Racism in Medical Education

Racial inequalities in healthcare manifest themselves in disparities in access, in the use of health-related services and facilities, as well as in pervasive racialized stereotypes and prejudices against affected groups and their underrepresentation—with regard to both healthcare personnel and patients (see Ahlberg et al. 2019). However, there is a lack of systematic research in Germany on the extent to which institutional risks of discrimination hinder equal access to the healthcare system and adequate medical care. 

The project examines the issue of institutional racism in the German healthcare system through a sociological, participatory approach to racist knowledge embedded in teaching materials and subtle socialization processes (“hidden curriculum”) in medical education. Given the central role of physicians in healthcare, their training and the knowledge imparted therein can be viewed as a key element in the context of everyday care practices.

In research, medical education in the context of racism in Germany has been examined primarily in three studies: The Afrozensus highlights not only the difficult professional barriers faced by Black doctors but also a lack of engagement with processes of othering, stereotyping, and the health consequences of racism (Aikins, M. A. et al. 2021: 139–145). A second study focusing on medical education in Germany highlights in particular the perspectives of students with and without experiences of racism: racism in medicine and healthcare is perceived by all students as a pervasive phenomenon. Consequently, students consider it important to take action against racism in medicine and healthcare at various levels already during medical training. However, since there is no uniform understanding of racism, many students find it difficult to recognize racist behaviors and structures (see Gerhards, Schweda & Weßel 2023). Houda Hallal’s (2015) work on diversity in medical education can be linked to findings from international research and provides important starting points for the present study (see Amutah et al. 2021; Chapman, Kaatz & Carnes 2013). Hallal describes the unreflective internalization of “normative and monocultural structural characteristics of [medical] institutions” (2015: 28) in Germany and a potentially resulting application of “prejudices, stereotyping, and ‘reductionist interpretations’” (ibid.) in medical practice.

The project addresses the issue of racism in medical education. It examines a sample of teaching materials from medical studies in Germany and reflects on them through interviews and focus group discussions with students and physicians who have experienced racism. The focus is on the experiences of the interview and focus group participants.

Through participatory research, this project examines the perspectives of medical students and physicians who have experienced racial discrimination regarding their everyday experiences in their studies and professional practice. A close examination of teaching materials and collective reflection on them provide insights into the institutionalization and organizational entanglement of racist knowledge at various levels of medical education in Germany.

To approach the issue systematically, the project proceeds in four steps:  

1. To explore and implement recruitment strategies and gain an understanding of the field’s content, preliminary discussions are held with stakeholders and experts, and contacts are established with various networks and organizations. 

2. Based on these discussions and contacts, relevant, widely used teaching materials (standard textbooks from market-leading publishers, the Amboss learning app including exam questions, the via medici learning platform from Thieme Publishers, NKLM, etc.) from various medical disciplines will be reviewed and subjected to an initial sample analysis.  

3. This analysis resulted in a written collection of examples and theses, which were then discussed in individual interviews with medical students and physicians who, according to their own statements, have been affected by racism (self-identification). The interviews were conducted using a guided interview framework and focused on the respondents’ professional and everyday experiences during their training. 

4. Based on an initial content analysis of the interviews, a collection of themes is documented and discussed collectively in two focus groups. The codes finalized in the focus groups are used to evaluate the data in a comprehensive analysis. 

The results highlight the central importance of the interplay between various mechanisms, dynamics, and structures in the manifestation and perpetuation of racist knowledge and practices in medical education and professional practice. For example, the content of teaching materials is reflected in everyday practices. Organizational and intersectional hierarchies contribute to the de-thematization of racism. Time pressure plays a role in the discrimination of patients. 

Underrepresentation of racially marked patient groups in teaching: In medical teaching materials and in teaching itself, racially marked groups are largely and systematically overlooked. For example, people with dark skin tones are almost entirely absent from dermatological and other teaching materials. Furthermore, colonial medical contexts are often omitted.

• Racially marked patient groups as deviations from the norm: When racially marked groups are included in medical teaching materials and in teaching, this often occurs by positioning them outside of supposedly Western or German norms and values. In the process, very diverse groups are generalized as “foreign,” “different,” or “particularly challenging.” At the same time, they are stereotyped through specific attributions and disproportionately linked to certain clinical conditions (e.g., HIV or tuberculosis) or behaviors (e.g., alcohol and drug use).

• The medical self-image hinders reflection on racism: Medical education promotes a normative self-image of the medical profession that is constituted in opposition to a stereotyped and exoticized “Other” or “Stranger.” Both patients marked by racism and medical students and physicians fall outside this image. Additionally, self-attributions and societal expectations of medical neutrality pose a barrier to a critical examination of racism. As a socially unacceptable phenomenon, racism runs diametrically counter to claims of humanistic neutrality and is therefore tabooed and ignored.

• Institutional structures perpetuate racist conditions: Medical care is often characterized by staff shortages, time constraints, heavy workloads, and rigid hierarchies. These factors can contribute to maintaining and reinforcing racism.

The findings highlight the aspects and interconnections that should be taken into account in further, in-depth studies and practical examinations of teaching materials and practices in medical education. They also contribute to the development of new indicators for researching racial discrimination in medical education.

The research project began in September 2021 and ran through the end of 2023.

The study is based on the assumption that the acquisition and application of medical knowledge go beyond purely medical and scientific knowledge and skills. Norms and patterns of behavior, which are conveyed in medical education rather subliminally or informally through a “hidden curriculum” as a medical habitus, are also essential to training (see, e.g., Witman 2014). In interactions with colleagues and patients, much depends on an internalized professional self-image in which social stratification and corresponding differentiation are inscribed as a significant dimension. The accompanying norms and patterns of behavior intertwine with medical expertise, scientific standards, and professional practices. All of this shapes the medical profession’s self-image and view of humanity, and thus their interactions with patients. The transmission and legitimization of subliminal bodies of knowledge through teaching materials, courses, and internships are not solely attributable to the actions of individual actors, such as lecturers. They are an expression and consequence of social conditions that are reflected in institutions and professional socialization.

The connection between racism and the production of knowledge constitutes an important focus of anti-racist research. In particular, the mutual interpenetration of power and knowledge emphasized by Michel Foucault (2014) serves as the starting point for much of this work. ‘Knowledge’ can be understood here as a socially recognized, made-available form of power that does not function as a (pure) resource, but rather ensures social functioning itself and repeatedly emerges from it. Knowledge moves between discourses and practices, as well as between the subject as a socialized individual and overarching structures of order such as the media, academia, institutions, or states. Knowledge can give rise to different scientific classification processes, interpretations, and norms depending on the historical era. According to sociological findings on knowledge, bodies of knowledge—which are always socially constructed and mediated through socialization processes—can never be viewed in isolation from social power relations and thus cannot be assumed to be true or false, right or wrong, independently of these relations.

Racist practices function primarily as group-based exclusionary practices based on the process of racialization. This process (re)produces knowledge that constructs, categorizes, homogenizes, and hierarchizes or devalues certain groups based on specific characteristics in favor of a norm (see Terkessidis 2004).