When my son was 4 years old, he fell off a swing at the playground. As a physician, I knew immediately that his dangling wrist was broken. I felt relieved to get him to the ER - but that relief was short-lived; the orthopedist started examining my son’s broken wrist, without giving him any pain medication. I will never forget the look of sheer agony on my son’s little face and the piercing shriek he let out. Later, I learned that not only are Black adults with fractures more likely to be undertreated for pain in the ER, but Black children, too, like my son. Pseudoscientific beliefs about racial differences in pain perception have contributed to this inequity in pain management.
In late March 2026, the Liaison Committee on Medical Education (LCME), the accrediting body for U.S. medical schools, issued updated standards for 2027-2028. The requirement that medical schools ensure students “learn to recognize and appropriately address biases in themselves, in others, and in the health care delivery process” was removed. While previous standards referenced structural competence, cultural competence, biases, health inequities, and approaches to reduce them, now there is only a vague mention of “instruction and experiential learning in the factors that contribute to disparate health outcomes,” which is included within a broader systems-based practice competency.
Removing health equity training requirements for medical students is a harmful decision with negative consequences for all patients, especially those from marginalized communities. Everyone suffers when physicians lack understanding of how health inequities happen, cannot examine their own biases, and cannot develop the skills to address them, for their patients and their communities.
This rollback of LCME requirements follows an Executive Order issued in April 2025 that threatened to revoke accreditors’ authority to validate medical schools if LCME were found to have DEI-related requirements. The EO specifically targeted LCME; a month later, LCME removed Standard 3.3, which required medical schools to maintain active diversity programs and partnerships.
To competently care for patients - all patients - physicians must understand their patients’ social context and how structural factors - social and economic policies, laws, and regulations - shape the health of the patient right in front of them.
This is structural competency. It involves understanding and recognizing that zoning laws often place industrial facilities near low-income and Black and Latine communities, which increases asthma rates, and that eviction policies lead to housing instability, disrupting access to health care. Physicians who understand these structural factors can then advocate for their patients and push for policy changes to improve their patients’ health and that of their communities. Although these policies disproportionately impact marginalized communities, they affect the vast majority of Americans.
Our patients do not exist in a vacuum. A patient’s neighborhood, their job, their insurance status, access to healthy food, their exposure to environmental pollutants - all of these shape a person’s health. Lacking understanding of the effects of these upstream factors on health means that a physician is working with an incomplete picture - one where they might call a patient ‘non-compliant’, when, in fact, the patient cannot afford their medication, or must prioritize buying food over their medication because their SNAP benefits have been cut.
Even the MAHA agenda, which emphasizes clean drinking water and healthy food access, relies on understanding how policies affect access to these social determinants of health. The contradiction in this is that the Trump administration pushed 53 medical schools to expand their curriculum on nutrition while at the same time pressuring the LCME to gut a Standard that would have taught how access to clean drinking water and healthy foods are connected directly to policies and regulations - in other words, to structural factors.
This is a critical time, with access to health care for Americans eroding on multiple fronts. The “One Big Beautiful Bill Act”, signed into law in 2025, enacts the largest Medicaid cuts in history and eliminates coverage for at least 10 million Americans. Separately, the loss of Affordable Care Act subsidies has increased out-of-pocket premium payments in the marketplace by an average of 114% for subsidized enrollees who stayed in the same plan. The $50 billion Rural Transformation Fund, part of the “One Big Beautiful Bill Act”, will only partially offset the $137 billion in Medicaid cuts to rural areas, already reeling from hospital closures. Nearly half of US counties lack a single obstetrician, midwife, or birthing facility. As of this year, 27 states have enacted laws or policies limiting youths’ access to gender-affirming care.
Medical schools must push back. They have an obligation to train physicians who ‘do no harm’, the foundational principle of medicine. This requires graduating physicians who understand health inequities, how bias and structural factors shape them, and how to act on that knowledge for and with their patients. LCME’s removal of this requirement does not change that duty; it does not actually prohibit medical schools from teaching this content, as the April 2025 EO targets LCME, not medical schools directly. A Congressional effort to withhold federal funding from medical schools that teach diversity, equity, and inclusion - the EDUCATE Act, which has been introduced twice, once in 2024 and again in 2025 - has so far not progressed.
Medical schools can comply with federal pressure and fail their students and the patients they will one day treat, or they can commit to teaching the skills that physicians need to care for all their patients competently.
Oni Blackstock, MD, MHS, is a primary care and HIV physician, founder and executive director of Health Justice, and Public Voices Fellow for Technology in the Public Interest with the OpEd Project.
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