There are currently calls for changes to the way migration, colonialism, and Britain’s role in the slave trade are taught in the school curriculum and included in teacher training. We call for a similar reassessment of medical training. 

There is now overwhelming and undeniable evidence that racism is a determinant of ill health. Health inequalities that disproportionately affect Black, Asian and other ethnic minorities include increased maternal mortality, mental health treatment, diabetes treatment and poorer breast cancer outcomes, to name just a few. [1] 

Genetic determinism, socioeconomics and co-morbidities have regularly been given as the explanations for these disparities. There has been only infrequent attention paid to the way that racial discrimination causes physiological stress, affects access to healthcare and impacts on treatment. Conscious and unconscious racial biases in clinician-patient interactions damage patient management and outcomes. [2]

For NHS staff, racial discrimination accounts for lack of career progression, an ethnicity-linked pay gap, and stress and psychological burdens that affect their performance. [3] These differences begin with medical training, where bias permeates the education of doctors and nurses at every step—in admissions, clinical signs and case presentations, undergraduate examination performance and postgraduate training. 

Teaching on racism is largely absent from nursing and medical curricula—health disparities are documented but not contested, and multi-culturalism and diversity training are confused with anti-racist pedagogy. Truly anti-racist teaching confronts prejudice through the discussion of racism, stereotyping and discrimination in society. It teaches the economic, structural and historical roots of inequality. [4]

The Association of American Medical Colleges (AAMC) has produced an Anti-racism in Medicine Collection to provide educators with practice-based, peer-reviewed resources to teach anti-racist knowledge and clinical skills. The US-based Association for Prevention Teaching and Research (APTR) has designed an anti-racism toolkit to assist health professions faculty address and reduce systemic racism through their teaching. 

Recently, many UK higher education institutions, including medical schools, have released statements claiming commitment to tackling structural racism. Student activism has prompted one medical school to outline measures in which they will ‘de-colonise the curriculum’ and  the UK Medical Schools Council, in collaboration with the Dental Schools Council, has announced workstreams to improve outcomes for BAME students, including tackling the award gap and supporting medical schools to create an inclusive environment. Adopting an explicitly anti-racist curriculum which includes training for educators that echoes that of the AAMC and APTR would mean these statements and desires would be backed up by concrete, measurable actions.

Anti-racist education addresses three interconnected components—making systemic oppression visible, recognising personal complicity in oppression through unearned privilege and developing strategies to transform structural inequalities. [6] We suggest using this framework to create an anti-racist medical curriculum that includes the following:

• teaching the structural causes of racism and inequity, including recognising and addressing privilege, conscious and unconscious bias, and the concept of race as a social construct without genetic basis 
• including eugenics and wrongs against ethnic minorities and other marginalised people in science and medicine in the history of medicine [7]
• diversifying clinical teaching to include clinical signs on darker skin tones.
• making “understanding and challenging the health effects of structural racism” an essential professional medical competency, recognised within the domains of  good medical practice.   
• understanding that representation matters and investing in the development and progression of BAME staff as teaching faculty and as mentors [8]

Dismantling structural racism means that “healthcare professionals must recognise, name, understand and talk about racism competently.” [9] Real change will only be achieved if the medical curriculum is reformed to equip trainees with the tools to tackle historic inequalities. Now is the time to rethink what we do, what we have learned, and what we will teach future generations. [10]

Padmasayee Papineni is a consultant in infectious diseases and acute medicine, London North West University Healthcare NHS Trust 

Sarah Filson is a specialist registrar in infectious diseases and microbiology, London North West University Healthcare NHS Trust

Tiffanie Harrison is an HIV clinical nurse specialist, London North West University Healthcare NHS Trust

Malachi McIntosh is editor and publishing director of Wasafiri

Competing interests: none declared

References:

1. Paradies Y, Ben J, Denson N, et al. Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. PLoS One. 2015;10(9):e0138511. 
2. Hall WJ, Chapman MV, Lee KM, et al. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. Am J Public Health. 2015;105(12):e60-e76.
3. Esmail A, Abel P. The impact of ethnicity and diversity on doctors’ performance and appraisal. British Journal of Health Care Management. 2006;12(10):303.
4. McGregor J. The effect of role playing and anti-racist teaching on student racial prejudice: A meta-analysis of research. Journal of Educational Research. 1993;86(2):15-226.
5. http://www.tideproject.uk/wp-content/uploads/2019/07/TIDE-Runnymede-Teaching-Migration_Report_July-2019.pdf
6. Lynch I, Swartz S, Isaacs D. Anti-racist moral education: A review of approaches, impact and theoretical underpinnings from 2000 to 2015, Journal of Moral Education 2017; 46:2, 129-144.
7. Washington H. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. New York: Doubleday, 2006.
8. Erondu NA, Peprah D, Khan MS. Can schools of global public health dismantle colonial legacies?. Nature Medicine. 2020 Aug 28:1-2.
9. Hardeman RR, Burgess D, Murphy K, et al. Developing a Medical School Curriculum on Racism: Multidisciplinary, Multiracial Conversations Informed by Public Health Critical Race Praxis (PHCRP). Ethn Dis. 2018;28(Suppl 1):271-278. 
10. Gishen F, Lokugamage A. Diversifying the medical curriculum. BMJ. 2019;364:l300