Toward an Anti-Racist Curriculum: Incorporating Art into Medical Education to Improve Empathy and Structural Competency

Anti-oppression pedagogy in health professions: a scoping review

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

Leveraging Resident-As-Teacher Training for Health Equity Education: A Transformative Approach

Issue: Resident teachers play an essential role in medical education and can support broader efforts to advance anti-racism and health equity in medicine. The Accreditation Council for Graduate Medical Education requires programs to provide education about health care disparities so residents can contribute to and lead work in this area. However, the literature includes few examples, frameworks, or strategies for preparing residents to develop the knowledge and skills needed to promote health equity, including in their role as clinical teachers. Evidence: In this article, the authors propose leveraging Resident-as-Teacher training to support residents in learning and teaching for health equity. Gorski's conceptualization of equity literacy provides an evidence-based framework for four main abilities (recognizing, responding, redressing, and cultivating/sustaining) residents and medical students can develop through co-learning about health equity in the clinical learning environment. The authors discuss preconditions, example activities, and assessments strategies for effective health equity education. Based on the principles of social learning theory, the authors recommend that Resident-as-Teacher training be part of an institutional strategy to cultivate a community of practice for health equity education. Implications: Incorporating health equity education into Resident-as-Teacher curriculum offers a potentially transformative part of the broader strategy needed to prepare the next generation of physicians to enact anti-racism and advance health equity.

Anti-racism curricula in undergraduate medical education: A scoping review

PURPOSE

Medical educators have increasingly focused on the systemic effects of racism on health inequities in the United States (U.S.) and globally. There is a call for educators to teach students how to actively promote an anti-racist culture in healthcare. This scoping review assesses the existing undergraduate medical education (UME) literature of anti-racism curricula, implementation, and assessment.

METHODS

The Ovid, Embase, ERIC, Web of Science, and MedEdPORTAL databases were queried on 7 April 2023. Keywords included anti-racism, medical education, and assessment. Inclusion criteria consisted of any UME anti-racism publication. Non-English articles with no UME anti-racism curriculum were excluded. Two independent reviewers screened the abstracts, followed by full-text appraisal. Data was extracted using a predetermined framework based on Kirkpatrick's educational outcomes model, Miller's pyramid for assessing clinical competence, and Sotto-Santiago's theoretical framework for anti-racism curricula. Study characteristics and anti-racism curriculum components (instructional design, assessment, outcomes) were collected and synthesized.

RESULTS

In total, 1064 articles were screened. Of these, 20 met the inclusion criteria, with 90% (n = 18) published in the past five years. Learners ranged from first-year to fourth-year medical students. Study designs included pre- and post-test evaluations (n = 10; 50%), post-test evaluations only (n = 7; 35%), and qualitative assessments (n = 3; 15%). Educational interventions included lectures (n = 10, 50%), multimedia (n = 6, 30%), small-group case discussions (n = 15, 75%), large-group discussions (n = 5, 25%), and reflections (n = 5, 25%). Evaluation tools for these curricula included surveys (n = 18; 90%), focus groups (n = 4; 20%), and direct observations (n = 1; 5%).

CONCLUSIONS

Our scoping review highlights the growing attention to anti-racism in UME curricula. We identified a gap in published assessments of behavior change in applying knowledge and skills to anti-racist action in UME training. We also provide considerations for developing UME anti-racism curricula. These include explicitly naming and defining anti-racism as well as incorporating longitudinal learning opportunities and assessments.

Bringing abstract concepts to life: A health humanities-based approach to teaching social determinants of health

Background

To address health inequities, emergency physicians must understand the structural underpinnings of health disparities, including social determinants of health (SDoH), and must critically reflect on the integration of SDoH into clinical practice. SDoH education should include reflective knowledge acquisition, while incorporating systemic sociohistorical forces and individual factors, such as bias, which propagate inequities but are rarely emphasized in graduate medical education (GME). The health humanities (HH), an inclusive transdisciplinary field combining arts, humanities, and social justice, may represent a novel unexplored approach toward incorporating SDoH in GME.

Methods

We sought to implement and evaluate a GME HH-based curriculum focused on SDoH. An interprofessional team applied Kern's framework to create a longitudinal HH curriculum integrating narrative medicine and visual thinking strategies with evidence-based practices for addressing SDoH in clinical practice. This curriculum was implemented for 52 residents in an EM program in 2019-2020; sessions were initially held in the classroom and community and then virtually during the COVID-19 pandemic. Objectives included encouraging (1) critical thinking about SDoH, (2) engagement with patients and communities, (3) self-reflection, and (4) translation of SDoH to patient care. Descriptive statistics and a constructivist paradigm were applied to results of a postcurriculum survey and focus group, respectively.

Results

A curriculum evaluation survey completed by 32/52 residents (61.5%) revealed agreement (75%-90%) that objectives were met. 93.1% of respondents thought humanities were important in residency training. Qualitative analysis of a focus group with 10 participants revealed additional impacts on individual growth, transformation of departmental culture, and transformation of patient care. Curriculum implementation was inexpensive and relied on interprofessional collaboration.

Conclusions

The HH represent a promising collaborative framework for integrating SDoH in GME and may inspire transformation of learners' attitudes and practices in EM, though clinical impacts still need to be established.

By Medical Students, for Medical Students: A Narrative Medicine Antiracism Program

Objectives

Medical schools have sought to incorporate concepts of race and racism in their curricula to facilitate students' abilities to grapple with healthcare disparities in the United States; however, these efforts frequently fail to address implicit bias or equip students with cultural humility, reflective capacity, and interpersonal skills required to navigate racialized systems in healthcare. The purpose of this study was to develop and evaluate an antiracism narrative medicine (NM) program designed by and for preclinical medical students.

Method

Preclinical medical students at a single center were eligible to participate from June-July 2021. Program evaluation included a postprogram qualitative interview and electronic survey. The semistructured interview included questions about program experience, lessons learned, and perspectives on antiracism curricula in medical education. Interviews were qualitatively analyzed using open and axial coding. Survey data were analyzed with descriptive statistics.

Results

A total of 30 students registered. All (100%) respondents reported "somewhat true" or "very true" in the postprogram survey when asked about their ability to reflect on their own racial identity, racial identity of others, and influence of their racial identity on their future role as a healthcare worker through the program. Qualitative analysis revealed 3 themes: (1) curricular engagement; (2) racism and antiracism in medicine; and (3) group experience. Subthemes included: meaningful theoretical content; multimodal works and unique perspectives; race, identity, and intersectionality; deeper diversity, equity, and inclusion engagement; reconstructive visions; future oriented work; close reading and writing build confidence in discomfort; community and support system; and authentic space among peer learners.

Conclusion

This virtual, peer-facilitated antiracism NM program provided an engaging and challenging experience for participants. Postprogram interviews revealed the program deepened students' understanding of racism, promoted self-reflection and community building, and propagated reconstructive visions for continuing antiracism work.

Facilitating difficult conversations through art: creating an anti-racism digital image library for health professions education

Racism has been recognised as a threat to patient outcomes, public health, and the healthcare workforce, and health professions (HP) educators and learners alike are seeking effective ways to teach anti-racism in HP education. However, facilitating conversations on race and racism in healthcare contexts can be challenging. Integrative arts and humanities approaches can engage learners in the critical dialogue necessary to educational interventions focused on anti-racism. Discussions of works of visual art, for instance, can leverage visual art as an avenue for indirection to balance introspection and revelation with psychological safety. Structured pedagogical frameworks that emphasise the perspectives and experiences of participants, such as the Visual Thinking Strategies approach, can lead to open-ended and collaborative discussions where participants can safely explore their assumptions in a space that encourages productive discomfort. Visual arts-based programs on anti-racism in HP are limited, though, in part because no collection of images exists to support HP educators in this endeavour. This paper describes the process of developing a digital image library to support HP educators seeking to generate discussions on race and racism as part of anti-racism curricula. We also highlight common themes, best practices, and potential pitfalls associated with use of the image library.

Character and virtue development in medical learners: another role for the arts?

Medical education serves to teach students how to think and act as future physicians. Doing so successfully requires supporting learners' acquisition of clinical skills and knowledge, but also attending to their character education and virtue development. The arts and humanities are widely embraced as a fundamental component of a complete medical education. While not frequently touted as a useful pedagogical tool for teaching character and virtue, we argue the integration of arts-based activities into medical education can promote virtue development. In this article, we use the virtues framework from the Jubilee Centre for Character and Virtues at the University of Birmingham to review existing empirical studies of arts-based programs for each of these virtue domains of intellectual, moral, civic, and performance virtues. Learners may benefit from further exploration-both conceptual and empirical-of how the arts can scaffold character development in medical education.

"A sorely neglected field": A multisite study of self-reported humanities exposure among emergency medicine residents

BACKGROUND

The Association of American Medical Colleges has identified the humanities as fundamental to medical education across all specialties. Evidence from undergraduate medical education (UME) demonstrates the humanities' positive impacts on outcomes that could be relevant to patient care and trainee well-being in emergency medicine (EM) residency training. However, less is known about the humanities' role in graduate medical education (GME).

OBJECTIVES

The objectives were to describe EM residents' self-reported exposure to the humanities and its relationship with their empathy, tolerance of ambiguity, and patient-centeredness, and to assess their attitudes toward the humanities in GME.

METHODS

This cross-sectional survey-based study was conducted at six U.S. EM residency programs in 2018-2019. Quantitative analyses included linear regressions testing for trends between humanities exposures and outcomes, adjusted for sex, year in training, and clustering within programs; adjunct analysis of free-text responses was performed using an exploratory constructivist approach to identify themes about views on the humanities' role in medicine.

RESULTS

Response rate was 54.8% (153/279). A total of 65% of respondents were male and 28.1% of respondents had a preceding humanities degree. Preceding humanities degree and current self-reported humanities exposure were positively associated with performance on empathy subscales (p = 0.02). Seventy-five percent (n = 114) of respondents agreed humanities are important in GME; free-text responses revealed perceived positive impacts of humanities on generating well-rounded clinicians and enhancing patient care.

CONCLUSIONS

Engagement with the humanities may be associated with empathy among EM residents. Although the magnitude of associations was smaller than that seen in UME, this study demonstrates resident interest in humanities and suggests that extracurricular engagement with the humanities may be insufficient to prolong positive impacts seen in UME. Further research is needed to explore how to sustain these benefits through integration or addition of the humanities in existing GME curricula.

Visual art-based training in undergraduate medical education: A systematic review

BACKGROUND

Visual art has been increasingly incorporated into medical education and has been shown to enhance important competencies, such as empathy. However, limited evidence on effective visual art program design and evaluation processes remain. This systematic review examines the format, content, and espoused outcomes of visual art-based training programs in undergraduate medical education.

METHODS

A comprehensive literature search of MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ProQuestERIC on undergraduate medical education and visual arts retrieved 1703 articles published from 2014 to 2020. After reviewing inclusion and exclusion criteria, 23 articles were chosen for full review and synthesis.

RESULTS

Program format and content varied, ranging from 1-day specific competency focused programs to well-structured comprehensive 6-12-week programs. 6 areas of program foci were identified: observation skills, empathy, tolerance to uncertainty, cultural sensitivity, team building and collaboration, and wellness and resiliency. Although several programs used validated measures to assess skills acquisition, they seldom addressed long-term outcomes.

CONCLUSIONS

Our findings indicate that visual art-based education hold a promise to enhance important competencies in medical education, particularly empathy. Clinical observation, in particular, had the strongest evidence of its effectiveness compared to the other competencies. Future programs incorporating visual arts will benefit from a longitudinal (greater than 6 weeks) program which incorporates guided artworks, reflection exercises, and a group discussion to provide a stronger foundation for the development of core competencies. We propose using validated scales to measure outcomes in future studies and follow-up with participants to better assess Kirkpatrick Level 3 and 4 outcomes.

Developing the "Upstreamist" through Antiracism Teaching in Pharmacy Education

Objective. To present antiracism teaching as a key modality and an upstream approach to addressing health disparities in pharmacy education. Relevant theoretical frameworks and pedagogical strategies used in other health disciplines will be reviewed to present how antiracism curricula can be integrated into pharmacy educational outcomes.Findings. Various disciplines have incorporated antiracism pedagogy in their respective programs and accreditation standards. While challenges to implementation are acknowledged, structural racism continues to compromise health outcomes and should be centralized when addressing health disparities.Summary. Pharmacy curricula has explored and implemented cultural competency as a means to address the social determinants of health. By intentionally addressing racism in the context of health disparities, student pharmacists will further acknowledge racism as a public health issue and a systemic barrier to patient-centered care.

Formation and Evaluation of an Academic Elective for Residents in a Combined Internal Medicine-Pediatrics Residency Program

Background

Recently, there has been increasing focus on skills that are crucial for success in residency that is not explicitly taught. Specifically, the four domains of teaching skills, evidence appraisal, wellness, and education on structural racism have been identified as topics that are important and underrepresented in current resident education curriculums, largely due to time constraints.

Methods

A task force consisting of one post-graduate year 2 (PGY-2) resident, one PGY-4 resident, the Associate Program Director, and the Program Director of the Internal Medicine-Pediatrics residency program was formed to explore current deficiencies in resident curriculum and to research possible solutions. As an intervention, we created and executed a four-week academic elective with dedicated time for upper-level residents to learn and explore the four domains of resident teaching, evidence-based clinical practice, wellness, and anti-racism work. The elective included several clinical sessions dedicated to implementing the skills taught in the elective. The month-long elective completed in January 2021. All residents evaluated each lecture or experience based on how valuable it was to their education on a Likert scale from 1 to 7, with 1 defined as “not valuable at all” and 7 defined as “extremely valuable.”

Results

Residents rated the overall value of teaching in each domain highly. Education and activities in wellness lectures were found to have the highest value-added material (6.20 ± 0.41, n = 18), followed by residents-as-teachers lectures (5.93 ± 0.25, n = 48), anti-racism (5.57 ± 1.11, n = 9), and evidence-based clinical practice (5.18 ± 0.50, n = 43). In addition, each domain was found to have at least one high-yield topic.

Conclusions

We were able to create and execute an academic elective with dedicated time for upper-level residents to develop and utilize valuable skills in teaching, evidence appraisal, wellness, and anti-racism. Future work will focus on refining the curriculum based on resident evaluations and expanding this elective to the Internal Medicine and Pediatrics categorical programs at our institution.