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; Gregory Sawin, MD, MPH; Danielle Jones, PhD
Programs of Excellence, mindful of the core principles of Family Medicine, design their mission, vision, strategies, faculty recruitment and development, resident selection and recruitment process, and curricula, to promote health equity for the diverse communities they serve. To accomplish that, Programs of Excellence strive to identify and remove biases and structural barriers that compromise achieving that goal and apply an equity lens to all decision making.
Advance health equity in family medicine residency programs
The ACGME in the 2024 Program Requirements was unequivocal about central role of health equity and inclusion as core tenets of Family Medicine:
“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, equitable, culturally humble, and relationship-based care to patients across the broad spectrum of society.
Through knowledge of structural determinants of health, family physicians advance equity in health care for all:
Family physicians excel at coordinated team-based care and advocate for high value care in their partnership with diverse, 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.
Family physicians advocate for social justice and ethical principles to remove barriers to equitable 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.”
Define health equity and health disparities
The Healthy People 2020 definition of health equity, which was adopted by the 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.”
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.”
The health disparities we seek to address are those wherein observed “differences in health are systematically associated with being socially disadvantaged.” (P. Braverman, Health Disparities and Health Equity, Ann Rev. Public Health 2006. 27: 167-94).
Disparities are differences in health that “are not only unnecessary and avoidable but, in addition, are considered unfair and unjust.” (M. Whitehead, 13 1992, The concepts and principles of equity in health. Int J. Health Serv. 22:429-45)
Use AAFP resources to address health equity
The AAFP launched the Center for Diversity and Health Equity (CDHE) in 2017 to operationalize health equity and diversity in medicine. The CDHE has developed high impact programs and products such as the SDOH Toolkit, Implicit Bias Training Guide, Issue Briefs and more. These resources are free and available at www.aafp.org/everyone.
Understand the evolving legal and policy environment for health equity
A. In 2023 the U.S. Supreme Court (Students for Fair Admissions, Inc. v. President & Fellows of Harvard College, 600 U.S. 181 (2023) (“Students v. Harvard” or “SFFA”) held that the admissions programs of the University of North Carolina and Harvard College violated the Equal Protection Clause of the Fourteenth Amendment to the U.S. Constitution and, coextensive with the Equal Protection Clause, Title VI of the Civil Rights Act, by impermissibly considering students’ race when making admissions decisions. The Court articulated a broad principle: “Eliminating racial discrimination means eliminating all of it.” The Court emphasized that students must be treated based on their experiences as individuals and not based on their race. It declared the admissions programs were unlawful because they employed racial stereotypes, disadvantaged members of particular races, were not sufficiently measurable, and lacked a logical endpoint.
The Court further held that the asserted compelling interest in “diversity” that the Universities were trying to achieve 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.” Equally, schools may not grant preferential benefits to members of certain races for the purpose of achieving a student-body composition that mirrors the racial makeup of the country, remedying general societal discrimination, or otherwise rectifying societal injustice.
Race can no longer be used as a proxy for socioeconomic disadvantage. Even if there is a correlation between race and socioeconomic status, the Court stated there are race-neutral alternatives by which to assess socioeconomic status.
The Court added 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.” However, the Court cautioned in the same paragraph that schools “may not simply establish through application essays or other means the regime we hold unlawful today[,]” adding that “[w]hat cannot be done directly cannot be done indirectly.”
B. On January 20, 2025 President Trump signed an executive action Ending Radical And Wasteful Government DEI Programs And Preferencing The stated purpose of the policy was to eliminate “the Biden Administration’s 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.”
Without identifying what DEI actually was the action ordered “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.”
It also ordered all Federal agencies provide the Director of the OMB with a list of among other entities “Federal grantees who received Federal funding to provide or advance DEI, DEIA, or “environmental justice” programs, services, or activities since January 20, 2021.”
C. 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 and subsequent FAQ to public school administrators in an apparent effort to clarify the Executive Action in light of the Supreme Court’s SFFA ruling.
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.”
Schools 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.
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.
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. 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.
Although GME programs to date have not been specifically targeted for compliance to these directives, given that all GME programs receive federal funds such scrutiny should be expected. To achieve the core values of Family Medicine outlined by the ACGME in 2024 while adhering to the new federal guidelines the Programs of Excellence should consider the steps 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 yet overlapping processes:
Personal self-awareness and transformation
Resident recruitment and education
Faculty recruitment, retention, professional development
Organizational commitment and practice redesign
Health care delivery and patient outcomes
While many root causes of health disparities are systemic, some barriers arise from within ourselves. Each of us has unconscious biases, but with targeted training, individuals can develop skills and self-awareness that can help mitigate them. To better understand one’s own unconscious biases the American Academy of Family Physicians (AAFP) has developed the Implicit Bias Training Guide.
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:
- Expanding opportunity in the pathway of healthcare workforce: 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 modeling access to opportunity: Medical schools vary widely on the proportion of students they matriculate who have encountered structural barriers. Programs of Excellence should conduct outreach to those schools who are excelling in this metric to strategically recruit resident candidates. Consider giving selection preference for candidates who train in these learning environments.
- Creating a welcoming website: Programs of Excellence should prominently display their commitment to healthy equity and proactively work to reduce bias and structural barriers on their recruitment website and materials to be transparent about their selection criteria.
- Accommodation for candidates with individual needs: Programs should also develop and effectively communicate accommodations that are designed to reduce barriers to the application process for candidates.
The recruitment and selection process for residents is an area fraught with potential biases and systemic barriers that can limit opportunity. Programs of Excellence are strongly encouraged to adopt a thoughtful process of redesigning their selection criteria and processes to include measures of success in achieving their health equity and equal opportunity goals. Specific changes to consider could include:
- Define the specific training mission of the program and identify those
characteristics most likely to lead to success in meeting that mission. For
instance, an academic program may have an important goal to produce primary care researchers and faculty, while another may desire to produce broad-scope rural physicians. The relative importance of candidates’ specific experience/skills/goals may be a better fit for the program depending on the educational goal. If so, the program should strive to identify valid and discriminating measures for each. These criteria should be transparent to applicants. - When dealing with so-called “objective” selection measures such as board scores or class rank, a strategy for creating a minimum threshold will likely increase the pool of otherwise well-qualified candidates who may have encountered structural barriers on their educational journey.
- The interview process should be reviewed closely and structured to reduce bias. The AAMC has published guidelines for programs conducting interviews intended to reduce bias while improving “fit” of candidates to the programs stated educational objectives.
- Consider using short, structured performance-based questions, and the use of group interviews where multiple observers judge the candidates' responses. Those participating in the interviews should be blinded to other information that is contained in the typical ERAS application including board scores, class rank, and medical school and should have some unconscious bias training before the interview season. Standardized performance questions should include all the core competencies and allow candidates to give short answers to their experiences that would perhaps demonstrate their ability in those areas. Candidates should be made aware of this process which should be executed in a non-threatening manner.
- Performance on the interview should be individually assessed by the team participating in the structured interview process. Rather than a simple Likert scale, the ranking should be pegged to specific observable measures similar to the Milestones.
- The program should consider inclusion of other staff members, and perhaps community members in the selection committee.
- The ranking process itself should include only those selection criteria thought to be valid and discriminating (as above); it should avoid pictures of candidates.
- Rather than a traditional numerical rank list, the committee should consider a more generic process such as: “Highly ranked, ranked, and do not rank” or simply “rank and do not rank” and randomize candidates who fall in the ranked categories. Randomization at this level will help dispel the inevitable bias that can enter into the selection process even with the best of intentions.
- Programs should invite all their candidates to complete an anonymous postinterview questionnaire about their perception of the fairness and transparency of the program’s recruiting and selection process.
Supporting 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, and together with their faculty advisor develop an individualized professional development plan. This could involve some remedial skill-building, structured time to meet with a mentor, or a plan to develop social support 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 should be performance based and pegged to specific observable criteria. All faculty including community faculty should participate in annual faculty development programs that include bias awareness training and mitigation techniques. Residents should have an anonymous reporting system to report on what they may perceive as bias in training or evaluations.
Awards that are given out in residency should be based on observable, transparent criteria.
During orientation, each enrolling resident should receive an individualized evaluation of their clinical skills, strengths, weaknesses, learning style, and potential barriers, and together with their faculty advisor develop an individualized professional development plan. This could involve some remedial skill-building, structured time to meet with a mentor, or a plan to develop social support 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 should be performance based and pegged to specific observable criteria. All faculty including community faculty should participate in annual faculty development programs that include bias awareness training and mitigation techniques. Residents should have an anonymous reporting system to report on what they may perceive as bias in training or evaluations.
Awards that are given out in residency should be based on observable, transparent criteria.
Many of the principles of faculty recruitment, selection, professional development, and retention follow the guidelines for resident selection. Assessments and evaluations of both faculty and residents should be performance based and pegged to specific observable criteria. Programs should provide Faculty Development focused on building skills in promoting health equity goals. The AAFP and AFMRD Health Equity Fellowship
can provide such professional development for existing faculty as well as build internal program capacity for modeling and teaching current and future faculty. Inspired by the Starfield Summit II, a team of 40 content experts in the U.S. and Canada developed a comprehensive Health Equity Curricular Toolkit. This toolkit provides structured curricular guides to facilitate exploration of social determinants of health, vulnerable populations, and economics and policy, and includes 14 modules.
As a start, programs should examine their mission and values statements, and update them to explicitly indicate their commitment to the principles of Family Medicine outlined in the 2024 ACGME Program Requirements. Ideally, this process should involve relevant parties at all levels to increase transparency, garner buy-in and provide accountability.
The AFMRD developed Milestones for Program Assessment. This tool is a way for individual programs to 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 diversity of people of many backgrounds, cultures, and life experience. Patient outcomes may be improved by having care teams better understand their patients’ lives and social, historical, and cultural context. Training the workforce on cultural proficiency should be considered standard and required upon hiring, and at least annually. Resources and evidence supporting this approach can be found here.
Supervisory staff should receive additional training in how to identify and address issues that arise in the workplace, and all staff should have a safe mechanism by which to report and disclose incidents they feel are discriminatory or promote bias. Programs of Excellence should consider an outside entity or ombudsman who can maintain anonymity where appropriate while advocating for positive change. The USCF SAFE reporting system could provide a model to other programs, as well as the American Medical Associations guidelines for confronting systemic racial bias in medicine.
Programs should survey staff at least annually on how well they feel the organization is progressing towards their stated goals. These surveys should be anonymous, with their results, and actions taken by leadership disclosed and communicated to all staff. There are multiple examples of benchmarking tools, including Partnerships for Health Equity and Opportunity: A Healthcare Playbook for Community Developers.
Promote approach to health equity as “a lens, not a list” and commit to applying a health equity lens to ALL decision making in the residency and clinical practice. The below tools are examples that can be adopted and systematically applied to meeting design and decision-making processes:
- Multnoma County’s “Equity and Empowerment Lens,” including the “5-P’s Worksheet” that guides systematic exploration into the areas of People, Place, Process, Power, and Purpose
- RaceForward.org: Racial Equity Impact Assessment Toolkit
- Section 9C in the Criteria for Excellence chapter on “Models of Care” contains a number of specific ways the Family Medicine Practice can achieve health equity objectives.