Cultural minority students' experiences with intercultural competency in medical education

Understanding faculty perceptions and experiences related to climate, diversity, equity, and inclusion at a college of pharmacy: A pilot study

INTRODUCTION

A climate survey was piloted to obtain an understanding of the perceptions and personal experiences of faculty for intentional planning of future meaningful, effective, and sustainable diversity, equity, and inclusion (DEI) efforts at a college of pharmacy.

METHODS

A 48-item, four section, online survey was developed and administered to 69 faculty between October and November 2021. Likert-like five-point scales and free-text items were included to determine an overall assessment of climate, as well as perceptions and/or personal experiences for each domain of DEI, and demographics.

RESULTS

Thirty-nine (57%) faculty completed the survey. For climate, every attribute had at least one respondent that observed someone make an insensitive or disparaging remark "rarely," "occasionally," and "frequently." The response pattern was similar for personal experience with insensitive remarks. For participation in diversity activities, "awareness without participation" was selected by 56% of respondents. For perceptions of diversity, "fairly" or "very" was selected by 38% to 54% of respondents. For equity, "attainable for some" to "not attainable" was identified for 15% to 26% of respondents.

CONCLUSIONS

These pilot climate survey results inform climate improvement as it relates to DEI and informs survey instrument refinement.

Using Active Learning Strategies to Strengthen Cultural and Linguistic Diversity Training in Communication Sciences and Disorders Programs

Purpose

Training in cultural competence is an accreditation requirement for graduate programs in Communication Sciences and Disorders (CSD; Council on Academic Accreditation in Audiology and Speech-Language Pathology, 2020). Cultural and linguistic diversity (CLD) instruction within CSD programs and current instructional models may not provide students with effective training in this area (Hammond et al., 2009; Higby et al., 2021; Stockman et al., 2008). In this paper, we present active learning as an instructional approach that may provide students with stronger training in the assessment and treatment of individuals with unfamiliar cultural and linguistic backgrounds.

Conclusions

Active learning emphasizes the creation of a supportive classroom environment, teaching skills rather than content, and fostering metacognition in students (Bransford et al., 2000; Gooblar, 2019). We propose a three-part pedagogical model for using active learning strategies to improve clinical training in assessment and treatment of clients with CLD backgrounds. This pedagogical model encourages instructors to set the scene for learning, present a problem to solve, and build in reflection and generalization. Active learning approaches, as described in the model, are ideal for teaching clinical problem-solving across populations while reflecting on one's lived experience and positionality. Sample materials for readers to create their own lesson plans using the model are provided and reviewed.

Social justice in medical education: inclusion is not enough-it's just the first step

INTRODUCTION

Medical schools worldwide are creating inclusion policies to increase the admission of students from vulnerable social groups. This study explores how medical students from vulnerable social groups experience belongingness as they join the medical community.

METHODS

This qualitative study applied thematic analysis to 10 interviews with medical students admitted to one medical school through an affirmative policy. The interviews followed the drawing of a rich picture, in which the students represented a challenging situation experienced in their training, considering their socio-economic and racial background. The analysis was guided by the modes of belonging (engagement, imagination, and alignment) described by the Communities of Practice framework.

RESULTS

Participants struggled to imagine themselves as future doctors because they lack identification with the medical environment, suffer from low self-esteem, aside from experiencing racial and social discrimination. Participants also find it troublesome to engage in social and professional activities because of financial disadvantages and insufficient support from the university. However, participants strongly align with the values of the public health system and show deep empathy for the patients.

DISCUSSION

Including students with different socio-economic and racial backgrounds offers an opportunity to reform the medical culture. Medical educators need to devise strategies to support students' socialization through activities that increase their self-esteem and make explicit the contributions they bring to the medical community.

"I have to do twice as well" - managing everyday racism in a Swedish medical school

BACKGROUND

Mounting evidence suggests that medical students from cultural/ethnic minority backgrounds face recurring and more or less subtle racist oppression, i.e., everyday racism. Insights into how they handle these inequalities, though, are scarce - especially in a Swedish context. In this interview study we therefore explored and analyzed the strategies used by racialized minority medical students to manage episodes of everyday racism - and their underlying motives and considerations.

METHODS

Individual interviews were carried out with 15 medical students (8 women, 7 men) who self-identified as having ethnic- or cultural minority backgrounds. Inspired by constructivist grounded theory, data were collected and analyzed simultaneously.

RESULTS

Participants strove to retain their sense of self as active students and professional future physicians - as opposed to passive and problematic 'Others'. Based on this endeavor, they tried to manage the threat of constraining stereotypes and exclusion. Due to the power relations in medical education and clinical placement settings as well as racialized students' experience of lacking both credibility and support from bystanders, few dared to speak up or report negative treatment. Instead, they sought to avoid racism by withdrawing socially and seeking safe spaces. Or, they attempted to adopt a professional persona that was resistant to racial slights. Lastly, they tried to demonstrate their capability or conform to the majority culture, in attempts to refute stereotypes.

CONCLUSIONS

Racism is not caused by the exposed individuals' own ways of being or acting. Therefore, behavioral changes on the part of minority students will not relieve them from discrimination. Rather, strategies such as adaptation and avoidance run the risk of re-inscribing the white majority as the norm for a medical student. However, as long as racialized minority students stand alone it is difficult for them to act in any other way. To dismantle racism in medical education, this study indicates that anti-racist policies and routines for handling discrimination are insufficient. School management should also acknowledge racially minoritized students' experiences and insights about racist practices, provide students and supervisors with a structural account of racism, as well as organize training in possible ways to act as a bystander to support victims of racism, and create a safer working environment for all.

Student ethnicity predicts social learning experiences, self-regulatory focus and grades

CONTEXT

Ethnic minority students find that their ethnicity negatively affects the evaluation of their capacities and their feelings in medical school. This study tests whether ethnic minority and majority students differ in their 'self-regulatory focus' in clinical training, that is, their ways to approach goals, due to differences in social learning experiences. Self-regulatory focus consists of a promotion and prevention focus. People who are prone to stereotypes and unfair treatments are more likely to have a prevention focus and conceal certain identity aspects. The objectives of the study are to test whether ethnic minority students, as compared with ethnic majority students, are equally likely to have a promotion focus, but more likely to have a prevention focus in clinical training due to more negative social learning experiences (Hypothesis 1), and whether the relationship between student ethnicity and clinical evaluations can be explained by students' gender, social learning experiences, self-regulatory focus and impression management (Hypothesis 2).

METHODS

Survey and clinical evaluation data of 312 (71.2% female) clerks were collected and grouped into 215 ethnic majority (69.4%) and 95 ethnic minority students (30.6%). Students' social learning experiences were measured as perceptions of unfair treatment, trust in supervisors and social academic fit. Self-regulatory focus (general and work specific) and impression management were also measured. A parallel mediation model (Hypothesis 1) and hierarchical multiple regression analyses were used (Hypothesis 2).

RESULTS

Ethnic minority students had higher perceptions of unfair treatment and lower trust in their supervisors in clinical training. They were more prevention focused in clinical training, but this was not mediated by having more negative social learning experiences. Lower clinical evaluations for ethnic minority students were unexplained. Promotion focus in clinical training and trust in supervisors positively relate to clinical grades.

CONCLUSION

Student ethnicity predicts social learning experiences, self-regulatory focus and grades in clinical training. The hidden curriculum plausibly plays a role here.

Five ways to get a grip on the shortcomings of logic models in program evaluation

Logic models are perhaps the most widely used tools in program evaluation work. They provide reasonably straightforward, visual illustrations of plausible links between program activities and outcomes. Consequently, they are employed frequently in stakeholder engagement, communication, and evaluation project planning. However, their relative simplicity comes with multiple drawbacks that can compromise the integrity of evaluation studies. In this Black Ice article, we outline key considerations and provide practical strategies that can help those engaged in evaluation work to identify and mitigate some limitations of logic models.

Diversity matters: the other doctor within the Dutch academic healthcare system

Introduction

Over the past year, there has been a worldwide increase in the focus on systemic discrimination and inequitable practices within different societies, particularly concerning race and ethnicity. The inherent (experience of) inequity in racism is notonly limited to individuals but also found in different domains of societal structures, including healthcare and academia. In academia and healthcare organisations, junior Black and Minority Ethnic (BAME) doctors and students regularly find themselves caught between the leaky pipeline phenomenon and hierarchically dependent positions in academic healthcare settings. Voicing their experiences after such encounters is neither an option nor a choice they can do without repercussions. The prejudices, stigmas, implicit biases present within these environments result in segregated practices, where BAME doctors become the ‘other’ doctor (otherism), and based on their religion, ethnicity, migrant background or physical features are boxed into a specific group or category.

Reflections & recommendations

The outcome of this exercise (re-) emphasised that more improvement in the Dutch healthcare systems concerning stigmas and biases towards race and ethnicity are needed to promote the inclusion of future BAME doctors and students. A pivotal turn is urgently needed to repair the racial stigmas and biases that have distorted the image of BAME doctors/students, limiting their academic and professional progress. By structurally implementing focused strategies to promote inclusivity, the current gap within healthcare and the participation between non- BAME and BAME-doctors/students can be bridged, inevitably leading to better healthcare services, safer learning environments and a balanced representation of our multicultural societies in healthcare.

We argue that increased self-reflection from such critical inquiry will ultimately result in clear and objective understandings of (pre) existent inequitable practices in our societies.

After Pierce and Sue: A Revised Racial Microaggressions Taxonomy

Harvard psychiatrist Chester Pierce's conception of "subtle and stunning" daily racial offenses, or microaggressions, remains salient even 50 years after it was introduced. Microaggressions were defined further by Sue and colleagues in 2007, and this construct has found growing utility as the deleterious effects of microaggressions on the health of people of color continues to mount. Many studies seek to frame microaggressions in terms of a taxonomic analysis of offender behavior to inform the assessment of and interventions for the reduction of racial microaggressions. This article proposes an expansion and refinement of Sue et al.'s taxonomy to better inform such efforts. We conducted a review of published articles that focused on qualitative and quantitative findings of microaggressions taxonomies (N = 32). Sixteen categories of racial microaggressions were identified, largely consistent with the original taxonomy of Sue et al. but expanded in several notable ways. Building on our prior research, other researchers supported such new categories as tokenism, connecting via stereotypes, exoticization and eroticization, and avoidance and distancing. The least studied categories included the denial of individual racism from Sue et al., and newer categories included reverse-racism hostility, connecting via stereotypes, and environmental attacks. A unified language of microaggressions may improve understanding and measurement of this important construct.

Assessment of the Diversity and Inclusion Culture in a Physician Assistant Program

PURPOSE

Physician assistant (PA) programs aim to foster a collaborative culture that enables stakeholders to feel included, empowered, and valued. The purpose of this study was to explore the cultural climate of diversity and inclusion in one PA program to identify areas of strength and to serve as a baseline needs assessment for future program initiatives.

METHODS

The study used a cross-sectional, descriptive approach for PA survey data (N = 85) to assess perceptions of diversity and inclusion of PA program students, faculty, and staff.

RESULTS

The respondents largely agreed that the program created an inclusive learning environment (92%), the curriculum positively affected their understanding of diversity and cultural responsiveness (84.6%), and the program had an adequate amount of inclusivity for all program stakeholders (87%). Some faculty members (25%) and students (6.2%) disagreed that faculty were open to diverse political beliefs, and 35% of the respondents believed that more emphasis could be put on religious diversity. A few students (7.7%) perceived faculty as not supportive of non-native English language speakers; students of color (11.5%) were more likely than White students (5.1%) to have this perception.

CONCLUSIONS

This study largely met the goal to create a professional environment of mutual respect and, ultimately, a climate of inclusiveness. It also identified opportunities for new initiatives to meet the needs of all program stakeholders. Follow-up research that distinguishes faculty from students and a multicenter study to explore perspectives based on demographic differences would be timely and useful.

Diversity and inclusion in simulation: addressing ethical and psychological safety concerns when working with simulated participants

Healthcare learners can gain necessary experience working with diverse and priority communities through human simulation. In this context, simulated participants (SPs) may be recruited for specific roles because of their appearance, lived experience or identity. Although one of the benefits of simulation is providing learners with practice where the risk of causing harm to patients in the clinical setting is reduced, simulation shifts the potential harm from real patients to SPs. Negative effects of tokenism, misrepresentation, stereotyping or microaggressions may be amplified when SPs are recruited for personal characteristics or lived experience. Educators have an ethical obligation to promote diversity and inclusion; however, we are also obliged to mitigate harm to SPs.

The goals of simulation (fulfilling learning objectives safely, authentically and effectively) and curricular obligations to address diverse and priority communities can be in tension with one another; valuing educational benefits might cause educators to deprioritise safety concerns. We explore this tension using a framework of diversity practices, ethics and values and simulation standards of best practice. Through the lens of healthcare ethics, we draw on the ways clinical research can provide a model for how ethical concerns can be approached in simulation, and suggest strategies to uphold authenticity and safety while representing diverse and priority communities. Our objective is not to provide a conclusive statement about how values should be weighed relative to each other, but to offer a framework to guide the complex process of weighing potential risks and benefits when working with diverse and priority communities.

The design and implementation of a longitudinal social medicine curriculum at the University of Vermont's Larner College of Medicine

BACKGROUND

Despite an abundant literature advocating that social determinants of health (SDH) be taught during undergraduate medical education, there are few detailed descriptions of how to design and implement longitudinal core curricula that is delivered to all students and accomplishes this goal.

METHODS

In this paper, we describe the design and implementation of a social medicine curriculum at the University of Vermont's Larner College of Medicine (UVM Larner). Using Kern's principles, we designed a longitudinal curriculum that extends through both preclinical and clinical training for all students and focused on integrating SDH material directly into basic science and clinical training.

RESULTS

We successfully developed and implemented two primary tools, a "Social Medicine Theme of the Week" (SMTW) in preclinical training, and SDH rounds in the clinical setting to deliver SDH content to all learners at UVM Larner.

CONCLUSIONS

Extensive student-faculty partnerships, robust needs assessment, and focusing on longitudinal and integrated SDH content delivery to all students were key features that contributed to successful design and implementation.

"It was as if I wasn't there" - Experiences of everyday racism in a Swedish medical school

The aim of this study was to explore and analyze how cultural/ethnic minority students at a Swedish medical school perceive and make sense of educational experiences they viewed as related to their minority position. We interviewed 18 medical students (10 women, and 8 men), who self-identified as coming from minority backgrounds. Data were collected and analyzed simultaneously, inspired by constructivist grounded theory methodology. The concepts 'everyday racism' and 'racial microaggressions' served as a theoretical framework for understanding how inequities were experienced and understood. Participants described regularly encountering subtle adverse treatment from supervisors, peers, staff, and patients. Lack of support from bystanders was a common dimension of their stories. These experiences marked interviewees' status as 'Other' and made them feel less worthy as medical students. Interviewees struggled to make sense of being downgraded, excluded, and discerned as different, but seldom used terms like being a victim of discrimination or racism. Instead, they found other explanations by individualizing, renaming, and relativizing their experiences. Our results indicate that racialized minority medical students encounter repeated practices that, either intentionally or inadvertently, convey disregard and sometimes contempt based on ideas about racial and/or cultural 'Otherness'. However, most hesitated to name the behaviors and comments experienced as "discriminatory" or "racist", likely because of prevailing ideas about Sweden and, in particular, medical school as exempt from racism, and beliefs that racial discrimination can only be intentional. To counteract this educational climate of exclusion medical school leadership should provide supervisors, students, and staff with theoretical concepts for understanding discrimination and racism, encourage them to engage in critical self-reflection on their roles in racist power relations, and offer training for bystanders to become allies to victims of racism.

"What kind of support do I need to be successful as an ethnic minority medical student?" A qualitative study

BACKGROUND

To be in alignment with the increasing diversity in the patient population, ethnic minorities should have appropriate representation in health care professions. Medical students from ethnic minorities therefore need to be successful in their medical studies. The current literature highlights that they underperform in comparison with the ethnic majority. The aim of the present study is to gain insight into what medical students from ethnic minorities experience during their education and what they need to become or stay motivated and to perform to their full potential.

METHODS

Medical students from ethnic minorities from year 1 to 6, enrolled at Amsterdam UMC, Faculty of Medicine, Vrije Universiteit, the Netherlands, were invited via email to participate in this study. Semi-structured interviews were conducted, using an interview guide, from August-October 2018. A constructivist paradigm was adopted.

RESULTS

Eighteen medical students from ethnic minorities (three from year 1, three from year 2, one from 3, four from year 4, two from year 5, and three from year 6) participated in this study. Students' negative experiences could be categorized as follows: (1) the effect of discrimination (2) lack of representation of ethnic minority role models, (3) lack of a sense of belonging, (4) lack of a medical network, (5) differences and difficulties in cultural communication and language, and (6) examiner bias in clinical assessments. Examples of support tips relating to these experiences are: increasing awareness about diversity and other religions, providing support groups, having visible ethnic minority role models, and facilitating support in networking.

CONCLUSIONS

Findings of this study suggest that medical students from ethnic minorities have negative experiences that influence their education. Supporting these students is essential for creating a good and safe educational and practical environment for ethnic minority students.

Useful to whom? Evaluation utilisation theory and boundaries for programme evaluation scope

CONTEXT

Programme evaluation is perpetually mandated in health professions education. Correspondingly, there has been an expansion in prescriptive methodological guides about 'how' to engage in various best practices in evaluation. However, what has gained less attention is an examination of the 'value' that different stakeholders seek to gain from programme evaluation. Evaluation utilisation theory and research can help us understand the diversity in both the driving forces for and the impact of programme evaluation. Awareness of the heterogeneity of evaluation utilisation priorities has implications for evaluation practices, including both methodological choices and understanding of the impact of programme evaluation in our field.

METHODS

In this article, I expound on the concept of evaluation utilisation by drawing on evaluation theory and research. 'Evaluation utilisation' refers to the application of programme evaluation processes and findings to influence thinking and action. Herein, different forms of 'evaluation utilisation' (including instrumental, conceptual, process and persuasive (symbolic and legitimative) utilisation) are discussed, as well as the related concept of 'evaluation misuse'. Furthermore, how the prioritisation of different forms of 'evaluation utilisation' can influence the scope and impact of evaluation scholarship are also discussed.

CONCLUSIONS

Programme evaluation is a form of inquiry that requires more than the exercise of robust methodological techniques. Rather, it necessitates attention to the, sometimes divergent, priorities of different stakeholder groups. Although there is scant research on evaluation practices in health professions education, evaluation utilisation theory can inform critical examination of evaluation practices and impact in our field. Critically, understanding this body of work can help inform those engaged in evaluation about what they are (or should be) prioritising when they conduct programme evaluation, and better align evaluation methodologies with their scholarly, curricular and administrative intentions. Implications for future research and high-quality, transparent evaluation scholarship are presented.

Not missing the opportunity: Strategies to promote cultural humility among future nursing faculty

As the demographics in the United States continue to change, nurses must deliver care to patients from diverse cultural backgrounds. Cultural humility is a lifelong process of self-reflection which is also defined by that individual. It allows an individual to be open to other people's identities, which is core to the nursing standard of providing holistic care. Embracing and incorporating cultural humility is essential for creating a comprehensive and individualized plan of care. One of the ways to achieve cultural humility in nursing is to train future faculty to become agents of cultural humility. This also helps to create a pipeline of nurses who have respect and empathy for the patients they serve. The aims of this paper include: 1) define cultural humility and its importance to healthcare professionals; 2) explore the intrapersonal, interpersonal, and system levels of cultural humility; 3) provide insight on how to promote cultural humility; 4) reflect on best practices across a variety of healthcare disciplines; and 5) provide suggestions for practice.

How to Make or Break Implicit Bias Instruction: Implications for Curriculum Development

PURPOSE

To analyze faculty experiences regarding facilitating discussions as part of the institution's curriculum on racial and ethnic implicit bias recognition and management.

METHOD

Between July 2014 and September 2016, the authors conducted 21 in-depth interviews with faculty who had experience teaching in implicit bias instruction or were interested in facilitating discussions related to implicit bias and the Implicit Association Test. Grounded theory methodology was used to analyze interview transcripts.

RESULTS

Participants identified challenges that affect their ability to facilitate instruction in implicit bias. Faculty described the influence of their own background and identities as well as the influence of institutional values on their ability to facilitate implicit bias discussions. They noted the impact of resistant learners and faculty during discussions and made suggestions for institutional measures including the need for implementation of formalized longitudinal implicit bias curricula and faculty development.

CONCLUSIONS

Faculty facilitating sessions on implicit bias must attend faculty development sessions to be equipped to deal with some of the challenges they may face. Buy-in from institutional leadership is essential for successful implementation of implicit bias teaching, and medical educators need to consider formalized longitudinal curricula addressing the recognition and management of implicit biases.

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.