University of South Florida

Fighting Racial Disparities In Health Through Student Education

USF Health students, staff and faculty during a White Coats 4 Black Lives demonstration outside of the USF Health Morsani Center, in June 2020.

In December 2020, Susan Moore, MD, an Indiana physician, died of COVID-19 after alleging she experienced racial discrimination while undergoing treatment at a hospital operated by Indiana University Health System. “Moore’s story of her pain being dismissed reinforces what studies have repeatedly shown: Even taking wealth, education and insurance status into account, Black patients receive worse medical care and face worse outcomes,” a Washington Post article on Dr. Moore’s death said.

Just one month before Dr. Moore’s death, the Association of American Medical Colleges (AAMC) shared an article that touched on a 2016 study published in the Proceedings of the National Academies of Science which included a survey that revealed that 40% of first- and second-year medical students endorsed the belief that “Black people’s skin is thicker than white people’s.” The study also showed that the trainees who believed this myth were less likely to treat Black people’s pain appropriately.

This article brought to light the continued need for institutions to address racial bias in healthcare starting with health education. USF Health is doing its part by building curriculums that teach the next generation of health care providers about social determinants of health and how to provide value-based and patient-centered care, and recruiting and retaining the diverse educators to teach it.

“Your goal as the practitioner is to truly understand who the patient is and all of the different aspects of the patient which may have some impact on their medical care,” Deborah DeWaay, MD, FACP, associate dean of undergraduate medical education for USF Health Morsani College of Medicine (MCOM), said. “It helps the provider battle unconscious bias because when they individuate patients in their mind, they’re less likely to give biased care.”

In 2016, MCOM started focusing on incorporating course objectives that examine prejudice, assumptions and privilege, such as Safe Zone training and poverty simulation activities. In 2019, Shirley Smith, MA, director of student diversity and enrichment for MCOM, became the College’s integration director for cultural competency. Using the AAMC’s objectives for cultural competency, Smith spent hundreds of hours reviewing the entire MCOM curriculum, and will continue to do so on an annual basis, highlighting places where the objectives were not being met to the highest level. These findings were then presented to the curriculum committee who make the final decision about changes to curriculum and if approved, provide recommendations for moving forward. In addition, Smith provided feedback to faculty about where there may be bias within the didactics. “It’s been really refreshing to have faculty embrace this and leadership like Dr. Lockwood, support this,” Smith said. Students also have the ability to provide real-time feedback to Smith and her team via an anonymous survey. “What we’re really trying to do is not have any judgement attached to the feedback,” Dr. DeWaay said. “We’re trying to create a method for our faculty who are teaching, to deal with their unconscious bias in a safe environment.”

USF College of Public Health Dean Donna Petersen, participating in the 2019 poverty simulation along with other USF Health deans, faculty, staff and students. Pre-Covid Photo.

MCOM is also in the process of partnering with Wake Forest University in North Carolina to create curriculum that can be used at both universities in order to maximize resources and reach more people. This material will become a curricular thread integrated across all four years of medical school which USF MCOM calls Humanism in Action. Smith quoted Bryan Bognar, MD, MPH, vice dean of MCOM educational affairs, when she explained that the important part of this effort is to make sure that they’re “baking things in” and that the curriculum is “not an à la cart menu.” The curriculum teaches students the communication skills necessary to elicit the values of their patients and then integrate those values into the patient’s medical plan. “It’s physically impossible in four years to teach students every single nuance about all the ways a human being or population can be different,” Dr. DeWaay said. “It’s far more important to teach the attitude that they need, the skills to illicit the information from the patient and the skills to keep up on the literature, so that they have the tools that they need moving forward, to take care of any patient that’s in front of them.” According to Smith, the objective is to teach students not to assume anything about their patient, not to project their own values onto the patient and not to deviate from what is fact or what is in the evidence. Janet Roman, DNP, APRN, ACNP-BC, director of the Doctor of Nursing Practice (DNP) program in the USF Health College of Nursing (CON), added that it’s not just about what question is asked, but about how it is asked. The way a question is worded can be loaded with an assumption and be offensive to the patient. “If you ask me, “Do I have access to healthy food?” now you’re assuming that I don’t,” Dr. Roman said. “If you ask me, “Where do I get my groceries?” then that gives you the answer.”

A taskforce is also being formed to include faculty and students who will help build and implement this new Humanism in Action curriculum and be a resource to faculty for recommendations or feedback on revamping lectures, small groups and activities. One component of change cultivated by the COVID-19 pandemic is the acceptance of virtual guest speakers and virtual learning by students and educators. This will allow for a more diverse representation of speakers to be a part of the courses as well as private, small group activities that can foster more vulnerable discussions. “These beliefs have to be socially unwoven through intentional, meaningful conversations and interactions with depth and the goal is to give students that opportunity,” Smith said. “I’m just planting seeds. I may never see the tree, but I must believe that the possibility is there.”

In January 2020, MCOM earned recognition from the Alpha Omega Alpha (AOA) Honor Medical Society for their dedication to diversity and understanding in various patient populations. The medical school was one of two medical schools in Florida to receive an Award for Excellence in Inclusion, Diversity and Equity in Medical Education and Patient Care. The award recognizes medical schools, and their associated AOA chapters, that demonstrate exemplary leadership, innovation, and engagement in fostering an inclusive culture that transforms the ideas of inclusion, diversity and equity into successful programs that support student, staff and faculty diversity in service to the community.

After the murder of George Floyd in May 2020, students pleaded for a call to action for faster implementation of changes to the curriculum. “The morbidity and mortality that social determinants of health, systemic racism, and health care disparities have cost people living in this country, far surpasses the toll COVID will take, and yet we’re not tackling it with the same resources,” Dr. DeWaay said. “With COVID hitting, it shows us on a local, regional and national level, what we’re capable of doing when we’re really worried about something.” Fueled by the same passion as the students who have championed these efforts from the very beginning, Smith and Dr. DeWaay returned to the curriculum committee and presented a 15-point, call to action. The committee mandated the plan in June 2020.

Dr. Deborah DeWaay (center), associate dean of undergraduate medical education for USF Health Morsani College of Medicine, with medical students. Pre-Covid Photo.

According to the Center for Disease Control and Prevention (CDC), there is increasing evidence that Black, Indigenous and Latinx communities are suffering disproportionately from COVID-19. This is the kind of information that can spark a myth about minorities if the root of the cause is misunderstood. Black Americans are infected with COVID-19 at nearly three times the rate of white Americans and are twice as likely to die from the virus, according to a report from the National Urban League based on data from Johns Hopkins University. This is not because of any biological differences between the two groups, but instead, social determinants of health and systemic racism. This is evident in the report which shows that Blacks are more likely to have preexisting conditions that predispose them to COVID-19 infection, less likely to have health insurance, and more likely to work in jobs that do not accommodate remote work. “Your zip code may be the biggest determinate of your health outcome more than anything else,” Kevin Sneed, PharmD, dean of the USF Health Taneja College of Pharmacy (TCOP), said.

Understanding these social determinants of health is instrumental in dispelling myths and providing patient-centered care and is another key component of USF Health education. Social determinants of health are conditions in the places where people live, learn, work and play that affects a wide range of health and quality-of life-risks and outcomes. Factors can include a person’s education, financial literacy, discrimination, and access to healthy food and safe places to exercise. Students in the USF Health College of Nursing learn about disease processes such as heart failure, hypertension and diabetes, and at the same time, “we want to point out to students which populations are disproportionately affected and then give them that background on why, so that we can help close that health disparity gap,” Dr. Roman said.

According to Dr. Sneed, one of the most meaningful courses offered at the Taneja College of Pharmacy, one that has been a requirement for first-years ever since the inaugural class of 2011, is the introduction to public health course. The course was developed by the USF Health College of Public Health (COPH), continues to have input from their faculty, and mainly focuses on social determinants of health. “You spotlight that in a course and then when you give the demographics of what that means for these various communities, it really does help broaden the expanse of how people view communities of color and why we do things like Bridge Clinic and Tampa Bay Street Medicine,” Dr. Sneed said. “We’re going to have to push to a different level of comfort, maybe even discomfort for many people in order for it to really take hold.”

A pharmacist has a unique place in the community. “Not everybody has a physician or has health insurance, but anybody can go to CVS and say, “my child has a fever,” Tricia Penniecook, MD, MPH, vice dean for education and faculty affairs for COPH, said. The patient benefits if the pharmacist has a public health world view and can help make decisions that are best for the patient’s situation.

USF College of Pharmacy Dean Kevin Sneed, PharmD, and Tricia Penniecook, MD, MPH, vice dean for education, participating in a Voices in Leadership panel discussion during USF Health Multicultural Week in 2019. Pre-Covid photo.

While colleges of medicine, nursing and pharmacy focus on helping patients where they are downstream, sick that day, public health looks upstream and tries to address what has happened to bring them to that point. Instead of individual-based care, public health professionals look at the care of groups of people in the population and find and fill gaps in their access to health care or the conditions for people to be healthy. That’s why interprofessional education is a critical part of USF Health because both kinds of roles are important. “As part of the discipline of public health, you’re supposed to take care of those who are at a disadvantage,” Dr. Penniecook, said. “The structures and systems in this country have put certain populations immediately at a disadvantage just because of that’s who they are when they are born.”

An integral part of every accredited college of public health in the United States is making sure that students learn about health inequities that are based on disparities. At USF Health’s COPH, students not only have courses specifically on health inequities, but the topic is addressed in every public health course from the undergraduate to the graduate level. Having this thread at every level means that students learn what the basis of those health inequities are, what they look like and how to address them no matter where their career takes them. According to Dr. Penniecook, this means that if the student is going to be working in the community, they’ve learned about community education and teaching people about self-advocacy in the healthcare system; if the student is going to be working within the system, they’ve learned about how to measure and address health inequities; or if the student is going to have a leadership role, they’ve learned about being proactive in looking for ways to solve the health inequities such as policy development.

Prior to COVID-19, COPH started working on an academic master plan. Dr. Penniecook, described an academic master plan as a road map within the strategic initiatives of the institution, that tells you what you need to do academically to get to your goals. In response to the murder of George Floyd, Dr. Penniecook asked Donna Petersen, ScD, MHS, CPH, dean of the USF Health COPH, if they could integrate structural racism into the academic master plan. Just like MCOM’s Dr. Bognar was previously quoted as saying that these changes have to be “baked in” the curriculum, Dr. Penniecook wanted these efforts to combat structural racism to be more strategic and woven into everything they do and who they are, so that it’s more likely to stick. A variety of work groups will be formed to include faculty, staff and students to look at admissions, curriculum, teaching methods, educational spaces and recruitment, and then make recommendations to the college structure. While this master plan is a work in progress and was paused when COVID-19 first hit, Dr. Petersen has already impacted and set the tone for the two freshman courses she teaches as a part of the Master of Public Health program. She has always had a required summer reading list, but this past summer, the entire list was equipped with books on structural racism. In addition, different aspects of structural racism have been the topic of several of the College’s townhall meetings, some lead by students, as well as episodes of the Activist Lab’s Activist Lab on the Road podcast.

An interprofessional student team across the Colleges of Medicine, Nursing and Public Health, and the School of Physical Therapy, at the 2018 USF Health Research Day. Pre-Covid Photo.

The curriculum used to educate our future health care professionals is only one piece of the puzzle. The faculty who teach it are the other. “Student exposure to those from impoverished backgrounds may occur for the first time when they are in medical school,” Haywood Brown, MD, professor of obstetrics and gynecology, associate dean of diversity for USF MCOM, and vice president for institutional equity for the University of South Florida System, said. “They don’t get that in the classroom because there is so few, diverse faculty teaching the curriculum.” According to a board diversity statement from the American Council on Education (ACE), diversity in university student bodies, faculties and staff, enriches the educational experience, promotes personal growth and a health society, strengthens communities and the workplace, and enhances America’s economic competitiveness. “If you do not have a diverse workforce, the patients don’t benefit as much because you’re learning from each other,” Dr. Brown said.

In November 2020, the USF Health College of Nursing appointed Usha Menon, PhD, RN, FAAN, as the new dean after serving as interim dean of the College since February of that year. According to Dr. Roman, under this new leadership, one of the College’s initiatives is to increase the diversity, equity and inclusion not only in the curriculum, but also in the student, faculty and staff populations. As a part of this initiative, Dr. Menon realigned her senior administrators which included creating a director of diversity role, now filled by Ivonne Hernandez, PhD, RN, IBCLC, assistant professor at the USF CON. “What we are developing now, before we even start recruiting, is a way to retain,” Dr. Roman said. “We are nurse scientists, and we treat our patients and our students by the evidence. We are doing the same thing with diversity, equity and inclusion, and what our data shows is that when we have persons of color, they don’t stay.” CON’s strategic goals include increasing the diversity of research faculty by 35% and of clinical faculty by 10%, by 2023. One retention method coming soon is a mentoring program.

According to Dr. Roman, CON is not making these changes just to check off a box for diversity on a list of requirements. “The College of Nursing is doing a 360,” Dr. Roman said. “We’re changing everything. We are doing the right thing for all people and it’ll be a complete culture change.” A healthy and safe culture and work environment will also help retain high quality, diverse faculty. “We have to reiterate that incivility is not tolerated, and micro and macro aggressions are not tolerated,” Dr. Roman said. “We also have to bring to the forefront what already exists in the University processes for what to do if you feel violated and not to suffer in silence.”

Even outside of the university classrooms, USF Health students are coming together to fight racial disparities in the healthcare system. In August 2020, MCOM became an official chapter of the national White Coats 4 Black Lives. Open to all USF Health students, the goal of the organization is to safeguard the lives and well-being of patients through the elimination of racism. To accomplish this goal, WC4BL and the USF Health chapter look to foster dialogue on racism as a public health concern, end racial discrimination in medical care, and prepare future physicians to be advocates for racial justice. “It’s everyone’s responsibility, but it’s only a priority to some,” Smith said. “For those who make it their priority, we want to give them tools to learn how to engage in these spaces that make it safe for them and make it safe for the other person to have these kinds of courageous conversations. Equipping the next generation of thought leaders so they can change the thoughts out there.”

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