Ethical guidelines for antiracism work in medicine: lessons from the antiracist healing collaborative.

An explosion of antiracism in medicine efforts have transpired since 2020. However, no ethical guidelines exist to guide them. This oversight is concerning because the racism and white supremacy rife within medicine can easily thwart them. This article addresses this gap by highlighting ethical guidelines for antiracism work in medicine. We present nine core tenets derived from our experience forming the Antiracist Healing Collaborative (AHC), a medical student-led initiative committed to developing bold and disruptive antiracist medical education content. Our lessons developing and implementing these tenets can guide other antiracism in medicine collaborations striving to promote liberation and healing, rather than recapitulating the racism and white supremacy culture embedded within medicine. We close by reflecting on how these tenets have steadied our recent decision to draw AHC to a close. They have allowed us to honour what we achieved together, strengthen the relationship that formed the foundation for our activism and bolster the shared antiracism mission that will guide our individual journeys moving forwards. The first of their kind, our ethical guidelines for antiracism work in medicine can facilitate greater recognition of the risks embedded in anti-oppression work transpiring in academic settings.

Reimagining Medical Education Toward Antiracist Praxis.

Medicine has a longstanding history of racism that promulgates existing health inequities. Current medical education, largely based on the biomedical framework, omits critical discourse on racism and White supremacy, which continue to harm individuals and communities of color. Such ahistorical and apolitical orientation inadequately trains learners to identify and address racism in clinical practice. Although curricula on racial health disparities, social determinants of health, cultural competency, and implicit bias have been operationalized by several medical schools, they do not identify the racism embedded in systems of care, nor do they provide transformative steps toward true health equity and justice. As such, this article proposes bold radical frameworks as the foundation for reimagining medical education in the United States. Founded on critical race theory, abolition, and decolonization, the authors provide a view of an antiracist medical education, one that highlights the history and legacy of racism in medicine and positions medical trainees and practicing physicians as active agents in medicine's antiracist transformation.

Teaching the Legacy of Slavery in American Medicine and Psychiatry to Medical Students: Feasibility, Acceptability, Opportunities for Growth.

Introduction: Understanding the legacy of slavery in the United States is crucial for engaging in anti-racism that challenges racial health inequities' root causes. However, few medical educational curricula exist to guide this process. We created a workshop illustrating key historical themes pertaining to this legacy and grounded in critical race theory. Methods: During a preclinical psychiatry block, a second-year medical school class, divided into three groups of 50-60, attended the workshop, which comprised a 90-minute lecture, 30-minute break, and 60-minute small-group debriefing. Afterwards, participants completed an evaluation assessing self-reported knowledge, attitudes and beliefs, and satisfaction with the workshop. Results: One hundred eighty students watched the lecture, 15 attended small-group debriefings, and 132 completed the survey. Seventy-six percent (100) reported receiving no, very little, or some prior exposure to the legacy of slavery in American medicine and psychiatry. Over 80% agreed or strongly agreed that the workshop made them more aware of this legacy and that the artwork, photographs, storytelling, and media (videos) facilitated learning. Qualitative feedback highlighted how the workshop improved students' knowledge about the legacy of slavery's presence in medicine and psychiatry. However, students criticized the lecture's scripted approach and requested more discussion, dialogue, interaction, and connection of this history to anti-racist action they could engage in now. Discussion: Though this workshop improved awareness of the legacy of slavery, students criticized its structure and approach. When teaching this legacy, medical schools should consider expanding content, ensuring opportunities for discussion in safe spaces, and connecting it to immediate anti-racist action.

White supremacy culture and the assimilation trauma of medical training: ungaslighting the physician burnout discourse.

The physician burnout discourse emphasises organisational challenges and personal well-being as primary points of intervention. However, these foci have minimally impacted this worsening public health crisis by failing to address the primary sources of harm: oppression. Organised medicine's whiteness, developed and sustained since the nineteenth century, has moulded training and clinical practice, favouring those who embody its oppressive ideals while punishing those who do not. Here, we reframe physician burnout as the trauma resulting from the forced assimilation into whiteness and the white supremacy culture embedded in medical training's hidden curriculum. We argue that 'ungaslighting' the physician burnout discourse requires exposing the history giving rise to medicine's whiteness and related white supremacy culture, rejecting discourses obscuring their harm, and using bold and radical frameworks to reimagine and transform medical training and practice into a reflective, healing process.

The Color of Child Protection in America: Antiracism and Abolition in Child Mental Health.

This article illuminates the color of child protection by exposing the risks of racist and white supremacist harm intrinsic to the child welfare, public education, and juvenile injustice systems, specifically when they intersect with the child mental health system. Relying on bold and radical frameworks, such as abolition, critical race theory, and decolonization, it positions child mental health providers to confront the color of child protection while protecting minoritized children against these systems of harm. These frameworks inspire a daily antiracist practice whereby child mental health providers challenge racist inequities and the historical arcs driving them; protect minoritized children and families against the systems of care designed to harm them; and work toward the longer-term goal of abolishing these systems altogether. In a white supremacist society, child mental health providers have no choice but to engage in such antiracist practices in order to uphold their fundamental oath to first do no harm. The failure to do so amounts to negligence and malpractice.

Nurturing Children's Mental Health Body and Soul: Confronting American Child Psychiatry's Racist Past to Reimagine Its Antiracist Future.

This paper unpacks the legacy of racism and white supremacy in American child psychiatry, connecting them to current racist inequities, to reimagine an antiracist future for the profession, and to serve all children's mental health body and soul. History reveals how child psychiatry has neglected and even perpetuated the intergenerational trauma suffered by minoritized children and families. By refusing to confront racial injustice, it has centered on white children's protection and deleted their role in white supremacist violence. An antiracist future for the profession demands a profound historical reckoning and comprehensive reimagining, a process that this paper begins to unfold.

An Abolitionist Approach to Antiracist Medical Education.

Medical education is limited to the biomedical model, omitting critical discourse about racism, the harm it causes minoritized patients, and medicine's foundation and complicity in perpetuating racism. Against a backdrop of historical resistance from medical education leadership, medical students' advocacy for antiracism in medicine continues. This article highlights a medical student-led antiracist curricular effort that moves beyond a biomedical model and uses abolition as the guiding framework in the creation process, the content itself, and iterative reflection through further study and dissemination.

La educación médica se encuentra limitada al modelo biomédico, mientras que omite el discurso crítico sobre el racismo, el daño que causa a los pacientes minoritarios y el fundamento y complicidad de la medicina en la historia de perpetuar el racismo. En un contexto de resistencia histórica por parte de los líderes de la educación médica, los estudiantes de medicina continúan militando por la necesidad del antirracismo en la medicina. Este artículo destaca un esfuerzo curricular antirracista dirigido por estudiantes de medicina que va más allá de un modelo biomédico y utiliza la abolición como marco de referencia en el proceso de creación, el contenido en sí mismo y el reflejo repetitivo a través de un mayor estudio y difusión.

Depression, Anxiety, and Suicide Risk among Ugandan Youth in Vocational Training.

The current study examines the prevalence of depression, anxiety, suicide risk, and PTSD in Ugandan youth (13-25 years) attending vocational training programs. Youth from five urban (n=224 females, 81 males) and four rural (n=153 females only) vocational training centers operated by a non-governmental organization completed demographic and mental health questionnaires. Nearly half of the youth reported moderate or severe depression and/or anxiety. More than half reported anxiety and depression-related impairment. Nearly a quarter of youth had considered or attempted suicide. More than half screened positive on the PC-PTSD screen. Rural female youth reported the most food insecurity (56.9%), trafficking (37.9%), severe depression (35.9%), depression-related impairment (56.9%), severe anxiety (26.1%), and anxiety-related impairment (55.6%). Results from this study suggest that Ugandan youth have exceedingly high rates of depression, anxiety, suicide risk, and probable PTSD. Rural female youth may be especially at risk. Relevant treatment interventions are needed that can be adapted to youth in vocational training centers.

What Will You Protect? Redefining Professionalism Through the Lens of Diverse Personal Identities.

INTRODUCTION: Professional identity formation (PIF) encapsulates the process of incorporating a physician's professional identity into existing personal identity. Medical schools shape PIF by reinforcing professional norms defined by a historical physician phenotype. Increasingly, medical students who are underrepresented in medicine must confront the apparent contradictions between personal identities and the often-subjective definitions of professionalism endorsed by faculty, patients, and peers. The lack of a framework for negotiating these conflicts can create barriers to achieving full academic and professional potential. METHODS: We designed a 2-hour professionalism module during the first-year medical student orientation at one medical school. Participating students listened to a physician discuss a defining career moment that required reconciliation of personal and professional identities. Afterwards, students broke into small groups and discussed vignettes illustrating personal identities challenged by professionalism norms. Students then anonymously wrote a reflection about one aspect of their identity they intended to protect during their PIF process. An overwhelming majority of students posted their anonymous reflections on a wall for other students, staff, and faculty to view. RESULTS: We analyzed the written reflective responses to the module. Several broad-ranging themes, including Mission, Identity, and Relationships, were identified. Both participant and facilitator evaluations were analyzed to determine the module's success. DISCUSSION: This module provides a framework for faculty and administrators to create other curricular and pericurricular experiences that positively shape PIF. The session format utilized may generate greater interest in proactively supporting medical students as they navigate formation of their professional identities.

How to Measure Racism in Academic Health Centers.

Institutional racism is a set of practices and policies that disadvantage individuals not part of societies' dominant groups. In academic health centers (AHCs), institutional racism mediates structural racism; it is embedded in institutional policies, clinical practice, health professional training, and biomedical research. Measuring institutional racism in AHCs at the individual, intra-organizational, and extra-organizational levels renders visible how AHCs mediate structural racism by implementing policies that unfairly treat minority groups.

An Anti-Racist Approach to Achieving Mental Health Equity in Clinical Care.

Racism is an important determinant of health and health disparities, but few strategies have been successful in eliminating racial discrimination from medical practice. This article proposes a novel antiracist approach to clinical care that acknowledges the racism shaping the clinical encounter and historical arc of racial oppression embedded in health care. Although preliminary, this approach can be easily implemented into clinical care and may reduce the harm done by racism. It could also serve as a template for antiracist service provision in other sectors, such as education and law enforcement.

A validation study of the Zanmi Lasante Depression Symptom Inventory (ZLDSI) in a school-based study population of transitional age youth in Haiti.

BACKGROUND: The Zanmi Lasante Depression Symptom Inventory (ZLDSI) is a screening tool for major depression used in 12 primary care clinics in Haiti's Central Plateau. Although previously validated in a clinic-based sample, the present study is the first to evaluate the validity and clinical utility of the ZLDSI for depression screening in a school-based population in central Haiti. METHODS: We assessed depressive symptoms in a school-based sample of transitional age youth (18-22 years; n = 120) with the ZLDSI. Other mental health-related assessments included a modified Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID) for current Major Depressive Episode, the Center for Epidemiologic Studies Depression Scale, and selected items adapted from the Global School-Based Health Survey mental health module. Diagnostic assignments of major depressive episode (MDE) were based on modified SCID interviews. RESULTS: The ZLDSI demonstrated good overall accuracy in identifying current MDE (Area under the Curve = .92, 95% CI = .86, .98, p < .001). We ascertained ≥12 as the optimal cut-off point to screen for depression with a sensitivity of 100% and a specificity of 73.9%. In addition, the ZLDSI was associated with other measures of depressive symptoms, suggesting that it demonstrates construct validity. CONCLUSIONS: Study findings support that the ZLDSI has clinical utility for screening for depression among school-going transitional age youth.

Telepsychiatry in an Alaska Native Residential Substance Abuse Treatment Program.

Introduction: Alaska Native communities experience high rates of alcohol and substance abuse and face challenges accessing quality, culturally appropriate treatment. Telepsychiatry could help bridge this gap, but no publications have examined its impacts for alcohol and substance abuse treatment directed at Alaska Native communities. This study explores one telepsychiatry clinic's impact on a residential substance abuse treatment serving the Alaska Native community in Anchorage, Alaska. Methods: Using a matched case - control design, 103 cases receiving telepsychiatry services between 2007 and 2012 were matched with 103 controls who did not. Outcome measures included length of stay, discharge plans, emergency room visits, and hospital admissions; clinical history, including previous suicide attempts, history of violence, and trauma history; social stressors such as current legal issues, unemployment, and homelessness; mental health, medical, and substance abuse diagnoses; and number of telepsychiatry appointments and nature of telepsychiatry services rendered. Results: Both groups exhibited high rates of mental and medical illness, socioeconomic challenges, and substance abuse. However, the telepsychiatry group demonstrated a significantly higher rate of post-traumatic stress disorder, history of violence, ongoing legal issues, and children in outside custody. It also remained engaged in treatment longer, had fewer discharges against medical advice, and was more likely to complete treatment. Discussion/Conclusions: Our study highlights this telepsychiatry clinic's real-world difference serving the complex substance abuse treatment needs of Alaska Native individuals. It also reinforces telepsychiatry's promise in serving other communities facing a high burden of addiction and mental illness yet facing barriers to high-quality, culturally competent services.

The Consequences of Family Separation at the Border and Beyond.

The Trump administration's decision to separate young children from their parents who cross the border illegally or seek asylum generated a strong response from medical and mental health organizations. The National Academies of Sciences, Engineering and Medicine outlined the known harms to such separations1.

Prevalence of stressful life events and their association with post-traumatic stress disorder among youth attending secondary school in Haiti.

The association between earthquakes and youth post-traumatic stress disorder (PTSD) has been well described, but little is known about the relationship between other stressful life events (SLEs) and PTSD among earthquake-affected youth. This study examines a variety of SLEs, including earthquake, and their association with PTSD among school-going Haitian youth following a major earthquake in 2010. In 2013, we assessed 120 students ages 18-22 for PTSD and other SLEs using a modified Structured Clinical Interview for DSM-IV (SCID)-based interview and the Stressful Life Events Checklist (SLE Checklist). Only 51.7% of participants on the SLE Checklist and 31.7% in the interview endorsed being affected by the earthquake or another disaster. Sexual assault showed the strongest association with PTSD in multivariable logistic regression. Contrary to our hypothesis, exposure to earthquake or another disaster was not significantly associated with current PTSD. In this population, exposure to interpersonal violence may have had a greater impact on PTSD risk than exposure to natural disaster. These data underscore the need to examine and reduce both acute and chronic stressors among disaster-affected youth.

A mobile clinic approach to the delivery of community-based mental health services in rural Haiti.

This study evaluates the use of a mental health mobile clinic to overcome two major challenges to the provision of mental healthcare in resource-limited settings: the shortage of trained specialists; and the need to improve access to safe, effective, and culturally sound care in community settings. Employing task-shifting and supervision, mental healthcare was largely delivered by trained, non-specialist health workers instead of specialists. A retrospective chart review of 318 unduplicated patients assessed and treated during the mobile clinic's first two years (January 2012 to November 2013) was conducted to explore outcomes. These data were supplemented by a quality improvement questionnaire, illustrative case reports, and a qualitative interview with the mobile clinic's lead community health worker. The team evaluated an average of 42 patients per clinic session. The most common mental, neurological, or substance abuse (MNS) disorders were depression and epilepsy. Higher follow-up rates were seen among those with diagnoses of bipolar disorder and neurological conditions, while those with depression or anxiety had lower follow-up rates. Persons with mood disorders who were evaluated on at least two separate occasions using a locally developed depression screening tool experienced a significant reduction in depressive symptoms. The mental health mobile clinic successfully treated a wide range of MNS disorders in rural Haiti and provided care to individuals who previously had no consistent access to mental healthcare. Efforts to address these common barriers to the provision of mental healthcare in resource-limited settings should consider supplementing clinic-based with mobile services.