Simran Kripalani [1], H-W. Banks [1], A. Sivendra [1], C. Rugama [1], I. DiBartolo [1, 2]
[1] Cooper Medical School of Rowan University, Camden, New Jersey 08103
[2] Cooper University Hospital, Camden, New Jersey 08103
Correspondance: Kripal36@rowan.edu
ABSTRACT
Medical schools around the US recognize the importance of reform in medical education, as well as the pervasive role of racism and health disparities in medicine. The 2019 Racism in Medicine Conference (RiMC) hosted by Cooper Medical School of Rowan University (CMSRU) is an example of a medical student-led initiative centered on education and advocacy through the implementation of safe spaces. Pre- and post- survey responses from conference participants were collected to determine if RiMC influenced attendees’ comfort addressing racism and knowledge on the subject. Specifically, qualitative comments in the post-conference survey showed the confidence and encouragement that attendees attained during the event, namely, to speak about racial issues in medicine and healthcare amongst colleagues. The conference served as a platform for future healthcare professionals to strengthen their foundational knowledge on the topics by studying and implementing a safe space model. This construct was followed to encourage education and thereby a commitment to elimination of fear of retaliation and retribution when participating in anti-racism work.
INTRODUCTION
Despite the medical community’s longstanding efforts to address health disparities, gaps in care for marginalized people still remain (1). The causes of these disparities are multifactorial and include a long-standing history of structural racism and systemic bias. This structural racism is pervasive in society as well as in medicine (2). Recently, there has been an institutional push to revamp medical education to not only focus on recognizing individual implicit biases and its relation to health inequities, but to also critically analyze the nuanced social contexts that perpetuate racism and maintain health disparities (3). Additionally, AAMC Medical Education Senior Leaders have released a document to provide resources for immediate action and goal setting in order to address and dismantle racism in educational programs (4).
While several medical schools around the US began revamping their curricula, medical students at several institutions began to recognize the importance of reform in medical education (5). Many of these students then took the initiative to bridge perceived gaps in health equity education in the interim by creating anti-racism task forces, social justice committees, and other avenues to address and engage in discussions around the topic (5-7). Medical students collaborated across medical schools to engage in initiatives to bring awareness to issues of racism and to create platforms for continued collaboration (6, 8).
The Racism in Medicine Conference (RiMC) is another example of medical student led activism centered on anti-racism. In 2015, an anti-racism group at Perelman School of Medicine at the University of Pennsylvania collaborated with interested medical schools in the Philadelphia area to host a conference to discuss the challenges and impacts of racism in healthcare. Attendees consisted of health professional students, as well as healthcare professionals in the community. Since then, RiMC has become an annual conference hosted by multiple sponsoring medical schools in the Greater Philadelphia and Delaware Valley area. The Conference's themes and objectives evolve every year at the hosting medical school’s discretion, but always encompass social injustices occurring in the current socio-political climate and must abide by the joint memorandum of understanding drafted and modified by the schools involved in the conference (9).
In 2019, several student-run diversity organizations at Cooper Medical School of Rowan University (CMSRU) hosted the 5th annual RiMC conference. Leaders of the conference implemented learning objectives that required discussions that promote evaluation of racism’s role in medicine in the past, present, and possible future. In addition, organizers aimed to widen discussions around systemic racism’s role in medicine by including how it impacts our colleagues, other health care professionals, medical institutions, and patients we serve. Therefore, the conference had explicit objectives that included to:
1. Understand the historical roots of racism in medicine,
2. Recognize racism and its impact in health care settings, and
3. Empower students, health care professionals, and community leaders to utilize tools learned from the conference to address racism in their own institutions.
The organizers of RiMC 2019 understood the necessity of active discussions around racism but were also aware of its challenges, which included the:
1. Challenge of putting yourself in others’ shoes to learn from each other’s experiences (1, 5, 10),
2. Fear of expression and open sharing due to potential retribution (11, 12),
3. Hierarchies present in medicine and healthcare (10), and
4. Trauma of sharing past experiences (12).
Recognizing the difficulties stated above, the RiMC 2019 organizers sought to create “safe spaces'' within the conference, so all participants can have meaningful discussions around anti-racism and anti-marginalization. A safe space is a concept that emerged during feminist, queer, and anti-racist movements in the late 20th century (13). There are specific components of safe spaces that we sought to include in our conference (Table 1).
After integrating the above principles and establishing a memorandum of understanding with neighboring institutions to address all needs of workshop hosts and participants, we made sure to integrate trained volunteers to each room, and to provide extra spaces for therapy, debriefing, and praying.
Table 1: Racism in Medicine Conference (RiMC) attendee demographics, based on pre-conference survey responses
METHODS
The 2019 RiMC took place at Cooper Medical School of Rowan University (CMSRU) in Camden, NJ on November 19, 2019, and followed the standard format of past conferences. Attendees were given the opportunity to learn from and participate in small group discussions concerning a number of issues affecting marginalized groups. The purpose of these discussions was to empower participants to address racism in their personal and professional environments. The conference featured two keynote speakers who addressed all attendees in a large lecture format. The opening keynote speaker provided an introduction to the difficult conversations participants will be having via a general didactic talk about the history of racism in medicine. Student leaders then provided an overview of the conference and itinerary. This introduction was essential to set the tone for the conference and ensure participants explicitly understood that this conference was meant for them to openly explore and engage in learning and discussion. It also contributed to adding to the participants’ knowledge base to help aid in facilitating these open discussions during workshops. These small-group workshops were formatted as a round-table discussion. The subcommittee ensured that the breakout session leaders adhered to strict learning objectives to ensure standardization in format. Workshop leaders were expected to provide time for open discussion, tangible tools, resources, and strategies for participants to use personally or at their own institutions to combat health inequity and racism in medicine. During the workshops, a RiMC volunteer was present to address any issues that arose during the session, thus maximizing time for open discussions and minimizing technical difficulties and any other potential interruptions.
For the closing keynote speaker, we invited an individual that would empower and provide tools for immediate action in regard to addressing racism in medicine. He encouraged participants to learn more about pathways in academic medicine and medical education, as well as the need to increase diversity in academic medicine. He emphasized ways for attendees to become involved in publishing and academic scholarship. This talk was framed in such a way where representation would pave the way for the creation of safe spaces in academia by providing underrepresented minority (URM) medical students with an in-depth understanding as well as avenues for immediate action. Through representation in academia, URM students could have their voices heard and respected in medical education spaces.
A new addition to the 2019 conference was the curation of safe spaces that provided an open, comforting environment with ample space to physically and emotionally process these difficult conversations and then have opportunities to make actionable changes. It was the committee’s top priority to provide designated zones in the form of healing corners on each floor utilized for breakout sessions so that participants can decompress, share experiences, express concerns, and/or have the capacity to receive and internalize information. For any possible emotional distress experienced, emotional support systems were also put in these spaces via recruitment of licensed social workers and therapists on site for attendees who needed to utilize their immediate professional expertise. There were also multiple physical “quiet zones” created for attendees to have time to themselves for decompression and recharging in a more private setting. In addition, there were numerous peer student volunteers available to talk to participants on demand if desired.
Creation of physical spaces was not the only accommodation made. It was important to the committee to take the concept of safe spaces and extend it to all aspects of the conference. Intentional planning of conference branding, food planning, community service, and social media promotion were all avenues taken to further the theme of fostering open communication. Conference subcommittees were formed to specifically work on the individual aspects. Food planning focused on providing sustenance with an emphasis on heritage and cultural diversity. By committing to supporting catering from local, small businesses of immigrant background, the conference exemplified a tangible example of “actionable change” and further created a welcoming and open space through representation. The community service aspect created a real time opportunity for attendees to participate in change themselves through winter clothing donations and a canned food drive held on site throughout the conference. Finally, the social media component served as a way to promote the conference and its speakers through use of multiple platforms ensuring an increase in public visibility and awareness. Conference attendees were also able to facilitate conversations and interact on these platforms, thus creating a physical archive of the conference and the dialogue shared.
A major goal of the conference was to evaluate its impact and any changes in attendee perception on topics of racial discrimination in medicine. The aim was to collect data (quantitative and qualitative) for each attendee both before attending the conference and after. Pre- and post-surveys were provided to participants in the form of QR codes in the folders they picked up during registration. Surveys were IRB approved and were created using past survey questions, which were not previously operationalized and were conceived for the conference itself. The survey was condensed compared to the previous questionnaires used in order to account for participant compliance. Pre-surveys were found in attendee folders (in the form of a QR code and link), which were provided to participants upon registration before the commencement of the conference. Attendees received a unique identification number which was the same for both pre- and post-surveys. Researchers did not have access to any personal identifiers linked to the numbers, as folders were not pre-assigned to participants. At the end of the conference, the post conference survey was provided to individuals and time was allotted at the end of the conference to ensure completion. Responses were collected using Qualtrics and analyzed using qualitative and quantitative statistical analyses, such as Fisher's exact test. Open ended responses were used to determine common themes among participants. This qualitative analysis on identifying common themes was done by two authors (SK and HWB), who each went through the responses separately and came up with common themes. The authors then came together and compared extracted themes. If there were any discrepancies between the themes, a third author reviewed the theme and served as a tiebreaker (AS) on whether or not to include the theme. No tiebreakers had to be conducted in this case.
RESULTS
Of the 82 participants who responded to the pre-test survey, 94% (77) identified as students. 76% (62) of identified as female, 22% (18) identified as male, and 2% (2) identified as non-binary (Table 1). 78% (64) of participants self-identified as non-White; of those, 28% (23) identified as Black or African-American, 26% (21) identified as Asian, 12% (10) identified as Hispanic, 4% (3) identified as Middle Eastern, 6% (5) identified as mixed, and 2% (2) identified as other. The remaining 22% (18) of participants identified as white (Table 1). There were 32 participants who responded to the post-test survey.
When asked what participants wanted to gain from this conference, qualitative analysis was done to determine common themes stated through open-ended responses (Table 2). Themes that were noted in these responses largely stated that participants wanted knowledge and guidance on how to integrate anti-racist practice into residency training and serve as an advocate for patients of color. Others stated that they wanted to gain more insight on how to become an ally and learn about current initiatives that medical students and institutions are implementing to combat racism in medicine and bridge the gap in existing healthcare. Additional themes included to have the proper tools to address racism and discrimination in medicine, the education foundation and exposure to identify and prevent disparities, and the practical advice on how to deal with racially discriminatory experiences. Another theme included being able to network with motivated medical students with similar goals. Some of these responses, as well as those we received from post-conference participants, are displayed together as a qualitative way to assess the participants’ attitudes and perspectives (Table 3). Many respondents stated that knowledge and understanding was crucial in their experience, and echoed that, in one way or another, education and awareness is needed in order to facilitate change and advocate for anti-racism in this space. Post-conference participants showed that, through their responses, this event was crucial in reinvigorating and rejuvenating their being and energy.
Table 2: Extracted qualitative themes on what participants wished to gain from the Racism in Medicine Conference (RiMC)
Table 3: Attitudes and Perspectives on what participants hoped to gain and/or gained from RiMC (Racism in Medicine Conference)
Notably, when participants were asked about their level of comfort in confronting an administrator who may be saying or doing something racist, there was a significant difference between pre-conference and post-conference responses (p=0.0371). The statement specifically read that “I am comfortable confronting an administrator who I see making a discriminatory or racist remark or discriminatory action,” and post-conference responses indicated that participants felt more comfortable confronting an administrator who made such remarks. Additional pre- and post-conference survey responses regarding comfortability were collected using a Likert scale (strongly agree to strongly disagree), and statistical analyses were performed using Fisher’s exact tests (Table 4).
Table 4: Pre-conference vs. post-conference survey responses
DISCUSSION
For the pre-conference comments and themes that participants identified and wished to be addressed during the course of the event, all expectations mentioned one common component: a safe space that was not only accepting, but also one that was challenging. Our conference was conducted to foster these open discussions and create spaces that allowed open learning on historical and structural racism and how to address these disparities in care. Specifically, qualitative comments in the post-conference survey showed the confidence and encouragement that attendees attained during the event, to speak about racial issues in medicine and healthcare amongst colleagues. Because this space was provided to attendees and was openly identified as a supportive and nurturing environment, it served as a platform for future healthcare professionals to strengthen their foundational knowledge on the topics so that they are able to change the “face and culture of healthcare.”
Many participants stated that a large reason that contributed to this increased drive for change was the speaker sessions, as these individuals empowered students to “embrace the tasks of fixing these issues through practical efforts” and provided them with the tools to do so. By providing this student body of future healthcare professionals in the Greater Philadelphia and surrounding region an annual conference on racism and inequity in medicine, we were able to provide trust and support to people who will develop into confident leaders in healthcare.
The change in participant comfort level pre and post conference for confronting an administrator who may be saying or doing something racist was statistically significant. Post-conference responses showed that the participants were more comfortable bringing this up to the administration, likely pointing to the racism in medicine conference as the catalyst for change. The 2019-20 report for the Collective Action for Safe Spaces (CASS) organization reported that, by hosting bystander intervention training and other safe action initiatives, participants were able to develop strategies to respond directly to harassment and violence (18). This organization as well as our conference reported similar data showing that safe spaces, when organized in the right way, had the ability to provide tools and confidence for actionable change. Safe spaces are often misconceived as “echo chambers” and ways to cushion reality and uncomfortable topics. In reality, they do the opposite by providing an atmosphere where people can share differing experiences and perspectives received with an open-minded and the absence of scrutiny and hostility.
Qualitative responses suggest that the creation of the Racism in Medicine conference as a safe space and annual platform was a large reason for the difference of participants stating that they were more comfortable confronting and addressing administration if they heard or saw a racist remark or action. These spaces are groups or communities that allow for “license to speak and act freely, form collective strength, and generate strategies for resistance,” a model used by the RiMC 2019 organization committee (11). By providing attendees with this platform where they are able to feel a sense of belonging and validation for their viewpoints, the conference was already a place where people felt that they would not be dismissed and would be heard.
Having a collective group conscience through symbolic convergence theory (SCT) enabled participants to envision a future where healthcare professionals are knowledgeable enough to dismiss false claims about race in medicine, confident enough to address and confront situations where racism is the motive, and work together to make racism and inequality in medicine a thing of the past (15). Talking about these important topics to higher professionals and administration require places to cultivate this strength.
Student cohesiveness, meaningful real-time feedback, and an amalgamation of thoughts and ideas are but some of the ways in which a safe space can develop (19). By providing an annual space for such conversations and allocating space and time for medical students to strengthen the foundation of knowledge on relevant subjects, we are positively influencing medical professionals and helping them mold into developed and confident leaders in healthcare.
One limitation in our data collection includes a smaller response rate, which decreased especially in the post-conference responses. While we initially thought that the conference would inspire people to answer the survey at the end of the conference, especially because time was allotted to do so, participants may have been emotionally and mentally drained after a day of deep and heavy conversation. Because the participants of this conference were possibly more invested in this specific topic to attend a weekend conference, another potential factor that could have contributed to the overwhelmingly positive responses could have been potential bias in terms of feedback, as the attendees may have naturally gained more due to their vested interest in the material and application. Because many survey questions were utilized from past conferences to possibly compare data, we relied more on qualitative and open-ended responses to focus on how the conference served as a successful safe space. We do believe that open-ended responses to questions on serious topics would provide a greater space and voice for true feelings and may indirectly promote feelings of understanding and security.
Furthermore, based on gathered attendee feedback, future sessions should include topics centered on how to specifically navigate conversations that may be uncomfortable in relation to micro- and macro- aggressions in professional settings. Attendees also recommended including more conversations about Asian-Americans and Native Americans, as they are often forgotten in discussions around race. In future studies, we wish to emphasize the importance of additional quantitative data. We believe that matched pre- and post-conference responses can add a strong element that further validates the utility and importance of this conference through paired statistical analyses.
CONCLUSIONS
The reality of limited avenues available for students and faculty members in healthcare to learn about and openly discuss issues of race and marginalization, especially in the context of medicine, has been at the forefront of modern medical education. The RiMC series was created to address this deficit and provide one possible solution in the form of creating a designated forum for these complicated conversations as well as creating an environment that makes addressing these issues in a professional setting as comfortable as possible. This allowed the creation of a safe space for participants to have a platform to increase their knowledge and participate in transformative conversations about racism in medicine. For allies and individuals who want to contribute to promoting changes within medicine, safe spaces provide an environment for uninhibited dialogue and avenues for action. This initiative was considered successful as feedback shows most attendees felt heard and cared for which enabled even more raw and impactful discussions. While this initiative was overall a success, there is still room for immense improvement as well as keeping in mind that this conference format should only be an interim solution while medical institutions revamp their internal curricula. However, for allies who want to implement this kind of format within their own educational efforts, the RiMC organization committee strongly endorses the provision of safe spaces and thereby a commitment to elimination of fear of retaliation, retribution, and ostracization when participating in anti-racism work.
ACKNOWLEDGEMENTS
The authors of this paper would like to acknowledge the work of and sincerely thank all those who participated and made the 2019 Racism in Medicine Conference a reality. We extend our gratitude to: Cooper Medical School of Rowan University, Dean Annette Reboli, Dean Mitchell-Williams, and Director of Service, Susan Liu, for providing a venue for the conference and assisting in all parts of planning and execution. Ms. Susan Cavanaugh for being a resourceful librarian. Roberto Merino Gonzalez for the creation of many tables utilized in this paper. The entire medical student conference planning committee for their commitment and hard work in bringing the conference to fruition. The Keynote Speakers, workshop leaders, community panelists, student volunteers, catering services of Old San Juan of Camden, NJ, and CMSRU Security for all of their innumerable contributions. The partnering healthcare programs and medical institutions for their co-sponsorship and monetary support. Finally, we would like to thank the founder of the Racism in Medicine Conference, Dr. Dorothy Charles, MD, who serves as a leader and advocate for patients and people of color. Thank you for all of your hard work; we hope we did justice to your vision.
DISCLOSURES
Funding: This research has not received any funding. This conference event received funding from the host school, Cooper Medical School of Rowan University, as well as partnering institutions in the Greater Philadelphia and Delaware Valley area.
Conflicts of interest: None.
Availability of data and materials: Collected on Qualtrics, unidentified.
Authors’ contributions: Authors listed in the manuscript have contributed per submission guidelines and standards for authorship.
Code availability: Not applicable.
Ethics approval: Study was IRB approved, exempt.
Consent to participate: Implied consent to participate, participation voluntary, survey completion indicated consent.
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