Anti-Racism

Definition(s) of Terms

Starting with a common understanding of key words, phrases, and potentially misunderstood related terms in DEI discussions helps ensure that all participants feel informed and welcome to participate in the discussion. Some terms have multiple definitions provided to help highlight nuances in the definitions.

Race:

Race is a social construct that does not have a biological basis. Although the construct of race is dynamic and evolves with changing social, political, and historical norms, the construct perpetuated the false idea that there are static, innate characteristics that apply to sets of people despite diverse origins, life experiences, and genetic makeups. However, race is distinct from ancestry. Ancestry denotes people’s shared traits based on the genetic similarities of their ancestors and accounts for the complexity of geographic variation and fluidity amongst peoples. While race is socially constructed, the consequences of this social construct are experienced individually and collectively by communities in the form of racism.

Racism:

Racism is not just individual prejudice - but a hierarchical system based on race, created and maintained by unequal distribution of power/resources
Dr. Camara Jones highlights that there are 3 different types of racism we should consider (1):
- Institutionalized racism: systematically created differential access to the goods, services, and opportunities of society by race.
- Personally mediated racism: prejudice and discrimination, where prejudice means differential assumptions about the abilities, motives, and intentions of others according to their race, and discrimination means differential actions toward others according to their race. (in short prejudidce is the negative thoughts and discrimination is the actions these thoughts engender). This is what most people think of when they hear the word “racism.” Personally mediated racism can be intentional as well as unintentional
- Internalized racism: acceptance by members of stigmatized races of negative messages about their own abilities and intrinsic worth. It is characterized by their not believing in others who look like them, and not believing in themselves.

Anti-Racism: Pairing thought with action

The author and activist bell hooks describes how any practical model for social change around racism should include “an understanding of ways to transform consciousness that are linked to efforts to transform structures (2).”
Ibram X. Kendi similarly notes that combating racism demands a “reorientation of our consciousness (3).”
Anti-racism includes critical reflection about, and subsequent action on, the impacts of power relations intrinsically tied to race, which represent crucial steps toward the structural change necessary to combat racism in healthcare (4).
It seeks to “explain and counteract the persistence and impact of racism” and to “promote social justice for the creation of a democratic society…” It involves “inquiry, experimentation and reflection; thereby, providing the opportunity to make changes based on current conditions.” Kishimoto (5) further describes anti-racist pedagogy as an “organizing effort for institutional and social change that is much broader than teaching in the classroom”, describing that faculty must not only be aware of their own social position, but must invest in the following components: (1) incorporating the topics of race and inequality into course content, (2) teaching from an anti-racist pedagogical approach, and (3) anti-racist organizing within the campus and linking our efforts to the surrounding community (6).
Solomon (7) and colleagues have described a framework for anti-racism in medical education: see, name, understand, act. They describe how each step of this framework mirrors concepts that are familiar in health professions education: “teaching clinical reasoning, confronting and learning from medical error, engaging in continuous quality improvement, and cultivating a growth mindset and adaptive expertise.”

Synonyms/Related Terms

This section highlights the definitions of other words that may be used in discussion of this topic. Sometimes these words can be used interchangeably with the terms defined above, and sometimes they may have been used interchangeably historically, but have distinct meanings in DEI conversations that it is helpful to recognize.

Antiracism and diversity are not the same

Diversity is the practice or quality of including or involving people from a range of different social, ethnic, gender, and sexual backgrounds while still respecting them for their differences. Unfortunately, this relies on the assumption that we live in a society where all people have equal access to resources. Even within diverse groups, there is an imbalance of power. As a result, those who identify as non-white are further marginalized by unchallenged systemic racism. Antiracism challenges systemic racism without undermining the intersectional work around diversity, equity and inclusion that has already been done, but by taking action.

Antiracist does not mean unbiased

We all have biases, and have to actively work to mitigate those biases in real time. Anti-racism reflects an intentional and thoughtful effort to understand biases and interrupt their continued impact on individuals, institutions, and society at large.

Scaling This Resource: Recommended Use

As many users may have varying amounts of time to present this material, the authors have recommended which resources they would use with different timeframes for the presentation.

1 minute options:

Provide a definition of what anti-racism actually means
Describe the CDC’s report on racism as a public health crisis
Provide a quote on anti-racism and encourage participants to individually reflect

10 minute options:

Combine video-viewing or quotations with a definition of anti-racism
Combine review of statistics on impacts of racism with a definition of anti-racism
Choose a video or quotation and encourage participants to reflect individually or share in pairs

30 minute options:

Combine overview of statistics on impacts of racism with definitions of race, anti-racism, and a description of the socio-ecological model of anti-racism in emergency medicine

Discussion/Background

This section provides an overview of this topic so that an educator who is not deeply familiar with it can understand the basic concepts in enough detail to introduce and facilitate a discussion on the topic. This introduction covers the importance of this topic as well as relevant historical background.

Racism is a threat to public and individual health and a threat to the diversity, inclusivity, and longevity of the healthcare workforce.

“In 2021, the Centers for Disease Control and Prevention declared racism a serious threat to public health (8). Racism has long been ingrained in the structures of health and the practice of healthcare, and this recognition, though belated, underscores the urgent need to address racism in medicine. The racist history of American healthcare is evident in the indelible examples of inequity that litter its past, including the practice of experimentation and exploitation without consent, disparate access to care, and segregation in hospital wards (8–11). Racism remains a threat to patients by contributing to rampant disparities in morbidity and mortality, including poor maternal outcomes amongst Black women, differential care and outcomes in stroke and cardiovascular disease for people of color, and disparities in COVID-19 outcomes. Furthermore, racism also represents a threat to the diversity and inclusivity of the healthcare workforce. Racist policies such as the early exclusion of Black students from medical schools and of Black physicians from national physician organizations, coupled with the closure of historically Black medical schools as a result of the Flexner report, have contributed to a persistent underrepresentation of Black and Indigenous People of Color (BIPOC) matriculants in medical schools (11,12). These disparities endure beyond medical school training; racial minorities graduating from US medical schools are less likely to initially secure residency positions compared to their White counterparts even after controlling for differences in test scores and consequently remain underrepresented in the physician workforce (11,13). Medical trainees continue to face race-based discrimination and harassment, which threatens their confidence, performance, well-being, and willingness to remain in medicine and academics (14–17). Finally, the lack of widespread acceptance of race as a social, not biological, construct continues to hinder medical research and propagate racist myths that can compromise patient care (18,19). Racism, in all its forms, whether institutionalized, personal, or internalized, must be addressed to mitigate the threats its continued existence poses to patients and physicians (1,8). In this context, health professionals must recognize the common refrain initially expressed by Angela Davis, “In a racist society, it is not enough to be non-racist; we must be anti-racist.” (4)

Anti-Racism in Healthcare: An Urgent Need for Reflection and Action

Health professionals must commit themselves to doing the proactive work of interrogating their own role and complicity in propagating harm, while also working to break down the intersecting structural and political landscapes that foster this reality.

Despite the immediacy and importance of this issue, there is little standardization or consensus on how to best equip emergency physicians to address racism on both an individual and institutional level. We do know, however, that implicit bias, diversity, and cultural humility trainings, while helpful, are not a panacea, and are insufficient. Additionally, while many feel a sense of duty to be antiracist and make it a priority when a high profile event occurs, the pressing need to commit ourselves to this principle is omnipresent, as racist structures and systems continue to persist regardless of media focus. It’s not good enough to just state “Black Lives Matter” or label messages with #StopAsianHate hashtags, for instance; we have to put in the work to make these statements meaningful and actionable.

Structured educational interventions for individual clinicians and departments alike are necessary for inspiring critical reflection. Past is prologue, so as emergency physicians, it is important that we have an awareness of the ways that racism has influenced our current state of affairs as individuals and as a specialty operating within a larger healthcare system and society. Armed with this awareness, individuals must ask themselves key questions including, “How do I benefit/contribute to these injustices?”, “What concrete decisions can I make each day to make things better?”, “How can we be better about fostering a more inclusive and equitable culture within our department?” and “ How can I better support my colleagues who have been harmed by these injustices?” This critical reflection should then be paired with action at the individual, departmental, and institutional level - this may include evaluating or changing policies, workflows, clinical guidelines, and hiring and recruitment practices. Consider the socio-ecological model described by Franks et al, to conceptualize how reflection and action can be applied at individual, organizational, community, and policy levels, including understanding the history of racism in healthcare, building and maintaining workforce diversity, applying principles of social emergency medicine to individual- and community-level patient care interventions, and local and national advocacy for reform (20).

Quantitative Analysis/Statistics of note

This section highlights the objective data available for this topic, which can be helpful to include to balance qualitative or persuasive analysis or to help define a starting point for discussion.

Patient Outcomes

Black patients with long bone fractures are 66% more likely to receive no analgesics than Whites and non-white Hispanic patients were 2 tmes more likely to receive no analgesics (21)
Black pediatric patients are 1.8 times more likely to be placed in physical restraints than Whites (22).
Experiencing racism is associated with 2 to 3 times the odds of lower satisfaction with care, inadequate communication and frayed provider relationships (23)

Healthcare Workforce

48% of non white academic emergency physicians experienced racial discrimination while on their job (24).
EM Residents of color are more likely than their white colleagues to experience racial discrimination at work (37.6 vs 7.9%) (25)
URM faculty are less likely to be promoted compared with white faculty (relative risk [RR], 0.68 [99% confidence interval CI, 0.59-0.77] for assistant professors and 0.81 [99% CI, 0.65-0.99] for associate professors) (26).
18% of chair/vice chair positions held by non white faculty (27)
Blacks have obtained about ~2% of RO1 grant funds and Latinos ~5% whereas Whites and Asians account for 93% of the grant funds (28,29)

Role-playing Scenario

Role-playing scenarios can enhance investment and participation. Always consider psychological safety when asking participants to engage in any role-playing activity to avoid potential adverse effects. We highly recommend a discussion for each group to agree on ground rules of respectful learning prior to engaging in any role-playing scenarios (embrace ambiguity, commit to learning together, listen actively, create a brave space, suspend judgment, etc.). It is reasonable to review these ground rules prior to each role-playing discussion.

Being an upstander
1. During the 7am signout you are taking a “medical minute” with the rest of the day team. A resident from a consulting service walks out of a room and asks the entire group if the patient has been tested for “China Flu” yet.
  1. How would you respond?
    1. Follow-up questions:
      1. What are the consequences if no one says anything?
      2. Whose responsibility is it to say something?
    2. Debriefing/reflection prompts for facilitator:
      1. How do we empower each other to speak up?
      2. How do we develop comfort with discomfort?
    3. Additional resources for facilitators to review or share with participants include:
Institutional change
1. While walking around the hospital, you and a colleague notice that the majority of portraits displayed on hospital walls are of men, and almost none are of people of color.
  1. How would you respond? Would you be comfortable bringing this to the attention of decision-makers in the institution? How would you do it?
    1. Debriefing/reflection prompts for facilitator:
      1. Using this article to guide discussion (30).
      2. Think about the walls of your hospital or department offices. Whose images are on the wall?
      3. Think about the virtual spaces of your department or hospital. Are the images online (website/social media) diverse? Are they representative?
      4. How does one balance the need for change with the risk of performative allyship? How about the risk of harm if institutions overstate the diversity of their workforce? What other considerations - history, legacy, acknowledging past failures or injustices - might you consider?
Critical reflection and awareness
1. After an educational session on anti-racism, a colleague remarks that “anti-racism is just a fad… this is just reverse discrimination.”
  1. How would you respond?
    1. Debriefing/reflection prompts for facilitator:
      1. There has been a lot of controversy around critical race theory and anti-racism. How much do you know about these topics? How comfortable do you feeling discussing them? Do you know where to look to educate yourself further?
        Facilitators may consider reviewing or sharing the following with participants: https://www.tandfonline.com/doi/abs/10.1080/13613324.2016.1248824?journalCode=cree20, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446334/pdf/10936998.pdf, sharetools.org

Barriers/Challenges/Controversies

This section should help the facilitator anticipate any questions, naysayers, rebuttals, or other feedback they may encounter when presenting the topic and allow preparation with thoughtful responses. Facilitators may experience concerns about their personal ability to present a specific DEI topic (ie a white facilitator presenting on anti-racism or minority tax), and this section may address some of those tensions.

The following barriers and tips for overcoming them are available on sharetools.org.

Meeting participants where they are:

At any given time different learners in a group may experience different levels of psychological safety, may have variable needs or expectations and may be in different “zones” in the process of becoming anti-racist (31). Such “zones'' include the “fear zone,” characterized by avoidance or denial; the “learning zone,” where increased discomfort is tolerated and accompanied by openness to vulnerability, self-critique, and diverse perspectives; and the “growth zone,” wherein one starts to assume responsibility and engage in advocacy and education (31). Participants’ readiness and receptiveness may vary, and those leading the curriculum may need to adapt to their specific learners and learning environment. Studies of anti-racism curricula among medical students have shown that students of color and White students have differing needs or experiences when participating in such curricula (17).

Prepare strategies for addressing harm:

Debriefs and check-ins with learners should be conducted, and appropriate resources or outlets for debriefing or counseling should be made available to all participants. Educators must make it a priority to ensure that the content of sessions minimizes risks of retraumatization, or vicarious or secondary traumatization, of faculty and participants alike.

Pair conversation with action:

Being an anti-racist is not defined by a single action, but instead represents an iterative, sustained, and multi-faceted effort. Most importantly, words without action are of limited utility; it is important to pair these discussions with actions that address the issues and concerns that are unveiled through conversation.

Build institutional engagement:

We recognize that each institution and their respective cultures are distinct and require different approaches to gaining buy-in to engage in these important discussions. Potential ways to encourage buy-in may include partnering with your institutions department of equity and inclusion to trial a session, beginning with less emotionally charged topics/sessions (personal responses tour, mural arts tour), connecting a session to a patient complaint or clinical case discussion that features relevant issues, or inviting outside speakers to help begin these conversation.

Opportunities

Sometimes DEI topics can present depressing history and statistics. This section highlights glimmers of hope for the future: exciting projects, areas of study inspired by the topic, or even ironic twists where progress has emerged or may be anticipated in the future.

There is unprecedented momentum now to implement antiracist educational and structural interventions in emergency medicine, as evidenced by popular media coverage, social media, editorials in the scientific literature, and presentations at national EM meetings. Individuals across the spectrum of emergency medicine training, from pre-health undergraduate students, medical students, residents, faculty, and leadership, along with interprofessional partners such as nurses or administrators, are engaged in, aware of, or invested in this topic. It is crucial to seize upon this momentum and this moment to make real and sustained change.

There is significant work ongoing within social emergency medicine on documenting health disparities, as well as within the graduate medical education field on the topic of inclusive resident recruitment processes and structural competency education.

There are opportunities for innovation and intervention in staff workforce recruitment and retention, mechanisms for understanding the impact of racism in clinical decision-making, implementing interventions to address disparities, incorporation of antiracism into EM education, and advocating for anti-racist policy change. Additionally, many major national EM organizations have committees dedicated to these topics, representing another avenue for individual involvement.

Journal Club Article links

A journal club facilitator can access several salient publications on this topic below. Alternatively, an article can be distributed ahead of a presentation to prompt discussion or to provide a common background of understanding. Descriptions and links to articles are provided.

https://pubmed.ncbi.nlm.nih.gov/34598829/

This article, written by emergency physicians of color, is a call to action addressed to their white colleagues, and describes the authors’ experiences with racism, especially in the context of specific events or occurrences, such as COVID-19 or police brutality.
This may be a thought-provoking piece that may both inspire its readers, and may make some uncomfortable, but should create productive dialogue, especially amongst a group of participants who are not necessarily in the same zone of anti-racism.

https://www.healthaffairs.org/do/10.1377/forefront.20201029.167296/full/

This article describes a “social-ecological framework that structures the intentional actions that emergency medicine must implement at the individual, organizational, community, and policy levels to actively respond to this emergency and be antiracist.” This may serve as a jumping off point for individual reflection or group discussion on 1) specific ways/examples they may individually implement the recommendations of this article, 2) barriers to doing so, and 3) ways to measure impact.

https://jamanetwork.com/journals/jama/fullarticle/2770682

This article is a good jumping-off point for thinking about biomedical racism. The article suggests differences in Covid-19 burden amongst Black patients because of differences in the expression of a certain gene in the nasal epithelium. However, as pointed out here (32), “the clinical relevance of that gene’s expression is unknown and Hispanic people, who also have higher death rates from Covid-19, do not have a higher rate of expression of the gene.” Discussion questions for this could include:

If race is a social, not a biological construct, how do we justify this sort of research?
1. What about ancestry or genetics vs race?
What about socioeconomic factors (including access to healthcare, employment in frontline occupations) that could impact COVID-19 infection rates? How do we reconcile this?
"What role do you think Institutional Review Boards (IRBs) could play to ensure that our research is not harmful to racial or ethnic groups in terms of reinforcing the notion that race is biologically based?"

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5774985/

This article illuminates the structural racism that exists within the American healthcare system, ED crowding and how it affects black patients with acute myocardial infarction (AMI) when compared to whites. This study assessed the impact of ambulance diversion times on outcomes in Black vs White patients presenting with AMI. The authors demonstrate that Black serving hospitals in California were more likely to experience ambulance diversion. Additionally, they found that after controlling for demographic variables and cardiac technology, Black patients presenting to a hospital that had had 6-12 or greater than 12 hours of ambulance diversion time, had a relative mortality increase of 19% at 90 days and 14% at 1 year in comparison to their White counterparts experiencing this same diversion times. This article can be used to emphasize the impact of structural racism and its tiered effects on community and individual health. It might also be an opportunity to partner with EMS and or administrative faculty on a session.

Discussion Questions

The questions below could start a meaningful discussion in a group of EM physicians on this topic. Consider brainstorming follow-up questions as well.

Tell us about a time when you experienced mistreatment while at work.
- Tell us what happened next. Did you feel safe or comfortable responding? Did others observe or act upon this mistreatment?
What privileges do you hold (within your department, community, society)?
- How might you leverage those privileges to help others that might have been historically marginalized?
The term ‘antiracism’ can be associated with discomfort for many people. Can you think of a time when you learned how to become comfortable with the uncomfortable (ex mastering a previously difficult skill)?
- How did you recognize your discomfort?
- Which resources, tools, or techniques did you use to overcome your discomfort?

Summary/Take-home Themes

The authors summarize their key points for this topic below. This could be useful to create a presentation closing.

Racism occurs at the personal, individual and systemic level, and represents a threat to public health and the healthcare workforce.
Antiracism is a proactive approach to addressing racism at the personal and systemic levels and requires sustained, intentional, and iterative reflective practice and work
Discomfort is a necessary and unavoidable part of the growth that is necessary to move forward, so don’t be afraid of it.

Relevant Quotations

Meaningful and relevant quotations (appropriately attributed) can be used to enhance presentations on this topic.

“When we speak, we are afraid that our words will not be heard or welcomed. But when we are silent, we are still afraid. So it is better to speak”. Audrey Lorde
“In a racist society, it is not enough to be non-racist, we must be anti-racist.” - Angela Y. Davis
“But there is no neutrality in the racism struggle...One either allows racial inequities to persevere, as a racist, or confronts racial inequities, as an antiracist. There is no safe space of ‘not racist.’ The claim of ‘not racist’ neutrality is a mask for racism.” - Ibram X kendi, How to be an Antiracist
“You must leave this world a better place than it would have been if you had not existed” Isabel Wilkerson
“Radical empathy…means putting in the work to educate oneself and to listen with a humble heart to understand another's experience from their perspective, not as we imagine we would feel. Radical empathy is not about you and what you think you would do in a situation you have never been in and perhaps never will. It is the kindred connection from a place of deep knowing that opens your spirit to the pain of another as they perceive it. Empathy is no substitute for the experience itself. We don't get to tell a person with a broken leg or a bullet wound that they are not in pain. And people who have hit the caste lottery are not in a position to tell a person who has suffered under the tyranny of caste what is offensive or hurtful or demeaning to those at the bottom. The price of privilege is the moral duty to act when one sees another person treated unfairly. And the least that a person in the dominant caste can do is not make the pain any worse.” Isabel Wilkerson, Caste: The Origins of Our Discontents

Specialty Resource links

Below are links to Emergency Medicine-specific resources for this topic.

ShareTools.org is a website developed by emergency medicine clinician educators with the goal of creating a toolkit for educators seeking to incorporate antiracist education into their curricula. The authors used humanities based pedagogies to develop the curricula which have been piloted for emergency medicine audiences within their own department.

Share Tools: Supporting humanities-based, anti-racism education for Health Professionals

Community Resource Links

Below are links to educational resources or supportive programs in the community that are working on this topic.

Video Links

Below are links to videos that do an excellent job of explaining or discussing this topic. Short clips could be used during a presentation to spark discussion, or links can be assigned as pre-work or sent out for further reflection after a presentation.

https://journalofethics.ama-assn.org/videocast/ethics-talk-antiracism-health-equity-and-post-covid-future

“In this video and audio edition of Ethics Talk, journal editor in chief, Dr Audiey Kao, talks with Dr Ibram Kendi about the impact of racist policies on historically discriminated-against groups and what it means to be an antiracist."

https://www.youtube.com/watch?v=Cozo8lj_RTA

“The first webinar in APHA's Advancing Racial Equity series examines racism and its historic and present-day impact on health and well-being.”

https://www.urban.org/policy-centers/cross-center-initiatives/social-determinants-health/projects/dr-camara-jones-explains-cliff-good-health

Dr. Camara Phyllis Jones explains her cliff analogy:

We can reduce health disparities and better connect people to high-quality medical care, but to really make a difference, we need to address the social determinants of health and equity that protect some people and push others off the cliff.

https://www.youtube.com/watch?v=GNhcY6fTyBM

“Dr. Camara Jones shares four allegories on “race” and “racism.”

https://www.ted.com/talks/ibram_x_kendi_the_difference_between_being_not_racist_and_antiracist

”There is no such thing as being "not racist," says author and historian Ibram X. Kendi. In this vital conversation, he defines the transformative concept of antiracism to help us more clearly recognize, take responsibility for and reject prejudices in our public policies, workplaces and personal beliefs. Learn how you can actively use this awareness to uproot injustice and inequality in the world -- and replace it with love.”

Quiz Questions/Answers

Possible questions and an answer key are provided below. These can be useful to document effectiveness in learning and knowledge gained but can also be useful to help learners identify that they may not actually know everything about a DEI topic, even if they have participated in presentations on it previously.

Racism can be institutionalized, personally mediated, or internalized. (T/F)
In the socio-ecological model, what are the 4 levels at which antiracism can be put into action?
What are the two core elements of anti-racism?

Answer Key

True
Individual, organizational, community, and policy levels
Reflection and Action

Call to Action Prompt

Below is a statement that inspires participants to commit to meaningful action related to this topic in their own lives. This could be used to prompt reflection, discussion, or could be used in a presentation closing.

Racism is a critical threat to each and every one of us - it is a public health crisis, and it is a threat to the health of our workforce. We have each witnessed, felt or propagated racism - whether as members of society, as patients, or as workers in healthcare. Racism will not “go away” unless each and every one of us actively works towards it. We must critically reflect upon how racism impacts our lives, our patients, our colleagues and our systems, and apply this awareness towards institutional and organizational change.

References

All references mentioned in the above sections are cited sequentially here.