William McDade, MD, PhD, discusses health equity and resident education

AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.

In today’s episode of Moving Medicine, a discussion with William McDade, MD, PhD, chief diversity and inclusion officer at the Accreditation Council for Graduate Medical Education, or ACGME, about the importance of incorporating health equity in resident education.

Learn more about the AMA's GME Competency Education Program and UME Curricular Enrichment Program.

Speaker

• William McDade, MD, PhD, chief diversity and inclusion officer, ACGME

Unger: Hello, this is the American Medical Association's Moving Medicine video and podcast. Today we're talking to Dr. William McDade, chief diversity and inclusion officer at the Accreditation Council for Graduate Medical Education or ACGME in Chicago about the importance of incorporating health equity in resident education. I'm Todd Unger, AMA's chief experience officer in Chicago. Well Dr. McDade, ACGME just enacted several common program requirements, addressing issues of diversity, equity and inclusion. Can you explain, give more background about those requirements?

Dr. McDade: Well, thanks very much for asking Todd. Yeah, there's a new common program requirement, which means every residency program and fellowship must engage in this activity and it's to engage in a mission-driven, ongoing systematic approach to increasing diversity and inclusion—which applies to residents and fellows, faculty, other GME staff and any other academic personnel involved in the GME program. The rationale behind the workforce solution to problems that we see with respect to health care disparities, health inequities is really that one, that we don't have enough physicians who are from those communities that bear the greatest brunt of the health disparities that we see in our country. And because of the way that we practice medicine in the United States, it seems as if people prefer physicians of their own race and ethnicity speaking in their own primary language. And they go to those people disproportionately.

If you look in primary care medicine, the ratio or the odds of you actually seeing a Black physician or Black patient, if you are a Black physician, are almost 40 times that a white physician seen a Black patient. If you look at data for across the board in medicine, as the Cambridge Health Alliance did, the ratios are 23 and a quarter times greater if you're a Black physician seeing a Black patient than if you're a white physician seeing a Black patient. Nineteen times greater if you're a Latinx physician seeing a Latinx patient, and about 26 times greater if you're an Asian physician, seeing an Asian patient.

William Julius Wilson, a Harvard sociologist, would argue that we live in hyper-segregated communities. And I think that has something to do with the propensity to see physicians of your same race. But I think there's also something additional with racial concordance and that physicians and patients of the same race and ethnicity have better communication. They have greater degrees of trust. They have the ability to actually adhere to medical advice if you're a patient seeing a physician of your same race and ethnicity.

And we see the way that physicians practice as well. That physicians who practiced disproportionately in their own communities occurs because of what's called professional obligations and the way that people navigate that space in between what's necessary as a physician to be effective in the community and what's necessary to give yourself professional fulfillment. And often physicians of minoritized races find the greatest fulfillment in taking care of patients who are concordant with respect to race.

Unger: Let's talk a little bit about the actual requirements that residency programs will implement. Can you give us some background on that? What are they going to be required to do?

Dr. McDade: Sure. So the flexibility of the ACGME common program requirements is such that residency programs can determine how they can best achieve them. We don't really tell them how they do it, but they innovate in order to do it. Now we've got some really good things about what we do at ACGME to help. What we do is every year we send out a survey and ask program directors to give us an annual program update, tell us what you're doing. And so we've got almost 12,000 responses now for the last two years in which programs have told us what they're trying to do to accomplish the mission of reaching diversity and inclusion goals as set forth in the common program requirements.

What we're doing is actually amalgamating those and narrowing them down into categories. So we can develop a taxonomy of approaches that people are using to try to increase diversity inclusion in residency programs. And we've created a tool that's almost ready for launching. And we refer to as Equity Matters. And Equity Matters is really a program to have us learn from the GME community, what it's doing to reach those goals. And so we also created an award that we've now named for Dr. Barbara Ross Lee, who was the first African American woman dean of a medical school in the United States.

And Dr. Ross Lee's award really focuses on those programs that think they've achieved excellence in diversity inclusion. And so when they were apply for the award, those applicants actually tell us in great detail what they do with respect to diversity, equity and inclusion in their programs. And we've now been able to glean that information, put it into that same toolkit and now it's going to be available for the entire GME community. So they can use their techniques that we've obtained in these ways a la carte, so they can apply what they think will work in their communities and then try to do the same sorts of things and meet with the same sort of success.

Unger: What kind of resources or solutions are you providing to help programs meet the requirements?

Dr. McDade: So what we're doing is we're suggesting that the requirement which asks you to increase diversity and inclusion isn't an immediate increase in your numbers of residents in your program. And I think that's the most important message that I'd like to really get out today to programs is that you can't make medical schools out of whole cloth ... Medical students, rather, out of whole cloth. What you have to do is develop them along the pathway into medicine.

And for 10 years or more now, the LCME has required undergraduate medical education to work with pre-medical learners to try to develop that pathway into medicine. But there hadn't been a parallel requirement in the graduate medical education area. And so graduate medical education often thought of itself as the passive recipient of those graduates from medical school. Well, now we're encouraging those graduate programs who aren't necessarily affiliated with the medical school to actually now engage in that work with pre-residency learners.

And so if you can touch the lives of medical students earlier than just the fourth year, when you recruit them and provide potentially, a way, electives for them. We want you to continue that if you do it. But in addition to that, look at what research opportunities that you could offer people between their first and second year potentially, or what opportunities you could offer to post-baccalaureate students, where people who are in college for research and shadowing experiences in your programs. Or you can even go as low as high school and look at students there and find opportunities and ways for them to come into graduate medical education spaces, whether it's research or it's shadowing or just mentorship.

One of the things I did when I was professor at the University of Chicago is I conducted these programs, these pathway programs, where I had even high school students as early as after the freshman year involved in R1 research labs at the University of Chicago, doing important research that they were now bringing in their own experiences. And what I found is that once you've been involved in high-level research like that, you can't go back to where you were before. And we've seen a lot of these students over the years now progress into college, into medical school and on into faculty work even beyond residency. So it's really very, very hopeful that we can have graduate medical education, have an impact on undergraduate and pre-learners in that pathway as well.

Unger: That kind of pipeline is incredibly hard to build as you pointed out. But that sounds very encouraging what you're saying.

Dr. McDade: It takes a long time to actually get people through, but when it happens, it's an amazing thing. The last thing I was going to say is that half of the programs that ACGME credits aren't covered through relationships with LCME accredited medical schools. And that means we put another 6,000 programs into the mix that can help in this work. So I really appreciate the opportunity to get that word out.

Unger: What are the risks for programs that are not currently meeting those requirements that you've laid out?

Dr. McDade: We've been rather, let me say, easy on programs that haven't been able to do it because what we hear is that programs don't know how. And so in order to help programs to learn how to do this, we've now expanded Equity Matters' focus from just creating this toolkit to really create and learning communities within the GME space. And so these learning communities are really going to help us innovate and develop new things that we can use to put into the toolkit. But it's also to get the word out to the GME community, that this is the sort of work that we want you to do and here's how you can think about doing it.

We've created a series of fundamentals courses, we call it, and we're working on a textbook—The Fundamentals of Diversity, Equity and Inclusion—that we're actually going to have amazing authors put together a nice background on what it takes to understand the problems that graduate medical education learners have in their systems. And it's not what they bring in as deficit. It's what the system within GME is doing that may be obstructive to the progress of learners.

And so with that sort of background, now you can start to do some reverse ideation and think about how you can change your environment to welcome these diverse learners. And then after that, you can start thinking about how to innovate solutions to those problems that you see that they may encounter in your environment. And that that goes from how do you recruit, how do you build a pathway program? How do you think about what happens when a resident who comes into your program who's not a great test taker at this point, how do you make them a better test taker and put them in a position to pass their specialty board?

How do you bring in a learner who may have never worked in a diverse environment and make them feel comfortable in that environment and give them a sense of belonging? So the idea of teaching people about allyship and thinking about holistic admissions and thinking about how to deal with trauma informed work in environments, in which you may be a victim in some sort of way, those are the sorts of toolkits, tools that we put in the tool box, and that we're going to expand upon with equity matters.

Unger: So, Dr. McDade, we talked a lot about residents, but when we think about faculty development, how will this work with the faculty to reinforce the knowledge and the supporting didactics of this program?

Dr. McDade: Well, Todd, the resources we just talked about that are part of Equity Matters are going to be available at our site at Learn at ACGME. They'll carry CME credit. You'll be able to engage in the fundamentals courses and we're going to make the toolkit available to the entire GME community from the very start. We're going to build that toolkit as we continue to get more responses, as we have our learning communities offer new solutions.

But what we expect that we'll be able to do is to see an element of education that you can work on as a faculty member. And then you can tell us how it worked for you when you implement it into your own programs. And so you'll give us feedback about how that worked in your environment and some characteristics about yourself and your environment so that other people can see. And it will be almost like a Yelp review where people tell you how well the idea worked in your environment.

Unger: So this is ambitious and it's exciting. Assuming that these strategies are effective, you know, what do you hope to see as your goal for changes in the physician workforce in health care in five or 10 years out from now?

Dr. McDade: Well, I would expect that we will have very robust pathway programs five years from now. That we'll find that residency programs are involving themselves with younger learners and they're driving now into college, driving into medical school, and probably 10 years from now, we're going to see an increased size of the pie with respect to diversity. And that's what we're really thinking about.

We don't want people to compete against one another and use resources that would somehow get by this residence, your program, as opposed to the other residents, a residency program down the street. What we want people to do is to work cooperatively within institutions or with even in cities to try to increase the number of learners who come into medicine in general of diverse backgrounds. And that will be the ultimate test of success of what we're doing right now.

Unger: Well, thank you so much, Dr. McDade for being here and sharing your perspective and outlining this important new program. That's it for today's Moving Medicine video and podcast. In addition to GCEP, which is the AMA's resource for graduate medical education, the AMA has also recently launched UCEP, the UME curricular enrichment program that offers institutions, a series of interactive modules developed it easily fill emerging, curricular gaps and support tracking of medical student progress. You can find out more information about GCEP and UCEP, including links in the description of this episode. We'll be back soon with another Moving Medicine video and podcast. In the meantime, have a great day. Thanks for joining us.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.