Systemic racism is one of many structural causes of inequity in health care, along with blind spots, and epistemic injustice. As described in an article (Monteiro, S. et al) published in the September 2024 issue of the periodical Journal of Evaluation in Clinical Practice, systemic racism implicates institutional values in perpetuating racial discrimination and manifests in policies and practices within health systems that systematically disadvantage certain racial groups. Institutional normative values also have been oppressive historically to many groups because of factors other than race, such as income status, sexual orientation, gender, or body shape. These structures, often designed from a point of privilege, result in disparities in agency, access to resources, and quality of life based on race. The extent to which patients have agency over their health has significant influence on health care outcomes. The authors acknowledge that health care inequity is a persistent systemic problem, yet many solutions historically have focused on “debiasing” individuals.
Individualistic strategies fit within a competency-based medical education and assessment paradigm, whereby professional values of social accountability, patient safety, and health care equity are linked to an individual clinician's competence. Unfortunately, efforts to realize the conceptual linkages between medical education curricula and goals to improve health care equity fail to address the institutional values, policies, and practices that enable structural racism. The authors explore alternative approaches that target collective and structural causes of health inequity. First, they describe the structural basis of health care inequity by identifying the ways in which institutional culture, power, and privilege erode patient-centered care and contribute to epistemic injustice. Next, they then outline some reasons that stereotypes, which are a culturally supported foundation for discrimination, bias, and racism in health care, cannot be modified effectively through individualistic strategies or education curricula. Finally, they propose a model that centers shared values for leadership by individuals and institutions with consistency in goal setting, knowledge translation, and talent development. Key recommendations are summarized, and cases are provided as a means of supplementing this work and facilitating discussion about the model's application to practice.