When she was 5 years old, Reine Ibala and her family moved to the United States as refugees amid civil war in their native Republic of the Congo. Her father later developed hypertension and faced challenges as he navigated the U.S. health care system. His physician was dismissive, Ibala recalled, and failed to address the real, personal and cultural reasons behind her father’s misgivings about his treatment plan. With a discordant patient-physician relationship and lack of shared decision-making about what treatment plan would be best, he ultimately died from a dissected aorta.
Reine Ibala
“Being a good physician isn’t just delivering scientifically and clinically excellent medicine,” said Ibala, 27, now a third-year medical student at Weill Cornell Medicine. “It’s about being able to meet patients where they are, understanding where they are coming from and knowing when to follow their lead.”
That experience, along with her upbringing as a Black woman and immigrant in the United States was formative for her, she said. It engrained in her the importance of social justice and health equity—values that underpin her aspiring medical career. The 2020 murder of George Floyd and the resulting national reckoning on race, along with the disproportional impact of COVID-19 on communities of color, further galvanized her, driving her participation in a newly established committee at Weill Cornell Medicine devoted to advancing those principles through the prism of medical education.
Convened in summer 2020 by Dr. Yoon Kang, senior associate dean for education, the Anti-Racism Curriculum Committee was charged with reinvigorating Weill Cornell Medical College’s curriculum to ensure that medical students gained a firm understanding of how social, economic and policy factors influence health outcomes. These social determinants of health, which co-chair Dr. Joy Howell calls the “social impediments to health,” have been recognized by the Centers of Disease Control and Prevention and the World Health Organization to be more important than genetics or ancestry, health behaviors, and even access to care and the quality of that care.
“We need to impress upon the next generation of health care workers the power that societal factors have on population health, as well as an individual’s health, so that they can become well-rounded, comprehensive physicians,” said Dr. Howell, who is also assistant dean for diversity and student life at Weill Cornell Medicine. “If you are just coming up with a medication to treat high blood pressure and not attending to the context in which this patient lives, I question your ability to effectively control that patient’s blood pressure.”
Infusing Anti-Racism in the Medical Curriculum
Comprised of Weill Cornell Medicine administrators, faculty, students and staff, the Anti-Racism Curriculum Committee met throughout 2020-21 and quickly identified the need to encapsulate social justice and health equity in a new medical college foundational learning objective.
The goal, said committee co-chair Dr. Joseph Safdieh, was to develop a framework in which social determinants of health, including racism, are taught longitudinally, across all four years of medical school, rather than in a single course.
“If we segmented it into an individual course, the concepts then just exist on their own,” said Dr. Safdieh, who is also the Gertrude Feil Associate Dean for Curricular Affairs, the Louis and Rachel Rudin Foundation Education Scholar and a professor of neurology at Weill Cornell Medicine. “The students learn it and then move on. We want to show them that understanding social determinants of health is relevant in heart disease, lung disease, kidney disease, brain disease, in all different organ systems. This isn’t a unique problem in medicine, or surgery, or neurology or OBGYN. It’s a pervasive societal problem that impacts every patient’s experience.”
In addition to understanding health disparities, the committee also wanted to dispel harmful stereotypes that have perpetuated over centuries as a result of the structural barriers society has erected. For instance, the color of one’s skin is often coupled with the incidence and severity of a particular medical condition.
“We feel very strongly that our students need to learn right away that race is a social construct,” said Dr. Safdieh. “It’s not biologically based. Race is something, as a concept, that has been developed by society to categorize different people into different groups based on how they look. The impact is that these groups get treated differently. The problem isn’t race; it’s racism.”
Simultaneously, the committee advocated for coursework to recognize the different ways in which disease can present based on skin color. The second-year dermatology course now includes images of rashes and lesions on black and brown skin, for example.
The Anti-Racism Curriculum Committee developed an overarching learning objective for the medical education program, which was formally approved recently by the medical college’s Executive Medical Education Committee. This learning objective codifies the ongoing inclusion of the impact of societal factors, including racism, on equitable healthcare delivery and patient outcomes in the curriculum.
Training a More Equitable Workforce
Dr. Gwendolyne Jack, an assistant professor of clinical medicine, had already conceptualized an expanded Social Justice, Policy, Advocacy and Community Engagement (SPACE) curriculum before the events of 2020, but that work took on greater meaning in the weeks and months that followed.
The curriculum is interwoven throughout the Essential Principles of Medicine course, which is taught in the first year of medical school. The SPACE curriculum explores the history of racism in medicine, the local and global impacts of bias and structural racism, privilege, discrimination, health inequity, structural determinants of health, and community advocacy through a series of lectures and clinical skills group sessions.
The coursework provides students with the foundational principles to apply a health equity lens and recognize how racism, neighborhood safety, food insecurity and other social determinants can affect patients’ health and well-being.
“Historically these concepts were left out of the initial discussions with students, and typically added on afterwards,” said Dr. Jack, who is co-director of the Patient Care and Physicianship unit within the Essential Principles of Medicine course. “The approach of Weill Cornell’s medical education leadership is to really address this early on and carry the principles through their four years, so that when students graduate they are equipped to deliver outstanding quality of care to a diverse patient population, and advocate for their patients in powerful and meaningful ways.”
The Brain and Behavior Unit, taught by Dr. Evan Noch, an assistant professor of neurology, carries these concepts forward into the second year of medical school. In small groups, students explore a particular neurological diagnosis through the lens of a patient case. This year, Dr. Noch has added personal details about the patients—from their cultural and religious understanding of disease, to the complexities of paying for expensive medications, to caregiver burden—as a way to reflect the real-world people with whom these aspiring physicians will interact.
“Students need to take care of real patients, not patients who they read about in textbooks,” said Dr. Noch, who in March presented at the Johns Hopkins School of Medicine Institute for Excellence in Education about his and his colleagues’ efforts to teach students about social determinants of health. “And the patients they see in the hospital and the clinic come from diverse backgrounds. They need to be prepared to encounter the complexities of the care they provide.”
Physicians As Advocates for Social Justice
Historically, the prevailing view was that medicine didn’t have a critical role in addressing social determinants of health, that these issues were entrenched too deeply for physicians and scientists to meaningfully tackle. But the cost of inaction is too great, with lives in the balance, Dr. Howell said.
“We have, as an institution and as a health care community, formidable structures to dismantle if we are looking to meaningfully mitigate health care disparities,” said Dr. Howell, who is also vice chair of diversity in the Department of Pediatrics and a professor of clinical pediatrics at Weill Cornell Medicine. “Our society is still structured such that opportunities and resources don’t equitably advantage and disadvantage individuals from different groups. And until our society reduces, if not eliminates, these inequalities, it’s going to be hard to get rid of those inequities in health care.
“But we in the health care system have to attack the proximal issues that are most under our control and advocate for change at a societal level,” she added. “We’ve got to be advocates for social justice.”
Weill Cornell’s medical students believe that intrinsically, Ibala said. In the aftermath of the events in 2020, students mobilized to create an anti-racism student task force to advocate for institutional change. Change in the diversity of the health care workforce, so that it reflects the community it serves. Change in the way in which physicians advocate for their patients, giving them a seat at the table so that they are empowered in their own health care. Change in the way physicians understand their role as advocates for new policies that seek to dismantle the structural barriers that have impeded health.
“What I really hope is that we reach an era in which racism and social justice are not just BIPOC (Black, indigenous and people of color) issues, where physicians do not believe that inequity, housing, police brutality and even politics, that these issues are not in our lane,” said Ibala, who is taking next year off from medical school to complete a master’s in public health at the Harvard T.H. Chan School of Public Health. “It is absolutely our lane because these are the issues that affect our patients and bring them through our doors.”