Remembering Freddie Gray: Medical Education for Social Justice

Exploring medical students' experiences with indigenous patient care: a phenomenological study

BACKGROUND

Indigenous Peoples in Canada bear a disproportionate burden of disease and experience poorer health outcomes as compared to non-Indigenous populations within Canada; these conditions are said to be mediated and exacerbated by pervasive and uninterrupted anti-Indigenous racism. Third and fourth-year medical students at a Canadian medical school were asked to reflect on their experiences working with Indigenous patients in clinical settings, and how their preclinical Indigenous health curriculum impacted these experiences.

METHOD

Phenomenology was used, guided by Goffman's theory of social stigma. Eleven undergraduate medical students were recruited using purposeful sampling. Semi-structured phone interviews were conducted to gain an in-depth understanding of the participants' experiences. Interviews were recorded and transcribed verbatim. Data were analyzed using the four main processes for phenomenological analysis.

RESULTS

Four main themes emerged from students' descriptions of clinical experiences involving Indigenous patients: 1) students describe how their Indigenous patients encounter the health care system and their own lack of cultural sensitivity in this context; 2) racism was evident in students' clinical interactions with Indigenous patients, but students do not always perceive these biases nor the impact of this on patient care; 3) identifying the impact of racism on care is complicated by situational clinical encounters; and 4) practicality of preclinical Indigenous health education is desired by students to prepare them for working with Indigenous patients in the clinical setting.

CONCLUSIONS

In their clinical experiences, students witness racism against Indigenous peoples yet are unprepared to stand up against it. Findings highlight the importance of enhancing undergraduate medical training to allow students to better understand the unique experiences and perspectives of Indigenous patients. The results support the need for ongoing Indigenous health education, to foster culturally sensitive experiences while learning about Indigenous patients.

Building on Strengths: An Affirmational and Systems-Level Approach to Revisiting Character in Medicine

ABSTRACT

Although U.S. medical education has continued to place increased emphasis on defining competency standards and ensuring accountability to the public, health care inequities have persisted, several basic health outcomes have worsened, public trust in the health care system has eroded, and moral distress, burnout, and attrition among practicing physicians have escalated. These opposing trends beg the question of how the "good doctor" concept may be strengthened. In this perspective, the authors argue that revisiting the construct of physician character from an affirmational perspective could meaningfully improve medical education's impact on overall health by more holistically conceptualizing what-and who-a good doctor is. The authors introduce positive psychology's framework of character strengths, probe the distinction between character strengths and medical professionalism, and summarize the role of character strengths in promoting physician engagement and well-being in health care work. They contend that a systems-level approach to cultivating character strengths will foster physician moral agency and well-being and, by extension, transformational change in health care. Consistent with best practice in modern character education, the authors propose that institutions mindfully cultivate moral community among all stakeholders (students, faculty, staff, postgraduate trainees, and patients) and that moral community interaction centers on each member's personal aspirations with respect to living a good life, guided by the character strengths framework and informed by patient perspectives.

Anti-oppression pedagogy in health professions: a scoping review

Health professional learners are increasingly called to learn about health inequity to reduce inequities and improve patient care and health outcomes. Anti-oppression pedagogy (AOP) addresses the need for health professional learners to understand multiple health inequities and the structures and systems that produce inequities. However, the inclusion of AOP in health professions education varies and there is a lack of clarity in its conceptualization and integration. A scoping review was conducted to address this gap and to understand how AOP is conceptualized and integrated in health professions education. Thirty-six articles met the inclusion criteria. The articles demonstrated that AOP is not commonly utilized terminology within health professions education. When AOP is integrated, it is not consistently conceptualized but is generally viewed as a broad concept that focuses on antiracism; decoloniality; intersectionality; and supporting learners to understand, critically reflect on, and act against structural and systemic forms of oppressions. In addition, there is variation in the integration of AOP in health professions education with the most common methods consisting of discussions, cases, reflection, learning through lived experiences, and the incorporation of humanities within a longitudinal curriculum. The results of this scoping review highlight the need for health professions education to develop one clear concept that educators use when teaching about anti-oppression, which may reduce working in silos and allow educators to better collaborate with each other in advancing this work. In addition, this review suggests that health professional programs should consider incorporating AOP in curricula with a broad and longitudinal approach utilizing the common methods of delivery. To better support programs in including AOP in curricula, further research is required to emphasize the benefits, provide clarity on its conceptualization, and determine the most effective methods of integration.

Social work's opportunity and obligation to achieve population health equity

US healthcare remains a system in crisis, wherein spending outpaces other Western economies but health inequities match those of an emerging market economy. As a country founded in tenets of white supremacy, structural racism persists as evidenced by longstanding race-based disparities. Although the population health approach offers a potential framework for preventative and community-based health, without overt race-conscious design, race-based disparities will be replicated. This article outlines the current US context and healthcare policy changes that led to population health taking hold. It then articulates social work's pivotal role in population health by explicitly challenging colorblindness to reach race-based health equity. Opportunities for social work practice, leadership, and research are discussed.

'You just emotionally break': understanding COVID-19 narratives through public health humanities

News reports that feature the experiences of healthcare workers have shaped public conversations about the pandemic from its earliest days. For many, stories of the pandemic have been an introduction to the way public health emergencies intersect with cultural, social, structural, political and spiritual determinants. Such stories often feature clinicians and other providers as characters in pandemic tales of heroism, tragedy and, increasingly, frustration. Examining three common categories of provider-focused news narratives-the clinician as a uniquely vulnerable front-line worker, clinician frustration with vaccine and masking resistance, and the clinician as a hero-the authors argue that the framework of public health humanities offers useful tools to understand and potentially shift public conversation of the pandemic. Close reading of these stories illuminates frames that relate to the role of providers, responsibility for the spread of the virus and how the US health system functions in a global context. Public conversations of the pandemic are shaped by and shape news stories and have important implications for policy. Acknowledging that contemporary health humanities in all its iterations considers how non-clinical factors, such as culture, embodiment and power, impact our understanding of health, illness and healthcare delivery, the authors locate their argument amid critiques that focus on social and structural factors. They argue that it is still possible to shift our understanding of and telling of those stories towards a more population-focused frame.

Against the Turn to Critical Race Theory and "Anti-racism" in Academic Medicine

Medical academics are increasingly bringing critical race theory (CRT) or its corollaries to their discourse, to their curricula, and to their analyses of health and medical treatment disparities. The author argues that this is an error. The author considers the history of CRT, its claims, and its current presence in the medical literature. He contends that CRT is inimical to usual academic modes of inquiry and has obscured rather than aided the analysis of social and medical treatment disparities. Remedies for racism suggested by CRT advocates will not work and some of them will make things worse. Academic medicine should avoid the embrace of CRT and should maintain an allegiance to rigorous empirical inquiry and to treating patients not as essentialized ethnic group members but as individual human beings in need of care.

ART Praxis: Evidence-Based Strategies for Antiracist Teaching in Nursing

AIM

This integrative review seeks to provide effective teaching and learning strategies for teaching about racism and advancing health equity.

BACKGROUND

Most faculty preparation remains devoid of an exploration of racism and the skills to critique how historical events and socialization create and reinforce the biases that influence how we teach and provide care. It is difficult to teach what we do not know.

METHOD

Using Whittmore and Knafl's approach, we conducted an integrative review of multidisciplinary literature from 2009 to 2021 to uncover best practices for teaching about racism. Seven databases yielded 55 relevant articles from 18 disciplines.

RESULTS

Four themes emerged illuminating effective strategies for teaching and learning about systemic racism: encounter education, reflection, discussion, and activism.

CONCLUSION

Findings of this review align with Mezirow's transformative learning theory and highlight the importance of not just "doing" antiracist activities in a course but "becoming" an antiracist educator.

Development of a curriculum in cultural determinants of health and health disparities

INTRODUCTION

Current sociopolitical events coupled with requirement modifications by the Liaison Committee on Medical Education have reinvigorated a need for training in cultural awareness and health disparities in undergraduate medical education. Many institutions, however, have not established longitudinal courses designed to address this content. Additionally, little is known about the change in learners' awareness of cultural determinants of health and health disparities after enrollment in such curricula. In 2016, the authors developed a yearlong required course entitled Cultural Determinants of Health and Health Disparities for first year medical students at a large university medical school in the United States. The course launched in the 2017 academic year.

METHODS

Two cohorts participated in twelve 2.5 to 3-hour multi-modal sessions focused on various aspects of healthcare delivery for marginalized populations and factors that contribute to health disparities. The Multicultural Assessment Questionnaire was used pre and post course to assess students' self-evaluated changes in knowledge, skills, and awareness related to cultural competency in healthcare.

RESULTS

Students' self-reported knowledge, skills, and awareness scores regarding cultural competence in health care increased from pre to post-course assessment. On the knowledge scale, students' mean score increased from 2.63 to 2.97 (P < .001), with 16% reporting a decreased score, 30% reporting no change, and 54% reporting growth. On the skills scale, students' mean score increased from 2.64 to 3.38 (P < .001), with 11% reporting a decreased score, 17% reporting no change, and 72% reporting growth. On the awareness scale, students' overall score increased from 3.76 to 3.97 (P < .05), with 16% reporting a decreased score, 50% reporting no change, and 34% reporting growth. There were no changes in KSA scores across cohorts pre and post course.

CONCLUSION

Perceived knowledge, skills, and awareness related to the importance of cultural competence in healthcare delivery increased at the end of the academic year. This type of longitudinal course model could be broadly adopted at other institutions to enhance patient, peer, and future provider awareness regarding cultural impacts on care and health disparities among vulnerable populations.

The time is now: addressing implicit bias in obstetrics and gynecology education

Obstetrician-gynecologists can improve the learning environment and patient care by addressing implicit bias. Accumulating evidence demonstrates that racial and gender-based discrimination is woven into medical education, formal curricula, patient-provider-trainee interactions in the clinical workspace, and all aspects of learner assessment. Implicit bias negatively affects learners in every space. Strategies to address implicit bias at the individual, interpersonal, institutional, and structural level to improve the well-being of learners and patients are needed. The authors review an approach to addressing implicit bias in obstetrics and gynecology education, which includes: (1) curricular design using an educational framework of antiracism and social justice theories, (2) bias awareness and management pedagogy throughout the curriculum, (3) elimination of stereotypical patient descriptions from syllabi and examination questions, and (4) critical review of epidemiology and evidence-based medicine for underlying assumptions based on discriminatory practices or structural racism that unintentionally reinforce stereotypes and bias. The movement toward competency-based medical education and holistic evaluations may result in decreased bias in learner assessment. Educators may wish to monitor grades and narratives for bias as a form of continuous educational equity improvement. Given that practicing physicians may have little training in this area, faculty development efforts in bias awareness and mitigation strategies may have significant impact on learner well-being.

Why and How Civic Health Should Be Incorporated Into Medical Education

Civic health refers to the ability of a community to organize and collectively address problems that affect the well-being of its members through democratic participation. Civic health should be an integral part of the medical school curriculum because improving a community's civic health shifts the distribution of power toward patients, better enabling them to address social determinants of health that are affecting their well-being. This article details how to effectively integrate civic health curriculum into already-existing medical education frameworks, outlines how these interventions will improve both patient care and the student experience, and addresses barriers that might restrict the implementation. Civic health can be integrated into the didactic curriculum in the form of lunchtime guest lectures, panels with community organizations, and small-group discussions; it can be integrated into experiential curriculum by distributing QR codes to aid in voter registration, organizing voter registration drives, and participating in nonpartisan canvassing. This civic health content can be integrated into existing social justice curricula without massive investment or structural change. Medical students are capable and effective messengers of civic health and can affect change at all levels of training. Notably, because civic health is directly actionable, it can be a source of motivation rather than burnout for medical students. As students develop into medical professionals, the training in civic health improves their understanding of social determinants of health and enables them to play an important role in promoting civic engagement and empowering patients with the democratic tools necessary to enact social change.

Trauma-Informed Acute Care of Patients With Violence-Related Injury

Violently-injured individuals presenting to the emergency department (ED) have an elevated risk of repeat injury after being discharged from acute care settings and a high rate of unaddressed mental health and social needs. While there is a growing body of programmatic interventions to address these needs, including hospital-based violence intervention programs, there is a lack of data regarding physician perspectives of current practice for this patient population. Understanding current practice is critical for integrating new programs into workflow and developing evidence-based medical education to improve care. The aim of this study is to elucidate current trauma-informed care practices of emergency medicine and general surgery trainee physicians to inform future curriculum development surrounding care of violently injured patients. In this study, emergency medicine and surgical trainees with at least one year of residency experience participated in simulation-primed interviews in pairs or small groups. Interviews garnered perspectives on the physician role in treating violently injured youth, using simulation as a priming event focused on previously known patient concerns. Qualitative themes that emerged were participants (1) perceived their role as managing medical/surgical concerns and seek others to build trust and manage psychosocial and legal concerns, (2) had a high level of knowledge of ED stressors and de-escalation strategies, (3) perceived that patient distrust can negatively impact their ability to provide care, and (4) perceived that law enforcement can negatively impact care and are sometimes uncertain about how to interact with law enforcement. These findings support that medical education for providers should focus on medicolegal issues, particularly managing law enforcement presence in the ED, structural and interpersonal causes of distrust of medical providers and the medical system, and addressing postdischarge mental health and social needs.

Beyond Humility: Empowering Minoritized Learners Through Culturally Reflective Medicine

In the wake of the Black Lives Matter and other antiracism justice movements, medical education is evolving to incorporate health equity principles for all medical students and residents, while also increasing institutional diversity recruitment of minoritized physicians. As the demographics of U.S. medical trainees shift to reflect a rapidly evolving patient population, the prevalence of culturally concordant patient-physician visits, where patients share elements of language, religion, customs, and identities with their physician, is also expected to increase. However, existing antiracist curricula are standardized to all learners and there is a dearth of cultural sensitivity training designed specifically for minoritized learners to interrogate the culturally concordant space they share with patients and mentors. In this article, the authors propose a new model for minoritized learners' cultural training, culturally reflective medicine (CRM) that identifies unanticipated tensions that may arise as minoritized learners bridge both White and Eurocentric professional and personal identities, examines how intersectionality can both strengthen encounters and lead to shared blind spots, and empowers minoritized physicians with tools for self- and group reflection to advocate for their communities. CRM is contextualized within the current landscape of cultural sensitivity training in medical education. The authors provide 2 clinical vignettes to demonstrate how CRM can unveil more nuanced understandings of health disparities than existing cultural training. As institutions work toward diversity, equity, justice, and antioppression, CRM provides a novel framework for redesigning medical education that better acknowledges and incorporates the unique knowledge of minoritized learners.

Medical students' knowledge of race-related history reveals areas for improvement in achieving health equity

BACKGROUND

Medical schools have increasingly integrated social justice, anti-racism, and health equity training into their curricula. Yet, no research examines whether medical students understand the complex history of racial injustice. We sought to investigate the relationship between medical students' historical knowledge and their perceptions regarding health equity.

METHODS

Medical students at one large urban medical school self-rated their familiarity and importance of various racially-significant historical events and persons, as well as their agreement with statements regarding health equity, education, and preparedness to act. Descriptive and multivariate analyses were conducted in R.

RESULTS

Of 166 (RR=31.3%) participants, 96% agreed that understanding historical context is necessary in medicine; yet 65% of students could not describe the historical significance of racial events or persons. Only 57% felt that they understood this context, and the same percentage felt other medical students did not. A minority of students felt empowered (40%) or prepared (31%) to take action when they witness racial injustice in healthcare. Multiracial identity was significantly associated with increased knowledge of African American history (p<0.01), and a humanities background was significantly associated with increased knowledge of Latin American history (p=0.017). There was a positive, significant relationship between advocacy statements, such as "I have taken action" (p<0.001) and "I know the roots of racism" (p<0.001) with mean familiarity of historical events.

CONCLUSIONS

This study demonstrates that while students agree that racism has no place in healthcare, there remains a paucity of knowledge regarding many events and figures in the history of American race relations and civil rights, with implications for future physicians' patient care and health equity efforts.

Teaching Health Equity in the Time of COVID-19: a Virtual Look Through the Lens of Structural Racism

INTRODUCTION

In the context of marked health disparities affecting historically marginalized communities, medical schools have an obligation to rapidly scale up COVID-19 education through the lens of structural racism.

AIM

To develop and implement a virtual curriculum on structural racism in a required COVID-19 course for medical students using "just-in-time" training.

SETTING

Academic medical institution during the height of COVID-19 in the spring of 2020.

PARTICIPANTS

Three hundred ninety-three 3^rd and 4^th-year medical students prior to re-entry into clinical care.

PROGRAM DESCRIPTION

Three educational sessions focused on (1) racial health disparities, (2) othering and pandemics, and (3) frameworks to address health inequity. The virtual teaching methods included narrated recorded presentations, reflections, and student-facilitated small group dialogue.

PROGRAM EVALUATION

In matched pre- and post-surveys, participants reported significant changes in their confidence in achieving the learning objectives and high satisfaction with small group peer facilitation.

DISCUSSION

The use of "just-in-time" training exploring the intersection between COVID-19 and structural racism facilitated the delivery of time-relevant and immediately clinically applicable content as students were preparing to re-enter a transformed clinical space. Similar approaches can be employed to adapt to changing healthcare landscapes as academic medical centers strive to build more equitable health systems.

Antiracism in Health Professions Education Through the Lens of the Health Humanities

Racism represents a public health crisis, adversely impacting patient outcomes and health care workplace inclusivity. Dismantling racism requires transforming both racist systems and individual and collective consciousness. Focusing on antiracism in health professions education through the transdisciplinary lens of the health humanities can spur self-reflection, critical thinking, and collaboration among health professions educators and trainees to create more equitable structures of care. This article describes how the health humanities provide a powerful framework for antiracist health professions education. The authors conclude with a snapshot of an existing humanities-based antiracist curriculum, with suggestions to facilitate implementation in other settings.

Structural competency in emergency medical education: A scoping review and operational framework

OBJECTIVES

Existing curricula and recommendations on the incorporation of structural competency and vulnerability into medical education have not provided clear guidance on how best to do so within emergency medicine (EM). The goal of this scoping review and consensus building process was to provide a comprehensive overview of structural competency, link structural competency to educational and patient care outcomes, and identify existing gaps in the literature to inform curricular implementation and future research in EM.

METHODS

A scoping review focused on structural competency and vulnerability following Arksey and O'Malley's six-step framework was performed in concurrence with a multistep consensus process culminating in the 2021 SAEM Consensus Conference. Feedback was incorporated in developing a framework for a national structural competency curriculum in EM.

RESULTS

A literature search identified 291 articles that underwent initial screening. Of these, 51 were determined to be relevant to EM education. The papers consistently conceptualized structural competency as an interdisciplinary framework that requires learners and educators to consider historical power and privilege to develop a professional commitment to justice. However, the papers varied in their operationalization, and no consensus existed on how to observe or measure the effects of structural competency on learners or patients. None of the studies examined the structural constraints of the learners studied.

CONCLUSIONS

Findings emphasize the need for training structurally competent physicians via national structural competency curricula focusing on standardized core competency proficiencies. Moreover, the findings highlight the need to assess the impact of such curricula on patient outcomes and learners' knowledge, attitudes, and clinical care delivery. The framework aims to standardize EM education while highlighting the need for further research in how structural competency interventions would translate to an ED setting and affect patient outcomes and experiences.

Symbolic Solidarity or Virtue Signaling? A Critical Discourse Analysis of the Public Statements Released by Academic Medical Organizations in the Wake of the Killing of George Floyd

PURPOSE

Many academic medical organizations issued statements in response to demand for collective action against racial injustices and police brutality following the murder of George Floyd in May 2020. These statements may offer insight into how medical schools and national organizations were reflecting on and responding to these incidents. The authors sought to empirically examine the initial statements published by academic medical organizations in response to societal concerns about systemic, anti-Black racism.

METHOD

The authors searched for initial public statements released by a sample of academic medical organizations in Canada and the United States between May 25 and August 31, 2020. They assembled an archive with a purposive sample of 45 statements, including those issued by 35 medical schools and 10 national organizations. They analyzed the statements using Fairclough's 3-dimensional framework for critical discourse analysis (descriptive, interpretive, explanatory), which is a qualitative approach to systematically analyzing language and how it reflects and shapes social practice.

RESULTS

Many statements used formal and analytical language and reflected hierarchical thinking and power differentials between statement producers and consumers. The authors identified several tensions in the statements between explicit messaging and implied ideologies (e.g., self-education vs action to address racism), and they found a lack of critical reflection and commitment to institutional accountability to address anti-Black racism in academic medicine. The authors also found that many statements minimized discussions of racism and de-emphasized anti-Black racism as well as portrayed anti-Black racism as outside the institution and institutional accountability.

CONCLUSIONS

This research offers insight into how 45 academic medical organizations initially responded following the murder of George Floyd. Many of these statements included self-exculpatory and nonracist discursive strategies. While these statements may have been well intentioned, organizations must move beyond words to transformative action to abolish institutional racism in academic medicine.

The impact of social determinants of health on the overall wellbeing of children: A review for the pediatric surgeon

Disparities in health care access, quality, and outcomes for pediatric patients, and their relationship to race and socioeconomic status (SES) have been extensively documented. The underlying causes behind such disparities have been less carefully studied, as clinicians and researchers often fail to look past immutable features such as race, into modifiable factors like social determinants of health (SDOH). A child's environment affects their patterns of social engagement, sense of security, and overall well-being. Resources such as affordable housing, access to education, public safety, and availability of healthy foods and safe play spaces impact and enhance quality of life, and have significant influence on both health and health care outcomes. These upstream indicators are often unrecognized or misidentified as health concerns. Few pediatric surgery publications discuss SDOH and their effects on children. This paper aims to introduce the five domains of SDOH (economic stability, education, social and community context, health and healthcare, and neighborhood and built environment) along with strategies to identify and address needs in these domains from a provider, hospital, and health system's perspective. It is anticipated that this information will serve as a foundation for pediatric surgeons to understand and develop processes that ameliorate disparities related to SDOH and improve surgical outcomes and the well-being of all children.

"It Makes Me a Better Person and Doctor": A Qualitative Study of Residents' Perceptions of a Curriculum Addressing Racism

OBJECTIVE

Explore how pediatric residents perceive the impact of a curriculum addressing racism on their knowledge, motivation, skills and behaviors, and investigate the contextual factors that promote or impede the curriculum's effectiveness.

METHODS

Open-ended, semistructured interviews were conducted at 2 academic medical centers between August 2019 and 2020 among pediatric residents who participated in the curriculum. Interviews were recorded, transcribed, and analyzed by using inductive content analysis.

RESULTS

Pediatric residents (n = 16) were predominantly white (66.7%), female (86.7%) interns (60%) from the Midwest (40%). Six major themes emerged describing the perceived impact of the curriculum on: knowledge - (1) Understanding of race and racism as structural forces in a historical context; motivation - (2) Owning the issue of racism, (3) Having the curriculum makes a statement; skills - (4) Critical self-reflection, (5) Perceived development of skills to mitigate biases; and action-planning - (6) Turning insight into strategies to combat racism and improve patient care. Two additional themes emerged describing contextual factors that promoted or impeded the curriculum such as the content of the curriculum itself, the racial demographics of the participants, the implementation infrastructure and environmental factors such as the culture of the training program.

CONCLUSIONS

Medical education addressing racism can facilitate the perceived acquisition of foundational knowledge regarding race and racism; motivation and skill-building to combat racism; and action planning aimed at improving patient care. Contextual factors should be considered when developing and implementing such curricula to not only promote racial equity but avoid unintended harms.

IMPROVing communication about diversity, equity, and inclusion in health professions education

There has never been a stronger call for authenticity in health professions education than this moment in time. The health inequities laid bare by the COVID-19 syndemic (a concept that describes the clustering of SARS-CoV-2 infection and disease by political, social, and economic factors) compels health professions educators to learn how to best engage in, sustain, and deepen conversations on diversity, equity, and inclusion (DEI) within our learning environments. Health professions curricula should address such concerns through explicit faculty training programs in dialogue models of communication. In this commentary, I propose that medical improv can help refocus health professions training to the humanistic values of empathy for others and respect for multiple viewpoints. Medical improv refers to teaching methods that adapt improvisation principles and exercises to enhance professional competencies in the health professions, such as communication. I describe a training series implemented at one institution to prepare faculty facilitators to engage in conversations about DEI in a discussion-based core course on the social determinants of health for first year medical students called "Humanity in Medicine." Key elements of dialogue training, including examinations of identity and positionality, caretaking and team-making, and conversations with a skeptic, are viewed through the lens of improv exercises as a pedagogy in communication. I report on facilitator and medical students' positive response to facilitator training and the Humanity in Medicine course. Potential next steps towards a formal evaluation of the method, and outcomes assessments of the use of improv in health professions training are discussed.

From Race to Racism: Teaching a Tool to Critically Appraise the Use of Race in Medical Research

INTRODUCTION

Despite the ubiquitous use of race within scientific literature, medical trainees are not taught how to critically appraise the use of racial categories. We developed a tool to appraise the use of race in medical literature and a workshop to teach this approach.

METHODS

Third-year medical students and second- and third-year residents participated in workshops between 2015 and 2018. We evaluated our UME workshop with a postworkshop survey. We evaluated our GME workshop with a pretest, immediate posttest, and 6-month posttest on self-assessed knowledge, skills, and use of the Critical Appraisal of Race in Medical Literature (CARMeL) tool in subsequent journal clubs.

RESULTS

We delivered this workshop to 560 students and 82 residents. Of the initial 140-student cohort evaluating the workshop, 99 (71% response rate) highly rated clarity of presentation, quality of teaching, and quality of slides. Of PGY 2 and PGY 3 residents, 67 (82% response rate) rated the workshop greater than 4.5 out of 5 on quality, clarity, and appropriateness of content. Residents had significant improvements in self-assessed knowledge and skills immediately after the session and 6 months later. Of residents, 74% reported using the CARMeL tool in subsequent presentations.

DISCUSSION

We designed the CARMeL tool and a workshop to teach it. Trainees rated this workshop as useful, with the majority of residents later applying the tool. Limitations included a lack of objective assessment of knowledge acquisition. We recommend that institutions invest time in faculty development and pair new faculty with those experienced in anti-oppressive facilitation.

Colonization, cadavers, and color: Considering decolonization of anatomy curricula

Anatomy is a discipline that, despite its universal nature, offers limited diversity in terms of representation in cadavers, imagery, technology, and models used within teaching. The universal move toward inclusive curricula has put anatomy education under the microscope, particularly with respect to efforts to decolonize curricula. This paper considers the challenges and opportunities to diversify the anatomy curriculum. Decolonizing anatomy education curricula will entail addressing the ingrained cultures within the disciplines, such that produces a number of challenges including: underrepresentation of certain bodies, difficulty talking about difference, and the hidden curriculum in anatomy education. In order to aid educators in achieving inclusive anatomy curricula, a toolkit and considerations are presented, alongside both do's, don'ts and case examples. We highlight the black-or-white dichotomy, and the absence of brown in between. The paper is a conversation starter for what it means to begin the process of decolonizing the curriculum within anatomy education.

Using Kern's 6-Step Approach to Integrate Health Systems Science Curricula Into Medical Education

The term "health systems science" (HSS) has recently emerged as a unifying label for competencies in health care delivery and in population and community health. Despite strong evidence that HSS competencies are needed in the current and future health care workforce, heretofore the integration of HSS into medical education has been slow or fragmented-due, in part, to a lack of evidence that these curricula improve education or population outcomes. The recent COVID-19 pandemic and the national reckoning with racial inequities in the United States further highlight the time-sensitive imperative to integrate HSS content across the medical education continuum. While acknowledging challenges, the authors highlight the unique opportunities inherent in an HSS curriculum and present an elaborated curricular framework for incorporating health care delivery and population health into undergraduate medical education. This framework includes competencies previously left out of medical education, increases the scope of faculty development, and allows for evidence of effectiveness beyond traditional learner-centric metrics. The authors apply a widely adopted 6-step approach to curriculum development to address the unique challenges of incorporating HSS. Two examples-of a module on quality improvement (health care delivery) and of an introductory course on health equity (population and community health)-illustrate how the 6-step approach can be used to build HSS curricula. The Supplemental Digital Appendix (at http://links.lww.com/ACADMED/B106) outlines this approach and provides specific examples and resources. Adapting these resources within local environments to build HSS curricula will allow medical educators to ensure future graduates have the expertise and commitment necessary to effect health systems change and to advocate for their communities, while also building the much-needed evidence for such curricula.

An analysis of social determinants of health and structural competency training in global emergency medicine fellowship programs in the United States

BACKGROUND

Clinicians must be aware of the structural forces that affect their patients to appropriately address their unique health care needs. This study aimed to assess the participation of global emergency medicine (GEM) fellowship programs in formal social determinants of health (SDH) and structural competency (SC) training to evaluate the existence and procedures of such programs.

METHODS

A cross-sectional study conducted with a short, online survey with questions regarding the presence of curriculum focused on SDH, SC, educational metrics, and the desire for further formal training in this domain was sent to all 25 GEM fellowship directors through the Global Emergency Medicine Fellowship Consortium (GEMFC) email listserv.

RESULTS

Eighty percent (20/25) of GEM fellowship directors responded to the survey. All (20/20) of participating fellowship programs included SDH and SC training in their didactic curriculum, and eight of 20 (40%) programs offered similar training for faculty. Additionally, 19 of 20 (95%) of respondents indicated interest in an open-source tool for emergency medicine (EM) fellowship training in SDH and SC.

CONCLUSIONS

While multiple GEM programs offer formal training on SDH and SC, gaps exist regarding similar training for faculty. Additionally, there is a lack of metrics to determine fellows' comfort with the content of this training. As a majority of GEMFC programs requested, an open-source tool would allow a uniform curriculum and measurement of EM fellowship training in SDH and SC.

Professionalism revisited during the pandemics of our time: COVID-19 and racism

In this article the authors review the current-day definition of professionalism through the lens of the two ongoing pandemics: COVID-19 and racism. The pandemics have led to contemporary practice-related questions, such as: does professionalism entail that health care providers (HCP) be compelled to treat patients without PPE or if patients refuse to wear masks? And what role do HCP play in society when confronted with glaring health disparities and police brutality? The authors propose using care ethics as a theory to view professionalism, as it takes into account broadly encompassing relationships between HCP and society, history and context. Professionalism viewed through a care ethics lens would require professionalism definitions to be expanded to allow for interventions, i.e., not just refrain from doing harm but actively interfere or take action if wrong is being witnessed. Principles related to the primacy of patient welfare need to be re-addressed to prevent systematic self-sacrifice which results in harm to HCP and burnout. Mature care should be a characteristic of professionalism ensuring that HCP care for the sick but be practically wise, highlighting the importance of balancing too little and too much care for self and others. Professionalism needs to be viewed as a bi-directional relational exchange, with society demonstrating solidarity with those providing care. Additionally, given the scale of health disparities, simply stating that HCP need to work towards social justice oversimplifies the problem. Professionalism needs to encompass incorporating critical action and critical pedagogy into health care training and the health care profession to demonstrate solidarity with those impacted by racism.

Seeing the Window, Finding the Spider: Applying Critical Race Theory to Medical Education to Make Up Where Biomedical Models and Social Determinants of Health Curricula Fall Short

A professional and moral medical education should equip trainees with the knowledge and skills necessary to effectively advance health equity. In this Perspective, we argue that critical theoretical frameworks should be taught to physicians so they can interrogate structural sources of racial inequities and achieve this goal. We begin by elucidating the shortcomings in the pedagogic approaches contemporary Biomedical and Social Determinants of Health (SDOH) curricula use in their discussion of health disparities. In particular, current medical pedagogy lacks self-reflexivity; encodes social identities like race and gender as essential risk factors; neglects to examine root causes of health inequity; and fails to teach learners how to challenge injustice. In contrast, we argue that Critical Race Theory (CRT) is a theoretical framework uniquely adept at addressing these concerns. It offers needed interdisciplinary perspectives that teach learners how to abolish biological racism; leverage historical contexts of oppression to inform interventions; center the scholarship of the marginalized; and understand the institutional mechanisms and ubiquity of racism. In sum, CRT does what biomedical and SDOH curricula cannot: rigorously teach physician trainees how to combat health inequity. In this essay, we demonstrate how the theoretical paradigms operationalized in discussions of health injustice affect the ability of learners to confront health inequity. We expound on CRT tenets, discuss their application to medical pedagogy, and provide an in-depth case study to ground our major argument that theory matters. We introduce MedCRT: a CRT-based framework for medical education, and advocate for its implementation into physician training.

Integrating equity and social justice for indigenous peoples in undergraduate health professions education in Canada: a framework from a critical review of literature

Understanding how to create structural change by actively counteracting racialized ways of interacting with Indigenous peoples at an individual and organizational level within health care systems and health professions education is essential for creating a more inclusive, equitable, and healthier society. In health professions education, the primary means of teaching about health inequities has been to frame them as stemming from culturally or ethnically based issues. While attention to culturally specific practices can be valuable to health and healing in some contexts, education that solely focuses on Indigenous cultures risks perpetuating cultural stereotypes and othering, rather than focusing on how Eurocentric systems continue to exert oppressive effects on Indigenous peoples. We present an organizational transformation framework grounded in equitable partnerships from a comprehensive critical review of the literature on the integration of equity and social justice in undergraduate health professions education with a focus on Indigenous health. We did a thematic analysis of the results and discussions presented in the 26 selected articles to identify promising practices and challenges associated with the integration of equity and social justice in undergraduate health professions education. The framework resulting from this analysis is composed of three interrelated components: 1) adopt critical pedagogical approaches that promote Indigenous epistemologies; 2) partner with Indigenous students, educators and communities; 3) engage educators in critical pedagogical approaches and health equity issues. This framework could guide the development of contextually tailored interventions that contribute to decolonizing health professions education.

What's race got to do with it? A proposed framework to address racism's impacts on child and adolescent mental health in Canada

This commentary responds to current events that have highlighted the ways that systemic racism affects a wide variety of health outcomes. We specifically discuss how systemic racism adversely affects the mental health of children and adolescents in a Canadian context and use a structural framework to demonstrate how race is embedded in various Canadian systems and thus affects child and adolescent mental health in both conscious and unconscious ways throughout the lifespan. Experiences of systemic racism affect the mental health of Canadian young people in multiple complex and intersecting ways including access to care, experience of mental health services, and outcomes of care. We currently lack a national best practice framework for mental health professionals that unifies approaches to research, education, and clinical care for young racialized Canadians; in addition, concerted efforts to collect race-based data are lacking. We suggest that a blueprint for improved services for racialized young people in Canada would include: Development of a funded and sustainable research agenda responsive to community expertise, development and implementation of a Canadian Child and Adolescent task force focused on educational strategies on racism and service provision at both the postgraduate and continuing professional development (CPD) levels, and consideration of clinical parameters that improve access to, and experience of, care for Canadian racialized youth.

Rapid transition of a preclinical health systems science and social justice course to remote learning in the time of coronavirus

As the coronavirus pandemic started, we rapidly transitioned a preclinical social justice and health systems sciences course at our medical school to asynchronous, remote learning. We describe processes, curricular innovations, and lessons learned. Small groups were converted into independent learning modules and lectures were given live via videoconferencing technology. We started with a simplified approach and then built technological capabilities over time. Current events were incorporated into curriculum and assessment. Our course ran from 16 March-3 April 2020 for the 155-person first-year class. Student attendance for optional, synchronous remote sessions was higher than in-person attendance in previous years. Completion rates for assignments were high but with minimal student collaboration. Faculty office hours were underutilized. Focus group and formal evaluations were largely positive, with numerical ratings for quality of the course and faculty teaching higher than the 2 years prior. Student engagement with social justice topics in aremote format was successful through modifications to small groups and lecture structure. Students, faculty, and administrative staff appreciated the consistency of session format throughout the course. Students exam performance was similar to prior years. Attention should be paid to what can be learned via self-study as opposed to small group learning. Better methods of soliciting real-time student feedback, and encouraging engagement with each other and with faculty in aremote environment are needed.

Interrupting Microaggressions in Health Care Settings: A Guide for Teaching Medical Students

INTRODUCTION

Microaggressions are connected to broader conceptualizations of the impact of implicit bias and systems of inequity. The body of evidence supporting the need for more-open discussions in medical education about race, racism, and their impact on health disparities continues to grow. Some have advocated for the importance of bringing anti-racist pedagogy into medical education curricula, which involves explicitly attempting to move beyond people's comfort zones and acknowledging that discomfort can be a catalyst for growth. To discuss the intent and impact of microaggressions in health care settings and how we might go about responding to them, we developed a workshop for third-year undergraduate medical students within a longitudinal undergraduate medical education diversity and inclusion curriculum.

METHODS

This workshop occurred during a regularly scheduled clerkship intersession during the 2016-2017 academic year for third-year undergraduate medical students (N = 154). Prior to the workshop, the students were asked to anonymously submit critical incident reports on any microaggressions experienced or witnessed to develop case studies for problem-based learning. Teaching modalities included lecture, problem-based learning with case studies, pair and share, and facilitated small- and large-group debriefs.

RESULTS

The session was evaluated using a 4-point Likert scale to assess students' comfort in learning about the information presented. Ninety-eight percent felt confident in identifying microaggressions, and 85% felt confident in interrupting microaggressions when they occur.

DISCUSSION

This personalized workshop exposes students to microaggressions personally experienced by colleagues with an attempt to interrupt them using empathy, awareness, and communication techniques.

Empowering future physicians to advocate for health equity: A blueprint for a longitudinal thread in undergraduate medical education

In light of a growing body of evidence demonstrating pervasive health disparities, medical schools are increasingly incorporating educational programs on social medicine in undergraduate and graduate medical curricula. In 2015, we significantly restructured the cultural competency instruction for medical students at our institution, focusing on achieving greater health equity through caring for vulnerable populations and acknowledging and addressing bias and stereotyping. In order to facilitate educational sustainability while students were immersed in clinical care, a key element of our approach included extending teaching into the clerkship year. The resulting longitudinal thread, Health Equity and Social Justice, empowers future physicians with the knowledge and skills to work towards greater health equity. This article discusses the lessons learned in the implementation of this novel educational program. Our approach can serve as a model for other institutions considering similar instructional reform.

Professionalism: The Wrong Tool to Solve the Right Problem?

Medical schools and other higher education institutions across the United States are grappling with how to respond to racism on and off campus. Institutions and their faculty, administrators, and staff have examined their policies and practices, missions, curricula, and the representation of racial and ethnic minority groups among faculty, staff, and students. In addition, student-led groups, such as White Coats for Black Lives, have emerged to critically evaluate medical school curricula and advocate for change. Another approach to addressing racism has been a focus on the role of professionalism, which has been variably defined as values, traits, behaviors, morality, humanism, a role, an identity, and even a social contract.In this article, the authors consider the potential role that professionalism might play in responding to racism in medical education and at medical schools. They identify 3 concerns central to this idea. The first concern is differing definitions of what the problem being addressed really is. Is it isolated racist acts or institutional racism that is a reflection of white supremacy? The second concern is the notion that professionalism may be used as a tool of social control to maintain the interests of the social groups that dominate medicine. The third concern is that an overly simplistic application of professionalism, regardless of how the problem of racism is defined, may result in trainees practicing professionalism that is performative rather than internally motivated. The authors conclude that professionalism may complement a more systematic and holistic approach to addressing racism and white supremacy in medical education, but it is an insufficient stand-alone tool to address this core problem.

"It's hard to speak up": Lessons learned from engaging U.S. white college men in conversations on racism

Objective: This position paper draws on findings from the Straight White College Men Project, a qualitative study with heterosexual white college male participants across college campuses in the United States. The purpose of the larger project was to explore and understand how participants perceived institutional and community diversity issues; how they conceptualized their own privileges; and how they articulated their own responsibility to engage in social change. Thus, this paper delivers "lessons learned" from engaging white men in conversations on racism and to provide recommendations for medical educators in the U.S. and in Europe. Methods: Following purposeful sampling methods using expert nominators, data were collected in phenomenological focus groups at 10 U.S. 4-year universities. Focus groups included 3 to 8 participants and were 60 to 90 minutes in length. Analysis included open and axial coding and two themes emerged from a single question focusing on students' potential dissent of racist family or peer comments. Results: Participants struggled articulating how and in what contexts they would challenge family members or friends on inappropriate language or behavior. Reasons for their reticence included struggling to confront parents, not wanting to ruin male friendships, or jeopardizing being ousted by the male peer group. Conclusion: Educators must find ways to help male university students explore their privileges and proclivity to engage in oppressive behaviors. Men also need to understand how their inactions perpetuate systemic oppression and create environments in which minoritized individuals cannot thrive. Recommendations for medical school educators are provided.

Police Brutality and Mistrust in Medical Institutions

BACKGROUND

People bring the social contexts of their lives into the medical encounter. As a social determinant of health, police brutality influences physical and mental health. However, negative experiences with institutions such as law enforcement might decrease trust in other institutions, including medical institutions. Mistrust might limit engagement with the healthcare system and affect population health. This study investigates the relationship between police brutality and medical mistrust and assesses whether it varies by race.

BASIC PROCEDURES

Data were obtained from a 2018 cross-sectional survey of adults living in urban areas in the USA (N = 4389). Medical mistrust was regressed on police brutality (experiences and appraisal of negative encounters with the police), controlling for socio-demographics, health status, and healthcare access. Means of mistrust were predicted by racial group after including interactions between police brutality and race.

MAIN FINDINGS

Respondents who had negative encounters with the police, even if they perceived these encounters to be necessary, had higher levels of medical mistrust compared to those with no negative police encounters. Police brutality increased mistrust for all racial groups.

PRINCIPAL CONCLUSIONS

Conditions outside the medical system such as experiencing police brutality impact relationships with the medical system. Given that clinicians are in a unique position of having access to firsthand information about the struggles and injustices that shape their patients' health, advocating for systemic change on behalf of their patients might build trust.

Health Equity Rounds: An Interdisciplinary Case Conference to Address Implicit Bias and Structural Racism for Faculty and Trainees

INTRODUCTION

The medical community recognizes the importance of confronting structural racism and implicit bias to address health inequities. Several curricula aimed at teaching trainees about these issues are described in the literature. However, few curricula exist that engage faculty members as learners rather than teachers of these topics or target interdisciplinary audiences.

METHODS

We developed a longitudinal case conference curriculum called Health Equity Rounds (HER) to discuss and address the impact of structural racism and implicit bias on patient care. The curriculum engaged participants across training levels and disciplines on these topics utilizing case-based discussion, evidence-based exercises, and two relevant conceptual frameworks. It was delivered quarterly as part of a departmental case conference series. We evaluated HER's feasibility and acceptability by tracking conference attendance and administering postconference surveys. We analyzed quantitative survey data using descriptive statistics and qualitatively reviewed free-text comments.

RESULTS

We delivered seven 1-hour HER conferences at our institution from June 2016 to June 2018. A mean of 66 participants attended each HER. Most survey respondents (88% or more) indicated that HER promoted personal reflection on implicit bias, and 75% or more indicated that HER would impact their clinical practice.

DISCUSSION

HER provided a unique forum for practitioners across training levels to address structural racism and implicit bias. Our aim in dissemination is to provide meaningful tools for others to adapt at their own institutions, recognizing that HER should serve as a component of larger, multifaceted efforts to decrease structural racism and implicit bias in health care.

Twelve tips for responding to microaggressions and overt discrimination: When the patient offends the learner

Microaggressions and expressions of overt discrimination negatively affect the experience of medical trainees at all levels. Mistreatment of trainees, including abusive and discriminatory behavior by patients and families, occurs commonly and is receiving increased attention in both the medical literature and popular press. Heightened awareness of the problem has sparked a call to engage in substantive conversations about bias in health professions education. The emphasis on direct observation in medical education makes the bedside a common setting for educators to witness these behaviors firsthand. Many educators are committed to developing a positive climate for learners but lack the training and skills to facilitate discussions about discrimination. As a result, these difficult but important conversations may not occur. The authors present a three-phase approach to responding to microaggressions and discrimination toward trainees from patients, and offer a communication toolkit that frontline medical educators can use in their daily practice.

A Matter of Trust

Trust is a fundamental tenet of the patient-physician relationship and is central to providing person-centered care. Because trust is profoundly relational and social, building trust requires navigation around issues of power, perceptions of competence, and the pervasive influence of unconscious bias-processes that are inherently complex and challenging for learners, even under the best of circumstances. The authors examine several of these challenges related to building trust in the patient-physician relationship. They also explore trust in the student-teacher relationship. In an era of competency-based medical education, a learner has the additional duty to be perceived as "entrustable" to 2 parties: the patient and the preceptor. Dialogue, a relational form of communication, can provide a framework for the development of trust. By engaging people as individuals in understanding each other's perspectives, values, and goals, dialogue ultimately strengthens the patient-physician relationship. In promoting a sense of agency in the learner, dialogue also strengthens the student-teacher relationship by fostering trust in oneself through development of a voice of one's own.

Social justice and the medical librarian

This lecture discusses social justice and the role that medical librarians can play in a democratic society. Social justice needs to be central to the mission of medical librarianship and a core value of the profession. Medical librarians must develop a new professional orientation: one that focuses on cultural awareness or cultural consciousness that goes beyond ourselves and our collections to that which focuses on the users of our libraries. We must develop a commitment to addressing the issues of societal, relevant health information. Using examples from medical education, this lecture makes the case for social justice librarianship. This lecture also presents a pathway for social justice medical librarianship, identifies fundamental roles and activities in these areas, and offers strategies for individual librarians, the Medical Library Association, and library schools for developing social justice education and outcomes. The lecture advocates for an understanding of and connection to social justice responsibilities for the medical library profession and ends with a call to go beyond understanding to action.

The lecture emphasizes the lack of diversity in our profession and the importance of diversity and inclusion for achieving social justice. The lecture presents specific examples from some medical libraries to extend the social justice mindset and to direct outreach, collections, archives, and special collection services to expose previously hidden voices. If medical librarians are to remain relevant in the future, we must act to address the lack of diversity in our profession and use our information resources, spaces, and expertise to solve the relevant societal issues of today.

Addressing Race, Culture, and Structural Inequality in Medical Education: A Guide for Revising Teaching Cases

PROBLEM

Sociodemographic identities, including race, culture, ethnicity, gender, and sexual orientation (race and culture), are recognized as important determinants of health, with significant impacts on patients' health outcomes, but teaching medical students about this is challenging. The authors sought to identify areas for improvement in delivery of critical content about race, culture, structural inequalities, and health disparities within a set of virtual patient cases used by U.S. medical schools and develop revision guidelines.

APPROACH

A workgroup (medical students and faculty) conducted a literature review in 2017 to identify challenges and best practices for teaching and learning about race and culture in medicine. Using an analytic framework informed by this review, they analyzed 63 Aquifer virtual patient teaching cases for effectiveness of the presentation of race and culture, resulting in six main themes describing common mistakes or pitfalls. They then developed an evidence-based guide for systematic case revision.

OUTCOMES

The authors present a novel, practical guide for medical educators to use to revise existing teaching cases and improve the delivery of critical concepts surrounding race and culture. This guide includes fundamental definitions and six sections to guide structured case revision based on the main themes. It includes examples of language, suggested edits, and the rationale and evidence for recommendations.

NEXT STEPS

Feedback from faculty and students regarding implementation of the guide and delivery of revised content in Aquifer cases will be critical in determining the guide's effectiveness. This structured guide may be adapted to a variety of teaching modalities in medicine.

Facilitating community connections among people with mental illnesses: Perspectives from grassroots community leaders

We conducted focus groups comprising 20 grassroots community leaders to identify social and structural elements that affect community engagement among people with serious mental illnesses. Community leaders not affiliated with mental health systems have been mostly left out of the discussions about inclusion and engagement, even though they possess unique information about the places where they live and can be essential partners in making community connections. The findings from the focus groups point to elements that both facilitate and inhibit connections, as well as roles community mental health practitioners may take on, to engage with community leaders and people with mental illness to minimize barriers and foster connections in community settings. Additionally, the focus groups elucidated the interplay between the right to be a member of one's community and a community's responsibility to create a welcoming environment. The current study garnered information regarding the broader needs and implications of community connections, as well as some specific suggestions to enhance community engagement among people with serious mental illness. Hesitation and stigma around engaging individuals with mental illnesses were identified as barriers to inclusion. Further study about how community leaders and groups may be involved in facilitating meaningful community connections is recommended.

Applying feminist theory to medical education

To adequately address gendered issues of sexual harassment, wage gaps, and leadership inequities, medical institutions must interrogate medical education. Feminist theories can help to understand how power operates within our classrooms and at the bedside. This scoping review maps the four main ways in which feminist theory has been applied to medical education and medical education research-namely, critical appraisal of what is taught in medical curricula; exploration of the experiences of women in medical training; informing pedagogical approaches to how medicine is taught; and finally, medical education research, determining both areas of inquiry and methodologies. Feminist theory has the potential to move clinicians and educators from theory to action, building bridges of solidarity between the medical profession and the community it is called to serve.

Structural competency in emergency medicine services for transgender and gender non-conforming patients

In this formative qualitative research, we draw upon the concepts of structural vulnerability and structural competency to examine how transgender and gender non-conforming (TGGNC) patients and healthcare personnel experience service delivery in Emergency Departments (EDs), and how this experience can be improved upon. Between October 2016 and June 2017, we undertook 31 semi-structured interviews with TGGNC patients (n = 11) and physicians (n = 6), nurses (n = 7), and non-clinical staff (n = 7) in four community-based EDs in New Mexico. Our iterative coding and analysis process resulted in eight sets of findings: (1) reasons why TGGNC patients seek care from EDs; (2) perceptions about and experiences of TGGNC patients; (3) relevance of gender identity and sex at birth; (4) bureaucracy and communication; (5) spatial considerations; (6) preparing providers and staff to care for TGGNC patients; (7) the lack of resources for structural prescriptions; and (8) respect, humanity, and sameness. Findings suggest that structural issues adversely impact the health and wellbeing of TGGNC patients and service-delivery practices in the ED. We describe study implications for training ED personnel and modifying this practice setting to prevent delayed care and ensure appropriate services for TGGNC patients in need of structurally competent emergency medicine.

Dialogues on the Threshold: Dialogical Learning for Humanism and Justice

Given the constant pressures of overflowing clinics, hospital wards, and emergency departments; shortened duty hours; and increased accreditation requirements, overburdened clinician teachers ask, "How does one teach for humanism and justice?" How does one step away-even momentarily-and focus teaching on the individual in front of us, the person who requires our attention and care? This approach must not only involve content (the patient's perspective of illness, social context, and life story) but also must be tightly linked with the ways in which these lessons in living are learned and taught. In this article, the authors propose recognition and use of a style of communication that is already implicitly present in clinical conversations and that is uniquely capable of stimulating reflection on the human dimensions of medicine: that of dialogue.Dialogue involves committing one's whole self to communicative exchange and emphasizes interpersonal relationships and trust. Its result is often not a specific answer; rather, it is enhanced understanding through the generation of new questions and possibilities and action in implementing solutions. It requires a reorientation of the teacher-learner relationship from top-down to one of open exchange and shared authority and responsibility. In the context of professional identity development, these conversations become dialogues on the threshold of transformative change. Through an exploration of dialogical teaching, the authors envision clinical education as constantly stepping in and out of goal-oriented discussions and reflective dialogues, all with the overall goal to educate physicians who practice with excellence, compassion, and justice.

The Clinical Examination and Socially At-Risk Populations: The Examination Matters for Health Disparities

Data from the United States show that persons from low socioeconomic backgrounds, those who are socially isolated, belong to racial or ethnic minority groups, or identify as lesbian, gay, bisexual, or transgender experience health disparities at a higher rate. Clinicians must transition from a biomedical to a biopsychosocial framework within the clinical examination to better address social determinants of health that contribute to health disparities. We review the characteristics of successful patient-clinician interactions. We describe strategies for relationship-centered care within routine encounters. Our goal is to train clinicians to mitigate differences and reduce disparities in health care delivery.