Five years ago, Yale’s Department of Psychiatry formally integrated anti-racism education and advocacy into its resident training program.
Through the Social Justice and Health Equity (SJHE) curriculum, a mandatory part of the four-year program, residents learn to recognize their own biases and appreciate the lived experiences of minority patients. They gain a deeper understanding of the history of racism in medicine and the tools needed to advocate for equal access and treatment for all patients. It’s one of just a few such programs in the country, and its mission is ambitious — to eradicate mental health disparities through training and interventions.
“The social justice curriculum is an important part of our broader effort to improve the culture of our department with respect to diversity and inclusion, and to bring the many legacies of racism to an end as rapidly as we can,” said department chair Dr. John Krystal.
Racism is a major contributor to poor health outcomes. Racial and ethnic minorities have less access to mental health services than whites, are less likely to receive care, and are more likely to receive poor quality care, according to reports from the U.S. Department of Health and Human Services. Minorities also make up a larger percentage of the homeless and incarcerated populations, and are especially susceptible to mental health disorders due to their environments. Racism adds to stress, depression, and anxiety, the reports show.
About one-third of the members of each incoming Yale psychiatry residency class in recent years have come from groups underrepresented in medicine, and the program’s anti-racism curriculum has become a national model. Dr. Robert Rohrbaugh, residency program director and deputy chair for education and career development, said Howard University, UCLA, and Albert Einstein College of Medicine have all consulted with or sought advice from Yale as they’ve developed similar anti-racism, advocacy-oriented programs.
An evolving curriculum
A decade ago, when Yale’s psychiatry department first recognized the need to incorporate cultural awareness into its training, Dr. Esperanza Diaz, medical director of the Yale Hispanic Clinic and associate director of the psychiatry residency program, took the lead. She developed programming that trained residents to better understand patients’ backgrounds and motivations.
What began as a “cultural competency” course would expand over the years into the formal Social Justice and Health Equity curriculum, which has been a collaboration among faculty, residents, and community members since its inception.
Current curriculum director Dr. Ayana Jordan said every resident brings his or her “own socialization and upbringing into the room.” They have to learn, she said, “how not to intentionally or unintentionally propagate racial disparities.”
During discussions, said Jordan, “We talk about power and privilege. We talk about the racist war on drugs. We think this is just as important as psychopharmacology.”
The curriculum is taught through faculty-led case studies, group discussions, and listening sessions with community leaders. Until recently, there were three tracks: structural competency, which addresses how neighborhoods and social factors impact mental health; human experience, about understanding patient experiences and examining personal biases; and advocacy, in which residents develop skills necessary to advocate for patients and challenge inequities.
A new fourth track focuses on a critical examination of the history of psychiatry.
“You can’t think about changing a system unless you think about the history of how it got that way,” said Rohrbaugh.
He cited the Civil War doctor who invented a psychological disorder called “drapetomania,” an “insane” impulse to flee attributed to runaway slaves, for instance, and the rise in diagnoses of schizophrenia for Black men associated with civil rights protests in the 1960s as a means to identify them as dangerous.
Said Jordan: “Psychiatry has been one of the main contributors to racism. If our residents don’t understand that, are we doing our job?”
Building a better pipeline
By directly addressing racism and its effects, Yale’s program attracts “residents that raise issues,” Diaz said, individuals “who are socially conscious and like to change things.”
First-year resident Dr. Amanda Calhoun is an example.
“I chose the Yale Department of Psychiatry because they were truly invested in these issues,” said Calhoun, a 2011 Yale College alumna. “Our program director talked about systemic racism and white supremacy, and that was very powerful.”
Half of the 16 first-year psychiatry residents at Yale who entered the program in 2019 and 35% of residents across all four years identify as underrepresented minorities, a marked contrast with the national average. In 2017, the most recent year for which data are available, just 17.3% of the nation’s first-year general psychiatry residents and 15.2% of general psychiatry residents overall identified as underrepresented minorities, according to the American Psychiatric Association.
“This transformation of the residency has effectively created a pipeline of exceptionally talented people, some of whom we have been able to recruit to our faculty,” Krystal said.
When there are too few racial or ethnic minorities in a program, minority students “get burned out, or they end up feeling gas-lit — isolated and questioning the veracity of their ideas,” said Flavia DeSouza ’16 M.D., ’16 M.H.S., a fourth-year resident and co-director of the curriculum,
Providing a curriculum that attracts and encourages Black psychiatry residents, SJHE’s leaders said, helps the field expand the number of Black providers, yielding critical representation for Black patients who may be wary of health-care interventions.
“I validate their experiences, and I talk to them about my experiences,” said Calhoun, who notes that she was just 4 years old when she first became aware “that white skin is seen as the ideal in the U.S.A., and I didn’t look like that.”
In February, Calhoun participated in a Grand Rounds for the pediatrics department in which she described her experiences with racism in medicine. In June at another Grand Rounds, she called on the audience “to help me protect our Black children from racism.” On June 5 she spoke over a megaphone on the steps of the Yale Sterling Hall of Medicine at a White Coats for Black Lives rally following the police killing of George Floyd.
“This white coat does not protect me,” she told 300 assembled physicians. “We are scared every day. We worry about our families every day.”
Calhoun’s father, Dr. Joshua Calhoun who also graduated from Yale College (1978), completed his residency in child and adolescent psychiatry at Harvard and is the medical director of Hawthorn Children’s Psychiatric Hospital in St. Louis. He will not walk home at night in his affluent residential neighborhood, she said, “because he’s been stopped by the police so many times and he’s concerned that things will turn violent.”
Recounting their own experiences with racism and having to explain its pervasive damage has been exhausting work, the physician-advocates said. But they are hopeful that the groundwork they’ve laid in Yale Psychiatry can serve as a blueprint for other departments and universities.
“The time is right for the conversation,” said Jordan. “It’s been time.”