In the early 1980s at a typical medical school set in Norfolk, Virginia, future physicians were trained on how to conduct a medical history, identify modalities, and treat ailing patients. However, at that same medical school, some of the students were exhibiting behaviors that served as a vestige of a horrible era in American history that many actively try to forget.
A group of medical students attended a party where two attendees, presumably medical students, decided to dress in Ku Klux Klan and blackface minstrel attire. Furthermore, someone at this party, perhaps another future doctor, took the picture and would eventually submit it to their medical school's yearbook staff, who also probably were working to become future doctors. These activities all occurred under the watch of a provost who was ultimately responsible for the curriculum and the culture from which these students learned.
This party is central to the scandal facing the sitting governor of the Commonwealth of Virginia, Ralph Northam, M.D., who was identified as the one in blackface makeup in that 1984 yearbook from Eastern Virginia Medical School (EVMS), where he earned his medical degree. This association is even more damning because his undergraduate classmates at the Virginia Military Institute referred to him by a racial slur also used to denigrate African Americans. These recent revelations have led many community and political leaders from both sides of the political aisle to call for his immediate resignation.
These revelations are horrible to say the least. However, these current events shed light on an even larger problem that transcends our political landscape. We now have a closer look inside the walls of institutions that are responsible for training medical professionals in how to save the lives of the sick and the afflicted. From the EVMS yearbook, we see the condoned behavior of adults who will eventually provide medical care to our children, friends, parents, grandparents, and people living with HIV, for decades to come.
For many African Americans, this is a toxic environment where explicit or implicit racism has kept many potential doctors from even pursuing medicine. In a groundbreaking report, the Association of American Medical Colleges reviewed the number of black male students who matriculated into medical school from 1978, when there were 542, as compared to 2014, when there were only 515. This lack of diversity in medical schools comes at the same time period when the total number of black men graduating from accredited colleges and universities has tripled. (This also tracks alongside the HIV crisis, which began in 1981 and when more black physicians could have provided the kind of care needed in the early days of the epidemic.) Multiple reasons may explain why African Americans decide to pursue other fields, i.e., cost of education or familial responsibilities that do not permit delaying earning a sustainable salary for 7 to 10 years due to medical school, residency, and internship(s). However, the medical school culture itself guides the decisions of many African-American candidates.
"As an applicant, I didn't feel comfortable when I visited predominately white schools to which I applied," says Richard L. Jones, M.D., FACOG, an African-American obstetrician/gynecologist with the University of Maryland and graduate of Howard University College of Medicine, a historically black institution. "They did make an effort to recruit a diverse class, but they did not make enough of an effort to create a place where I felt comfortable." He shared that the black students at those schools confided that they were often confused as janitors, in addition to repeatedly being questioned about their academic acumen and doubted about whether they really deserved to be there.
The experiences of the medical students who Jones spoke to as a prospective student are unfortunately not rare. At the now-infamous Eastern Virginia Medical School, the only African American in its first medical school class was Marcus Martin, M.D., who went on to become the University of Virginia's vice president and chief officer of diversity. This EVMS graduate wrote, "A growing body of research shows that a diverse workforce is more capable of relating to patients, detecting and addressing health disparities, and overcoming the challenges that face healthcare. Diversity accelerates our delivery of quality of care to all people." Nurturing diversity in medical school can have immediate benefits for students and the patients they serve.
One physician stated that meaningful engagement with underserved communities at some medical schools is a major draw for many African-American applicants. Hyman Scott, M.D., M.P.H., with the University of California at San Francisco and the San Francisco Department of Health, chose to attend Yale University Medical School. "While visiting potential schools," Scott recalls, "I was impressed by both the strong, tight-knit, and active black/Latinx medical student association at Yale in addition to community-focused activities in New Haven [Connecticut] which is predominately a black city." He believes these connections can go a long way to improving the health outcomes for racial minorities.
It is well documented that African-American women are diagnosed later and receive disparate care when presenting for breast cancer as compared to white women, regardless of similar educational attainment and socioeconomic backgrounds. For people living with HIV, disparate care and medical mistrust between physicians and African-American patients are so profound that some patients do not adhere to their life-sustaining antiretroviral treatment even when it is offered to them by their physicians, albeit later than the white patients. These cuts lead to wounds. And the emotional wounds sometimes are much deeper than the physical ones.
Healing the wounds between the medical community and the African-American community will take time and intentional effort. Many African Americans are acutely aware of the Tuskegee Syphilis Study and its subsequent impacts on medical mistrust decades later. Also, in cities like Baltimore, among African Americans, distrust runs high for institutions like Johns Hopkins Hospital that are seen to be actively displacing lifetime residents for expansion. In addition, Hopkins is also known for past transgressions in research, including the now-infamous story of Henrietta Lacks, a black Baltimore resident whose cells were used for scientific studies across the globe unbeknownst to her or her family. Her story became a film starring Oprah Winfrey.
Some physicians are not aware of their implicit biases or the cultural contexts that accompany them into the exam room while seeing patients. White and Asian clinicians were found to exhibit lower levels of rapport-building nonverbal cues such as making direct eye contact and casual contact when speaking with black patients as compared to white patients. This typically unintentional behavior is often rooted in implicit bias that can lower trust between the physician and the patient. The impact of implicit bias can be evidenced by black men being more trusting and adherent to medical advice from black male physicians as compared to white ones.
Today at Governor Northam's alma mater, EVMS, there is an intentional effort to embrace diversity while focusing on health equity. The contributions of women and people of color have been elevated, and their future clinicians are now taught to address the unconscious bias that they may bring into the patient's exam room.
"The presence of a diverse class is necessary, but it is not sufficient," Scott warned. "There must be explicit and intentional training to undo those biases. The leadership in the medical school must not allow [racism] to occur. They did not make a conscious effort to unteach these biases that have been taught or have not been challenged. People's biases can be just as dangerous to patient outcomes without ever putting on a Ku Klux Klan outfit. Those [medical students] in that yearbook did not learn that [behavior] in medical school. They came with those perspectives."
The medical field must look closely in the mirror to ensure that the patients of tomorrow have doctors receiving the best education of today. As Jones aptly advocates, "In order to save more lives, medical schools must teach the three C's: cultural competency, comfortability, and compassion."
Ace Robinson is a leading HIV advocate and population health expert residing in Los Angeles. He is a board director of the Avielle Foundation, which combats violence through brain health research, and co-chairs the LA County HIV Commission's Standards & Best Practices Committee. He holds a Master of Public Health from the University of Cape Town, South Africa, and a Master of Health Administration from Brown University with a thesis on improved HIV biomedical prevention and treatment access for black/Latinx gay/bi/same gender loving men and transgender women.