By Alida M. Gertz, MD, DrPH, MSc, MPH, DTM&H, Wellstar Douglas Family Medicine Residency Program, Marietta, GA, University of South Florida, College of Public Health, Tampa, FL; Michele Smith, PhD, MS, LMFT, Wellstar Douglas Family Medicine Residency Program, Marietta, GA; Davon Thomas, MD, Wellstar Douglas Family Medicine Residency Program, Marietta, GA; Angeline Ti, MD, MPH, Wellstar Douglas Family Medicine Residency Program, Marietta, GA, University of South Florida; Charles Eaddy MD, Wellstar Douglas Family Medicine Residency Program, Marietta, GA; Cheryl Vamos, PhD, MPH, University of South Florida, College of Public Health, Tampa, FL; Joe Bohn, PhD, MBA, University of South Florida, College of Public Health, Tampa, FL

Introduction

Racism has a well-documented negative effect on physical and mental health ¹. Family physicians across the United States (U.S.) comprise the frontline of medical care for large portions of the population including many underserved and underinsured patients ². Providing family medicine physicians with the tools they need to combat racism may help to decrease disparities ^3,4. Both the American Academy of Family Physicians (AAFP) and the Society for General Internal Medicine (SGIM) have developed tools to help educators design curricula to accomplish this ^5,6. Despite these calls to action, only a small number of graduate medical education programs report implementing curricula specifically focused on anti-racism teaching ⁷.

Strategies previously described for teaching residents to combat inequities include knowledge improvement techniques, competency-based curricula, and increasing underrepresented minorities in medicine⁸. Previous studies demonstrate that residents believe implementation of such a curriculum would be useful for their development as effective physicians⁹. Components of the similar curricula focused on disparities in general, described in the literature, include lectures, direct patient experiences, longitudinal experiences, and increased diversity of the residents and faculty ^10-12. Some of these papers also include descriptions of curricular evaluations, however, none include patient oriented outcomes ¹³. Wolff et al. (2007) demonstrated that a competency-based curriculum improved resident capabilities ¹⁴; while Dennis et al (2019) showed that lecture curriculums and workshops changed knowledge and attitudes, increased awareness and understanding of racism in medicine ¹⁵. Implementing anti-racism curricula is a challenging undertaking in the United States for multiple reasons including the long history of discrimination and racist systems and structures that exist in American Society and the health care system,  and the Southern region of the US is particularly difficult given the history of Slavery and ongoing racist beliefs held by many¹⁶. This paper describes the experience and lessoned learned during the first year of implementing and evaluating an anti-racism curriculum for a community-based family medicine residency program in the Southeastern United States. 

Methods

From June 2021 to July 2022, the first year of the program's anti-racism curriculum was implemented. Evaluation of the program also began during this period with pre-curriculum surveys being conducted in July of 2021 and late curriculum surveys in February of 2022. Focus group discussions (FGDs) were also conducted mid-way through the curriculum in winter of 2021-2022. De-identified data for a patient-oriented outcome were extracted from the medical record from the three months prior to curriculum implementation (April through June of 2021) and the three months after the first year of the curriculum was completed (July through September of 2022). The curriculum consisted of the following activities: (1) One grand rounds lecture every two months with an anti-racism theme, conducted by an expert in racism in medicine. (2) One Balint session every 6-9 months focused on anti-racism. Balint groups focused on discussing patient-related race issues once every other month; discussions were meant for resident reflection and were not recorded or analyzed. (3) One-hour sessions at the start, middle, and end of each year where residents discussed how the curriculum was going and how it could be improved. (4) Assigned readings for selected sessions and a resource list for residents to pursue further reading on their own if desired. Curriculum Learning objectives were as follows: (1) Understand the United States’ racist roots. (2) evaluate how racism and our current medical system have shaped our narrative about disparities. (3) Identify racism in healthcare and health services research, and (4) Create tools for healthcare professionals to counteract existing racism and dismantle structures that perpetuate racism. The learning priority was ensuring that residents have the tools to confront racism, teach those tools to others, and be motivated to continue learning and teaching even after they finished the curriculum. 

Focus groups were conducted partway through the curriculum’s first year in late 2021. The focus groups were separated by self-identified race to allow for open discussion. A semi-structured guide was used to facilitate discussion. FGDs were recorded and transcribed. Transcriptions were de-identified. Qualitative analysis was done to determine common themes and sub-themes. Open coding was used to identify recurring themes. Online surveys were conducted before (in summer of 2021) and during (early 2022) curriculum implementation to assess the residents’ perception of curriculum effectiveness. Surveys were anonymous and no personal information was collected. Data from surveys were analyzed descriptively. Three patient-oriented outcome measures were planned. The specific outcomes were chosen as previous data suggested racial disparities within the community existed. First, the change in colon cancer screening rates among Black patients in the resident clinic: the percentage of eligible patients who were up to date on their colon cancer screening before the curriculum started was compared to the percentage of eligible patients who were up to date on their colon cancer screening after the curriculum ended. The change in percentage among Black patients compared to the change in other groups (e.g. White, Hispanic, and Asian) was also a planned measure. The second was the change in hemoglobin A1C (HbA1C) levels among Black patients with diabetes from before to after curriculum implementation. The average change in HbA1C in Black patients was compared to the average change for White, Hispanic, and Asian patients. The last was referrals to nephrology among Black patients with CKD from before to after the implementation of the curriculum. The referral rate among Black patients compared to that for White, Hispanic, and Asian patients was also a planned measure. Approval for curriculum evaluation using surveys, focus groups, and patient oriented outcomes evaluation was sought and obtained from the institutional IRB.

Results

One hundred percent of residents and faculty voluntarily participated in four focus groups of 6 (24 total). The first focus group identified a number of themes: (1) The majority of residents were in favor of having an anti-racism curriculum. (2) Most residents had some in experience with anti-racism teaching but thought that more would be useful. (3) Most residents felt that racism affected them and their patients. (4) Residents were concerned that anti-racism instruction might take away from learning in other medical topics. (5) Residents hoped the curriculum would better prepare them to discuss racism with patients and colleagues. (6) Residents preferred interactive sessions over straight lectures and in general hands-on experience or case studies. (7) Residents reported that they wanted to learn fact-based knowledge such as history and the evidence base for how racism affects health in disparate ways. 

For the surveys, 25 of 27 (93%) of residents and students rotating with the program at that time responded to the pre-curriculum survey, and 18 of 25 (72%) participated in the late-curriculum survey. Quantitative analyses showed no difference from pre-curriculum to mid-curriculum in resident responses to questions about demographics; however, there was a shift to greater percentages of residents believing that racism plays a role in medical outcomes and has an effect on them and their patients, and a belief that they are better prepared to combat racism in medicine (Table 1).  

Table 1: Participant demographics, reported patient racial/ethnic mix, perspective on racism's role in practice — pre- and late-curriculum

*Categories were not mutually exclusive

While many residents learned about the influence of racism on healthcare and learned about themselves, fewer residents changed the way they interacted with patients (Table 2). Many residents were interested in continued discussions or lectures.

Table 2: Participant perspective on curriculum effectiveness- late-curriculum

With regards to the one patient oriented outcome able to be measured, prior to the curriculum, there was no difference at the clinic among Black and non-Black patients in the average HbA1c value (mean 7.8 vs 7.8, p=0.67). However, Hispanic patients did have a higher HbA1c prior to the curriculum than non-Hispanic patients (mean 8.3 vs 7.8, p=0.01). On average, there was an improvement in HbA1c from before compared to after curriculum implementation (mean 7.9 vs 7.7, p=0.02). When stratified by race/ethnicity however, the improvement was only significant among Hispanic patients (mean 9.5.vs 7.8, p<0.001), not Black patients (mean 7.9 vs 7.6, p=0.38)

Discussion 

Implementation challenges were common but also represented opportunities for future years. Given curriculum planning occurred as the Black Lives Matter movement was gaining momentum and as the COVID-19 pandemic had recently again brought to the forefront of public attention, long-existing inequities in the US population and medical system, the faculty were able to gain support at the individual resident and faculty levels, as well as the institutional and systems levels. At the same time, the AAFP and other medical groups were also in the process of updating recommendations for medical education curricula to include racism, diversity, equity, and inclusion, which provided an opportunity for faculty to successfully advocate for creation of the curriculum. Multiple evaluation challenges were also encountered. Of the planned data collection, only partial data could be collected due to staffing shortages within the healthcare system and staff turnover during the COVID pandemic. Funding for lecture honoraria did not continue after the first year. Lectures, reading, and Balint discussions were the only aspects of the curriculum that were able to be implemented in the first year due to staffing limitations. End of year surveys and focus groups as well as two out of the three patient-oriented outcome measures were unable to be completed. Additionally, it is hard to argue for causality given the brief time period. While the available survey data indicated that residents found the curriculum helpful, many data were unavailable to assess the impact on patient-oriented outcomes or more in-depth dive into how the residents felt and what could be improved. Notably, faculty champions also faced difficulty obtaining funding, lack of protected faculty time for curriculum development, finding qualified and willing speakers, and scheduling curriculum activities.

Plans for future years involve strategies developed from the faculty champions and resident feedback. These strategies include: (1) securing a permanent funding source, (2) identifying permanent speakers, (3) continuous quality improvement including continued solicitation of feedback from residents and faculty, (4) and continued efforts to measure meaningful patient-oriented outcomes.

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