From Anguish to Action: Turning Despair Into Efforts to Improve Racial Equity

Jacob N. Stein, MD, MPH

I remember exactly where I was when I first saw the footage of George Floyd’s murder.

I was at the University of North Carolina (UNC) Lineberger Comprehensive Cancer Center, where I spent most of my time as a first-year oncology fellow. Walking to the team room after consults, I got a notification on my phone and opened the video. The hall around me went dark. I felt nauseous and had to brace myself against a wall.

For a moment, I forgot everything else—the consult service, the bone marrow biopsies I had to perform, the patients starting chemotherapy that day, the notes I had to write. Floyd’s pleas, the fear in his voice, and the cold, emotionless look on Minneapolis Police Officer Derek Chauvin’s face as he knelt on Floyd will be forever etched in my mind.

That afternoon, the other fellows and I were trying to process the horrific act we and the nation had seen. The deaths of Breonna Taylor and Ahmaud Arbery just months before only sharpened our feelings of helpless anger. We talked about the brutality of the killings, the distrust that exists between Black Americans and the police that are supposed to protect them, and the injustice of our society as a whole.

But we also talked about the problems we saw in the hospital every day: racial gaps in health care, the challenges colleagues of color face, racism in our profession, and the way the health care system has its knee on the necks of the underserved.¹

Those conversations continued over the ensuing days and weeks. Someone pointed out that it was the first time we had talked as a group about pervasive racial injustice in the US. As difficult as the discussions were, it felt good to talk, to get those topics out in the open. But we wanted to turn that talk into action.

Jacquelyne “Jackie” Gaddy, MD, and I had an idea. We wanted to expand the conversation beyond our team room and into the division as a whole. We wanted to challenge the faculty, leadership, and our colleagues to make institutional changes to better care for patients of color, better support faculty and trainees of color, and fight injustice in the health system.

Of course, we weren’t the only ones advocating for change. Across the nation, institutions of all types were grappling with the same questions. Fortunately, UNC had already begun working on a training course for internal medicine residents about race and racism in health care that would soon be introduced.² Jackie and I began to adapt that course to the needs of oncology fellows. After some work, we approached leadership about discussing the course at the divisional conference. Thankfully, they shared our view and spotlighted the proposed course at divisional meetings.

Our course, which was delivered via Zoom, consisted of 4 sessions. The first focused on implicit bias, and we asked participants to take the Implicit Association Test beforehand and discuss what they had learned. In session 2, we presented a case in which implicit bias impeded high-quality cancer care and talked about how to mitigate such bias. Session 3 was devoted to a “journal club” on the use of race in clinical calculators across medicine, and we debated how this could influence delivery of care and affect disparities.³

Session 4 featured a highly respected health services researcher in genitourinary oncology who spoke about his decades of work on advancing equity in clinical care. Our division chiefs also participated in this session, which centered on creating a more equitable health system. We surveyed participants and found that they were “significantly” interested in future sessions. Finally, we presented the series at the 2022 American Society of Clinical Oncology (ASCO) annual meeting and submitted a manuscript.⁴

Did we achieve what we set out to do? Partly. Racial inequity has developed over centuries, and we cannot hope to reverse it with a course for oncology fellows and an ASCO poster. But we do see our efforts as a first step, and we encourage other institutions to follow. To that end, we want to share what we have learned.

First, collaboration is critical in diversity, equality, and inclusion efforts. Because we partnered with colleagues in other divisions and training programs, we benefitted from their experience and were able to reach a wider audience. Our work is now aligned with that of the Lineberger Equity Council, which is tasked with improving equity at UNC’s cancer center.⁵

Second, nuanced conversations about race and bias can promote equity. A training course doesn’t change policy, improve access to care, or mitigate bias. But by inviting faculty and fellows to discuss these topics, we can help realign priorities and encourage leadership to hire diverse faculty, fund care delivery projects aimed at reducing inequities, and emphasize community outreach. Shifts in priorities are what lead to progress.

Finally, trainees can have an impact on their institution. After those conversations in the team room, Jackie and I were able to change the divisional curriculum. Our energy and enthusiasm have influenced others. And we hope that many more will use their passion to make equity in cancer care a reality.

Jacob N. Stein, MD, MPH, is an assistant professor in the Bone and Soft Tissue Oncology Program in the Division of Oncology at the University of North Carolina School of Medicine in Chapel Hill, North Carolina.

References

1. Nuriddin A, Mooney G. White AIR. Reckoning with histories of medical racism and violence in the USA. Lancet. 2020;396(10256):949-951. doi:10.1016/S01406736(20)32032-8
2. Internal medicine residency program holds noon conference series EMBRACE: “Ending Medical Bias and Racism by Advocating for Change and Equity.” News release. UNC School of Medicine. October 29, 2020. Accessed August 23, 2022. https://unc.live/3KfkLmZ
3. Vyas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight - Reconsidering the Use of Race Correction in Clinical Algorithms. N Engl J Med. 2020;383(9):874-882. doi: 10.1056/NEJMms2004740
4. Stein JN, Gaddy JJ, Sorah JD, et al. Seeking racial equity in hematology and oncology: a fellow-led educational series to promote reflection and action. J Clin Oncol. Published online June 2, 2022. doi:10.1200/JCO.2022.40.16_suppl.11004
5. UNC Lineberger Equity Council phase 1 recommendations. UNC Lineberger Comprehensive Cancer Center. Accessed August 23, 2022. https://bit.ly/3AIYr1S