemeni Tiako MJ, Lowe SR. "They Wanted to Talk to a 'Real Doctor'": Predictors, Perpetrators, and Experiences of Racial and Ethnic Discrimination Among Healthcare Workers. J Gen Intern Med. 2022 May;37(6):1475-1483. [PMC free article: PMC8475391] [PubMed: 34561823]

13.

Krieger N. ENOUGH: COVID-19, Structural Racism, Police Brutality, Plutocracy, Climate Change-and Time for Health Justice, Democratic Governance, and an Equitable, Sustainable Future. Am J Public Health. 2020 Nov;110(11):1620-1623. [PMC free article: PMC7542259] [PubMed: 32816556]

14.

Crawford A, Serhal E. Digital Health Equity and COVID-19: The Innovation Curve Cannot Reinforce the Social Gradient of Health. J Med Internet Res. 2020 Jun 02;22(6):e19361. [PMC free article: PMC7268667] [PubMed: 32452816]

15.

Devakumar D, Selvarajah S, Shannon G, Muraya K, Lasoye S, Corona S, Paradies Y, Abubakar I, Achiume ET. Racism, the public health crisis we can no longer ignore. Lancet. 2020 Jun 27;395(10242):e112-e113. [PMC free article: PMC7289562] [PubMed: 32534630]

16.

Xierali IM, Nivet MA. The Racial and Ethnic Composition and Distribution of Primary Care Physicians. J Health Care Poor Underserved. 2018;29(1):556-570. [PMC free article: PMC5871929] [PubMed: 29503317]

17.

Steinecke A, Terrell C. Progress for whose future? The impact of the Flexner Report on medical education for racial and ethnic minority physicians in the United States. Acad Med. 2010 Feb;85(2):236-45. [PubMed: 20107348]

18.

Campbell KM, Corral I, Infante Linares JL, Tumin D. Projected Estimates of African American Medical Graduates of Closed Historically Black Medical Schools. JAMA Netw Open. 2020 Aug 03;3(8):e2015220. [PMC free article: PMC7441360] [PubMed: 32816033]

19.

Savitt T. Abraham Flexner and the black medical schools. 1992. J Natl Med Assoc. 2006 Sep;98(9):1415-24. [PMC free article: PMC2569717] [PubMed: 17019906]

20.

Rivera Juarez AG, Prichard JR, Berg SS. Psychological Well-Being in Asian and Asian American University Students: Impacts of Discrimination During the COVID-19 Pandemic. J Adolesc Health. 2023 Sep;73(3):510-518. [PubMed: 37318412]

21.

McGarity-Palmer R, Saw A, Tsoh JY, Yellow Horse AJ. Trends in Racial Discrimination Experiences for Asian Americans During the COVID-19 Pandemic. J Racial Ethn Health Disparities. 2024 Feb;11(1):168-183. [PMC free article: PMC9815050] [PubMed: 36602751]

22.

Hastings PD, Hodge RT. Considering the experiences and adjustment of sexual and gender minority youths during the COVID-19 pandemic. Curr Opin Psychol. 2023 Oct;53:101660. [PubMed: 37517165]

23.

Jones CP. Toward the Science and Practice of Anti-Racism: Launching a National Campaign Against Racism. Ethn Dis. 2018;28(Suppl 1):231-234. [PMC free article: PMC6092166] [PubMed: 30116091]

24.

Bailey ZD, Feldman JM, Bassett MT. How Structural Racism Works - Racist Policies as a Root Cause of U.S. Racial Health Inequities. N Engl J Med. 2021 Feb 25;384(8):768-773. [PMC free article: PMC11393777] [PubMed: 33326717]

25.

Zhu DT, Zhao L, Alzoubi T, Shenin N, Baskaran T, Tikhonov J, Wang C. Public health and clinical implications of Dobbs v. Jackson for patients and healthcare providers: A scoping review. PLoS One. 2024;19(3):e0288947. [PMC free article: PMC10980209] [PubMed: 38551970]

26.

Yang YT, Sudarshan S. Preserving diversity in healthcare after the US Supreme Court's affirmative action ruling. BMJ. 2023 Jul 21;382:1691. [PubMed: 37479230]

27.

Ueda D, Kakinuma T, Fujita S, Kamagata K, Fushimi Y, Ito R, Matsui Y, Nozaki T, Nakaura T, Fujima N, Tatsugami F, Yanagawa M, Hirata K, Yamada A, Tsuboyama T, Kawamura M, Fujioka T, Naganawa S. Fairness of artificial intelligence in healthcare: review and recommendations. Jpn J Radiol. 2024 Jan;42(1):3-15. [PMC free article: PMC10764412] [PubMed: 37540463]

28.

Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016 Apr 19;113(16):4296-301. [PMC free article: PMC4843483] [PubMed: 27044069]

29.

Burgess DJ, Warren J, Phelan S, Dovidio J, van Ryn M. Stereotype threat and health disparities: what medical educators and future physicians need to know. J Gen Intern Med. 2010 May;25 Suppl 2(Suppl 2):S169-77. [PMC free article: PMC2847106] [PubMed: 20352514]

30.

Bullock JL, Lockspeiser T, Del Pino-Jones A, Richards R, Teherani A, Hauer KE. They Don't See a Lot of People My Color: A Mixed Methods Study of Racial/Ethnic Stereotype Threat Among Medical Students on Core Clerkships. Acad Med. 2020 Nov;95(11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 59th Annual Research in Medical Education Presentations):S58-S66. [PubMed: 32769459]

31.

Dogra N, Bhatti F, Ertubey C, Kelly M, Rowlands A, Singh D, Turner M. Teaching diversity to medical undergraduates: Curriculum development, delivery and assessment. AMEE GUIDE No. 103. Med Teach. 2016;38(4):323-37. [PubMed: 26642916]

32.

Smith WR, Betancourt JR, Wynia MK, Bussey-Jones J, Stone VE, Phillips CO, Fernandez A, Jacobs E, Bowles J. Recommendations for teaching about racial and ethnic disparities in health and health care. Ann Intern Med. 2007 Nov 06;147(9):654-65. [PubMed: 17975188]

33.

Stern AM. Cautions About Medicalized Dehumanization. AMA J Ethics. 2021 Jan 01;23(1):E64-69. [PubMed: 33554851]

34.

Grodin MA, Miller EL, Kelly JI. The Nazi Physicians as Leaders in Eugenics and "Euthanasia": Lessons for Today. Am J Public Health. 2018 Jan;108(1):53-57. [PMC free article: PMC5719686] [PubMed: 29161068]

35.

Eneanya ND, Yang W, Reese PP. Reconsidering the Consequences of Using Race to Estimate Kidney Function. JAMA. 2019 Jul 09;322(2):113-114. [PubMed: 31169890]

36.

Vyas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight - Reconsidering the Use of Race Correction in Clinical Algorithms. N Engl J Med. 2020 Aug 27;383(9):874-882. [PubMed: 32853499]

37.

Muller M, De Vries E, Tomson A, McLachlan C. An introduction to gender affirming healthcare: What the family physician needs to know. S Afr Fam Pract (2004). 2023 Jul 31;65(1):e1-e5. [PMC free article: PMC10483305] [PubMed: 37526532]

38.

Doebrich A, Quirici M, Lunsford C. COVID-19 and the need for disability conscious medical education, training, and practice. J Pediatr Rehabil Med. 2020;13(3):393-404. [PubMed: 33252100]

39.

Tervalon M, Murray-García J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998 May;9(2):117-25. [PubMed: 10073197]

40.

Zanting A, Meershoek A, Frambach JM, Krumeich A. The 'exotic other' in medical curricula: Rethinking cultural diversity in course manuals. Med Teach. 2020 Jul;42(7):791-798. [PubMed: 32160094]

41.

Kumagai AK, Lypson ML. Beyond cultural competence: critical consciousness, social justice, and multicultural education. Acad Med. 2009 Jun;84(6):782-7. [PubMed: 19474560]

42.

Brottman MR, Char DM, Hattori RA, Heeb R, Taff SD. Toward Cultural Competency in Health Care: A Scoping Review of the Diversity and Inclusion Education Literature. Acad Med. 2020 May;95(5):803-813. [PubMed: 31567169]

43.

Daya S, Illangasekare T, Tahir P, Bochatay N, Essakow J, Ju M, van Schaik S. Using Simulation to Teach Learners in Health Care Behavioral Skills Related to Diversity, Equity, and Inclusion: A Scoping Review. Simul Healthc. 2023 Oct 01;18(5):312-320. [PubMed: 36194859]

44.

Paul CR, Devries J, Fliegel J, Van Cleave J, Kish J. Evaluation of a culturally effective health care curriculum integrated into a core pediatric clerkship. Ambul Pediatr. 2008 May-Jun;8(3):195-9. [PubMed: 18501867]

45.

Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med. 1998 Apr;73(4):403-7. [PubMed: 9580717]

46.

Turbes S, Krebs E, Axtell S. The hidden curriculum in multicultural medical education: the role of case examples. Acad Med. 2002 Mar;77(3):209-16. [PubMed: 11891157]

47.

Dharamsi S. Moving beyond the limits of cultural competency training. Med Educ. 2011 Aug;45(8):764-6. [PubMed: 21752071]

48.

Leyerzapf H, Abma T. Cultural minority students' experiences with intercultural competency in medical education. Med Educ. 2017 May;51(5):521-530. [PubMed: 28394059]

49.

Heisler CA, Mark K, Ton J, Miller P, Temkin SM. Has a critical mass of women resulted in gender equity in gynecologic surgery? Am J Obstet Gynecol. 2020 Nov;223(5):665-673. [PubMed: 32585225]

50.

Manzi F. Are the Processes Underlying Discrimination the Same for Women and Men? A Critical Review of Congruity Models of Gender Discrimination. Front Psychol. 2019;10:469. [PMC free article: PMC6414465] [PubMed: 30894831]

51.

Hilton EJ, Lunardi N, Sreedharan R, Goff KL, Batakji M, Rosenberger DS. Two Sides of the Same Coin: Addressing Racial and Gender Disparities Among Physicians and the Impact on the Community They Serve. Anesthesiol Clin. 2020 Jun;38(2):369-377. [PubMed: 32336390]

52.

Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003 Dec 02;139(11):907-15. [PubMed: 14644893]

53.

Traylor AH, Schmittdiel JA, Uratsu CS, Mangione CM, Subramanian U. Adherence to cardiovascular disease medications: does patient-provider race/ethnicity and language concordance matter? J Gen Intern Med. 2010 Nov;25(11):1172-7. [PMC free article: PMC2947630] [PubMed: 20571929]

54.

Greenwood BN, Carnahan S, Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci U S A. 2018 Aug 21;115(34):8569-8574. [PMC free article: PMC6112736] [PubMed: 30082406]

55.

Marrast LM, Zallman L, Woolhandler S, Bor DH, McCormick D. Minority physicians' role in the care of underserved patients: diversifying the physician workforce may be key in addressing health disparities. JAMA Intern Med. 2014 Feb 01;174(2):289-91. [PubMed: 24378807]

56.

Laurencin CT, Murray M. An American Crisis: the Lack of Black Men in Medicine. J Racial Ethn Health Disparities. 2017 Jun;4(3):317-321. [PMC free article: PMC5909952] [PubMed: 28534304]

57.

Moy E, Bartman BA. Physician race and care of minority and medically indigent patients. JAMA. 1995 May 17;273(19):1515-20. [PubMed: 7739078]

Disclosure: Brandon Togioka declares no relevant financial relationships with ineligible companies.

Disclosure: Derick Duvivier declares no relevant financial relationships with ineligible companies.

Disclosure: Emily Young declares no relevant financial relationships with ineligible companies.