Reclaiming the mission of academic medicine: An examination of institutional responses to (anti)racism

INTRODUCTION

The utility of institutional statements is said to provide clarity and reinforcement of purpose.¹ Unfortunately, at many institutions—just like mission statements—these statements can be perceived as hollow and without actual substance. Institutional statements often do not accurately reflect the goals and philosophies of the institution.² Yet, the reputation and success of an institution largely rely upon the consistency of its leadership's statements and actions. In our current era, given the misalignment between proclaimed words with environments that are less than welcoming for marginalized populations, institutional statements may also highlight a failure to deliver on this utopic purpose.

Despite strongly verbalized and growing commitments to institutional diversity, equity, and inclusion, scholars have found that these statements do not reflect enacted commitments.^{3, 4} Instead, many institutions used these statements to misrepresent the demographic composition of their campus, create false narratives of diversity, frame students of color as outsiders, and reinforce notions of exclusion and inequality.^{3, 5} When college presidents issued official statements in response to campus racial incidents, the leaders’ rhetoric rarely mentioned the specific racial incident, heavily focused on the perpetrator, and rarely situated the racial incidents within the larger context of systemic and institutional oppression.⁶ Clearly, there are concerns about the use of diversity, inclusion, and social justice discourse.^7-10 As social unrest continues to grow amid a global pandemic that only highlighted the inequalities in our social systems and world, institutional statements have proliferated, offering a unique opportunity to analyze this discourse in relation to diversity, equity, inclusion, and antiracism.

The year 2020 can be described as the “perfect storm” that led to a renewed nationwide movement against racism. Setting the context of 2020 is unlike any other. Amidst a global pandemic where most of the nation was subjected to varying quarantine orders, Black communities continue to live under the attack of economic inequities, persistent health inequities, and police brutality. Higher education institutions were also spaces where acts of bias, discrimination, and racism continued to occur. While college and university leaders often proffered campuswide statements in response to incidents of bias and discrimination on their campuses, rarely had they commented on instances of injustice and other racist acts across the nation. However, following the murders of George Floyd, Breonna Taylor, and Ahmaud Arbery, and the subsequent nationwide protests against police brutality, a new phenomenon emerged. Between May and June 2020, college and university leaders across every institutional type, including academic medicine institutions, issued statements calling for justice. One by one, statements acknowledging and condemning these deaths emerged.

Higher education scholars began to question these statements, interrogating leadership's motives.^{11, 12} One of many critiques involved a noticeable pattern in the ways these statements were crafted. This pattern appeared formulaic and included the following aspects: speaking out against the specific recent occurrences; acknowledging racism in the United States; expressing a desire for the specific institution to commit to the value of diversity; stating that the campus should be a safe place for all faculty, staff, and students; and recognizing that people of color in the community were hurting. Also noticeable were those elements not included in this pattern: recognition of privilege held by the authors, specific actions to be taken, mention of Black Lives Matter, and acknowledgment of the ways the institution and its leaders were complicit in reinforcing inequitable systems. Certainly, what is not being said may be more important than the statements themselves.

In the context of 2020, where some articulated the twin pandemics of coronavirus and institutional racism,¹³ it is important to examine how academic medicine institutions employed discourse on diversity, equity, inclusion, and antiracism in their institutional statements. The purpose of this study was to analyze the content of academic medicine institutional statements that followed the murders of George Floyd and others. As these statements became public, we reflected on the mission of academic medicine and focused on institutional accountability. Hence, our research questions: What do institutional leaders “say” through institutional statements that helps connect structural racism to the mission of academic medicine? What concepts or terms are included (or not) in these statements? How are these concepts connected (or not) to each other?

CONCEPTUAL FRAMEWORK: ACADEMIC MEDICINE MISSION

The academic medicine mission provides the foundational concept to this study. Generally, academic medicine is connected to a traditional tripartite mission of educating the next generation of physicians and biomedical scientists, discovering causes of and cures for disease, and advancing knowledge of patient care while caring for patients.^{14, 15} Furthermore, academic medicine might be defined as “the capacity of the system for health and health care to think, study, research, discover, evaluate, innovate, teach, learn, and improve.”¹⁶

However, scholars have highlighted additional realities and emphasized what can be considered a misalignment.^{16, 17} For example, faculty of color perceived a lack of attention to the social mission of providing care for all people and to the community, a lack of prioritization of excellence in clinical care, a devaluing of educational roles, questionable ethical behavior among leadership or management, and the necessity for self-promoting behavior to achieve success.¹⁸ Others continue to emphasize the mission of improving the health of the public and retaining the obligation to facilitate and support the mission of social responsibility.¹⁹ Reclaiming the social mission will be a major step toward recentering all activities that support that mission. Therefore, in this study, we center this social responsibility component of the academic medicine mission and rearticulate the definition of academic medicine as follows: academic medicine is the discovery and development of basic principles, effective policies, and best practices that advance research and education in the health sciences, ultimately to improve the health and well-being of individuals and populations.

METHODS

We conducted a manifest content analysis of institutional statements generated by academic medical centers after George Floyd's murder and subsequent periods of protests and calls to action. Content analysis is a scientific tool used to determine the presence of certain words, themes, or concepts within some given qualitative data (i.e., text). As such, content analysis allows researchers to quantify and analyze the presence, meanings, and relationships of certain words, themes, or concepts.²⁰ More specifically, manifest content analysis is concerned with data that are easily observable both to researchers and to the coders who assist in their analyses, without the need to discern intent or identify deeper meaning.²⁰ The purpose of qualitative manifest content analysis is to go beyond simple word counts and delve into a deeper examination of the language used to organize large amounts of text into categories that reflect a shared meaning.²⁰ As a qualitative method, it seeks to identify constructs within the text using specific words or phrases for substantiation.²¹ In this study, because we did not have access to institutional leaders’ intent behind their statements, we used manifest content analysis to gain insights about how institutional statements connect structural racism to the mission of academic medicine as well as salient concepts and concepts of emphasis.

We collected and examined institutional statements from 26 academic medicine centers, a sample representative of 18 states and U.S. geographic regions, diverse in size, inclusive of public and private institutions. Selection parameters included statements that were publicly available through the Internet (e.g., institutional websites, posted/linked on social media by institutional representatives) and published by the institutions between May 25, 2020, and June 9, 2020. Boolean searching allowed the research team to combine words and phrases (i.e. George Floyd, academic medicine). This 2-week period was determined based on the news cycle and saturation of published statements. Specifically, these statements were issued within 2 weeks after George Floyd's murder. Generally, these statements were issued by deans and assistant and associate deans and may have included joint statements with presidents, vice presidents, and chief diversity officers. Some statements were published in collaboration with a health care system. We did not include statements issued by specific departments or entity groups within the institutions, because our interest was focused on institutional-level statements (Table 1).

The statements were collected and analyzed through Atlas TI software. We conducted a four-stage analysis (Figure 1). In the first stage (decontextualization), we identified the most commonly used terms across the statements, our meaning units. In stage 2 (recontextualization), the research team reviewed these terms in the context of the academic medicine mission and subsequently selected a set of terms based on consensus. Because it was important for us to keep in mind what was not said, we also added terms that we thought were clearly missing based on the academic medicine mission (e.g., empathy).

In stage 3 (categorization), we reviewed each institutional statement by using this list of selected terms to understand how the terms were used and the meanings and connections among them, therefore bringing the subjects together. We identified salient themes and organized these themes into conceptual categories (e.g., “public health,” “racism,” “institutional values”). We continued to refine these categories until we reached a consensus. In stage 4 (compilation), we identified the relationships between these categories in the context of the academic medicine mission and created an image to depict this relationship. To better understand the collection of statements, we plotted these institutional statements according to the most salient discussed themes and subthemes and positioned them relative to other statements.

RESULTS

Herein, we describe our findings. First, we report the frequency of terms used in the 26 statements based on the academic medicine mission framework. The top five terms used were “community,” “health,” “racism,” “medicine,” and “diversity” (Figure 2). The five terms that were least commonly used were “health care,” “public health,” “systemic,” “disparities,” and “commitment.” It is important to note that the terms we added, “humanization,” “empathy,” “murder,” and “police,” were not used as we anticipated.

Connections between categories

When examining the institutional statement in its entirety, we found that these statements often drew connections between two of these categories (e.g., institutional values and racism, public health and racism) and rarely across all three categories (Table 4). Statements that drew explicit connections between all three categories were more robust in evoking each category.

TABLE 4. Sample categorization across categories

Institution	Institutional values	Connecting institutional values to public health	Public health crisis	Connecting racism to public health	Racism	Connecting racism to institutional values
Georgetown University School of Medicine		At GUSOM, it is our highest priority to exemplify and promote a diverse community, inclusive of talents, interests, and backgrounds for the greater good of society, and respectful dialogue and points of commonality in areas of disagreement.		We are experiencing an unprecedented time of tragedy, sorrow, and rage as tensions around racial injustices during the backdrop of a pandemic are currently ravaging this country.		we want to affirm our GUSOM community that we do NOT stand with the systemic racism that continues to prevail in our society.
University of Pittsburgh		It's essential that we in health care increase our understanding of these social, economic and cultural determinants of health and how our current structures, including those within health care delivery systems, work against huge segments of our people.		We recognize that health care, as many systems and institutions, has a deeply flawed history and that the health of many people in this nation are impacted by ongoing injustice and inequity related to the places they live, the air they breathe, the education they receive, the jobs they do, and the biases of the people they encounter every day, all of which is perpetuated by established policies and institutions.		The City of Pittsburgh Gender Equity Commission's report, "Pittsburgh's Inequality Across Race and Gender" lays out very clearly how much needs to change in our community.
Eastern Virginia Medical School	As a community dedicated to healing humanity, we must also commit ourselves to illuminating the injustices that create inequity.		True healing means moving beyond treating just the symptoms. True healing means focusing on prophylaxis; on preventing the root causes of injustice and inequity.	Unfortunately, events over the last several days have once again presented the deadly symptoms of the underlying disease plaguing our country.	We cannot overlook the symptoms of systemic racism manifesting now … Injustice is not new. But events over the last several days have once again emphasized a long pattern of tragic deaths of black men and women at the hands of an unjust system.	We cannot call ourselves “healers” and fail to take the necessary actions to eradicate the cancerous spread of racism … We will act overtly and resolutely to oppose racism and social injustice on our campus, in our clinics and in our community.
Emory Healthcare			We have been battling COVID-19 for the past several months and have seen the destructive power of this new threat to our communities and especially to communities of color.	Indeed, our nation's ongoing history of structural and sustained racism, along with systemic disparities of justice and healthcare, have resulted in far too many examples of violence and injury against people of color, and this fundamental injustice is deeply distressing and must be ended.	resurgence of highly publicized acts of racism is a painful and difficult reminder of an ongoing struggle in those same communities."… "None of us were naïve enough to imagine that racism did not exist before these horrific incidents, and many in our community have personal experience with racism and bias.	Our diversity of backgrounds is one of our greatest strengths … And I know that I am more determined than ever to ensure that our Emory community continues to confront and address racism as we strive to embody the best values of our institution and of our nation.
Ohio State University College of Medicine	Know that we at the Ohio State College of Medicine stand with those who are impacted by injustice. You have our full support … As a community of healers, we are here for each other.	We join the ranks of decisions and choose the path of medicine so we can heal others and improve their lives—which makes the horrific events of the last few weeks even more appealing.
University of Colorado, Anschutz Medical Campus	In a message shared earlier today, we made clear that our campus—and our community—has no place for hate of any kind." … "We are focused on science, medicine and, most importantly, healing for those in need. "

These statements were also more aligned with the academic medicine mission we defined earlier (Figure 3). The University of Pittsburgh's institutional statement demonstrates this alignment:

We recognize that health care, as many systems and institutions, has a deeply flawed history and that the health of many people in this nation are impacted by ongoing injustice and inequity related to the places they live, the air they breathe, the education they receive, the jobs they do, and the biases of the people they encounter every day, all of which is perpetuated by established policies and institutions. It's essential that we in health care increase our understanding of these social, economic and cultural determinants of health and how our current structures, including those within health care delivery systems, work against huge segments of our people.

In this paragraph, although the statement does not explicitly name racism or racial implications, the statement does name that the health care system contributes to structural disparities that impact the health and health care of “people … impacted by injustice and inequity.” The statement also draws a connection between institutional values and public health by calling upon the critical role “we in health care” have in understanding and addressing these issues. Later in the statement, the statement explicitly connects racial inequities to the roles of the academic medicine institution by stating:

The City of Pittsburgh Gender Equity Commission's report, "Pittsburgh's Inequality Across Race and Gender" lays out very clearly how much needs to change in our community. The Schools of the Health Sciences, along with Pitt as a whole, and UPMC are positioned to play a crucial role in making those changes happen.

DISCUSSION

Recent literature in academic medicine demonstrates an increased and heightened focus on the structural and social determinants of health, but medicine continues to fail to dismantle structural racism in support of Black lives and achieving health equity for minoritized groups,²³ to address structural racism in undergraduate and graduate medical education, and to significantly move the needle toward representational diversity and inclusive environments. Even as there is some consensus that racism is a public health crisis (2018), there were no uniform or collective statements until 2020 in the context of a global pandemic.

The academic medicine institutional statements were largely crafted under the same content categories of speaking out against the specific recent occurrences; acknowledging racism in the United States; expressing a desire for the specific institution to commit to the value of diversity; stating that the campus should be a safe place for all faculty, staff, and students; and recognizing that people of color in the community are hurting. In 2006, Morphew and Hartley²⁴ questioned if mission statements were organizational window dressings that are normative necessities. Our study adds to this critical approach to institutional statements by revealing that most institutions that published a public institutional statement addressed the academic mission and its connections to racism, public health, and their institutional mission as shown in Figure 3. The impetus for these statements was the murder of George Floyd, a Black man who was killed by a police officer, yet the statements lacked mention of Black Lives Matter and key terms such as murder and police. Moreover, the statements generally lacked the acknowledgment of the systems in which our institutions operate, but also the leadership, and leaders, that take part in perpetuating these systems. This omission itself raises the issues of motivation and substance.

Furthermore, we noticed that there was a familiar pattern in the approach for most of the statements. This pattern also mimics and represents the concept of institutional isomorphism. Institutional isomorphism involves “how organizations adopt similar models of structure and strategy, not only because of competitive dynamic and the desire to maximize their performance but also as a way to legitimize themselves in the eyes of their peers.”²⁵ Sociologists Dimaggio and Powell²⁶ noted how environmental events pressure institutions to respond in similar ways, hence borrowing the term isomorphism. Two types of isomorphism exist in this study: coercive and mimetic. Coercive isomorphism results from formal and informal pressures imposed by an entity that enjoys a degree of influence or power over the institution. Mimetic isomorphism refers to how universities operate in ways that are nonstrategic, merely mimicking the actions of respected peers as a means to define what it means to engage legitimately.²⁵ We posit that in the context of institutional responses to racial justice, isomorphism may have contributed to a monolithic response that perpetuated the appearance of hollowness. Therefore, more than ever, action is the only valid approach in academic medicine.

LIMITATIONS

There are several limitations to this study. First, the institutional statements collected represent a specific period in time and availability through public means. As such, our examination did not include institutional statements sent internally nor did it include statements sent by entities within each institution. Second, because we focused on the statements, we did not examine or seek additional information about the contexts, politics, and dynamics that shaped the development of the public statement or the content included in that statement. Third, we recognize that the espoused values described in the statements may not wholly or accurately represent the lived realities and daily environments faculty and learners of color at those institutions. Our study only focused on the ideas and content reflected in the statements and did not verify whether these values were actualized at the institutions.

CONCLUSION

The events and contexts of 2020 finally called for academic medicine to respond to national calls for justice. One after another, statements condemning racial injustice emerged. Our study provides a critical review of academic medicine statements that followed the murder of George Floyd. Institutional leaders covered three overarching themes through these statements. First, the acknowledgment that structural racism exist among us. Second, the attempt to connect this response to institutional values of diversity, equity, and inclusion. Finally, the declaration of racism as a public health issue, therefore also elevating much needed conversations about health equity. Unfortunately, this also included statements that decentered race and manifestations of racism.

In addition, our study underscores a critical and necessary realignment to the social mission of academic medicine, conceptually defined as the discovery and development of basic principles, effective policies, and best practices that advance research and education in the health sciences, ultimately to improve the health and well-being of individuals and populations. Reclaiming the social mission will be a major step toward advancing health equity. This reclamation is required to improve the health and well-being of individuals and marginalized populations. We commend institutions that were at the forefront of this reclamation and issue a call to all institutions to more thoughtfully and purposefully grapple with the role of academic medicine in eradicating injustice.