Disrupting a Disparate System: Addressing Segregated Care at a Large Academic Medical Center

Proposal: Problem being addressed
In the past three years, academic medical centers (AMCs), unequivocally proclaimed the need to dismantle systemic racism within their institutions. Segregated healthcare, which refers to disparate tracks of care based on a patient’s race, insurance status, or other social characteristics, is one important arena for change (Blum, 2023). Within AMCs, payor status replaces formal policy with de facto racial segregation. Patients with Medicaid are ushered into resident-based clinics to be seen by physicians-in-training, whereas patients with private insurance are seen in separate spaces by more experienced physicians (Vinekar, 2021). Several studies have noted that resident physicians in AMCs disproportionately care for Black and Latino patients and patients with Medicaid than attending physicians, leading to variable health outcomes (Essien, 2019). Additionally, segregated environments lead to student and staff moral injury.

At Columbia University Irving Medical Center (CUIMC), most medical departments still practice within this two-tiered system, despite institutional leaders recognizing desegregation of care as a priority.

Program description
We are engaged in a novel program that advocates for health equity by investigating the causes, effects, and potential solutions to segregated care practices at our institution. CUIMC is part of an 11 school Anti-Racism Transformation in Medical Education (ARTinMedEd) cohort led by Mount Sinai School of Medicine, through a Harvard Macy Foundation grant. Our local ARTinMedEd Addressing Segregated Care subgroup brings together community members, trainees, and staff to consolidate advocacy efforts in conjunction with hospital leaders. Efforts have included collating data to understand community healthcare priorities, a crucial step in recognizing existing health disparities that continue to stand in the way of achieving health justice (NYP, 2023). Most recently, we organized a panel featuring four medical center leaders to facilitate accountability and understand solutions being implemented in department-wide desegregation.

Relevance to social mission
Health professions students often train in systems that perpetuate some of the very inequities students are taught to criticize. An understanding of structural factors that enable segregated care to remain in practice will equip trainees and those working around health professions education to form effective coalitions to advocate for transformative change.

Expertise of presenters
All presenters are members of the Columbia VP&S Anti-Racism Coalition. Mansi Shah and Jeremiah Douchee are third-year medical students. Gunjandeep Singh is a research technician at the Columbia Taub Institute. Hetty Cunningham is the Director for Equity and Justice in Curricular Affairs. Maria De Miguel is an Associate Professor of Medicine.