Integrating Theory, Content, and Method to Foster Critical Consciousness in Medical Students: A Comprehensive Model for Cultural Competence Training

Twelve tips for teaching culturally and socially responsive care to medical students

In recent years, discourse on topics like cultural humility, social determinants of health (SDOH), and health disparities and inequities has greatly increased in medical education as attention to their impact on health has magnified. Unfortunately, traditional medical education models may fail to optimize learning in this area. To address these complex social health issues, we must find innovative ways to engage students in an educational partnership in which they are challenged to critically think and reflect on their attitudes, role, and actions in health equity and culturally responsive care. Through reviews of existing literature coupled with our own experience with iterative implementation of a model that includes interpersonal engagement paired with individual self-directed learning, we assembled 12 tips on how to prepare diverse students to practice lifelong cultural humility and provide culturally and socially responsive care in an ever-changing social landscape.

Exploring the implicit meanings of 'cultural diversity': a critical conceptual analysis of commonly used approaches in medical education

Existing approaches to cultural diversity in medical education may be implicitly based on different conceptualisations of culture. Research has demonstrated that such interpretations matter to practices and people concerned. We therefore sought to identify the different conceptualisations espoused by these approaches and investigated their implications for education. We critically reviewed 52 articles from eight top medical education journals and subjected these to a conceptual analysis. Via open coding, we looked for references to approaches, their objectives, implicit notions of culture, and to implementation practices. We iteratively developed themes from the collected findings. We identified several approaches to cultural diversity teaching that used four different ways to conceptualise cultural diversity: culture as 'fixed patient characteristic', as 'multiple fixed characteristics', as 'dynamic outcome impacting social interactions', and as 'power dynamics'. We discussed the assumptions underlying these different notions, and reflected upon limitations and implications for educational practice. The notion of 'cultural diversity' challenges learners' communication skills, touches upon inherent inequalities and impacts how the field constructs knowledge. This study adds insights into how inherent inequalities in biomedical knowledge construction are rooted in methodological, ontological, and epistemological principles. Although these insights carry laborious implications for educational implementation, educators can learn from first initiatives, such as: standardly include information on patients' multiple identities and lived experiences in case descriptions, stimulate more reflection on teachers' and students' own values and hierarchical position, acknowledge Western epistemological hegemony, explicitly include literature from diverse sources, and monitor diversity-integrated topics in the curriculum.

Experiential Learning as a Path to Critical Consciousness in the Medical Curriculum: A Qualitative Study

OBJECTIVES

Clinical settings are increasingly focused on addressing patients' social needs, thus medical education must prepare future clinicians for this task. Critical consciousness, an awareness that puts health within a broader social, historical, and cultural context, could help shape students' understanding of patient social needs. Our paper explores how experiential learning through participation in a social care intervention deepened students' critical consciousness, or their understanding of the systems and structures that make it difficult for patients to meet their basic needs.

METHODS

We conducted one-on-one semistructured interviews with all 24 students who served as advocates for the intervention. Of the 24 advocates, 75% (n = 18) were first-year medical students, 17% (n = 4) were public health students, and 8% (n = 2) were social work students. Interviews were audiorecorded, transcribed verbatim, and analyzed using framework analysis.

RESULTS

We identified themes informed by critical consciousness, including individual (assumptions and biases), interpersonal (communication and relationship), and structural (organization and power) factors. Within these categories, advocates expressed deeper self-awareness of personal biases (individual), the importance of interpersonal communication to build trust with caregivers (interpersonal), and the identification of the structural factors that influence health, such as housing conditions (structural). The advocates highlighted the importance of experiential learning to help them understand social determinants of health. By witnessing multiple patients experiencing social needs, advocates saw the cascading effects of social needs, the structures that make it difficult to meet basic needs, and the effect on health and healthcare behavior.

CONCLUSION

Students engaged in the intervention demonstrated the development of critical consciousness. Although limited, our findings suggest that when students engage with patients around social needs, students can better understand the broader social context of patients' lives. Experiential learning through social care interventions may have the potential to influence critical consciousness development and shape the practice of future clinicians.

The impact of a student-led anti-racism programme on medical students' perceptions and awareness of racial bias in medicine and confidence to advocate against racism

INTRODUCTION

Systemic racism impacts personal and community health; however, education regarding its role in perpetuating healthcare inequity remains limited in medical curricula. This study implemented and evaluated the impact of a student-led anti-racism programme on medical students' perceptions of racial bias in medicine, awareness of, and confidence to advocate against racism in medicine.

METHOD

A total of 543 early stage medical students were invited to participate in the programme. Participants were assigned readings and videos exploring racial injustice in medicine and attended a virtual small-group discussion facilitated by faculty and students. Online surveys were used to collect pre- and post-programme data using Likert scales for response items. Open-ended questions were independently reviewed by three authors using reflexive thematic analysis.

RESULTS

Sixty-three early-stage medical students enrolled in the programme, of which 42 completed the pre-programme survey. There was a 76% (n = 32) response rate for the post-programme survey. The majority of students (60%, n = 25) had no previous education about racism in medicine. From pre- to post-programme, there was a significant change in students' perceived definition of race from genetic, biological, geographical, and cultural factors to socio-political factors (P < 0.0001). Significant increases in almost all factors assessing student awareness of racism and confidence to advocate against racism were observed. Student-identified barriers to discussing racism included lack of education and lived experience, fear of starting conflict and offending others. All survey respondents would recommend this programme to peers and 69% (n = 32) engaged in further topical self-directed education.

CONCLUSION

This simple and reproducible programme improved awareness and confidence to advocate against racism in medicine and resulted in a change in opinion regarding race-based medical practice. These findings are in line with best practice towards addressing racial bias in medicine, decolonizing medical curricula and strengthening anti-racism teaching of future physicians.

Moving towards social dentistry: How do dentists perceive the Montreal-Toulouse model?

OBJECTIVES

This study aimed to understand the perspectives of dentists towards the Montreal-Toulouse model, an innovative approach that encompasses person-centredness and social dentistry. This model invites dentists to take three types of actions (understanding, decision-making, intervening) on three overlapping levels (individual, community, societal). This study aimed to understand (a) How dentists perceived the Montreal-Toulouse model as a framework for the practice of dentistry and (b) What parts of this model they were ready to adopt in their own practice.

METHODS

A qualitative descriptive study was conducted based on semi-structured interviews with a sample of dentists in the Province of Quebec, Canada. A combination of maximum variation and snowball sampling strategies was employed and 14 information-rich participants were recruited. The interviews were conducted and audio-recorded through Zoom and lasted approximately 1 h and a half. The interviews were transcribed verbatim and thematically analysed through a combination of inductive and deductive coding.

RESULTS

The participants explained they valued person-centred care and tried to put the individual level of the Montreal-Toulouse model into practice. However, they expressed little interest in the social dentistry aspects of the model. They acknowledged not knowing how to organize and conduct upstream interventions and were not comfortable with social and political activism. According to them, advocating for better health-related policies, while a noble act, 'was not their job'. They also highlighted the structural challenges that dentists face in fostering biopsychosocial approaches such as the Montreal-Toulouse model.

CONCLUSIONS

To promote the Montreal-Toulouse model and empower dentists to address social determinants of health, an educational and organizational 'paradigm shift' towards social accountability might be necessary. Such a shift requires curricular modifications and reconsidering traditional teaching approaches in dental schools. Moreover, dentistry's professional organization could facilitate dentists' upstream actions through proper resource allocation and openness to collaboration with them.

A cancer disparities curriculum in a hematology/oncology fellowship program

BACKGROUND

After George Floyd's murder in 2020, the Center for Disease Control and Prevention (CDC) called systemic racism a public health crisis. This health crisis is connected to the already-documented racial and socioeconomic disparities in cancer care. Ensuring hematologists and oncologists are aware of these disparities through their medical education can help to address these disparities.

METHODS

The authors implemented a healthcare disparities-focused curriculum in a Hematology/Oncology fellowship program during the 2020-2021 academic year at The Ohio State University Hematology/Oncology Fellowship Program. They implemented a pre- and post- survey to evaluate the efficacy of the program.

RESULTS

Fifteen fellows completed the pre-curriculum survey and 14 completed the post-survey. Before the curriculum, 12 fellows (80%) noted a "Fair" or "Good" understanding of healthcare disparities, and 6 (40%) had a "Fair" understanding of disparities in clinical trials and access to novel therapies. Fourteen fellows (93.3%) had not previously participated in a research project focused on identifying or overcoming healthcare disparities. After the curriculum, 12 (85%) fellows strongly agreed or agreed that the information presented in the curriculum was useful for training as a hematologist/oncologist. Twelve fellows (85%) noted "Agree" or "Strongly Agree" that the information presented was relevant to their practice. Eleven fellows (92%) noted that they plan to incorporate healthcare disparities into a future research or clinical project. The majority of fellows, 11 (79%) recommended that the fellowship program continue to have a formal health disparities curriculum in the future.

DISCUSSION/CONCLUSION

There is utility in incorporating cancer disparities education into a hematology/oncology academic curriculum. We recommend further analysis of such curricula to improve fellowship education and patient outcomes with these interventions.

A Freirean liberatory perspective of community colleges education: critical consciousness and social justice science issues in the biology curriculum

This paper discusses the value of a Freirean liberatory perspective in community colleges, countering the traditional "second chance" or "social reproduction" viewpoints attributed by scholars to the education offered in these institutions, emphasizing its vital need in science and healthcare careers education. I explore the potential of this perspective by providing illustrative examples from a biology course incorporating social justice science issues in the curriculum to examine their relationship in cultivating students' critical consciousness at a community college with a programmatic emphasis on healthcare professions.

Improvisational and Standup Comedy, Graphic Medicine, and Theatre of the Oppressed to Teach Advancing Health Equity

Ninety-minute virtual workshops that used improvisational comedy, standup comedy, graphic medicine, and Theatre of the Oppressed were implemented in 2020 within a required health equity course at the University of Chicago Pritzker School of Medicine to train 90 first-year medical students in advancing health equity. Learning objectives were to (1) deepen understanding of diverse human experiences by developing relationship skills, such as empathy, active listening, engagement, and observation; (2) recognize how diverse patients perceive students and how students perceive them to gain insight into one's identity and how intersectional systems of oppression can stigmatize and marginalize different identities; and (3) engage in free, frank, fearless, and safe conversations about structural racism, colonialism, White and other social privileges, and systemic factors that lead to health inequities. With a 61% (109/180 [90 students × 2 workshops per student]) survey response rate, 72% of respondents thought workshops were very good or excellent, and 83% agreed or strongly agreed they would recommend workshops to others. Key recommendations are to (1) incorporate experiential storytelling and discussion; (2) define clear learning goals for each workshop, map exercises to these goals, and explain their relevance to students; and (3) create a safe, courageous, brave space for exploration and discussion. For health equity, transformation happens as students share their perspectives of curriculum content from their intersectional identities, experiences, and varied privileges; are challenged by others' perspectives; and attempt to understand how others can experience the same content differently. The arts create a powerful form of sharing beyond routine conversations or discussions, which is critical for honest dialogue on difficult topics, such as racism, homophobia, and White privilege and other social privileges. Educators should enable students to have the space, time, and courage to share their true perspectives and engage in authentic discussions that may be uncomfortable but transformative.

Preparing Medical Students to Address Health Disparities Through Longitudinally Integrated Social Justice Curricula: A Systematic Review

PURPOSE

The education of health care professionals is a contributing factor to persistent health disparities. Although medical students are expected to understand racism, classism, and other social and structural drivers of health (SDH), standardization and best practices for teaching these concepts are lacking. Some medical schools are adopting social justice curricula (SJC) that prioritize health equity in teaching students to recognize SDH and preparing them to address the consequent health disparities. This systematic review sought to evaluate how these schools have integrated SJC into their core teaching; the criteria they have used to measure success and to what extent these criteria are met; and best practices in planning, implementing, and evaluating SJC.

METHOD

The authors searched 7 databases for English-language studies published between January 2000 and April 2020, reporting on longitudinally integrated SJC at U.S. medical schools intended for all students. Quantitative and qualitative outcomes were synthesized and summarized.

RESULTS

Searches identified 3,137 articles, of which 11 met inclusion criteria. Results demonstrated schools use a variety of teaching methods over a wide range of didactic hours to teach SJC concepts. Surveys and objective tests indicated students in SJC are generally satisfied and demonstrated improved knowledge and skills related to understanding and mitigating SDH, although findings related to changes in attitudes were equivocal. Evaluations at graduation and in residency demonstrated students who experience SJC are more prepared than their peers to work with patients who are underserved. Best practices in SJC included addressing the hidden curriculum, considering medical mistrust, and using tools like the Racial Justice Report Card and Tool for Assessing Cultural Competence Training.

CONCLUSIONS

These findings indicated SJC can prepare students to better address the root causes of health disparities. Future research should consider the long-term influences of these curricula on students, patients, and the community.

Critical Theory, Culture Change, and Achieving Health Equity in Health Care Settings

Achieving optimal health for all requires confronting the complex legacies of colonialism and white supremacy embedded in all institutions, including health care institutions. As a result, health care organizations committed to health equity must build the capacity of their staff to recognize the contemporary manifestations of these legacies within the organization and to act to eliminate them. In a culture of equity, all employees-individually and collectively-identify and reflect on the organizational dynamics that reproduce health inequities and engage in activities to transform them. The authors describe 5 interconnected change strategies that their medical center uses to build a culture of equity. First, the medical center deliberately grounds diversity, equity, and inclusion efforts (DEI) in critical theory, aiming to illuminate social structures through critical analysis of power relations. Second, its training goes beyond cultural competency and humility to include critical consciousness, which includes the ability to critically analyze conditions in the organizational and broader societal contexts that produce health inequities and act to transform them. Third, it works to strengthen relationships so they can be change vehicles. Fourth, it empowers an implementation team that models a culture of equity. Finally, it aligns equity-focused culture transformation with equity-focused operations transformation to support transformative praxis. These 5 strategies are not a panacea. However, emerging processes and outcomes at the medical center indicate that they may reduce the likelihood of ahistorical and power-blind approaches to equity initiatives and provide employees with some of the critical missing knowledge and skills they need to address the root causes of health inequity.

Standup comedy principles and the personal monologue to explore interpersonal bias: experiential learning in a health disparities course

BACKGROUND

Interpersonal biases between clinicians and patients contribute to disparities in health care and outcomes by race, ethnicity, and socioeconomic status. We used standup comedy principles and exercises to help medical students recognize how others perceive them and how they perceive others, and engage in difficult discussions around implicit biases and interpersonal racism.

METHODS

90 min Zoom workshop with 40 first-year medical students in urban medical school. Intervention consisted of three exercises: Naming icebreaker, Rant and Rave (communicate strong perspective clearly), and Personal Monologue about how others perceive you and how you perceive yourself. Discussion debriefed the personal monologue exercise. Likert scale questions on post-session survey evaluated workshop overall, whether workshop increased skills, and safety of learning environment. Open-ended questions included what trainees liked about the module, what could be improved, and what impact the module had on them?

RESULTS

Seventeen (42.5%) students responded to survey. Six respondents identified as white, 4 as Asian, 1 as Black, 1 as multiracial, and 5 did not identify. Seventy-six percent rated the module as "very good" or "excellent", and 94% would recommend the module to others. Most respondents reported the workshop helped them become better listeners (75%) and more observant (82%). Eighty-three percent reported the training could help them take better care of patients with lived experiences different than their own. All respondents believed the learning environment was safe, and 94% reported that instructors created an atmosphere in which they could take risks. Thirty-six percent felt stressed. Students reported the workshop helped them recognize their own identities, others' perceptions, and bidirectional biases, and inspired them to strive for more accurate, authentic interactions with patients.

CONCLUSIONS

Standup comedy principles show promise for engaging students in meaningful, safe discussions about perceptions and interpersonal biases rooted in their own personal experiences and those of their classmates.

Enhancing existing medical school curricula with an innovative healthcare disparities curriculum

BACKGROUND

Effective healthcare disparities curricula seek to train physicians who are well equipped to address the health needs of an increasingly diverse society. Current literature on healthcare disparities curricula and implementation focuses on courses created independent of existing educational materials. Our aim was to develop and implement a novel resource-conserving healthcare disparities curriculum to enhance existing medical school lectures without the need for additional lectures.

METHODS

This non-randomized intervention was conducted at the University of California Los Angeles. The curriculum was offered to all first-year medical students in the class of 2021 (n=188). With institutional approval, a new healthcare disparities curriculum was created based on the Society of General Internal Medicine's core learning objectives for effective healthcare disparities curricula (J General Internal Med 25:S160-163, 2010). Implementation of the curriculum made use of "teachable moments" within existing medical school lectures. Teachable moments were broad lecture topics identified by the research team as suitable for introducing relevant healthcare disparities content. The new lecture-enhancing healthcare disparities curriculum was delivered with the related lecture via integrated PDF documents uploaded to an online learning management system. Students were encouraged to complete pre- and post- course assessments to examine changes in disparities knowledge and self-rated confidence in addressing disparities. Matched χ2 tests were used for statistical analysis.

RESULTS

Participating students (n=92) completed both pre- and post-course assessments and were retrospectively stratified, based on self-reported use of the new lecture enhancing curriculum, into the "high utilizer" group (use of materials "sometimes" or "very often," n=52) and the comparison "low utilizer" group (use of the materials "rarely" or "very rarely," n=40). Students who self-identified as underrepresented racial and ethnic minorities in medicine were more likely to utilize the material (41% of the high utilizers vs. 17% of the low utilizer group, p<.01). Post-course knowledge assessment scores and self-reported confidence in addressing healthcare disparities improved only in the high utilizer group.

CONCLUSIONS

Integrating new guideline based curricula content simultaneously into pre-existing lectures by identifying and harnessing teachable moments may be an effective and resource-conserving strategy for enhancing healthcare disparities education among first year medical students.

The KAIROS Blanket Exercise: Engaging Indigenous ways of knowing to foster critical consciousness in medical education

PURPOSE

Indigenous Peoples across Turtle Island (North America) experience ongoing health disparities tied to the effects of colonization and persistent racism toward Indigenous Peoples. Educating future clinicians to develop a critical consciousness is an important way to work toward cultural safety and improve the health care experiences of Indigenous patients. The present study evaluated the ability of the KAIROS Blanket Exercise (KBE) to foster critical consciousness.

METHODS

Two hundred thirteen medical students at the University of Toronto participated in the KBE. Subsequently, 174 students completed a paper evaluation, designed to capture concepts of cultural safety and critical consciousness. Data were analyzed using quantitative and qualitative methods to identify shifts in perspectives.

RESULTS

The majority of students reported the exercise altered the way they viewed those from backgrounds different from their own, and comments regarding bias, power and privilege were highlighted throughout the responses. Engaging in critical reflection through dialogue and revealing the complex sociopolitical context of Indigenous Peoples' history were emphasized as central to this transformation.

CONCLUSIONS

Following participation in the KBE, medical students demonstrated a shift in their perspectives. This suggests that creating curricular space for critical pedagogy may be effective in fostering critical consciousness, ultimately encouraging reflexive practice and social action.

New Horizons-Addressing Healthcare Disparities in Endocrine Disease: Bias, Science, and Patient Care

Unacceptable healthcare disparities in endocrine disease have persisted for decades, and 2021 presents a difficult evolving environment. The COVID-19 pandemic has highlighted the gross structural inequities that drive health disparities, and antiracism demonstrations remind us that the struggle for human rights continues. Increased public awareness and discussion of disparities present an urgent opportunity to advance health equity. However, it is more complicated to change the behavior of individuals and reform systems because societies are polarized into different factions that increasingly believe, accept, and live different realities. To reduce health disparities, clinicians must (1) truly commit to advancing health equity and intentionally act to reduce health disparities; (2) create a culture of equity by looking inwards for personal bias and outwards for the systemic biases built into their everyday work processes; (3) implement practical individual, organizational, and community interventions that address the root causes of the disparities; and (4) consider their roles in addressing social determinants of health and influencing healthcare payment policy to advance health equity. To care for diverse populations in 2021, clinicians must have self-insight and true understanding of heterogeneous patients, knowledge of evidence-based interventions, ability to adapt messaging and approaches, and facility with systems change and advocacy. Advancing health equity requires both science and art; evidence-based roadmaps and stories that guide the journey to better outcomes, judgment that informs how to change the behavior of patients, providers, communities, organizations, and policymakers, and passion and a moral mission to serve humanity.

Imagining the 'structural' in medical education and practice in the United States: A curricular investigation

A number of conceptual frameworks have emerged with the goal of helping clinicians understand and navigate the intersections of the health system and broader political, economic, and cultural processes when they care for patients. In this study, we analyze the impact that one emerging framework, "structural competency," had on medical students' and physicians' understanding of societal problems affecting patient health and the practices of health systems. In this sub-analysis of a longitudinal qualitative study conducted between August and December 2020, we analyzed 19 semi-structured interviews with 7 first-year medical students, 7 upper-level medical students, and 5 physician course facilitators who participated in a course called Introduction to Medicine and Society at an medical school in the United States affiliated with a large urban academic medical center. This paper focuses on three main findings: how medical students and faculty describe "structures" and their effects on patients and patient care; how they use or imagine using structural competency to improve patient-physician communication and work interprofessionally to address social needs; and the emotional and personal reactions that confronting societal challenges provokes. We conclude that structural competency enhances existing efforts to improve patient-physician communication and to address patients' social needs. However, we highlight how structural competency efforts might fall short of their goal to shift physicians' perspectives "upstream" to the determinants of health due to both critical ambiguities in the concept and inattention to the emotional and personal impacts of addressing societal problems in the clinic. These findings have practical implications for how clinicians are trained to act on societal issues from within the health system and conceptual implications for refining how existing frameworks and curricula conceive of the intersection between healthcare and broader processes.

Team Belonging: Integrating Teamwork and Diversity Training Through Emotions

With the worldwide focus shifting toward important questions of what diversity means to society, organizations are attempting to keep up with employees’ needs to feel recognized and belong. Given that traditionally team and diversity trainings are provided separately, with different theoretical backgrounds and goals, they are often misaligned and ineffective. We review 339 empirical articles depicting a team, diversity, or emotional management training to extract themes and determine which methods are most effective. Although research has demonstrated the importance of belonging for providing positive workplace outcomes, we found that the traditional design of these trainings and lack of emotional management prevent a balance between team and diversity goals, preventing belonging. We propose an integrative training with emotional management to help teams foster optimal belonging, where members can unite together through their differences. Accordingly, our themes inform this training model that can inspire future research into more effective training.

A Comparative Case Study Analysis of Cultural Competence Training at 15 U.S. Medical Schools

PURPOSE

Twenty years have passed since the Liaison Committee on Medical Education (LCME) mandated cultural competence training at U.S. medical schools. There remain multiple challenges to implementation of this training, including curricular constraints, varying interpretations of cultural competence, and evidence supporting the efficacy of such training. This study explored how medical schools have worked to implement cultural competence training.

METHOD

Fifteen regionally diverse public and private U.S. medical schools participated in the study. In 2012-2014, the authors conducted 125 interviews with 52 administrators, 51 faculty or staff members, and 22 third- and fourth-year medical students, along with 29 focus groups with an additional 196 medical students. Interviews were recorded, transcribed, and imported into NVivo 10 software for qualitative data analysis. Queries captured topics related to students' preparedness to work with diverse patients, engagement with sociocultural issues, and general perception of preclinical and clinical curricula.

RESULTS

Three thematic areas emerged regarding cultural competence training: formal curriculum, conditions of teaching, and institutional commitment. At the formal curricular level, schools offered a range of courses collectively emphasizing communication skills, patient-centered care, and community-based projects. Conditions of teaching emphasized integration of cultural competence into the preclinical years and reflection on the delivery of content. At the institutional level, commitment to institutional diversity, development of programs, and degree of prioritization of cultural competence varied.

CONCLUSIONS

There is variation in how medical schools approach cultural competence. Among the 15 participating schools, longitudinal and experiential learning emerged as important, highlighting the needs beyond mere integration of cultural competence content into the formal curriculum. To determine efficacy of cultural competence programming, it is critical to conduct systematic assessment to identify and address gaps. While LCME standards have transformed aspects of medical education, further research is needed to clarify evidence-based, effective approaches to this training.

Critical Consciousness as a Framework for Health Equity-Focused Peer Learning

INTRODUCTION

Recognizing the need to teach concepts of health equity, diversity, and inclusion as a part of medical students' preclinical training, we developed a series of workshops in the first year of medical school that introduced students to issues of discrimination and inequity and their effects on health outcomes. This student-led, faculty-supported project, known as Critical Consciousness in Medicine (CCM), adopted critical consciousness as a guiding principle for student learning.

METHODS

Over the course of the 2018-2019 academic year, student leaders developed and delivered five 2-hour workshops to 197 first-year students, with the assistance of student facilitators and input and guidance from faculty advisors. Workshops involved a mix of whole-class presentations and small-group discussions. Session topics included identity and interpersonal relationships, privilege, health disparities, and implicit bias.

RESULTS

Paired t-test analysis showed statistically significant growth in student self-ratings related to CCM learning objectives as measured in the end-of-year pre-/postsurvey. Student comments in year-end reflections further suggested learning, self-assessment, growth, and appreciation for the workshops' place in the preclinical curriculum.

DISCUSSION

This project modeled a student-faculty partnership for approaching diversity, inclusion, and health equity in medical education and highlighted the role of students as leaders in educating their peers. The CCM workshop series demonstrated high acceptability as a component of preclinical medical education and may increase student engagement around social issues in health care. CCM also illustrated the promise of using critical consciousness as an approach to educating medical students about equity, diversity, and inclusion.

From the "top-down" and the "bottom-up": Centering Foucault's notion of biopower and individual accountability within systemic racism

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Medical Students' Experience in a Trauma Chaplain Shadowing Program: A Mixed Method Analysis

Despite the importance of spirituality to health and patient care, there remains a lack of educational opportunities for medical students to learn about and engage the spiritual needs of patients. Shadowing of hospital chaplains has been employed as a means of providing instruction in spirituality, but published experiences of this pedagogy are limited. This study therefore analyzed an elective, first-year medical student, eight-hour, trauma chaplain shadowing experience, the objectives of which are to increase students' knowledge and understanding of (i) the role of chaplains/pastoral care in patient care; (ii) strategies for engaging patients and/or families in difficult situations; and (iii) approaches for discussing issues of spirituality with patients and families. Aquestionnaire was sent to participants after the experience assessing the value of the experience. Two focus groups provided additional qualitative data. Of the 148 participants over 6 years, 100 completed the questionnaire (68%). Participants on average engaged 1.78 trauma patients or their families and experienced 3.63 overall patient/family interactions during their shadowing. Over 90% of respondents agreed or strongly agreed that the experience provided agreater understanding of the role of the chaplain, and was educationally, professionally, and personally useful. Over 60% of respondents agreed or strongly agreed that the experience improved their understanding of discussing difficult or spiritual topics with patients and families. Nearly all respondents (98%) would recommend asimilar shadowing experience to fellow medical students. Qualitative remarks echoed these findings, revealing themes surrounding the educational benefits, surprise, and awe experienced by participants, and indicating appreciation for the interprofessional aspect of the experience. These data demonstrate that trauma chaplain shadowing may be effective for introducing first-year medical students to healthcare chaplaincy, educating them about the challenges of navigating difficult spiritual conversations with patients and families, and exposing them to interprofessional collaboration.

The role of explanatory models of breast cancer in breast cancer prevention behaviors among Arab-Israeli physicians and laywomen

Background:

‘Explanatory Models’ (EMs) are frameworks through which individuals and groups understand diseases, are influenced by cultural and religious perceptions of health and illness, and influence both physicians and patients’ behaviors.

Aims:

To examine the role of EMs of illness (cancer-related perceptions) in physicians’ and laywomen’s behaviors (decision to recommend undergoing regular mammography, adhering to mammography) in the context of a traditional-religious society, that is, the Arab society in Israel.

Methods:

Two combined samples were drawn: a representative sample of 146 Arab physicians who serve the Arab population and a sample composed of 290 Arab women, aged 50–70 years, representative of the main Arab groups residing in the north and center of Israel (Muslims, Christians) were each randomly sampled (cluster sampling). All respondents completed a closed-ended questionnaire.

Results:

Women held more cultural cancer-related beliefs and fatalistic beliefs than physicians. Physicians attributed more access barriers to screening as well as fear of radiation to women patients and lower social barriers to screening, compared with the women’s community sample. Higher fatalistic beliefs among women hindered the probability of adherence to mammography; physicians with higher fatalistic beliefs were less likely to recommend mammography.

Conclusions:

The role of cultural perceptions needs to be particularly emphasized. In addition to understanding the patients’ perceptions of illness, physicians must also reflect on the social, cultural, and psychological factors that shape their decision to recommend undergoing regular mammography.

Developing a Sexual Orientation and Gender Identity Nursing Education Toolkit

BACKGROUND

Current education lacks lesbian, gay, bisexual, transgender, questioning, intersex, and two-spirit (LGBTQI2S) content for health care providers (HCPs). Providing HCPs with understanding of LGBTQI2S health issues would reduce barriers. The Innovative Thinking to Support LGBTQI2S Health and Wellness trainee award supported the development of a website with virtual simulation games (VSGs) about providing culturally humble care to LGBTQI2S individuals to address this need.

METHOD

An online educational toolbox was developed that included VSGs and resources. Development processes included a visioning meeting, development of learning objectives, and using a decision-point map for script writing. Bilingual VSGs were filmed, and the website was developed.

RESULTS

The Sexual Orientation and Gender Identity Nursing Toolkit was created to advance cultural humility in practice. Learning modules focus on encounters using cultural humility to meet the unique needs of the LGBTQI2S community.

CONCLUSION

Our innovative educational toolkit can be used to provide professional development of nurses and other HCPs to care for LGBTQI2S individuals. [J Contin Educ Nurs. 2020;51(9):412-419.].

The 'exotic other' in medical curricula: Rethinking cultural diversity in course manuals

Introduction: Implementation of cultural diversity training in medical education faces challenges, including ambiguity about the interpretation of 'cultural diversity'. This is worrisome as research has demonstrated that the interpretation employed matters greatly to practices and people concerned. This study therefore explored the construction of cultural diversity in medical curricula.Methods: Using a constructivist approach we performed a content analysis of course materials of three purposefully selected undergraduate curricula in the Netherlands. Via open coding we looked for text references that identified differences labelled in terms of culture. Iteratively, we developed themes from the text fragments.Results: We identified four mechanisms, showing together that culture is unconsciously constructed as something or someone exotic, deviant from the standard Dutch or Western patient or disease, and therefore problematic.Conclusions: We complemented earlier identified mechanisms of othering and stereotyping by showing how these mechanisms are embedded in educational materials themselves and reinforce each other. We argue that the embedded notion of 'problematic stranger' can lead to a lack of tools for taking appropriate medical action and to insecurity among doctors. This study suggests that integrating more attention to biological and contextual differences in the entire medical curriculum and leaving out static references such as ethnicity and nationality, can enhance quality of medical training and care.

Honoring Medicine's Social Contract: A Scoping Review of Critical Consciousness in Medical Education

PURPOSE

To explore how the construct of critical consciousness has been conceptualized within the medical education literature and identify the main elements of critical consciousness in medical education so as to inform educational strategies to foster socially conscious physicians.

METHOD

In March 2019, the authors conducted a literature search of 4 databases and Google Scholar, seeking articles discussing critical consciousness in medical education published any time after 1970. Three of the authors screened articles for eligibility. Two transcribed data using a data extraction form and identified preliminary emerging themes, which were then discussed by the whole research team to ensure agreement.

RESULTS

Of the initial 317 articles identified, 20 met study inclusion criteria. The publication of academic articles around critical consciousness in medical education has expanded substantially since 2017. Critical consciousness has been conceptualized in the medical education literature through 4 overlapping themes: (1) social awareness, (2) cultural awareness, (3) political awareness, and (4) awareness of educational dynamics.

CONCLUSIONS

Critical consciousness has been conceptualized in medical education as an intellectual construct to foster a reflexive awareness of professional power in health care, to unearth the values and biases legitimizing medicine as currently practiced, and to foster transformation and social accountability. Scholars highlighted its potential to improve sociocultural responsibility and to foster compassion in doctors. Adopting a critical pedagogy approach in medical education can help uphold its social accountability through an intrinsic orientation to action, but any enterprise working toward embedding critical pedagogy within curricula must acknowledge and challenge the current structure and culture of medical education itself.

What knowledge is needed? Teaching undergraduate medical students to "go upstream" and advocate on social determinants of health

BACKGROUND

We rarely teach medical students the skills required to engage in policy change to address the structural factors that underpin the social determinants of health, which are driven by the unequal distribution of power and resources in society. Acquiring the knowledge and skills to influence policy can empower students to act on healthcare inequities rather than simply be aware of them.

METHODS

Using Metzl and Hansen's structural competency framework, we designed and piloted an intervention for medical students. Participants attended a workshop, presented to a hypothetical political stakeholder, and wrote anopinion editorial piece. Students participated in a focus group that was audio-recorded and transcribed. We coded and analyzed presentations, editorials, and transcripts to develop a thematic analysis.

RESULTS

Nine students participated in the workshop. They chose structural interventions and presented potential solutions to structural barriers in written and oral outputs. Students identified a lack of knowledge about health and political systems as a potential barrier to future advocacy work.

CONCLUSION

Medical trainees require training in specific advocacy skills such as oral and written communication, however this alone may be insufficient. As future advocates, trainees must also acquire a specific skill set and associated knowledge about health systems and policy to navigate the systems in which they will practice.

Cultural Competency Interventions During Medical School: a Scoping Review and Narrative Synthesis

Many medical accreditation bodies agree that medical students should be trained to care for diverse patient populations. However, the teaching methods that medical schools employ to accomplish this goal vary widely. The purpose of this work is to summarize current cultural competency teaching for medical students and their evaluation methods. A scoping review was completed by searching the databases PubMed, Scopus, MedEdPORTAL, and MEDLINE for the search terms "medical education" and "cultural competency" or "cultural competence." Results were summarized using a narrative synthesis technique. One hundred fifty-four articles on cultural competency interventions for medical students were systematically identified from the literature and categorized by teaching methods, length of intervention, and content. Fifty-six articles had a general focus, and ninety-eight articles were focused on specific populations including race/ethnicity, global health, socioeconomic status, language, immigration status, disability, spirituality at the end of life, rurality, and lesbian, gay, bisexual, transgender, and queer. About 54% of interventions used lectures as a teaching modality, 45% of the interventions described were mandatory, and 9.7% of interventions were not formally evaluated. The authors advocate for expansion and more rigorous analysis of teaching methods, teaching philosophies, and outcome evaluations with randomized controlled trials that compare the relative effectiveness of general and population-specific cultural competency interventions.

Speaking up culture of medical students within an academic teaching hospital: Need of faculty working in patient safety

BACKGROUND

Speaking up behavior is a manifestation the culture of safety in an organization; however, withholding voice is commonly observed. Within one academic teaching hospital, it was the aim to assess students' speaking up behaviors and perceived culture in order to stimulation of the academic development in terms of patient safety.

METHODS

Survey amongst medical students using a validated questionnaire. Data were analysed using descriptive statistics.

RESULTS

326 individuals completed the questionnaire (response rate 24%). 37% of responders were in their 5th- 6th clinical term, 32% were in their 7th-8th term and 31% were in the 9th-12th term. 69% of students had a specific safety concern in the past four weeks, 48% had observed an error and 68% noticed the violation of a patient safety rule. Though students perceived specific patient safety concerns, 56% did not speak up in a critical situation. All predefined barriers seemed to play an important role in inhibiting students' voicing concerns. The scores on the psychological safety scale were overall moderately favourable. Students felt little encouraged by colleagues and, in particular, by supervisors to speak up.

CONCLUSION

Speaking up behaviour of students was assessed for the first time in an Austrian academic teaching hospital. The higher the term the more frequent students reported perceived patient safety concerns or rule violations and withholding voice. These results suggest the need to adapt the curriculum concept of the faculty in order to address patient safety as a relevant topic.

Three zones of cultural competency: surface competency, bias twilight, and the confronting midnight zone

BACKGROUND

Regulatory authorities in healthcare are authorised to develop and assess the cultural competence of their professionals. There remains significant diversity on approaches to cultural competency training and assessment. Little evidence exists about whether existing cultural competency training leads to improved patient health outcomes and reductions in health disparity.

DISCUSSION

In this paper I frame cultural competency as analogous to the ocean and consisting of three zones: surface competency zone, bias twilight zone, and the confronting midnight zone. The surface competency zone focuses on deployment of culturally-specific knowledge: what people see, say, and do. The bias twilight zone is where people engage in critical reflection on their inherent/unconscious biases, and how such biases inform their thoughts and practices. The confronting midnight zone is where people engage in critical consciousness and self-awareness. Here they look beyond their biases to interrogate their power and positionality in society (their own privileges and centralisation). This attention is coupled with a commitment to social justice and to working within their means to reduce health disparities.

CONCLUSIONS

I suggest surface cultural competency is somewhat easier to see, teach and reach than the bias twilight or confronting midnight zones. But it is these deeper zones that cultural competency training needs to attend to if we are to see systemic cultural changes in healthcare provision. Research assessing the extent by which cultural competency training within each zone informs improved patient outcomes and reductions in health disparity is called for.

Not Just a Specimen: A Qualitative Study of Emotion, Morality, and Professionalism in One Medical School Gross Anatomy Laboratory

Medical schools are increasingly integrating professionalism training into their gross anatomy courses, teaching ethical behavior and humanistic attitudes through the dissection experience. However, many schools continue to take a traditional, technical approach to anatomical education while teaching professionalism in separate courses. This interview-based study explored how students viewed the body donor and the professional lessons they learned through dissection at one such medical school. All students oscillated involuntarily between seeing the cadaver as a specimen for learning and seeing the cadaver as a person, with some students intentionally cultivating one of these ways of seeing over the other. These views shaped students' emotional and moral responses to the experiences of dissection. The "specimen" view facilitated a technical, detached approach to dissection, while the "person" view made students engage emotionally. Further, students who intentionally cultivated a "specimen" view generally felt less moral distress about dissection than students who intentionally cultivated a "person" view. The concept of respect gave students permission to perform dissections, but "person-minded" students developed more complex rules around what constituted respectful behavior. Both groups of students connected the gross anatomy experience to their professional development, but in different ways. "Specimen-minded" students intentionally objectified the body to learn the emotional control physicians need, while "person-minded" students humanized the body donor to promote the emotional engagement required of physicians. These findings support efforts to integrate professionalism teaching into gross anatomy courses, particularly content, addressing the balance between professional detachment and concern.

"Rebuilding what has eroded": a descriptive, survey-based study of near-peer instructors' experiences in a critical pedagogy-based sociomedical course

Purpose: Near-peer assisted learning has been deployed in numerous settings within medical education with promising results. However, there is very little experience utilizing near-peers in sociomedical or cultural competency training. We recently described a novel model for sociomedical learning based on Introduction to Medicine and Society (IMS), a critical pedagogy-based course at the Perelman School of Medicine at the University of Pennsylvania (PSOM). Near-peer facilitation, by senior medical students, is central to this model. The aim of this descriptive study is to examine how facilitating within this curriculum impacts senior medical students' self-reported attitudes toward course content, medical education, as well as self-care and medical practice. Methods: At the conclusion of the course, near-peer facilitator attitudes were assessed in three key domains through an anonymous survey. Attitudes were rated according to a 5-point Likert scale. Data from subgroups were analyzed using standard two-tailed t-tests. Optional narrative data were also collected. Results: Twenty six of 34 (76%) eligible facilitators completed the survey. Strong majorities of facilitators felt that their experience facilitating IMS had a favorable effect on attitudes related to course content (sociomedical issues and communication skills). A majority also endorsed favorable changes in their attitudes toward teaching and medical education. Large proportions of facilitators endorsed positive changes in a number of domains linked to trainee resilience. Conclusions: Our descriptive data suggest that acting as a near-peer facilitator as a senior medical student within a critical pedagogy-based course could help to fill multiple important curricular gaps at the transition from medical school to residency. Moreover, we find that a sociomedical facilitation experience during this important transition may increase enthusiasm for careers in medical education and undo some of the negative impacts of clinical training during medical school.

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.

Living in two worlds: Becoming and being a doctor among those who identify with "not from an advantaged background"

We aim to deepen understanding of the experiences of becoming and being a physician among those in medicine who are 'not from advantaged backgrounds'. Despite modest success with institutional efforts to increase the diversity of medical school students, individuals with this less visible dimension of diversity remain under-represented across North America and the UK. Further, little is known about their experiences and contributions following medical school entry. In-depth interviews were carried out with twelve participants, including eight medical students, a resident and three physicians to explore experiences in medicine among those who self-identify with 'not from an advantaged background'. Reflection on the meaning of those experiences was encouraged. Intersectional identifications were common in relation to 'not from an advantaged background'. For some, the latter was background to identification with upbringings that were rural, influence by ethnicity, personal or parental immigration, and parents who were single or had limited education. Themes that arose in relation to being and becoming a doctor for these participants included: (1) the hidden curriculum's contribution to silencing markers of socioeconomic under-privilege; (2) limited formal curriculum opportunities to discuss socio-economic difference; (3) professional identity construction including empathy for the varied challenges of low-income patients in clinical situations and (4) living in two worlds: with a tension between the medical world and one's original world of socializing with friends and family from a non-advantaged upbringing. This study offered a unique, welcome opportunity to reflect on professional identity development in relation to one's family's socio-economic status. Safe, inclusive pedagogical opportunities to discuss socio-economic status and its intersectional elements, may support professional identity development that includes empathy and responsiveness to health inequities. The open dialogue, although perhaps uncomfortable, may be valuable to enhance cultural humility among medical students. The assessment of such initiatives in relation to professional identity formation is an important next step.

Commentary: Racism and Bias in Health Professions Education: How Educators, Faculty Developers, and Researchers Can Make a Difference

The Research in Medical Education (RIME) Program Planning Committee is committed to advancing scholarship in and promoting dialogue about the critical issues of racism and bias in health professions education (HPE). From the call for studies focused on underrepresented learners and faculty in medicine to the invited 2016 RIME plenary address by Dr. Camara Jones, the committee strongly believes that dismantling racism is critical to the future of HPE.The evidence is glaring: Dramatic racial and ethnic health disparities persist in the United States, people of color remain deeply underrepresented in medical school and academic health systems as faculty, learner experiences across the medical education continuum are fraught with bias, and current approaches to teaching perpetuate stereotypes and insufficiently challenge structural inequities. To achieve racial justice in HPE, academic medicine must commit to leveraging positions of influence and contributing from these positions. In this Commentary, the authors consider three roles (educator, faculty developer, and researcher) represented by the community of scholars and pose potential research questions as well as suggestions for advancing educational research relevant to eliminating racism and bias in HPE.

Time to Develop Social Dentistry

Knowledge Transfer Statement: We are calling researchers, educators, and dental professionals to be at the forefront of actions addressing social determinants of health. We indeed argue that 1) it is the dentists’ and other oral health care professionals’ role to tackle social determinants of health and 2) as researchers and educators, we need to help clinicians in this endeavor and lead the development of a “social dentistry” movement.

New Medicine for the U.S. Health Care System: Training Physicians for Structural Interventions

Structural competency provides a language and theoretical framework to promote institutional-level interventions by clinical practitioners working with community organizations, non-health-sector institutions, and policy makers. The special collection of articles on structural competency in this issue of Academic Medicine addresses the need to move from theory to an appraisal of core educational interventions that operationalize the goals of and foster structural competency. In this Commentary, the authors review the role of clinical practitioners in enhancing population-level health outcomes through collaborations with professionals in fields outside medicine, including the social sciences and law. They describe the core elements of structural competency in preclinical and clinical education, as illustrated by the articles of this special collection: perceiving the structural causes of patients' disease, envisioning structural interventions, and cultivating alliances with non-health-sector agencies that can implement structural interventions. Finally, the authors argue that preparing trainees to form partnerships will empower them to influence the social determinants of their patients' health and reduce health inequalities.

Cultural hegemony? Educators' perspectives on facilitating cross-cultural dialogue

BACKGROUND

We live in an age when education is being internationalized. This can confront students with 'cultural hegemony' that can result from the unequal distribution of power and privilege in global society. The name that is given to awareness of social inequality is 'critical consciousness'. Cross-cultural dialogue provides an opportunity for learners to develop critical consciousness to counter cultural hegemony. The purpose of this research was to understand how learners engage with cross-cultural dialogue, so we can help them do so more effectively in the future.

METHOD

The setting for this research was an online discussion in an international health professions educator fellowship program. We introduced scenarios with cultural references to study the reaction of participants to cultural conversation cues. We used an inductive thematic analysis to explore power and hegemony issues.

RESULTS

Participants reflected that personally they were more likely to take part in cross-cultural discussions if they recognized the context discussed or had prior exposure to educational settings with cultural diversity. They identified barriers as lack of skills in facilitating cross-cultural discussions and fear of offending others. They suggested deliberately introducing cultural issues throughout the curriculum.

CONCLUSION

Our results indicate that developing critical consciousness and cross-cultural competency will require instructional design to identify longitudinal opportunities to bring up cross-cultural issues, and training facilitators to foster cross-cultural discussions by asking clarifying questions and navigating crucial/sensitive conversations.