You are on page 1of 4

Invited Commentary

Breaking the Silence: Time to Talk About Race


and Racism
David Acosta, MD, and Kupiri Ackerman-Barger, PhD, RN

Abstract
Recent events in the United States have educational challenges of delving into faculty development. Training should
catalyzed the need for all educators issues of race, power, privilege, identity, cover how best to engage in, sustain, and
to begin paying attention to and and social justice. deepen interracial dialogue on difficult
discovering ways to dialogue about topics such as race and racism within
race. No longer can health professions Engaging in such conversations, however, academic health centers (AHCs). If such
(HP) educators ignore or avoid these can be overwhelmingly stressful for
Downloaded from https://journals.lww.com/academicmedicine by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3mH5nK33R3Qjy5s3Dqg6N1YvYp4Vpko2xZQ8TMfXR2zA= on 04/12/2018

faculty development training—in how


difficult conversations. HP students untrained faculty. The authors argue
to conduct interracial dialogues on race,
are now demanding them. Cultural that before any curriculum on race and
sensitivity and unconscious bias training racism can be developed for HP students, racism, oppression, and the invisibility
are not enough. Good will and good and before faculty members can begin of privilege—is made standard at all
intentions are not enough. Current facilitating conversations about race AHCs, HP educators might be poised
faculty development paradigms are and racism, faculty must receive proper to actualize the real benefits of open
no longer sufficient to meet the training through intense and introspective dialogue and change.

Editor’s Note: This is an Invited Commentary (HP). No longer can we ignore or avoid Currently, in most cases faculty do not speak
on Wear D, Zarconi J, Aultman JM, Chyatte these discussions. As Brooks,4 a fourth- against, or even about, racism. In her essay,
MR, Kumagai AK. Remembering Freddie Gray: year medical student, has aptly written, “The Patient Called Me ‘Colored Girl’—The
Medical education for social justice. Acad Med. “if we refuse to deeply examine and Senior Doctor Training Me Said Nothing,”
2017;92:312–317. challenge how racism and implicit bias Okwerekwu writes, “Every one of us needs
affect our clinical practice, we will continue to own the principles that protect us and our
Not everything that is faced can be to contribute to health inequities in a patients from racism and bias. That means
changed, but nothing can be changed way that will remain unaddressed in our learning to see prejudice and speaking up
until it is faced. curriculum and unchallenged by future against it.” She also admits that “that is far,
—James Baldwin1 generations of physicians.” Our students far easier said than done.”9 She experienced
are now demanding open dialogue, and we faculty who chose to avoid the discussion,

Recent events in the United States


educators are currently denying them. or worse, were silent and acted as if the
2,3 discriminatory incident never occurred. She
have catalyzed the need for all educators to As many have recognized, cultural stopped questioning the faculty in fear of
begin paying attention to and discovering sensitivity training, through which retribution and the impact it might have on
ways to dialogue about race. All includes participants learn about cultural her evaluation.9 Her experience highlights
us: educators in the health professions differences and the importance of not the need for training that goes beyond
assigning more value to one culture over learning about cultural sensitivities and
another, is not enough.5–7 Such training unconscious bias. HP faculty need deeper
D. Acosta is associate vice chancellor, Diversity provides a starting point, but it does not training because, as Okwerekwu writes
and Inclusion, University of California Davis Health
System, senior associate dean, Equity, Diversity and prepare faculty to talk about race and eloquently in a second essay, “Silence in the
Inclusion, and health sciences clinical professor, racism in the classroom or at the bedside. face of injustice not only kills any space for
Department of Family and Community Medicine, Likewise, unconscious bias training is not productive conversations, but also allows
University of California Davis School of Medicine,
Sacramento, California. enough. Unconscious bias training assists cancerous ideas to grow.”10
faculty members with self-reflection and
K. Ackerman-Barger is assistant adjunct
professor, assistant director, Master’s Entry Program
identifying personal biases,8 but it does We believe that now is the time to stop the
for Nurses, and codirector, Interprofessional Teaching not provide a deeper understanding of silence. We also acknowledge, however,
Scholars Program, University of California Davis how and why we are impacted by race. that, as Murray-García and colleagues11
Betty Irene Moore School of Nursing, Sacramento,
Nor does it provide the skills to dialogue suggest, these experiences—witnessing
California.
about race especially with students, staff, discrimination and openly discussing
Correspondence should be addressed to David and faculty of other races and ethnicities. racism—can be overwhelmingly stressful for
Acosta, Office for Equity, Diversity, and Inclusion,
UC Davis Health System, 4800 2nd Ave., Suite 2300, Both cultural sensitivity training and untrained faculty “who may quickly leverage
Sacramento, CA 95817; telephone: (916) 734-2926; unconscious bias training are important, their authority to divert these awkward
e-mail: dalacosta@ucdavis.edu. but faculty need more. HP faculty need dialogue opportunities to less threatening,
not only the ability to recognize prejudice more safe ground, role modeling the very
Acad Med. 2017;92:285–288.
First published online September 20, 2016 and discrimination but also the tools to avoidance behavior we are trying to identify
doi: 10.1097/ACM.0000000000001416 speak up against it when they witness it. and transform in trainees.”

Academic Medicine, Vol. 92, No. 3 / March 2017 285

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Invited Commentary

At our own academic health center and how it impacts their clinical decision possible venues for developing authentic
(AHC), HP students have indicated making for patients who are of a different cognitive and empathetic connections
that they need to talk about these issues. race or ethnicity than they are.13 When with one another, for facing structural
Students are looking to faculty to catalyze all is said and done, faculty development inequality, and for building familiarity
conversations about race and racism, needs to be deliberate in addressing race, with how to hold and facilitate difficult
but faculty have been largely silent racism, and white privilege. conversations with students. Wear and
and unengaged. Students attending colleagues14 suggest that faculty should be
the local first-year anniversary event We argue that before any curriculum willing “to examine uncomfortable realities
celebrating White Coats for Black Lives on race and racism can be developed that are exceedingly difficult to confront”
hypothesized about why local faculty for HP students, and before faculty can and should “practice fearlessness”; they
(the overwhelming majority being non- begin facilitating conversations about propose applying the antiracist pedagogy—
Hispanic white) did not talk about race race and racism, faculty must receive that is, critically reflecting on the ways
and racism. They shared the following proper training. AHCs need to provide, in which oppressive power relations and
insights: and faculty should actively pursue, the embedded privilege are made visible within
skills needed to catalyze conversations the institution and ultimately impact
“Faculty are not interested.” faculty, staff, students, even patients.
about race and structural inequality. HP
“Faculty don’t think it’s their problem or students deserve faculty who have the skill
issue.” sets and capacity to look introspectively A prerequisite for dialoguing about
first—that is, to discover how they race and racism is to understand the
“Faculty feel too vulnerable to talk about complexity of racism. In a 2000 article,
such a sensitive topic.” themselves contribute to the difficulty
in discussing race, to process and take Jones16 neatly describes and exemplifies
“Faculty don’t want to be ‘found out’” ownership of their contributions—and three levels of racism within institutions
[i.e., some faculty have deep-seeded bias then to move forward in participating that can help faculty understand how
and prejudice that they do not want to race and racism can be operational in
reveal].
in meaningful dialogues about race and
racism in a safe environment.12 As Wear academic medical institutions, and how
“Faculty don’t know how to talk about race.” and colleagues14 state: racism can lead to health inequities.
Personally mediated racism is based on
“Faculty fear that they will say the wrong Good will and good intentions alone prejudice and discrimination, whether
thing and sound like a racist or a bigot.” are insufficient to meet the educational intentional or not. Prejudice refers to
“Faculty worry that they will become challenges inherent in confronting race, the beliefs and assumptions held by
power, privilege, and identity. Good
defensive.” individuals about other groups which
intentions must be accompanied by the
skills needed to facilitate open dialogue, are often based on limited knowledge.
We could not agree more with the preserve safety, and address conflicts—not Discrimination is action based on
students’ provocative insights. To meet in order to achieve “conflict resolution,” prejudice that includes things like
the contemporary learning needs of but in order to place one’s own and poor quality or no service, suspicion,
students, the faculty teaching them others’ views and assumptions into the avoidance, surprise at competence, police
need the proper skills; they need open and to allow questioning so that all brutality, and hate crimes.15,16 Internalized
may achieve new perspectives, insights,
faculty development programming racism refers to the acceptance of the
and understanding.
that addresses their fears and any other assumptions, biases, and stereotypes
reasons for avoiding dialogues about race, placed on racial groups, and how they are
racism, and other difficult topics. supposed to be—for example, believing
What Can Be Done? that because of their race or ethnicity
Many may assume that because faculty If we swim against the “current” of racial people of color are not as capable of
members are highly educated instructors privilege, it’s often easier to recognize, while succeeding in HP and are therefore
well versed in their fields, they have the harder to recognize if we swim with it. destined for jobs that require less rigorous
skills to openly dialogue with students —Robin DiAngelo15 education. Institutionalized racism
about difficult topics, yet, for the most entails the unspoken societal norms
part, HP faculty are not even formally Faculty development must be intentional, that are accepted and practiced within
trained to teach, let alone trained to teach and it must stimulate deep introspection, an institution that promote inequities.
about race. Without training, faculty a willingness to be honest, and a Institutionalized racism includes the
tend to teach how they were taught, and commitment to change. It must go historical accumulation and ongoing
therefore, they tend be more comfortable beyond the usual (and safer) approach use of institutional power to support
lecturing to students rather than dialoging of completing online modules or reading differential access by race to goods,
with them. In doing so, faculty often take books and journal articles on race and services, and opportunities.15,16 Sharing
the privileged path of least resistance racism. Faculty development should clear definitions and examining the levels
and avoid or ignore the topic of race encourage and facilitate fluid discourse of racism and how they exist in the health
altogether. In addition, to constructively on high-stakes issues such as racism, care setting will help faculty begin the
facilitate conversations about race, many internalized dominance, internalized difficult but necessary conversations about
faculty members need to examine and oppression, and the invisibility of racial injustice. In turn, current and future
talk about white privilege and how this privilege.15 Spaces (e.g., trainings and generations of health care providers will
impacts their teaching,12 how it impacts faculty development) where faculty already be better positioned to ameliorate health
their perspective of students of color,12 meet and dialogue regularly represent disparities and promote health equity.

286 Academic Medicine, Vol. 92, No. 3 / March 2017

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Invited Commentary

The kind of training we advocate is Overall, a courageous conversation a sense that they are part of the
currently outside the scope of topics strategy “engages those who won’t organizational fabric.8,19,20 HP educators
broached in faculty development programs talk” (first and second conditions), will be better prepared to design and
at most HP schools, so the need to confront “sustains the conversation when it gets implement curricula that shape future
race requires us to rethink what is possible uncomfortable or diverted” (third and health care professionals who, in
and to consider approaches outside the fourth conditions), and “deepens the turn, have the skills to have difficult
HP education box. AHCs should consider conversation to the point where authentic conversations about difficult topics
piloting proven approaches from fields understanding and meaningful actions (racism, prejudice, biases) not only with
such as multicultural education that could occur” (fifth and sixth conditions).12 In their peers and their faculty but also with
provide the proper and intense dialogue summary, courageous conversations serve their patients, their patients’ families, and
training necessary for faculty to overcome as a dialogue tool to deinstitutionalize the communities they serve.
the resistances and challenges they face racism.
in talking about race and racism. For To attempt to create such a curriculum
example, the courageous conversation We recognize that there are many other without engaging in an antiracist
strategy and protocol12 addresses the models for learning how to dialogue framework and the pedagogy of
impact that race and racism have on about race and racism including, for discomfort would be discordant. Actually,
the achievement of students of color. example, those discussed by Wear and having faculty and students experience
This dialogue strategy entails specific colleagues14 and the Undoing Racism discomfort after talking about race
agreements, conditions, and monitoring Methodology developed by the People’s and racism should not necessarily be
that not only engage participants but Institute.17 We invite others to bring their considered a poor outcome. Learning
also help sustain and expand interracial educator’s attention to some of these how to push past the discomfort, to
dialogue about race. The protocol requires approaches, to share their strategies, confront it, and to effect positive change
a commitment from educators to adopt and to discuss the outcomes they have is the goal. Like any lifelong learning skill,
“four agreements” that define the witnessed and/or experienced. We dialoguing about race with members
conversation process: believe that the Association of American of other races and ethnicities requires
Medical Colleges (AAMC) should frequent practice and the desire for
1. “Stay engaged,” develop a repository of best practices continuous improvement. Further, we
2. “Speak your truth,” and make them accessible to all AHCs must be cognizant that the discomfort
for faculty development. Additionally, that faculty experience while simply
3. “Experience discomfort,” and the AAMC should develop its own discussing race and racism does not
faculty development model that member begin to compare with the very real
4. “Expect and accept non-closure.”12
institutions could adapt and benefit discrimination many students, faculty,
from. After all, the communication of and staff of color still experience daily.
Collectively, these provide a space that
these resources should be an integral As Paulo Freire21 states, “Sometimes a
is open, honest, and safe, ensuring more
component of Diversity 3.0.18 simple, almost insignificant gesture on
meaningful interracial dialogue. To
the part of a teacher can have a profound
support the four agreements, the strategy
formative effect on the life of a student.”
includes “six conditions” that serve as a Conclusion Being on the receiving end of a “simple,
road map to keep participants focused
The time to break the silence and almost insignificant” microaggression
on the subject matter at hand. The six embrace our vulnerability is now. Recent can trigger a deep reaction in students,
conditions are as follows: events are pressuring HP educators to staff members, or faculty members
1. “Establish a racial context that is lean in and learn how best to engage of color no matter how resilient they
personal, local, and immediate,” in, sustain, and deepen interracial might be. Several faculty of color have
dialogue on race within AHCs. If we recently described such experiences.22,23
2. “Isolate race while acknowledging the can make faculty development training For example, Montenegro,22 a Latino
broader scope of diversity,” in interracial dialogue on race, racism, physician, was dressed formally while
3. “Develop an understanding of race oppression, and the invisibility of attending a professional dinner at a
as a social/political construction of privilege standard at all AHCs, HP hotel and was repeatedly mistaken
knowledge, and engage multiple faculty and learners might be poised to for the valet. Olayiwola,23 an African
racial perspectives to surface critical actualize the real benefits of open, honest, American physician, relays a racist
understanding,” safe discussions about race. Effecting rant she received from a mental health
positive change may lead some AHCs patient who refused to have her “touch
4. “Monitor the parameters of the to achieve inclusion excellence—that him with her black hands.” Instantly,
conversation by being explicit and is, to nurture within the workplace a she writes, “racism stripped me of my
intentional,” learning environment where faculty, white coat, my stethoscope, my doctor’s
5. “Establish agreement around a staff, and learners are validated and badge, my degrees and credentials, my
contemporary working definition of valued; where they can share their voices titles, my skills, and my determination to
safely; where they can be open, genuine, serve.”23 To some, the rant or mistaken
race,” and
and respected—no matter their race; identity may seem negligible, and those
6. “Examine the presence and role of where the intersection of their multiple experiencing these events have even been
Whiteness and its impact on the identities are celebrated; and where accused of overreacting.22 However, “the
conversation.”12 everyone feels a sense of belonging, sense of ‘otherness’ builds with every

Academic Medicine, Vol. 92, No. 3 / March 2017 287

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Invited Commentary

occurrence, be it overt or accidentally 6 Kumagai AK, Lypson ML. Beyond cultural Medical education for social justice. Acad
scarring.”22 These experiences serve to competence: Critical consciousness, social Med. 2017;92:312–317.
justice, and multicultural education. Acad 15 Sensoy O, DiAngelo R. Is Everyone Really
“silence us and enforce an uncomfortable Med. 2009;84:782–787. Equal? An Introduction to Key Concepts
environment that is not conducive to 7 Wear D, Kumagai AK, Varley J, Zarconi J. in Social Justice Education. New York, NY:
professional development.”22 Cultural competency 2.0: Exploring the Teachers College Press, Teachers College
concept of “difference” in engagement with Columbia University; 2012.
Now is the time to break that silence and the other. Acad Med. 2012;87:752–758. 16 Jones CP. Levels of racism: A theoretic
8 Ross HJ. Everyday Bias: Identifying and framework and a gardener’s tale. Am J Public
change the environment. No longer can Navigating Unconscious Judgments in Health. 2000;90:1212–1215.
we afford to ignore racism; no longer Our Daily Lives. Lanham, MD: Rowman & 17 The People’s Institute for Survival and
can we avoid talking about its real and Littlefield Publishing Group Inc.; 2014. Beyond. Undoing Racism. http://www.pisab.
damaging effect on all of us. 9 Okwerekwu JA. The patient called me org. Updated 2016. Accessed August 1, 2016.
“colored girl.” The senior doctor training 18 Nivet MA. Commentary: Diversity 3.0:
Funding/Support: None reported. me said nothing. Stat News. April 11, 2016. A necessary systems upgrade. Acad Med.
https://www.statnews.com/2016/04/11/ 2011;86:1487–1489.
Other disclosures: None reported. racism-medical-education/. Accessed August 19 Workplace Diversity Network. The Netter
1, 2016. principles: A framework for building
Ethical approval: Reported as not applicable. 10 Okwerekwu JA. What happened when I organizational inclusion: What will an
talked about what others ignore—racism in inclusive workplace look like when it’s
medicine. Stat News. April 27, 2016. https:// achieved? Report from the 1998 Netter
References www.statnews.com/2016/04/27/racism- Seminar. http://www.mghihp.edu/files/
1 Wilson DE. Change. In: Treasury of Black medicine-lessons/. Accessed May 17, 2016. about-us/diversity/netter-principles-
Quotations. 2nd ed. Lincoln, NE: Authors 11 Murray-García JL, Harrell S, García JA, inclusion.pdf. Published 2000. Accessed
Choice Press; 2004:24. Gizzi E, Simms-Mackey P. Dialogue as skill: August 1, 2016.
2 Rochon TR. Why embattled leaders should be Training a health professions workforce 20 Equality and Human Rights Commission.
stepping up, not stepping down. Chron High that can talk about race and racism. Am J An employer’s guide to creating an inclusive
Educ. November 16, 2015. http://chronicle. Orthopsychiatry. 2014;84:590–596. workplace. http://www.smarttar.co.uk/wp-
com/article/Why-Embattled-Leaders- 12 Singleton GE. Courageous Conversations content/uploads/2015/12/an_employers_
Should/234222. Accessed August 1, 2016. About Race: A Field Guide For Achieving guide_to_creating_a_diverse_workforce.pdf.
3 Bonilla-Silva E. The white racial innocence Equity in Schools. 2nd ed. Thousand Oaks, Published March 2010. Accessed August 1,
game. Racism Rev. November 12, CA: Corwin; 2015. 2016.
2015. http://www.racismreview.com/ 13 Peek ME, Odoms-Young A, Quinn MT, 21 Freire P. Pedagogy of the Oppressed. 30th
blog/2015/11/12/white-racial-innocence- Gorawara-Bhat R, Wilson SC, Chin MH. anniv ed. New York, NY: Continuum
game/. Accessed August 1, 2016. Racism in healthcare: Its relationship International Publishing Group, Inc.; 2005.
4 Brooks KC. A piece of my mind. A silent to shared decision-making and health 22 Montenegro RE. A piece of my mind.
curriculum. JAMA. 2015;313:1909–1910. disparities: A response to Bradby. Soc Sci My name is not “interpreter.” JAMA.
5 Wear D. Insurgent multiculturalism: Rethinking Med. 2010;71:13–17. 2016;315:2071–2072.
how and why we teach culture in medical 14 Wear D, Zarconi J, Aultman JM, Chyatte MR, 23 Olayiwola JN. Racism in medicine: Shifting
education. Acad Med. 2003;78:549–554. Kumagai AK. Remembering Freddie Gray: the power. Ann Fam Med. 2016;14:267–269.

288 Academic Medicine, Vol. 92, No. 3 / March 2017

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.