To achieve equity, help medical students thrive, not just survive

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Dr. Sunny Nakae

When we talk about equity, diversity, and inclusion (EDI) in medical education, the conversation often focuses on admissions. Here’s the problem: representation without structural justice can set students up for struggle. Admitting students from a wide array of diverse backgrounds does not guarantee their success. The hardships they faced as premedical students do not vanish once they enter training because systemic inequity is baked into every institution, system, policy, and process. That’s why Dr. Sunny Nakae, Senior Associate Dean of Equity, Inclusion, Diversity and Community Partnerships at California University of Science and Medicine is laser-focused on the world beyond admissions. “Students deserve to thrive in medical school, not just survive,” she says.

So what is preventing students — especially historically excluded students like first-generation and underrepresented minorities — from thriving in medical school? For Dr. Nakae, it’s a lack of universal resources and prevention. “Some schools do a tremendous job at supporting students from day one, while others have significant resource and equity practice gaps.”

She goes on to explain that student support teams are often too reactive, and they can make assumptions about students that are detrimental to their well-being. For example, many schools don’t give students a career trajectory overview, and they assume all students understand the matching process, boards, and the time and financial costs associated with the boards. That’s not always the case for first-generation students. 

“We tend to assume everyone is doing fine until someone isn’t, and only then do we take action,” says Dr. Nakae. She calls this a deficit-based recovery model, which is psychologically unsafe for students. She adds, “we simply need to invest more in their well-being. Why do we require mask fitting and current immunizations, but not sessions on study skills and time management? We are aware of the potential hazards of medical education, so why not regularly screen students for anxiety and help them come up with action plans for when they face discrimination or feel overwhelmed?”

Faculty also need to be hyper-aware of the infinite number of ways that bias creeps into evaluations and the curriculum. Because we’re attracted to what’s familiar, we may not always realize how stereotyping affects our decisions. Dr. Nakae shares the example of an instructor giving feedback to an Asian student about being too quiet in class when that student is actually quite vocal and highly engaged. Instructors may also not realize that they emphasize a particular student’s mistakes more than others and use those mistakes as evidence against an entire group with which that student identifies. Thankfully there are tools to help evaluators examine their bias in real time. These tools prompt evaluators to consider internal and external factors such as the amount of time spent with the student before determining whether they are in a position to really comment on that student’s character or skills. 

As for the curriculum, “the fact that it’s largely only taught by MDs is itself biased,” says Dr. Nakae. “Do we not have anything valuable to learn from other health professionals, community partners, and experts in other disciplines?” 

Medical schools must also do a better job at addressing the social and structural determinants of health. She explains, “we’re still making the mistake of teaching ‘race’ as a risk factor for disease instead of ‘racism.’” Evidence of this has come up repeatedly during the pandemic. In every wave, people of color were negatively impacted by Covid, and that was because they were more likely to have living or work conditions that compounded risk — not their race. These structural vulnerabilities intersect with racism in the US and contribute to health inequities.

“It’s so easy to inadvertently teach and act on stereotypes,” explains Dr. Nakae. To overcome these challenges, medical schools need to prioritize teaching the history of medical education, patient populations, and how to effectively treat patients who are structurally vulnerable. 

Checking our biases in real time, rethinking our approach to the curriculum, and opening our eyes and ears to other perspectives on medicine require overhauling the status quo. “It does require a lot of work, but we have the opportunity to ride this wave of increased interest in equity to create lasting change,” says Dr. Nakae. “We can’t become complacent and let this be just another passing phase.”

Referencing Project 3000 by 2000 from the 1990s, which aimed to secure 3,000 URM matriculants to medical schools by the year 2000, Dr. Nakae said that the project had built great data infrastructure and produced some published research to inform future equity initiatives. “People often forget about this project because it was largely done on the fringes by people in minority and cultural affairs departments, not admissions.”

For current efforts, there must be collaboration between multiple departments and institutions, as well as a focus on producing more research and effective practices for equity. “We need to create a clear path so that future generations can build on the great work that’s been started,” says Dr. Nakae. “This is important because only long-term collective action will move the needle.”

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