Despite a national call for increased under-represented in Medicine (URiMs) in the
United States’ (US) medical schools, data from 2018 to 19 indicate that the number
of Latino/Hispanic (6%) African American (7%), and American Indian/Alaska Natives
(0.2%) has plateaued [1]. Attention to creating a culture that is supportive of URiM
trainees is critical to providing our increasingly diverse patients a similarly representative
healthcare workforce. Increasing URiM physicians will not only help to meet a predicted
139,000 physician shortfall by 2033 but it will also help to ensure greater access
to quality care for all patients including racial and ethnic minorities [1]. A lack
of mentorship, stereotype threat, and racial bias from instructors resulting in isolation
in medical training are factors responsible for a disproportionate number of URiMs
[2,3]. A necessary starting point for reversing this trend is promoting an understanding
of the racism endemic in medical centers, departments, and individuals in conjunction
with institution-wide educational programs focused on creating an antiracist culture.
Exploration of education research, the historical perspective of medicine and the
current racial climate in the US has provided us an opportunity to consider novel
approaches for medical education.
Our current medical education system was designed to be exclusionary and that groundwork
was effectively laid out by the Flexner report in 1910 [4]. Achieving an antiracist
culture in education will require attention to what is often referred to as the ‘hidden
curriculum’: unspoken values, beliefs, and norms perpetuated by educators who serve
as behavioral models in medicine [5]. However, physician educators are not explicitly
trained in educational theory for developing pragmatic approaches for learning. While
the goals of medical education are clear we are lacking pedagogical standards to create
a coherent and uniform training for residents (the current pedagogy is based on individual
preference). Additionally, segregated spaces promote reliance on potentially harmful
stereotypes of URiMs which limit White faculty's understanding of URiM trainees, precluding
meaningful relationship building [2,3]. Unlearning years of systemic oppression in
medicine will require an educational curriculum which affords awareness and engagement
to support self-reflection, morality-inspired consciousness, and daily effort to evoke
change.
Psychologist Dr. Carol Dweck has compiled multiple studies on the growth vs. fixed
mindset in education. Mindset theory holds that our implicit assumption about the
origin of our abilities, intelligence and talent have a profound impact on how we
view our mistakes or failures. According to Dweck, the growth mindset approach to
education promotes the idea that ability is acquired through effort with failure as
an opportunity for improvement while the more prevalent fixed mindset promotes the
idea that intelligence or ability cannot be changed [6]. Building upon Dr. Carol Dweck's
research, the fixed mindset characterizes our current medical education climate which
may be undermining the development of our learners [6]. Consideration of her work
for expanding diversity and inclusion programming to incorporate the growth mindset
will undoubtedly promote a more suitable educational culture necessary for deconstructing
systemic racism in academic health centers and fostering a culture of inclusion and
belonging. Systemic racism is an injurious example of the fixed mindset inaugurated
with the enslavement of Black people as a free workforce in the US which ended “officially”
in 1865 when the 13th Amendment was passed. Historically, medical providers were complicit
in the indispensable fixed characterizations of Black people as “less than” White
people evidenced by a lengthy history of harmful surgeries and the denial of treatment
to Black people for the purpose of experimentation. This occurred in American history
from the moment Black people were enslaved until the early 1970′s [7]. These fixed
racist mindsets historically overlooked knowledge gaps, omissions in care, and abusive
practices which are pivotal to understanding Black people's mistrust of the US medical
system. Historically, the highly competitive field of medicine was populated by White
men over Black people—stereotyped as intellectually inferior [4,8]. According to Dr.
Dweck, educators who regard members of under-represented groups as fixed or less than
decide early on who is “smart” and who is weak. Such educators unilaterally determine
which students to give up on before training begins. In medicine, these adverse learning
environments weaken academic performance and increase stress for trainees leading
to increased numbers of URiMs to drop out of medical training or leave academic medicine
entirely [2,9]. It is this same fixed mindset that has led to the characterization
of Black men as “guilty” or “dangerous” resulting in a self-defense justification
for the police killing of George Floyd and countless other Black Americans. The antiracist
sentiments being proclaimed by a majority of medical training institutions today requires
dismantling of this apparent fixed mindset.
Within education, results from a university sample of 150 STEM Professors and >15,000
students revealed that racial achievement gaps in courses taught by fixed mindset
faculty were twice as large as the gaps in courses taught by more growth mindset-oriented
faculty. Student evaluations in classes taught by fixed mindset faculty indicated
a negative educational climate [10]. In contrast, the growth mindset may offer an
opportunity for a more positive learning environment in medical education (Table 1).
The success of the growth mindset for learning requires full engagement from educators
[6].
Table 1
Racism to Anti-racism: Example Dialogue and Actions Moving from Fixed to Growth Mindset
in Medical Education with a Racialized Lens.
Table 1
Image, table 1
In summary, the growth mindset requires an understanding of the varied levels and
experiences of our trainees. Learning about the history of racism in health care and
education is the starting point for faculty to undo assumptions about the URiM learner
and focus on community building by appreciating differences as strengths. The growth
mindset educator is relational, actively listens, recognizes growth and hard work,
and collaborates with learners to create an environment and plan for academic success.
The power of the growth mindset in improving the educational climate for URiM is one
aspect of a multi-factorial approach for change including: education to promote awareness
of systemic racism; policy instituted by educationally equipped leaders to support
equity and inclusion; and institution-wide educational programs which incorporates
the growth mindset for teaching. By framing the growth mindset to include a race equity
lens White faculty will necessarily focus on effort for growth and proficiency; relationship
building; valuing different races, cultures, and perspectives and will create clear
actionable goals for educating a diverse healthcare workforce.
Author contribution
All authors contributed equally to this article. Dr. Harrison specifically contributed
to all aspects of this work, theory, design, literature searches, writing, and editing,
design and development of Table 1.
Declaration of Competing Interest
The authors declare no competing interests.