Criteria for Excellence | Chapter 1A: Health equity, bias and structural barriers to care and opportunity
Apply an equity lens to residency education, recruitment, operations and patient care.
Authors: Steven Crane, MD; Walt Mills, MD; Stephen Schultz, MD; Karen Mitchell, MD; Danielle Jones, PhD
Programs of Excellence, mindful of the core principles of family medicine, design their mission, vision, strategies, faculty recruitment and development, resident recruitment and selection, and curricula with a goal of promoting health equity for the diverse communities they serve. To accomplish this, they strive to identify and remove biases and structural barriers that compromise health equity, applying an equity lens to all decision-making.
Advance health equity in family medicine residency programs
In the 2025 Program Requirements, the Accreditation Council for Graduate Medical Education(ACGME) was unequivocal about the central role of health equity and inclusion as core tenets of family medicine. The following are key excerpts from the ACGME’s definition of the family medicine specialty.
“Family physicians are specialists in primary care for individuals of all ages. This personalized care is provided within the context of their families and communities through accessible, comprehensive, continuous, and coordinated care. Family physicians champion holistic, empathic, compassionate, culturally aware, and relationship-based care to patients across the broad spectrum of society.”2
“Through knowledge of social determinants of health, family physicians advance equity in health care for all.”2
“Family physicians excel at coordinated team-based care and advocate for high value care [in] their partnership with interprofessional teams. They are superb communicators and serve as teachers to patients, colleagues, and community groups. Family physicians employ respect and compassion with colleagues, allied health professionals, patients, and patients’ families.”2
“Family physicians advocate for all patients and work to remove barriers to care for all populations. They advocate for their patients through the development and promotion of health policy by working with local organizations and partnering to promote better health within the intricacies of the health care system.”2
Defining health equity and health disparities
Health equity
The Healthy People 2020 definition of health equity, which was adopted by the American Academy of Family Physicians (AAFP), is the “attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.”3
The Robert Wood Johnson Foundation (RWJF) offers the following definition: “Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care. For the purposes of measurement, health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.”
Use AAFP resources to address health equity
To operationalize health equity and diversity in medicine, the AAFP launched the Center for Diversity, Health Equity and Global Health(CDHEGH) in 2017. The CDHEGH (formerly the Center for Diversity and Health Equity) has developed high-impact programs and products such as a social determinants of health toolkit, an implicit bias training guide, health equity issue briefs and more. These resources are free and available at AAFP.org/everyone.
Health disparities
Health disparities are differences in health that “are not only unnecessary and avoidable but, in addition, are considered unfair and unjust.”5The health disparities that Programs of Excellence seek to address are those wherein observed “differences in health … are systematically associated with being socially disadvantaged.”6
Controversy and confusion around health equity goals
Recent legal and policy developments have introduced new complexities for residency programs seeking to achieve health equity goals.
In 2023, the U.S. Supreme Court held that the admissions programs of the University of North Carolina and Harvard University violated the Equal Protection Clause of the 14th Amendment to the U.S. Constitution and Title VI of the Civil Rights Act (coextensive with the Equal Protection Clause) by impermissibly considering students’ race in admissions decisions. The court’s majority opinion articulated a broad principle: “Eliminating racial discrimination means eliminating all of it.”7 It emphasized that students must be treated based on their experiences as individuals and not on their race. The court declared the schools’ admissions programs were unlawful because they employed racial stereotypes, disadvantaged people of particular races, were not sufficiently measurable and lacked a logical end point.
Regarding the asserted compelling interest in “diversity” that the universities were trying to advance, the Supreme Court held that it failed strict scrutiny because “the question whether a particular mix of minority students produces ‘engaged and productive citizens,’ sufficiently ‘enhance[s] appreciation, respect, and empathy’ or effectively ‘train[s] future leaders’ is standardless.”7In addition, the court held that schools may not grant preferential benefits to people of certain races in order to achieve a student body composition that mirrors the racial makeup of the country, remedy general societal discrimination or otherwise rectify societal injustice.
Race can no longer be used as a proxy for socioeconomic disadvantage. Regardless of whether there is a correlation between race and socioeconomic status, the Supreme Court stated that there are race-neutral alternatives by which to assess this status. The syllabus summarizing the court’s opinion noted that “nothing prohibits universities from considering an applicant’s discussion of how race affected the applicant’s life, so long as that discussion is concretely tied to a quality of character or unique ability that the particular applicant can contribute to the university.”7 However, the court also cautioned that schools “may not simply establish through application essays or other means the regime we hold unlawful today” and added that “[w]hat cannot be done directly cannot be done indirectly.”7
On January 20, 2025, President Donald Trump signed Executive Order 14151, titled “Ending Radical and Wasteful Government DEI Programs and Preferencing.” Its stated purpose was to eliminate actions by the Biden administration that “forced illegal and immoral discrimination programs, going by the name ‘diversity, equity, and inclusion’ (DEI), into virtually all aspects of the Federal Government, in areas ranging from airline safety to the military.”8
Without identifying what DEI actually encompasses, the order stated, “The Director of the Office of Management and Budget (OMB), assisted by the Attorney General and the Director of the Office of Personnel Management (OPM), shall coordinate the termination of all discriminatory programs, including illegal DEI and ‘diversity, equity, inclusion, and accessibility’ (DEIA) mandates, policies, programs, preferences, and activities in the Federal Government, under whatever name they appear.”8 It also ordered all federal agencies to provide the director of the OMB with information that included a list of all “Federal grantees who received Federal funding to provide or advance DEI, DEIA, or ‘environmental justice’ programs, services, or activities since January 20, 2021.”8
On February 14, 2025, the U.S. Department of Education’s Office for Civil Rights (OCR)—which enforces federal civil rights in schools—sent a “Dear Colleague” letter to public school administrators in an apparent effort to clarify Executive Order 14151 in light of the Supreme Court’s ruling in Students for Fair Admissions, Inc. v. President and Fellows of Harvard College. The following are key excerpts from the FAQ document that was subsequently released to answer questions about the OCR’s letter.
- “Schools may not intentionally discriminate on the basis of race, color, or national origin in their programs or activities. Many schools have advanced racially discriminatory policies and practices under the banner of ‘DEI’ initiatives. Other schools have sought to veil racially discriminatory policies with terms like ‘social-emotional learning’ or ‘culturally responsive’ teaching. But whether an initiative constitutes unlawful discrimination does not turn solely on whether it is labeled ‘DEI’ or uses terminology such as ‘diversity,’ ‘equity,’ or ‘inclusion.’ … [S]chools with programs focused on interests in particular cultures, heritages, and areas of the world would not in and of themselves violate Title VI, assuming they are open to all students regardless of race. Nor would educational, cultural, or historical observances—such as Black History Month, International Holocaust Remembrance Day, or similar events—that celebrate or recognize historical events and contributions, and promote awareness, so long as they do not engage in racial exclusion or discrimination. However, schools may not sponsor programming that creates a hostile environment based on race for students who do participate.”9
- “[M]ore extreme practices at a university—such as requiring students to participate in ‘privilege walks’ that are designed to make them feel guilty about being part of a certain race, segregating them by race for presentations and discussions with guest speakers, pressuring them to participate in protests or take certain positions on racially charged issues, investigating or sanctioning them for dissenting on racially charged issues through DEI or similar university offices, mandating courses, orientation programs, or trainings that are designed to emphasize and focus on racial stereotypes, and assigning them coursework that requires them to identify by race and then complete tasks differentiated by race—are all potential forms of school-on-student harassment that could create a hostile environment under Title VI. Specifically, such conduct could be deemed to create a hostile environment if, viewed by a reasonable person, of the same race and age, under similar circumstances, it is sufficiently severe, pervasive, or persistent so as to interfere with or limit the ability of an individual to participate in or benefit from the school’s program or activity.”9
- “To determine whether a school acted with a racially discriminatory purpose, OCR may analyze different types of circumstantial evidence that, taken together, raise an inference of discriminatory intent. A non-exhaustive list may include (1) whether members of a particular race were treated differently than similarly situated students of other races; (2) the historical background or administrative history of the policy or decision; (3) whether there was a departure from normal procedures in making the policy or decision; (4) whether there was a pattern regarding policies or decisions towards members of a particular race; (5) statistics demonstrating a pattern of the policy or decision having a greater impact on members of a particular race; and (6) whether the school was aware of or could foresee the effect of the policy or decision on members of a particular race. [See Village of Arlington Heights v. Metro Housing Development Corp., 429 U.S. 252, 266–68 (1977).] A school’s history and stated policy of using racial classifications and race-based policies to further DEI objectives, ‘equity,’ a racially-oriented vision of social justice, or similar goals will be probative in OCR’s analysis of the facts and circumstances of an individual case.”9
As of August 2025, graduate medical education (GME) programs have not been specifically targeted to assess their compliance with these directives. However, since all GME programs receive federal funds, such scrutiny should be expected. To uphold the core values of family medicine outlined by the ACGME while also complying with the new federal guidelines, Programs of Excellence should consider the processes outlined below.
Apply health equity strategies across your residency program
Achieving health equity goals within a family medicine residency program is multilayered, complex and can include five distinct but overlapping processes:
Personal self-awareness and transformation
Resident recruitment and education
Faculty recruitment, retention and professional development
Organizational commitment and practice redesign
While many root causes of health disparities are systemic, some barriers arise from within the individual. Every person has unconscious biases. However, with targeted training, people can develop skills and self-awareness to help mitigate these biases. To help individuals better understand their own unconscious biases, the AAFP has developed implicit bias training resources.
Programs of Excellence should participate in activities that enhance the candidate pool of residents, faculty, and staff to include individuals who may have experienced limited opportunities due to bias or structural barriers. Examples of activities include the following:
- Expansion of opportunity on the health care workforce pathway: Programs of Excellence should create experiential and mentoring programs in the communities they serve. These programs should target high school students who have an interest in health care careers.
- Outreach to medical schools that excel in providing access to opportunity: Medical schools vary widely in the proportion of students who have encountered structural barriers they matriculate. Programs of Excellence should conduct outreach to schools that are excelling in this metric to strategically recruit resident candidates. Consider giving selection preference to candidates who train in these learning environments.
- Creation of a welcoming website: Programs of Excellence should prominently display their commitment to health equity on their recruitment websites and in their materials. They should also be transparent about their selection criteria and proactively work to reduce bias and structural barriers across all recruitment communications.
- Accommodation for candidates with individual needs: Programs of Excellence should develop and effectively communicate accommodations that are designed to reduce barriers to the application process for candidates.
Resident candidate selection
The recruitment and selection process for residents is fraught with potential biases and systemic barriers that can limit opportunity. Programs of Excellence are strongly encouraged to adopt a thoughtful process for redesigning their selection criteria and processes to include measures of success related to achieving health equity and equal opportunity goals. Specific changes to consider include the following:
- Define the specific training mission of the program and identify resident characteristics most likely to lead to success in fulfilling that mission. For example, one academic program may have an important goal to produce primary care researchers and faculty, while another may desire to produce broad-scope rural physicians. Depending on a program’s educational goal, the relative importance of candidates’ specific experience, skills and goals may be different. If so, the program should strive to identify valid and distinguishing measures for each characteristic, and these criteria should be transparent to applicants.
- Develop a strategy for creating a threshold and eliminating ranking for so-called “objective” selection measures, such as board scores or class rank. This will likely increase the pool of otherwise well-qualified candidates who may have encountered structural barriers on their educational journey.
- Review the interview process closely and structure it to reduce bias. The Association of American Medical Colleges has published best practices for creating and conducting residency interviews to reduce bias while improving “applicant-program fit.”
- Consider using both short, structured, performance-based questions and group interviews in which multiple observers judge the candidates’ responses. Candidates should be made aware of this process, which should be guided in a nonthreatening manner. Standardized performance-based questions should assess all the core competencies and allow candidates to give short answers about their experience that might demonstrate their ability in those areas. Other information contained in the typical Electronic Residency Application Service® application, including board scores, class rank and medical school, should not be disclosed to interviewers and observers. In addition, they should have some implicit bias training before the interview season.
- Have the team participating in the structured interview process individually assess each candidate’s performance on the interview. Rather than using a simple Likert scale, they should tie candidate rankings to specific, observable measures similar to the ACGME Milestones.
- Consider including other staff and community members on the selection committee, as appropriate.
- In the ranking process, only include selection criteria that are thought to be valid and distinguishing for the characteristics most likely to lead to success in fulfilling the program’s educational mission. Avoid including pictures of candidates.
- Consider having the selection committee use more generic ranking categories, such as “highly ranked, ranked and do not rank” or simply “rank and do not rank,” rather than a traditional numerical rank list. Randomize candidates who fall into the ranked categories. Randomization at this level will help dispel biases that can enter into the selection process, even with the best of intentions.
Invite all candidates to complete an anonymous post-interview questionnaire about their perception of the fairness and transparency of the program’s recruitment and selection process.
Support for success in resident education
During orientation, each enrolling resident should receive an individualized evaluation of their clinical skills, strengths, weaknesses, learning style and potential barriers to success. They should work with their faculty advisor to create a professional development plan. This could involve some remedial skill-building, structured time to meet with a mentor or a plan to develop social supports in the community. Progress along this professional plan should be reviewed at least monthly during the PGY1 year until both resident and faculty are satisfied that the resident is thriving in the program.
Assessments and evaluations of residents should be based on performance and tied to specific, observable criteria. In addition, awards given out in residency should be based on observable, transparent criteria. All faculty, including community faculty, should participate in annual development programs that include bias awareness training and mitigation techniques. An anonymous reporting system should be in place so that residents can report any bias they may perceive in their training or evaluations.
Many of the principles of faculty recruitment, retention and professional development follow the best practices for resident recruitment, selection and education. For example, as with residents, faculty assessments and evaluations should be based on performance and tied to specific, observable criteria.
Programs of Excellence should provide faculty development focused on building skills in promoting health equity goals. One example of a professional development resource is the health equity curricular toolkit, which includes 14 modules and provides structured curricular guides to facilitate exploration of issues related to social determinants of health, populations that have been made vulnerable, and economics and policy. It was inspired by the Starfield Summit II and developed by a team of 40 content experts in the United States and Canada.
A Program of Excellence should review its mission and values statements and update them to explicitly indicate the program’s commitment to the family medicine principles outlined in the 2025 ACGME Program Requirements. Ideally, this process should involve relevant parties at all levels to increase transparency, garner buy-in and provide accountability. One program’s approach is described in a Family Medicine article by Guh et al.
Milestones developed by the Association of Family Medicine Residency Directors can help individual programs assess themselves and their institutions on aspects of supportive work environments and identify areas of opportunity and strength.
Workforce diversity is not about racial diversity but rather diversity of people of many backgrounds, cultures and life experiences. Patient outcomes may improve when care teams have a better understanding of their patients’ lives and social, historical and cultural contexts. Workforce training on cultural sensitivity should be considered standard, and it should be required upon hiring and at least annually thereafter. The University of Wisconsin Population Health Institute’s County Health Rankings & Roadmaps program offers training resources and evidence supporting this approach.
Supervisory staff should receive additional training on how to identify and address issues that arise in the workplace. The AMA has developed guidelines for confronting systemic racial bias in medicine. All staff should have a safe mechanism for reporting and disclosing incidents they feel are discriminatory or promote bias. The University of California, San Francisco SAFE (Supporting A Fair Environment) reporting system is one example. Programs of Excellence should also consider using an outside entity or ombudsman that can advocate for positive change while maintaining anonymity within the program, as appropriate.
Programs should survey staff at least annually on how well they feel the organization is progressing toward its stated goals. These surveys should be anonymous, and the results and actions taken by leadership should be disclosed and communicated to all staff. One example of a benchmarking tool is Partnerships for Health Equity and Opportunity: A Healthcare Playbook for Community Developers from the Build Healthy Places Network.
Programs of Excellence should approach health equity as “a lens, not a list” and commit to applying a health equity lens to ALL decision-making in the residency and in clinical practice. The following tools can be adopted and systematically applied to decision-making processes:
- Equity and empowerment lens webpage: Information and resources provided by Multnomah County include the 5P’s worksheet, which guides systematic exploration into the areas of people, place, process, power and purpose.
- Racial equity impact assessment toolkit: This resource from Race Forward can help programs evaluate how proposed decisions or actions may affect racial and ethnic groups.
Chapter 9 in the Criteria for Excellence contains a number of specific ways a family medicine practice can achieve health equity objectives.
- King says AMA discriminates. Ironwood Daily Globe. March 26, 1966. Accessed February 6, 2025.
- Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in family medicine. September 3, 2025. Accessed September 10, 2025.
- American Academy of Family Physicians. Health equity. December 2024. Accessed September 10, 2025.
- Braveman P, Arkin E, Orleans T, et al. What is health equity? And what difference does a definition make? Robert Wood Johnson Foundation; 2017. Accessed September 10, 2025.
- Whitehead M. The concepts and principles of equity in health. Int J Health Serv. 1992;22:429-445.
- Braveman P. Health disparities and health equity: concepts and measurement. Annu Rev Public Health. 2006;27:167–194.
- Students for Fair Admissions, Inc. v. President and Fellows of Harvard College, 600 U.S. 181 (2023).
- The White House. Ending radical and wasteful government DEI programs and preferencing. January 20, 2025. Accessed September 10, 2025.
- U.S. Department of Education Office for Civil Rights. Frequently asked questions about racial preferences and stereotypes under Title VI of the Civil Rights Act. February 28, 2025. Accessed September 10, 2025.