Remembering Freddie Gray: Medical Education for Social Justice Delese Wear, Phd, Joseph Zarconi, MD, Julie M

Perspective

Remembering Freddie Gray: Medical Education for Social Justice Delese Wear, PhD, Joseph Zarconi, MD, Julie M. Aultman, PhD, Michelle R. Chyatte, DrPH, MPH, and Arno K. Kumagai, MD

Abstract Recent attention to racial disparities in orientation. The authors detail two learners and naming specific resources law enforcement, highlighted by the specific approaches—antiracist that can be brought to bear on these death of Freddie Gray, raises questions pedagogy and the concept of structural strategies. The fundamental aim of about whether medical education competency—to construct a curriculum such a curriculum is to help trainees adequately prepares physicians to oriented toward appropriate care for and faculty understand how equitable care for persons particularly affected patients who are victimized by extremely access to skilled and respectful health by societal inequities and injustice challenging social and economic care is often denied; how we and the who present to clinics, hospitals, and disadvantages and who present with institutions where we learn, teach, and emergency rooms. In this Perspective, health concerns that arise from these work can be complicit in this reality; and the authors propose that medical disadvantages. In memory of Freddie how we can work toward eliminating the school curricula should address such Gray, the authors describe a curriculum, societal injustices that interfere with the concerns through an explicit pedagogical outlining specific strategies for engaging delivery of appropriate health care.

On April 12, 2015, as nearly 20,000 medical educators, we wondered how than 7% come from families with annual fourth-year medical students in the we might memorialize Freddie Gray, incomes below $25,000.1 United States were finishing their last as well as other young black men killed electives, packing up their apartments, prematurely and unjustly, including Yet because most academic medical or beginning their summer vacations, a Trayvon Martin, Michael Brown, Eric centers are located in urban settings, 25-year-old African American man in Garner, Tamir Rice, Walter Scott, Laquan a majority of students learn medicine Baltimore, Maryland, named Freddie McDonald, Alton Sterling, and Philando caring for patients with significant social Gray, lay dying. Gray was arrested, Castile, through a renewed commitment and economic disadvantages and with cuffed with his hands behind his back, to education for social justice. In the same profound health problems that are far restrained with leg irons, and placed spirit as the Black Lives Matter movement beyond easy fixes. The task has fallen to us without proper safety restraints into and its medical school version, White as medical educators to teach the relevant a police van. On the way to the police Coats for Black Lives, we wish to realize knowledge and skills needed to provide station, Gray reportedly called out several this commitment through action— care to such economically disadvantaged times for medical help and said he could educational action. The ultimate goal of and historically marginalized patients, not breathe. He was subsequently found this effort is to educate ourselves and our who are often members of racial to be unresponsive and taken to a local students to advocate and provide care minorities, and who often live in hospital. Seven days later, he died. The for people who are disempowered and devastatingly poor neighborhoods. stories of Gray’s life and arrest and of the dispossessed, for people with no voice, for subsequent investigation into his death the individuals whom our new medical So we ask, “How are we doing?” were captured in the 24-hour news cycle. graduates will most surely encounter in Though the story is no longer daily front- the months ahead. In her eloquent essay, then-medical page news, it remains tragic—emblematic student Katherine Brooks2 tells us “not of the struggles, resilience, and despair of Freddie Gray’s story—of his childhood, so well.” The problem is not merely whole communities in the United States community, parents, education, health, an inadequate formal curriculum, she who are not able to enjoy the benefits of work status, and interaction with civil argues, one that does little to address an advanced industrialized society. As authorities—is vastly different from that why disparities exist, or why, for such of most medical students. The economic conditions as coronary heart disease in profile of U.S. medical students’ families black patients, standards of care are still Please see the end of this article for information is quite different from that of the not met.2 Rather, she believes, a silent about the authors. mainstream, and profoundly different curriculum exists, one that does not Correspondence should be addressed to Delese from that of many patients whom trainees address the current or critical health Wear, Family and Community Medicine, 4209 encounter in hospital wards, clinics, and needs of people in communities such as Rte. 44, PO Box 95, Rootstown, OH 44272-0095; telephone: (330) 325-6125; e-mail: dw@neomed. emergency departments. To illustrate, those where “Trayvon Martin lost his life, edu; Twitter: @NEOMEDedu. 64% of U.S. medical students come from [where] Michael Brown was left to die in families whose income is $100,000 or the streets …, and [where] Eric Garner Acad Med. XXXX;XX:00–00. First published online higher; 22% from families whose income was choked by officers as he repeated 11 doi: 10.1097/ACM.0000000000001355 is a quarter-million dollars or more. Fewer times that he could not breathe.”2 Brooks

wonders where in the curriculum is a competency. Next, we offer specific postures of pseudo-objectivity and adopt critical examination of these specific suggestions that would characterize a such strategies as applying an antiracist events, which are certainly emblematic of curriculum informed by the lessons of pedagogy or exploring structural the health of communities; and, where, Freddie Gray’s experiences and aimed competency. Below, we describe each more broadly, is an examination of at fostering a deeper understanding of strategy individually, recognizing that the class bias and racism, especially as they societal inequities and social justice. two overlap substantially. manifest in the culture of medicine? We offer these ideas in the spirit of the #FergusonSyllabus Twitter campaign, Antiracist pedagogy Of course, one would be hard pressed which is designed for educators to share Faculty who adopt the goals of antiracist to find a medical curriculum that ideas on how to talk about Ferguson in pedagogy must first give up the idea does not address health disparities in their classrooms.4 of neutrality by explicitly stating that some manner. Brooks2 writes of being the goal of a class/discussion/group is “inundated with lecture PowerPoint to “move beyond their comfortable, Pedagogical Orientation: Making slides that list diseases with higher rates deeply rooted views of the world.”9 It Visible among minorities.” But the curriculum This openness and surrender do not rarely focuses on the forces—from One of the core values in medicine is come easily. In fact, the “resistance and individual biases and stereotypes to the objectivity. Coupled with objectivity emotions which are likely to accompany myriad societal, cultural, legal, political, is a reluctance to discuss events, such such pedagogy”—not to mention and medical structures—that impact as the death of Freddie Gray or the anger and defensiveness from learners health outcomes and, in a broader shooting of Trayvon Martin, which and teachers alike—are difficult for context, lead to the discrimination may be deemed as “too political” for many faculty who are used to more and oppression of individuals such as a medical school curriculum. From polite, orderly classrooms, even when Freddie Gray. How, then, can medical the basic sciences to evidence-based controversial topics are addressed.9 school and clinical faculty create learning medicine, medical educators teach the spaces and experiences to help students importance of knowledge and critical Specifically, antiracist pedagogy “seeks see the next person who appears in reasoning; however, critical reasoning, to provide students with the ability the clinic or hospital ward or the although necessary for providing the to critically reflect on the ways in emergency department as more than a best care possible, is by itself insufficient which oppressive power relations are set of characteristics/demographics or to address social injustice, disparities, inscribed in their own lives, as well as worse, as a social caricature created by and inequities.5 Curricular attempts to the lives of others.”10 This approach deeply embedded stereotypes? How do capture issues regarding race and class stands in sharp opposition to the focus medical educators create an environment through the characteristics, individual on beliefs, values, and health practices that fosters practicing medicine with behaviors, and beliefs typically ascribed of “others,” most often marginalized excellence and justice? How do faculty to members of particular classes or groups, in a depoliticized way. Such nurture a society that embodies such racial groups are important but, even efforts in cultural competency are often values? collectively, represent a limited, and often accompanied by larger institutional simplistic, attempt to move students efforts to celebrate diverse cultures The first step, we believe, is the willingness toward “cultural competency.” They without addressing inequalities. These of educators to examine uncomfortable are simplistic because they ask little of celebrations often come to resemble realities that are exceedingly difficult to students other than memorizing lists of “cultural safaris”6 that involve observing confront: the messy landscapes that are characteristics of people mostly unlike the interesting characteristics of “Others” America’s legacy of racism, brutality, themselves, or listening to the stories of (most often people who are not white, violence, poverty, hopelessness, and individuals, while rarely addressing the not economically stable, not Judeo- despair. Racism and other forms of formidable contribution of institutions Christian, not able-bodied, and so on) bigotry have particularly deleterious (e.g., lending institutions, public schools) with an attitude of “tolerance,” while effects, for they reduce human beings to to racism, bias, and exclusion. We have ignoring “systems of oppression … objects without individuality, agency, or previously argued for going beyond responsible for the development and value, and thereby allow debasement and notions of “cultural competency” to perpetuation of health disparities.”10 In even destruction without moral objection. consider issues of power and privilege, contrast, antiracist pedagogy continually To effectively address these issues, difference, and identity in fostering a attempts to examine issues from multiple educators must leave the relative comfort professional self committed to fairness standpoints—including the standpoints of abstraction, and instead teach and and justice.6–8 Here we extend our of the providers themselves—so that practice fearlessness.3 In this Perspective, arguments by asking students and systems of power, the systems that create we explore theoretical frameworks as faculty to look deeper into themselves, privilege in some people and not others, well as practical applications as means the culture of medicine, and the larger are made visible. toward accomplishing this objective. structural contexts in which they (and The Perspective contains two major their patients) live to gain an always- This pedagogy, of course, necessarily threads. First, we propose a morally incomplete yet more rigorous and involves an examination of white just medical curriculum pedagogically difficult understanding of race and class privilege, the clear preference for oriented from two theoretical positions: in the United States. To foster this critical whiteness that saturates mainstream U.S. antiracist pedagogy and structural perspective, we must move beyond culture, providing advantages to white

people that are unearned and which higher education classrooms across the However, our propensity as a culture make them unaware of, if not immune country, yet rarely in medical education. to look to the individual as the single to, many challenges experienced by those In fact, a June 2016 PubMed search of most important determinant of his or who are not white. We note, however, the term “white privilege” yielded just her health gets in the way of structural that the discourse of white privilege is 35 entries with only 2 in medicine/ competency. Such a view suggests that not without controversy due to, among medical education, the majority found “people’s health status is largely within other factors, conflicting meanings of in the social sciences and nursing. As one their control through their health whiteness, along with the potential for educator, Kandaswamy,15 has aptly noted, behavior choices,”22 and ignores the such discourse to be a distraction from “students and teachers do not check their fact that social and economic status effective action toward racial equality histories at the door when they enter it.… shapes a person’s ability to make healthy and fairness.11,12 That said, considerations In the classroom, just as in the society in choices regarding housing, available of how white privilege manifests itself which we live, there are no blank slates food, safe neighborhoods, and the like. in U.S. culture in general, and in health or level playing fields for any of us.” This fallacy is the old “bootstraps” care in particular, could offer insights to Antiracist pedagogies attempt to tackle belief that individuals are capable of medical students as they consider social the myth of the blank slate, along with the and responsible for simply “pulling justice in medicine. Whiteness is the belief voiced by well-meaning students themselves up.” prevailing racial atmosphere at nearly that they are “color blind” when it comes every medical school in the United States, to caring for patients. Understandably, no A focus on structural competency, and “while students of color perceive one wants to be labeled racist, particularly however, does not replace an awareness that constantly, white administrators, students entering the medical profession, of cultural factors in the clinical setting faculty members, and students just don’t yet it is essential to design learning but, rather, recognizes “how ‘culture’ and see it.”13 White privilege is, perhaps, a experiences that attempt to draw out ‘structure’ are mutually co-implicated in more difficult idea to address in the our conscious and unconscious biases producing stigma and inequality.”21 Metzl classroom where any number of white surrounding race and class which get and Hansen21 posit a number of skills students may cite examples of social and in the way of providing effective and and orientations leading to structural economic struggles experienced by their humane health care to all patients— competency, including (1) identifying families (e.g., “My grandfather came to especially given the compelling and structures that influence clinical this country with a dollar in his pocket”). consistent evidence that clinician bias is encounters; (2) developing understandings Such thinking, however, misses the point one factor among others that contributes of structure from other disciplines such entirely: to have struggles even as one has to racial inequities in health care.16–18 as sociology, urban planning, economics, privilege is possible, but white privilege is etc.; (3) recasting case presentations to “the lack of struggle in a very specific and Structural competency acknowledge structural barriers to health; profound aspect of life. It does not mean The idea of “structural competency”—a (4) developing interventions to address 13 no struggle, just not that struggle.” play on and extension of cultural health infrastructures; and, importantly, competency—“emphasizes recognition (5) nurturing a critical awareness of The idea of the unearned, often taken- of the complex ways that matters such structural humility. The ultimate goal for-granted privileges that certain groups as rising income inequalities, decaying is producing clinicians who “are at enjoy is not new. Over a quarter-century infrastructure, poor food distribution once speakers and listeners, leaders and 14 21 ago, Peggy McIntosh examined how networks,” among other social and collaborators, experts and benighted.” her male colleagues were generally economic factors, lead to poor health.19,20 unaware of their own privilege as men This model, developed in large part by Below, we offer some specific ideas of (even as many of them acknowledged the Vanderbilt’s Center for Medicine, Health how, with these pedagogical orientations disadvantages experienced by women), and Society director, Jonathan Metzl, in play, medical educators might develop and realized that as a white woman promotes looking at forces beyond the learning experiences focused on the she, too, had an invisible weightless patient–doctor interaction: ubiquitous and unjust inequalities that knapsack of unacknowledged privileges manifest in health. that included “special provisions, maps, We train doctors to listen to passports, codebooks, visas, clothes, tools, individualized stories, not to structural and blank checks.” McIntosh lists 50 of ones. For instance, methods such as Remembering Freddie Gray: A these unspoken advantages from everyday cultural competency or narrative analysis Curriculum for Social Justice experiences that white people take for teach doctors to better listen to the In memory of Freddie Gray as an “cross-cultural” aspects of the stories granted, such as “I can go shopping most that their patients tell at moments of individual and as a symbol of the of the time, pretty well assured that I will clinical encounter.… such approaches inequity, brutality, and racism in modern not be followed or harassed,” or “I do not … do little to address the complex American society, we wish to promote have to educate my children to be aware relationships between clinical symptoms curricular efforts that aspire toward of systemic racism for their own daily and social, political, and economic social justice and equity. We provide the physical protection,” or “I can be pretty systems. We thus argue that medical following suggestions in response to the education needs to more broadly engage sure that if I ask to talk to the ‘person with knowledges and methods beyond its injustices of Gray’s experiences (and in charge,’ I will be facing a person of traditional purview if it wishes to train all the injustices that lead to disparities my race.” Faculty have engaged learners its practitioners to effectively address the in health, income, schooling, housing, with her essay innumerable times in pressing health issues of our time.21 employment, and treatment by public

servants—health care professionals, the black people are “sprinkled.” Manning’s of medicine and science to privileged courts, and the police alike). essay serves well as a companion to systems of power. “Urology blues,” Ugo Ezenkwele’s29 To these ends, antiracist pedagogy portrait of his encounters with racist All of the aforementioned types of and a focus on structural competency patients while a medical student. teaching resources are used across are but two approaches to addressing the four-year course, Human Values bias in the classroom. Whichever Jonathan Metzl’s meticulously researched in Medicine, at NEOMED, and are strategy one adopts, it must be one Protest Psychosis30 (2009) shows how specifically applied in the reflective that emphasizes critical reflection and schizophrenia became the diagnostic practice component of that course. In this dialogue—preferably in small-group term overwhelmingly applied to African component, students assemble in small settings—in which issues of power, American men in the 1960s, mirroring groups, with clinical, social sciences, and privilege, identity, and oppression may how racial tensions seep into medical humanities faculty preceptors, and engage be safely and productively explored.6–8 culture and even shape disease categories. in reflective writing and group discussion The term “critical reflection” used here is Ta-Nehisi Coates’s31 recent Between the stimulated by assigned materials such synonymous with “critical consciousness” World and Me, a six-chapter “letter” to as those described above. We have and entails a questioning of one’s own his son explaining what it means to be previously described the benefits of values, perspectives, and assumptions, as black in the United States, examines, these teaching approaches: to teach and well as those of others and of society, in among many other important issues, foster deep and meaningful reflection36; an effort to uncover and address sources “America’s ongoing romance with its own to slow down the medical education of injustice.23 This approach differs from unexamined platitudes of innocence and process, allowing for a richer and more the traditional lecture-based, PowerPoint- equality.”32 productive critical self-examination and fueled formats of traditional medical more profound professional identity education and is meant to be deliberately Film. Film offers a rich source of development37; and to demonstrate the provocative in order to stimulate representations of race and racism. numerous ways that stories, read closely, discussion and inquiry. Written and directed by Paul Haggis, can broaden perspectives toward others.38 Crash (2004) illuminates how racism While we recognize that physicians often Resources for teaching and learning arises and is enacted in multiple and see the exploration of such literature as Although the content and skills of contradictory ways, even in those who a “soft science,” we agree with Kathryn humanities inquiry have been extolled deny its existence in themselves. Precious, Montgomery, who observes that “the for nearly half a century in U.S. medical Lee Daniels’s 2009 film, is a disturbing profession that scorns the anecdotal is in education as a means to improve the portrait of a young woman whose fact up to its ears in stories, using them patient–physician relationship, here predicaments arise at the intersection of to educate, to suggest the uncertainty of we call on them to “make strange”24 race, poverty, and violence, dispelling any today’s fact.”39 taken-for-granted beliefs, assumptions, mythology of a level playing field. Peter and world views in our “engagement Nicks’s documentary The Waiting Room Clinical and community experiences with Otherness.”25 What follows is a (2012) offers viewers an intense look, In clinical settings medical educators brief description of resources from the over a 24-hour period, at an overstretched have vast untapped curricular options humanities and bioethics that have been ER in Oakland, California, in which when it comes to addressing the lived implemented at the Northeast Ohio individuals without financial and health realities of patients from economically Medical University (NEOMED). care resources appear routinely. disadvantaged backgrounds who are often from racial minorities and/or Literature and written texts. Short Bioethics. Bioethics inquiry is fertile who often reside in overwhelmingly stories, poetry, narrative nonfiction, and ground for exploration of race- and class- poor neighborhoods. Although we books are rich sources for the medical based issues in health care. Discussions of are careful not to conflate poverty and educator to examine race- and class- narrative ethics and narrative medicine race, we nonetheless proceed with the based bias in medicine. Toni Morrison’s through readings such as Arthur Frank’s knowledge that many devastatingly poor story “Recitatif,”26 for example, offers “How can they act like that?”33 challenge communities have high concentrations readers a portrait of embodied differences students to reflect on their own stores in of black residents—like that of Freddie such as race, class, and disability, and it relation to the stories of others. Likewise, Gray, the Sandtown-Winchester illuminates how multiple identities exist short stories written by physicians that neighborhood in West Baltimore, where in all of us, such as being white and being speak to poverty and aloneness (Jay 96.9% of the population is black.40 poor, or being black and being wealthy. Baruch’s “Hug or ugh?”34) or to aversion Spending an afternoon or two in Freddie Neil Calman’s27 “Out of the shadow” is (Irvin Yalom’s “Fat lady”35) challenge Gray’s neighborhood clinic would hardly an essay exploring a white inner-city students to feel discomfort as they begin to reveal the depth and breadth physician’s confrontation with his own confront inequities in health care, some of issues that bear on the patients who racial prejudice. Kimberly Manning,28 even at the individual physician level. typically seek care there or in places writing about the hospital setting, reveals In addition, a bioethics curriculum, like it. For many students, such drop-in “The Nod”—a “tiny downward head including material on eugenics, the visits amount to little more than a kind bow” shared among African American Holocaust, and modern genetics, can of “safari,”6 a “drive-by” providing them people as they pass one another, an “I see address historical and contemporary little insight into the lives of patients you” here in this place where just a few examples of racism and the contributions whose health issues arise from myriad

factors long before they even arrive at of a critical perspective—is by itself we can work toward eliminating the the clinic. In fact, such visits not only fail insufficient. Attitudes such as the belief injustices Freddie Gray and others like to address structural racism, but, given that one is importing “better” or “more him have endured. To gain understanding “a topic so complex,” such “transient advanced” knowledge or practices and eliminate injustice is not easy; exposure is unlikely to optimally (clinical, educational, or otherwise) it involves difficult conversations prepare students” to care effectively for to “the ignorant” or “less developed” and startling revelations. It involves such patients.41 Medical educators are threaten to evolve into a smugness and cultivating cultural humility— before beginning to realize that greater exposure hegemony that may lead to an “us” doing even talking about cultural competency. is necessary, and a number of medical for “them” mentality that does little This humility is part and parcel of what schools currently offer experiences that to foster partnerships in health.43,50–52 Megan Boler would call a “pedagogy of far exceed such curricular drop-ins, Thus, taking the time to engage students discomfort,” through which “we invite including urban pathways and electives in critical reflection on such issues is one another to risk ‘living at the edge of embedded within core clerkships.42,43 imperative. our skin,’ where we find the greatest hope of revisioning ourselves.”53 It is, in the NEOMED offers clinical curriculum words of Paulo Freire,23 “an education for experiences that illuminate how Conclusions liberation”—from poverty, injustice, and structures and elements outside the In applying the principles of antiracist oppression. sterile bubble of the hospital largely pedagogy and structural competency Funding/Support: None reported. influence the health of individuals and to medical education, faculty members communities. With guidance, students must resist the temptation to avoid Other disclosures: None reported. who actively engage with people living explicit discussion of topics that are in impoverished communities and cities not directly related to health care. For Ethical approval: Reported as not applicable. begin to ascertain the predominant example, a reaction to a proposal by one D. Wear is professor, Family and Community health problems as well as the structural of us (A.K.K.) to use the movie Crash Medicine, Northeast Ohio Medical University, impediments to good health, and they for faculty development in multicultural Rootstown, Ohio. learn to “triage” resources in order to pedagogy was met with the objection, J. Zarconi is professor and chair, Internal Medicine, effect improvement in these settings. For “but this has nothing to do with health Northeast Ohio Medical University, Rootstown, Ohio. example, NEOMED students, working care.” We would argue that, in order to J.M. Aultman is professor, Family and Community closely with community health workers understand and address the attitudes, Medicine, Northeast Ohio Medical University, to study specific health issues, recently biases, and assumptions that shape the Rootstown, Ohio.

became focused on infant mortality. interactions among patients and health M.R. Chyatte is assistant professor, Family and This public health issue, identified care professionals and the health care Community Medicine, Northeast Ohio Medical not from lectures or textbooks or system in which they are all immersed, University, Rootstown, Ohio. preexisting community assessments but exploring race relations in a larger A.K. Kumagai is professor of medicine and through interaction with community societal context has everything to do with vice chair for education, University of Toronto stakeholders, was particularly relevant in health care. Department of Medicine, Toronto, Ontario, Canada. this community where the 2012 infant mortality rate for African American Of paramount importance to References babies was 19.69 per 1,000 live births,44 implementing a curriculum for social 1 Association of American Medical Colleges. compared with the U.S. African American justice, then, is the question, “Who Matriculating student questionnaire. 2014 all rate of 11.19, and compared with the teaches the teachers?” Good will and schools summary report. https://www.aamc. 45 org/download/419782/data/msq2014report. overall U.S. infant mortality rate of 5.98. good intentions alone are insufficient to pdf. Published December 2014. Accessed June meet the educational challenges inherent 25, 2016. Using the Centers for Disease Control in confronting race, power, privilege, 2 Brooks KC. A silent curriculum. JAMA. and Prevention’s Racial and Ethnic and identity. Good intentions must be 2015;313:1909–1910. 3 Wear D, Zarconi J, Dhillon N. Teaching Approaches to Community Health accompanied by the skills needed to fearlessness: A manifesto. Educ Health 46 model, these medical students helped to facilitate open dialogue, preserve safety, (Abingdon). 2011;24:668. create centering pregnancy groups at two and address conflicts—not in order to 4 Georgetown College. The #Ferguson syllabus. hospitals. Each group focused not only achieve “conflict resolution,” but in order http://college.georgetown.edu/Collegenews/ on tending to the physical health of the to place one’s own and others’ views and the-ferguson-syllabus.html. Published August 27, 2014. Accessed June 25, 2016. mother and baby but also on providing assumptions into the open and to allow 5 Kumagai AK. From competencies to a social nucleus of support for each questioning so that all may achieve new human interests: Ways of knowing and woman. Previous research has shown perspectives, insights, and understanding. understanding in medical education. Acad that such support systems reduce poor Med. 2014;89:978–983. 6 Wear D. Insurgent multiculturalism: Rethinking pregnancy outcomes and improve child We—faculty and students—are in this how and why we teach culture in medical health.47–49 quest together, trying to understand how education. Acad Med. 2003;78:549–554. equitable access to skilled and respectful 7 Kumagai AK, Lypson ML. Beyond cultural The very act of placing students into health care is often denied, how we and competence: Critical consciousness, social justice, and multicultural education. Acad communities and societies where the institutions where we work and Med. 2009;84:782–787. health care disparities exist—although learn are complicit in this reality in ways 8 Wear D, Kumagai AK, Varley J, Zarconi J. potentially important to the development known and unknown to us, and how Cultural competency 2.0: Exploring the

concept of “difference” in engagement with onlinelibrary.wiley.com/doi/10.1111/j.1468- Sandtown.pdf. Published December 2011. the other. Acad Med. 2012;87:752–758. 0009.2008.00530.x/full#b76. Accessed June Accessed June 26, 2016. 9 Wagner AE. Unsettling the academy: 25, 2016. 41 Doran KM, Kirley K, Barnosky AR, Williams Working through the challenges of anti-racist 23 Freire P. Pedagogy of the Oppressed. Ramos JC, Cheng JE. Developing a novel Poverty in pedagogy. Race Ethnic Educ. 2005;8:261–275. MB, trans. New rev 20th anniversary ed. New Healthcare curriculum for medical students 10 Hassouneh D. Anti-racist pedagogy: York, NY: Continuum; 1993. at the University of Michigan Medical Challenges faced by faculty of color in 24 Kumagai AK, Wear D. “Making strange”: A School. Acad Med. 2008;83:5–13. predominantly white schools of nursing. role for the humanities in medical education. 42 Ford-Jones L, Levin L, Schneider R, Daneman J Nurs Educ. 2006;45:255–262. Acad Med. 2014;89:973–977. D; Social Pediatrics Working Group. A new 11 Gordon LR. Critical reflections on three 25 Dalos LAP. Transformative learning for the social pediatrics elective—A tool for moving popular tropes in the study of whiteness. common good. In: Mezirow J, ed. Learning to life course developmental health. J Pediatr. In: Yancy G, ed. What White Looks Like: as Transformation: Critical Perspectives on 2012;160:357–358.e2. African-American Philosophers on the a Theory in Progress. San Francisco, CA: 43 van den Heuvel M, Au H, Levin L, Bernstein Whiteness Question. New York, NY: Jossey-Bass; 2000:103–123. S, Ford-Jones E, Martimianakis MA. Routledge; 2004. 26 Morrison T. Recitatif. In: Baraka A (LJ), Evaluation of a social pediatrics elective: 12 Zack N. White Privilege and Black Rights: Baraka A, eds. Confirmation: An Anthology Transforming students’ perspective through The Injustice of U.S. Police Racial Profiling of African American Women. New York, NY: reflection. Clin Pediatr (Phila). 2014;53:549– and Homicide. Lanham, MD: Rowman and Quill; 1983:243–261. 555. Littlefield; 2015. 27 Calman NS. Out of the shadow. Health Aff 44 Ohio Department of Health, Office of Vital 13 Kolowich S. White like you: The challenge of (Millwood). 2000;19:170–174. Statistics. Neonatal, postnatal, and infant getting white students to grapple with racial 28 Manning K. A piece of my mind: The nod. mortality, Ohio and selected counties, identity. Chron High Educ. May 29, 2015. J Am Med Assoc. 2014;312:133–134. 2007–2012. https://www.odh.ohio.gov/~/ http://chronicle.com/article/White-Like-You- 29 Ezenkwele UA. Urology blues. In: Takakuwa media/ODH/ASSETS/Files/cfhs/Infant%20 The-Challenge/230509. Accessed June 25, KM, Rubashkin N, Herzig KE, eds. What I Mortality/collaborative/2014/2007–2012%20 2016. Learned in Medical School: Personal Stories IM%20BY%20RACE%20%20COUNTY.pdf. 14 McIntosh P. White privilege: Unpacking the of Young Doctors. Berkeley, CA: University of Accessed July 12, 2016. invisible knapsack. Peace Freedom Mag. July/ California Press; 2004. 45 Matthews TJ, MacDorman MF, Thoma ME. August 1989. http://nationalseedproject.org/ 30 Metzl J. The Protest Psychosis: How Infant mortality statistics from the 2013 white-privilege-unpacking-the-invisible- Schizophrenia Became a Black Disease. period linked birth/infant death data set. Natl knapsack. Accessed June 25, 2016. Boston, MA: Beacon Press; 2009. Vital Stat Rep. 2015;64:1–30. http://www.cdc. 15 Kandaswamy P. Beyond colorblindness and 31 Coates T-N. Between the World and Me. New gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf. multiculturalism: Rethinking anti-racist York, NY: Spiegel & Grau; 2015. Accessed July 12, 2016. pedagogy in the university classroom. Radical 32 Hamilton J. Between the world and me. Slate 46 Centers for Disease Control and Prevention. Teach. 2008;80:6–11. Book Rev. http://www.slate.com/articles/arts/ Racial and ethnic approaches to community 16 van Ryn M, Burke J. The effect of patient race books/2015/07/between_the_world_and_ health. http://www.cdc.gov/nccdphp/dch/ and socio-economic status on physicians’ me_by_ta_nehisi_coates_reviewed.html. programs/reach/. Reviewed and updated perceptions of patients. Soc Sci Med. Accessed June 25, 2016. November 4, 2015. Accessed June 25, 2016. 2000;50:813–828. 33 Frank AW. “How can they act like that?” 47 Olds DL, Kitzman H. Can home visitation 17 Fincher C, Williams JE, MacLean V, Allison Clinicians and patients as characters in improve the health of women and children at JJ, Kiefe CI, Canto J. Racial disparities in each other’s stories. Hastings Cent Rep. environmental risk? Pediatrics. 1990;86:108– coronary heart disease: A sociological view of 2002;32:14–22. 116. the medical literature on physician bias. Ethn 34 Baruch J. Hug or ugh? Hastings Cent Rep. 48 Penny ME, Creed-Kanashiro HM, Robert Dis. 2004;14:360–371. 2010;40:7–8. RC, Narro MR, Caulfield LE, Black RE. 18 van Ryn M, Burgess DJ, Dovidio JF, et al. 35 Yalom ID. Fat lady. In: Yalom ID. Effectiveness of an educational intervention The impact of racism on clinician cognition, Love’s Executioner and Other Tales of delivered through the health services to behavior, and clinical decision making. Du Psychotherapy. New York, NY: Basic Books; improve nutrition in young children: A Bois Rev. 2011;8:199–218. 1989. cluster-randomised controlled trial. Lancet. 19 Metzl J. The case for structural competency. 36 Wear D, Zarconi J, Garden R, Jones T. 2005;365:1863–1872. Nashville Post. June 30, 2014. http://www. Reflection in/and writing: Pedagogy and 49 Barnes-Boyd C, Fordham Norr K, Nacion nashvillepost.com/home/article/20477276/ practice in medical education. Acad Med. KW. Promoting infant health through home the-case-for-structural-competency. Accessed 2012;87:603–609. visiting by a nurse-managed community June 25, 2016. 37 Wear D, Zarconi J, Kumagai A, Cole-Kelly worker team. Public Health Nurs. 20 Metzl JM, Roberts DE. Structural K. Slow medical education. Acad Med. 2001;18:225–235. competency meets structural racism: 2015;90:289–293. 50 Bleakley A, Brice J, Bligh J. Thinking the post- Race, politics, and the structure of medical 38 Blackie M, Wear D. Three things to do with colonial in medical education. Med Educ. knowledge. AMA J Ethics. 2014;16:674–690. stories: Using literature in medical, health 2008;42:266–270. http://journalofethics.ama-assn.org/2014/09/ professions, and interprofessional education. 51 Hodges BD, Maniate JM, Martimianakis spec1-1409.html. Accessed June 25, 2016. Acad Med. 2015;90:1309–1313. MA, Alsuwaidan M, Segouin C. Cracks and 21 Metzl JM, Hansen H. Structural competency: 39 Hunter KM. Literature and medicine: crevices: Globalization discourse and medical Theorizing a new medical engagement Standards for applied literature. In: Callahan education. Med Teach. 2009;31:910–917. with stigma and inequality. Soc Sci Med. D, Caplan AL, Jennings B, eds. Applying 52 Abedini NC, Gruppen LD, Kolars JC, 2014;103:126–133. the Humanities. Hastings-on-Hudson, NY: Kumagai AK. Understanding the effects of 22 Niederdeppe J, Bu QL, Borah P, Kindig DA, Hastings Center; 1985. short-term international service-learning Robert SA. Message design strategies to raise 40 Baltimore City Health Department. 2011 trips on medical students. Acad Med. public awareness of social determinants of neighborhood health profile: Sandtown- 2012;87:820–828. health and population health disparities. Winchester/Harlem Park. http://health. 53 Boler M. Feeling Power: Emotions and Milbank Q. 2008;86:481–513. http:// baltimorecity.gov/sites/default/files/47%20 Education. New York, NY: Routledge; 1999.