The adverse effects of dual loyalties in academic medicine echo and extend a long history of racial capitalism. Harkening back to medical experimentation on Black and Brown bodies, the disproportionate burden of health risks arising from dual loyalties represents similar exploitation of marginalized communities.19,20 The normalization of this insidious process reifies the notion that some populations are expendable. ARCs need not perpetuate such racism, but making the ARC model more just and equitable will require awareness, alignment, advocacy, and accountability.
Awareness means ensuring that everyone from high-level administrators to frontline workers can recognize structural racism. Experts have increasingly been publishing descriptions and case studies of structural racism,21 though its intentional invisibility can make it difficult to understand. It may be helpful to compare normalized sites of structural racism, such as ARCs, with sites that are generally recognized as violent, such as prisons.22,23 Indeed, a telling intellectual exercise is to consider whether ARC patients have more in common with private-practice patients or with prisoner patients.
Institutional leaders play central roles in the day-to-day functioning of their organizations,24 and leaders who are just awakening to institutional-level manifestations of structural racism can learn from those who’ve begun addressing institutional racism. One successful example is Montefiore Medical Center, where, in 1970, a group of physicians created the Residency Program in Social Medicine. Affiliated with Albert Einstein College of Medicine, this program has produced physician-leaders in pediatrics, family medicine, and internal medicine who have gone on to center antiracist practices in their work.25 The culture of these outpatient-based residency programs has spread throughout the institution. In 1998, Montefiore president Spencer Foreman, who was also chairman of the Association of American Medical Colleges (AAMC), spoke at the AAMC’s annual meeting about the social responsibility of academic medical centers, outlining an agenda for better aligning institutions’ priorities with societal needs. Institutions should, said Foreman, identify a community and build a network of primary care to respond to its needs, build a critical mass of faculty who are well trained in clinical medicine and population health and are excited to inspire and engage medical students in caring for people living on the margins, and build a body of community-based research that interrogates the community’s health and needs, informs services provided and new research questions, and evaluates performance in improving community health.26 When Steven Safyer, a graduate of the social medicine program, became president of Montefiore in 2008, he expanded the ambulatory care network throughout the Bronx, including into schools, shelters, and other locations.27
Some institutions have built on these principles by inviting their local community into the academic space and valuing the expertise conferred by lived experience. For example, Chicago’s Community Grand Rounds, a partnership of the University of Chicago, Northwestern University, and community organizations, is a seminar series that empowers the community to engage with academic health centers on population health topics, helping to target interventions more effectively and generate more relevant research questions.28
Beyond awareness, ARCs require alignment of physicians’ roles and responsibilities with patients’ needs. Physicians working at ARCs face conflicting pressures; beyond patient care responsibilities, they must oversee residents, participate in faculty meetings, and undertake scholarly activities to ascend the academic ladder. Improving the quality of clinic care is rarely a priority and is virtually never reflected in a positive light on a physician’s profit-and-loss statement. If ARC physicians’ responsibilities are to be aligned with patients’ needs, they will have to be afforded similar time, space, and prestige as academic researchers.
Any additional resources are most likely to emerge from physician advocacy in the form of grant writing, pilot projects, and unpaid supervision of additional staff. At Brown University’s internal medicine residency clinic, clinical leaders have advocated for a compensation model not based on relative value units. Attending physicians are asked to have eight patients scheduled during each clinical session but are not held responsible for no-show rates. This policy allows physicians to provide high-quality care and promotes a focus on quality improvement during administrative time. Clinic physicians have been able to supervise grant-funded community health workers in supporting patients who have a history of incarceration, substance use disorder, or both; to build novel programming, including a Social Medicine Assistance Clinic that helps patients apply for housing and advocates for patients facing criminal charges or court debt; and to oversee volunteers from the AmeriCorps VISTA program tasked with building clinic capacity to address population health. None of these activities, however, generate revenue in a way that compels the academic health system to support physician time spent on these tasks, so the agreement allowing 30 minutes for each patient visit and not penalizing physicians for no-shows is just the beginning of creating a patient-supportive system.
It’s also important to realign the goals of training with outpatient care. Most residency programs prioritize inpatient-based curricula even though the majority of clinical medicine occurs in outpatient settings.29 Shifting residency toward an office-based model better serves both trainees and patients. “Clinic is the curriculum” is the motto of one health system that prioritized outpatients in restructuring residency schedules and curriculum and in generating excitement among residents and attendings for primary care. One practical aspect of this transformation was capping the preceptor-to-resident ratio at 1:3, which resulted in both a better teaching environment and higher-quality care.30
Academic health centers cannot do this work alone: advocacy is needed, since policymakers help shape the systems that perpetuate structural racism. Since ARCs and FQHCs care for similar populations, academic physicians can advocate for ARCs to qualify for enhanced Medicaid and Medicare reimbursements. Policymakers could then require ARCs to maintain certain standards and ranges of services and to monitor the relative quality of care provided by residents and attendings and intervene when clinically significant disparities are identified. Furthermore, residency programs could be encouraged to first explore partnering with an FQHC for outpatient-based training; if a partnership proved infeasible, they could apply for enhanced reimbursements for an existing ARC. Such policy changes would have important downstream effects in a country with a primary care shortage: a better-resourced, higher-functioning outpatient training environment would encourage more trainees to pursue primary care careers.
Another opportunity for advocacy is at the level of the Accreditation Council for Graduate Medical Education. For instance, current internal medicine program requirements specify that residents spend at least one third of training time in ambulatory settings and at least one third in inpatient settings. Increasing the ambulatory care requirement to at least 50% would better align education with societal need and lead to improved continuity of care, increased comfort with outpatient practice, greater focus on outpatient quality-improvement initiatives, and more residents pursuing primary care.31
Finally, ARCs need to be held accountable. The Young Lords understood that dual loyalties could be mitigated, and true accountability achieved, only if an ARC’s governing body and patient population were one and the same.32 Though this goal seemed lofty in 1970, there is now a precedent for such community governance: Dr. H. Jack Geiger’s CHC model. Established as nonprofit organizations, CHCs were governed by boards on which a majority of members were clinic patients; the patient community thus had “the power to set policy, hire and fire executive leadership, and chart their center’s strategic course.”18 Applying a similar funding condition to ARCs would instill a sense of ownership in patients and unite physicians and patients in service to the community.32