Case and Commentary
Jan 2023
Peer-Reviewed

Is It Reasonable to Expect Students and Trainees to Internalize Equity as a Core Professional Value When Teaching and Learning Occurs in Segregated Settings?

Adriana Pero and Emily L. Xu
AMA J Ethics. 2023;25(1):E15-20. doi: 10.1001/amajethics.2023.15.

Abstract

Training in a segregated health care system means that health professions students and trainees learn bias and experience helplessness and burnout if they wish to—but cannot—rectify segregated care. When racial segregation is built into training environments, many students and trainees quickly internalize which patients are de facto deemed more worthy of care. Students and trainees who recognize this feature of their professional training as dysfunctional and as an ethical and equity problem need support when reporting inequities and advocating for desegregated health systems. By supporting such efforts, faculty and organizations can help desegregate health care, minimize iatrogenic harm from bias, motivate health equity, and promote equitable access to quality health service delivery.

Case

AB is a student who often hears patients referred to as “clinic patients” when they are insured by Medicaid and as “private patients” when they have more generous insurance coverage. Now rotating in an obstetrics and gynecology unit, AB talks with fellow students about having also observed a norm of asking a laboring patient with private insurance whether they will permit a student to participate in their delivery and a norm of not asking a laboring patient insured by Medicaid—often a person of color or fluent in languages other than English—whether they will permit a student to participate in their delivery. Several students agree that they observe differences in how patients are treated and that they are invited, if not de facto required, to participate in routine, long-standing patterns of inequitable care of patients, which makes them feel complicit, morally distressed, and outraged. Some students express fear of reprisals if they question the unit’s practices and their teachers’ perpetuation of inequity and suggest it’s not “worth it” to speak up. Some students, however—even some among those who fear reprisals—also state that they feel terrible about not speaking up. The students exchange ideas and consider how to respond.

Commentary

We stood in the hallway, peering into the room as the attending physician spoke to the patient—a petite, Black woman with metastatic cancer. Despite the patient’s initially declining an unnecessary physical exam by us, the preclinical medical students, the attending physician asked her again if we could examine her. Caught up in the thinly veiled power dynamic between physician and patient, she agreed despite her pain and fatigue. Six students piled into the cramped room as the attending physician began describing the patient, as if she were not laying in front of us. Interspersed among medical jargon, the attending physician mentioned that the patient needed a second chest tube. Alarmed, the patient shook her head nervously, saying, “Not another one.” The attending physician only briefly acknowledged her concern before inviting several students to examine her.

Being early in our training, we could have easily overlooked this patient’s multiple marginalized identities. Yet, after experiencing several similar clinical encounters in addition to learning about endless examples of racial inequity in medicine—from the use of Black bodies for the advancement of medicine1 to those bodies being targeted for sexual assault2—we cannot discount this pattern of injustice. Who are we, the primarily White, wealthy medical students, allowed to see and examine in our training? How does that affect how we think and talk about patients for the rest of our careers? How can we reject the normalization of segregation?

A Legacy of Separate, Inequitable Care

We began medical school with an idealized view of our future profession. We were quickly jolted into reality when, in our first week, we learned that in many academic medical centers (AMCs),3 including our own in New York City (NYC), privately insured patients and patients with Medicaid or no insurance receive care at different clinics and hospitals. Nationwide, a greater number of Black and Brown patients access health care through Medicaid than White patients, who predominantly have private insurance.4 Health care segregation by ability to pay is de facto segregation by race and demonstrates that many health systems still hold the erroneous belief that separate can be equal.5 As we learned more, we realized that racial and socioeconomic inequities run far deeper than individual institutions; inequities have been created and sustained through government policies, such as New York State’s General Hospital Indigent Care Pool, which disproportionately allocates funding to private hospitals at the expense of safety-net hospitals that predominantly serve patients of color.6

We define segregated care as race- and class-based differential treatment resulting from government and hospital policies and practices that intentionally sort patients and distribute resources so as to maximize hospital profits and maintain existing power structures. To take one example, private NYC hospitals prioritize “serving as referral centers” for patients with private insurance, a majority of whom are White in New York State.7 Those who are excluded from NYC private hospitals—disproportionately people of color and the working class—are funneled to under-resourced hospitals or forced to wait months to access medical care.5 Many private hospitals forgo their public responsibility as nonprofits to provide care to patients who struggle to afford health care, instead prioritizing patients whose care is reimbursed at higher rates, thus accumulating financial surplus.8 In NYC during the COVID-19 pandemic, one well-resourced health care institution’s satellite hospital that treats uninsured and underinsured patients had a COVID-19 mortality rate more than twice that of the flagship hospital—not because the satellite hospital treated sicker patients or because safety-net hospitals inherently provide worse care, but because, like many other safety-net hospitals, it was systematically drained of resources.9

Shifting priorities would stabilize the tightrope that students walk between advancing their careers and upholding their values. 

The segregated system of our training obscures the biases dictating which patients are used for student learning. During Jim Crow segregation, medical schools boasted of the abundance of “clinical material,” or the availability of Black bodies for medical education,1 teaching medical students to view Black patients as learning material rather than as patients with the right to health care. After the passage of the Medicare and Medicaid Act of 1965, which supposedly forced racial integration of hospitals,10 Jim Crow racial segregation morphed into a more socially acceptable segregation on the basis of insurance status. How much has changed when, in a purportedly “equal” health system, medical students continue to learn primarily on certain bodies?

Contemporary Inequity in NYC

Segregated health care has persisted, despite litigation efforts. In 2006, a report released by the Bronx Health REACH Coalition found that Black and Latino New Yorkers were more than twice as likely to be uninsured as White New Yorkers and that Medicaid and uninsured patients were more likely to receive care in public hospitals.5 In 2008, Bronx Health REACH filed a civil rights complaint against 3 AMCs in NYC for segregation on the basis of “source of payment, race, and national origin.”11 An individual involved in the case verbally confirmed in a conversation that there has been no movement on this complaint (January 2022). Despite advocacy groups’ repeated attempts to bring justice to these institutions,11,12 to obtain equitable hospital funding,13,14 to raise the Medicaid spending cap,15 and to create a single payer system in New York State,16 many hospital systems have only consolidated their power by acquiring private practices and forcing hospital closures.17,18

Training in Bias

The assumption of “separate-but-equal” treatment is ubiquitous in medical training. For example, some medical schools continue to attract applicants with opportunities to participate in student-run free clinics that primarily rely on Black and Brown bodies for student learning. Students’ provision of services to patients denied access to medical care by racist health care systems is portrayed as community service and marketed as early clinical exposure, sending the message that antiracism consists of providing a necessary service to people who otherwise would not receive care. Yet, in our experience, students have minimal solidarity with patients who have been stripped of their right to health care, and we know of no organization that acknowledges that these clinics are also a product of a racist and xenophobic system that blocks these patients from receiving health care in the first place.

Training in a segregated health care environment, we struggle to navigate a deeply unethical system. In one survey of medical students, more than half reported witnessing segregated care on the basis of insurance in their clinical training, and the authors speculated that medical students “may see insurance-based segregation as one piece of broader structural racism.”19 Students witnessing segregated care may fall into learned helplessness, seeing no way to create meaningful change. The dissonance between health systems declaring their commitment to antiracism while upholding modern-day racial segregation creates a medical school atmosphere that forces trainees to make an impossible choice: continually resist the indoctrination of passively learning bias or compromise their values to fit into the mold of academic medicine. With looming residency applications and constant evaluations, the latter can too often be the chosen path. Students hoping for competitive applications and positive performance evaluations must remain silent and, in doing so, maintain harmful power structures.

Medical schools have a responsibility to support, protect, and train students advocating for desegregated health systems. The coalition of medical trainees we helped found, New York City Against Segregated Healthcare, has pioneered education about segregated care, but education is not enough to encourage students to become agents of change. For students to become advocates, we must train in a system in which fear of retaliation is nonexistent—one in which students are supported when reporting inequities in their training and can witness and emulate clinicians openly refusing to be neutral bystanders of segregation. We envision a training system in which applicant evaluations—from medical school through residency and career promotions—emphasize dedication to fighting for a more equitable health system. Shifting priorities would stabilize the tightrope that students walk between advancing their careers and upholding their values. Creating a more equitable health system must be a priority of medical schools and their associated AMCs.

Rejecting Segregation Normalization

As student activists, we create petitions, host social media storms, and lobby government officials. Working in pursuit of decent treatment of all patients is unpaid, underrecognized, and even more difficult to complete while our clinical education pressures us to accept the current system without question. Moreover, we have encountered resistance to changing the current system. In response to our calls to desegregate care, some AMCs have vehemently denied segregation, refusing to acknowledge the sorting of patients on the basis of race or ability to pay. When the patients we see during our training are primarily those with marginalized identities and when our institutions are silent on segregation, we learn that separating patients along racial lines and delivering differential treatment is normal and tolerable. We learn that, in medicine, valuing human life differently is acceptable.

The medical apartheid of our training cannot become the medical apartheid of our future. As trainees, we have the privilege of envisioning an ideal health care system. We imagine a desegregated health care system in which all patients with the same needs or condition are seen in the same location, by the same clinician, with equal wait times for an appointment. AMCs would not benefit from funding structures and policies that disadvantage safety-net hospitals and, by extension, their patients. Patients and community stakeholders would be the drivers of their care, diminishing the power differential between patients, who are often exploited for student learning, and doctors. As long as we are learning to practice medicine in a segregated health care system, we will learn and propagate racism and bias. If we are ever to achieve a truly equitable health care system and training environment, we must desegregate our health care system now.

References

  1. Washington HA. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present. Doubleday Books; 2006.

  2. Miller L. One night at Mount Sinai. The Cut. October 15, 2019. Accessed July 5, 2022. https://www.thecut.com/2019/10/mount-sinai-david-newman.html

  3. King R. Lown Institute: hospitals across 15 major cities deliver high racially segregated care. Fierce Healthcare. March 17, 2022. Accessed August 16, 2022. https://www.fiercehealthcare.com/providers/lown-institute-hospitals-across-15-major-cities-deliver-high-racially-segregated-care

  4. Artiga S, Hill Latoya, Orgera K, Damico A. Health coverage by race and ethnicity, 2010-2019. Kaiser Family Foundation. July 16, 2021. Accessed August 16, 2022. https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/

  5. Calman NS, Golub M, Ruddock C, Le L, Hauser D; Action Committee of the Bronx Health REACH Coalition. Separate and unequal care in New York City. J Health Care Law Policy. 2006;9(1):105-120.

  6. Tikkanen R, Woolhandler S, Himmelstein D. Funding charity care in New York: an examination of Indigent Care Pool Allocations. New York State Health Foundation; 2017. Accessed August 16, 2022. https://nyshealthfoundation.org/wp-content/uploads/2017/12/examination-of-indigent-care-pool-allocation-march-2017.pdf

  7. Tikkanen RS, Woolhandler S, Himmelstein DU, et al. Hospital payer and racial/ethnic mix at private academic medical centers in Boston and New York City. Int J Health Serv. 2017;47(3):460-476.
  8. Bai G, Zare H, Hyman DA. Evaluation of unreimbursed Medicaid costs among nonprofit and for-profit US hospitals. JAMA Netw Open. 2022;5(2):e2148232.

  9. Rosenthal BM, Goldstein J, Otterman S, Fink S. Why surviving Covid might come down to which NYC hospital admits you. New York Times. July 1, 2020. Accessed June 26, 2022. https://www.nytimes.com/2020/07/01/nyregion/Coronavirus-hospitals.html?auth=login-email&login=email

  10. Berkowitz E. Medicare and Medicaid: the past as prologue. Health Care Financ Rev. 2005;27(2):11-23.
  11. Agarwal N. Complaint of Bronx Health REACH pursuant to Title VI of the Civil Rights Act of 1964, the Hill Burton Act, the New York State Patients’ Bill of Rights, and the New York City Human Rights Law. New York Lawyers for the Public Interest; 2008. Accessed August 10, 2022. https://www.nylpi.org/images/FE/chain234siteType8/site203/client/COMPLAINT-FINAL-FULL.pdf

  12. What we do: CPHS mission statement. Commission on the Public’s Health System. Accessed June 26, 2022. http://www.cphsnyc.org/cphs/What_We_Do/

  13. Guarantee the survival of the healthcare safety-net: let us get it right for all New Yorkers! Medicaid Matters New York. January 2021. Accessed February 4, 2021. https://medicaidmattersny.org/wp-content/uploads/2021/01/ICP-statement-2020-2021-Final.pdf

  14. Payment & delivery system reform. Medicaid Matters New York. Accessed June 26, 2022. https://medicaidmattersny.org/payment-delivery-system-reform/

  15. 2022 health justice agenda. Medicaid Matters New York. November 17, 2021. Accessed June 26, 2022. https://medicaidmattersny.org/2022-health-justice-agenda/

  16. Healthcare for every New Yorker. Campaign for New York Health. Accessed June 26, 2022. https://www.nyhcampaign.org/

  17. Lewis C. Following pandemic battle, Brooklyn hospital moves forward with plan to cut 200 beds. Gothamist. June 29, 2021. Accessed December 12, 2021. https://gothamist.com/news/following-pandemic-battle-brooklyn-hospital-moves-forward-plan-cut-200-beds

  18. Evelly J. New law will require NY hospitals to assess community impact of closures, mergers. City Limits. December 28, 2021. Accessed August 16, 2022. https://citylimits.org/2021/12/28/new-law-will-require-ny-hospitals-to-assess-community-impact-of-closures-mergers/

  19. Wilkinson R, Huxley-Reicher Z, Fox GC, et al. Leveraging clerkship experiences to address segregated care: a survey-based approach to student-led advocacy. Teach Learn Med. Published online June 30, 2022.

Citation

AMA J Ethics. 2023;25(1):E15-20.

DOI

10.1001/amajethics.2023.15.

Acknowledgements

Both authors contributed equally to this work. This work could not have been completed without support from community organizers, including Judy Wessler, MPH; Anthony Feliciano; Elizabeth “Betty” Kolod, MD, MPH; and Duncan Maru, MD, PhD. We gratefully acknowledge work done by our colleagues in New York City Against Segregated Healthcare—namely Cameron Clarke, MPP; Anna Rose; Zay Smolar; Paige Cloonan; Anjali Jaiman, MD; and Andrea Martinez. In addition, we are indebted to Rachel Wilkinson, MD; Denisse Rojas Marquez, MD, MPP; and Hazel Lever, MD, MPH, who provided critical feedback on drafts of this piece.

Conflict of Interest Disclosure

The author(s) had no conflicts of interest to disclose.

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.