Zainab Doleeb is an incoming obstetrics and gynaecology medical resident at the University of Toronto.
Laura Carson is the manager of the Global Oncology Program at Queen’s University.
Nazik Hammad is a professor and medical oncologist at Queen’s University School of Medicine.
As the medical field acknowledges its history of bias and racism and pursues a more inclusive trajectory, organizations and institutions have begun to formalize their commitment to equity, diversity, and inclusion (EDI). In March 2020, for example, the Canadian Medical Association (CMA) released its first policy statement on equity and diversity. This statement put forth three key recommendations to increase equity in the medical profession. We offer examples of how to apply the CMA’s policy recommendations so as to foster a more inclusive clinical learning environment in healthcare education (summarized in the figure below). However, before emphasizing outward action at the individual and institutional levels, it is important to engage in introspection and self-directed learning about the inequities that presently exist so that subsequent actions are well-informed.
Both self-reflection and a commitment to continual learning are needed. Self-reflection supports the goals of EDI through creating an environment for empowering individuals to stand for change through “conscientization” – the process of developing a critical awareness of one’s social reality through reflection and action. Self-reflection can enable health care professionals to examine their own biases, overcome them, and provide better care for patients who are impacted by racism, oppression, and related social determinants of health. Reflecting inwardly is often uncomfortable and challenging, as it requires a critical lens of introspection. However, embracing this discomfort is essential to allow for the consciousness-raising that the medical profession needs. Good intentions will not be enough to dismantle the deep-rooted systemic discrimination that prevails today. It must be coupled with reflexivity, defined as “the act of acknowledging individual positionality and motivation when engaging with the rhetoric on systems transformation.”
Before taking action, medical professionals should learn about the past racist history of medicine and its present implications. For example, North American academic medicine still continues under the shadows of the Flexner Report and its unequivocally hostile view of Black physicians, the Tuskeegee Study, and the 1918 ban on Black medical students at Queen’s University. Health care professionals must understand the roles that racism, bias and oppression have played and still play in health, and utilize this knowledge when treating patients. This could be encouraged through incorporating the health effects of structural racism as a professional competency for physicians.
Translating the CMA Policies to Action
The first recommendation put forth by the CMA policy is that “all medical organizations, institutions and physician leaders take a leadership role in achieving greater equity and diversity by co-creating policies and processes in an accountable and transparent manner.” Enhancement of the clinical learning environment can drive action on this recommendation. Learning in a clinical context is foundational to health care training, and a suboptimal CLE has been associated with adverse patient care outcomes. Enhancing clinical learning environments requires a transition in attitudes and narratives, particularly among those in leadership positions. This begins with a rejection of the nostalgia towards a previous medical past in which there was no “political correctness.” For learning environments to change, educators must actively embrace inclusive evolution and a recognition of the ways in which marginalized populations have been historically and presently disadvantaged – regardless of the complexity and discomfort that will accompany this.
Clinical learning environments can be further enhanced by adopting policies to prevent and address microaggressions. Microaggressions are defined as “brief, commonplace, daily, verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults that potentially have a harmful or unpleasant psychological impact on the target person or group.” Many Canadian physicians have spoken about their experiences with systemic discrimination in the workplace and in medical school. Educating patients, learners, and faculty on microaggressions (e.g. through direct workshops and posters in the clinical environment), and adopting a zero tolerance policy towards racism, are initial steps that can be taken. Learners who face bigotry and microaggressions must also be supported. Equipping learners and teachers with the tools to confront mistreatment, such as Wheeler’s twelve tips for responding to microaggression, is one step towards making the medical environment safer and more inclusive for all. Importantly, the act of acknowledging and confronting mistreatment and microaggressions must not fall solely on the shoulders of the oppressed. Rather, this is an opportunity for allies to use their privileged positions to support marginalized colleagues and junior learners.
The second recommendation the CMA presented is that “all medical organizations, institutions and physician leaders encourage the collection and use of data related to equity and diversity through research and funding, and specifically review their data practices.” To pursue this recommendation, there needs to be broader collection of race-based data about not only patients but also medical learners and faculty members. While data are limited in Canada, available data indicate that Black people in Canada report poorer health than their white counterparts. Rather than engage in exceptionalism when making comparisons to the United States, Canadian institutions should strive to further study current inequities in Canada. Knowledge of these disparities is critical for medical professionals to understand the ongoing ways in which minority populations are disadvantaged and the implications of this on their health.
Medical faculties are strongly encouraged to develop diverse committees that meet regularly and are engaged in longitudinal equity work. These committees should be permitted to access faculty demographic data and surveys on learner wellness, and should be empowered to develop policy changes, assess impact, and make iterative changes. Their recommendations should be implemented by the faculty and their work must be synergistically supported by faculty leaders.
The third recommendation in the CMA policy is that “all medical organizations, institutions and physician leaders support equity and diversity in recruitment, hiring, selection, appointment, and promotion practices.” The corresponding step for this recommendation is to increase mentorship to nurture the development of marginalized learners and faculty members. Access to mentors remains a large problem for minority learners. In Ontario, despite 4.5% of the population being Black, only 2.3% of practicing physicians in the province are Black. This disproportionate underrepresentation of Black physicians puts a burden on these individuals as they are often expected to impart their knowledge through mentorship of minoritized learners and also engage in community work. Such increased responsibility is often referred to as a “minority tax.” It should be acknowledged and compensated for by institutions and organizations through additional funding, protected time, administrative support, and recognition in tenure and promotion. Engaging in community work and mentorship should be as lauded as research productivity. Furthermore, non-minority faculty should make a concerted effort to mentor racialized learners and junior faculty.
It is not sufficient only to ensure greater enrollment of students from marginalized backgrounds; the clinical learning environment should also be made welcoming and conducive to their thriving. It is essential to develop student organizations as they can help promote social wellness and foster a sense of community for marginalized learners who may be feeling isolated. Flourishing student organizations can serve as powerful forces within their respective communities. For example, the Black Medical Students’ Association (BMSA) at the University of Toronto assists faculty with recruitment, drives change in the medical curriculum, supports members with networking and research, and engages in considerable community health work in the Greater Toronto Area.
Racism, harassment, and mistreatment still exist within the clinical learning environment and rhetoric alone will not be enough to rectify these injustices. As outlined in the CMA policy statement, there is a clear desire for organizations to change and improve. However, it is vital that policies are not simply written about, but rather translated into direct action that is grounded in knowledge. The implementation and utilization of approaches highlighted here may help medical institutions and organizations spur further change and progress within the profession.
Here is a link to recent advocacy efforts by the AMA on behalf of IMGs. Given our current national health care crisis with emergency departments shutting down and 5 million Canadians without a primary care provider, why do we not see CMA making similar efforts? IMGs are an obvious answer to our current health care crisis rather than waiting another 10 years for newly announced medical schools to be established and graduate Canadian trained doctors. But IMGs continue to face multiple barriers to licensure, and CMA remains silent, failing to advocate for IMGs or Canadians in need of doctors. This is why other commenters on this Blog see CMA as failing to “walk the walk” when it comes to their policy on Equity and Diversity.
En 2010, la Commission des droits de la personne et des droits de la jeunesse du Québec a déposé un rapport qui signalait une importante sous-représentation des médecins diplômés de programmes internationaux et un processus de recrutement qui contenaient de multiples embuches au recrutement de Diplômés internationaux en médecine (DIM). Aucune des recommandations émises par la Commission n’ont été appliquées depuis l’émission de ce rapport il y a 12 ans passés. Pourtant le Québec a une entente spéciale avec la France pour le recrutement de médecins français qui sont majoritairement de race blanche. Et à chaque année, le Québec remporte la palme pour le nombre important de postes réservés aux DIM qui ne sont pas comblés (plus de 75 en 2021). Il n’en faut pas davantage pour conclure que les candidats internationaux de couleur sont vus avec méfiance par le système de santé québécois et qu’on se sert d’embuches bureaucratiques pour justifier l’élimination de ces candidats.
While the authors are correct that institutions like the CMA are prepared to talk the talk, none so far, including the CMA, have been prepared to walk the walk. IMGs approached the CMA after the publication of the CMA policy about the current practices affecting access to residency jobs which adversely affect IMGs,. These practices are in clear contravention of the new CMA policy considering Canadians citizens and permanent residents who are IMGs are prohibited from competing for 90% of residency jobs despite having proven that they are qualified and meet the Canadian standard. Considering that IMGs from white Commonwealth countries need not re-take residency training, it is not surprising that most of these IMGs who are unable to fairly compete for residency jobs which blocks their path to medical licensure are people of colour. The CMA responded that their Equity and Diversity policy does not apply to the barriers imposed on IMGs. IMGs are entitled according to the CMA to “reasonable”– not equal– access to the medical profession. Read the correspondence here: https://socasma.com/general/socasma-calls-on-its-members-to-question-cmas-application-of-its-new-equity-and-diversity-policy/.
The white glaze is still working well to justify the second class status of IMGs. It will be some time yet before the marginalization and racism IMGs endure will be visible to the majority of the medical profession.