The Society of General Internal Medicine’s vision is a just system of care in which all people can achieve optimal health.1 In recent years, the Society and its official journal, The Journal of General Internal Medicine, have committed to intentional work focused on anti-racism and integrating equity and justice into policies, practices, and work plans. It is particularly gratifying then that this JGIM special theme issue in medical education includes seven papers representing essential scholarly work across the continuum of education, and aligned with the Society’s vision and commitment. In this editorial, we highlight three themes around equity that emerge from these manuscripts: the role of systems and institutions in equity, efforts focused on actively addressing anti-racism and critical consciousness, and measures to reduce bias and eliminate the amplification cascade.
The amplification cascade,2 in which small differences in assessed performance lead to large differences in outcomes (such as grades, selection for awards, career achievement), is a theme across two studies and highlights the uphill battle marginalized groups face in medical education where disparities are perpetuated—with amplified impact—through embedded and well-established practices and norms. Addressing a notable gap in the literature related to student perceptions of Alpha Omega Alpha (AOA), Jones et al. sought the opinions of medical students at one institution.3 Almost 60% of respondents favored discontinuation of AOA, believed it was biased and impacted well-being and the learning environment negatively, and raised concerns about transparency in selection processes. Underlying students’ concerns was an awareness of biased clinical education assessment practices that impact selection into AOA and, subsequently, the problematic utilization of AOA membership in residency selection. Heath et al. found a significant association between mentions of the word “confidence” (and its iterations) and women resident gender that persisted after adjustment for faculty gender, post-graduate year, and numeric ratings in a study of over 5000 narrative faculty evaluations of internal medicine residents.4 Given the literature linking the “confidence gap” in women to long-term career achievement differences, this important study offers critical insights into a unique form of bias that warrants critical reflection and intervention.
Two papers in this issue focus on curricula to actively address anti-racism and create a sense of community to confront systems of oppression. Shahram et al. implemented a faculty and staff development program using critical consciousness pedagogy to foster dialogue and reciprocity.5 The inclusion of local histories and institutional disparities data in the curriculum as well as strategies to motivate attendees to work together to take action was a unique aspect of this program’s design. Ayyala et al. provide initial outcomes of embedding structural racism pedagogy into a COVID-19 pandemic course for medical students.6 The course deconstructed health inequities in the context of events surrounding the pandemic and thus sought to raise critical consciousness thinking and stimulate action, similar to the work by Shahram et al.
The powerful role systems and institutions play in maintaining the status quo, and critical calls to use their influence to shift power and justice to advance equity represent the themes in three additional papers. Tiako and colleagues synthesize the scholarship on race and racism in medical training to demonstrate that medical schools are racialized organizations with longstanding institutionalized structures that prioritize the dominant racial group and negatively impact those who are underrepresented in medicine.7 They advocate for governing bodies of medical education to expand access to medical education, foster safe and supportive learning environments, and allocate resources to adequately and equitably train the next generation of physicians. Campbell et al. surveyed the landscape of assessment and evaluation related to social determinants of health (SDOH) and note significant heterogeneity among programs as well as gaps and barriers in educational practices.8 The authors call for specific guidance from accrediting and professional organizations, agreement on SDOH competencies, and resources and training to enhance SDOH education. Finally, Williams and colleagues highlight racial and ethnic disparities in end-of-life care experiences and note the less-than-adequate expectations by accreditors related to medical student education in this area.9 They advocate for more formal expectations related to racially and culturally sensitive end-of-life training, and for medical schools to prioritize cultural humility and diversity on care teams to advance equity and patient experiences at the end-of-life.
Collectively, these seven papers represent critical work in equity and justice, and serve as a call-to-action for continued research and scholarship to deliver on SGIM’s vision and commitment.
SGIM Vision and Values. Available at https://www.sgim.org/about-us/vision%2D%2Dvalues. Accessed April 14, 2022.
Teherani A, Hauer K, et al. How small differences in assessed clinical performance amplify to large differences in grades and awards: A cascade with serious consequences for students underrepresented in medicine. Acad Med. 2018;93(9):1286-1292.
Jones JM, Berman AB et al. Amplifying the student voice: medial student perceptions of AOA. JGIM. 2022. (SPI 7544).
Heath JK, Alvarado ME et al. The context of “confidence”: Analyzing the term confidence in resident evaluations. JGIM. 2022. (SPI 7535).
Shahram Y, Lowry D et al. The Tea House series: Striving together to be antiracist. JGIM. 2022. (SPI 7519).
Ayyala M, Hill J et al. Teaching health equity in the time of COVID-19: A virtual look through the lens of structural racism. JGIM. 2022. (SPI 7516).
Tiako MJ, Ray V, South EC. Medical schools as racialized organizations: How race-neutral structures sustain racial inequality in medical education. JGIM. 2022. (SPI 7500).
Campbell M, Liveris M et al. Assessment and evaluation in social determinants of health education: A national survey of U.S. medical schools and physician assistant programs. JGIM. 2022. (SPI 7498).
Williams DW, Quinlan CM, Reid AE. A “good death” for all: The need to teach racially-sensitive end-of-life care. JGIM. 2022 (SPI 7489).
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Karani, R., Teherani, A. Equity and Justice in Health Professions Education: Delivering on SGIM’s Vision and Commitment. J GEN INTERN MED 37, 2142–2143 (2022). https://doi.org/10.1007/s11606-022-07664-5