Medical Education Must Answer the Call for Diversity

Florida Woods, Gator Country (oil) by Ralph C. Williams Jr.

Civil unrest in response to racism is a call for realignment of priorities in all aspects of society, including medical education. Hospital preparedness demands training in the treatment of victims of pepper spray, tear gas and rubber bullets, as well as planning for lockdown procedures in healthcare facilities and medical schools. Beyond logistics though, events like the 2015 death of Freddie Gray in police custody in Baltimore led to calls for renewed emphasis on addressing racism in medical training programs. Indeed, curricular reform to illuminate and begin to redress the complicity of medical education in societal injustices that are barriers to equitable care is of paramount importance for victims of social and economic disadvantage, as well as society at large.

Globally, such calls for medical education reform are exemplified by student-led campaigns in South Africa to diversify medical curricula by increasing incorporation of traditional African indigenous knowledge. These campaigns have resulted in the initiation of dialogues between faculty, students and traditional health practitioners regarding decolonization of the curriculum.

Based on the premise that colonization distanced medical providers from their own heritage of traditional values, beliefs and practices, one group of nursing students and faculty reached several conclusions. These scholars suggested that widespread adoption of a monolithic Western training approach in a culturally diverse society, such as South Africa, impedes the ability to deliver holistic, nondiscriminatory healthcare. They noted that reversing the effects of the eradication of African philosophy and traditional healing techniques from the medical curriculum would take intentional action in an environment of respect and advocacy on the part of institutions.

Confronting the tension between a monolithic mindset of traditional medical education and a more culturally relevant curriculum requires that educators recognize that utilization of the scientific method results in only one way of knowing. A systemic failure to call out both overt and implicit bias further insulates the ivory tower of medical schools and medical educators from community input and access.

Embracing pluralistic thinking is one path to dismantling bias. Inviting and encouraging societal input into medical education can help accomplish this.

Adopting an expanded perspective on who can participate in curricular development and how they can do so could redefine authoritative medical meaning-making and who confers authoritativeness on academia. In short, we believe it is pos­sible, and preferable, to move away from didactic orthodoxy in education to a col­labor­ative, community-learning model. This is in keeping with the 1995 WHO declaration that medical education address the priorities of the communities they serve.

Social responsiveness in the arena of medical education—in this case, through enhanced community participation—is a mechanism by which training programs can better emphasize fairness and achieve health equity and enhance transparency about where the power to make curricular change rests.

The Need for Change

Philosophical and methodological calls for curricular reform in the medical and lay literature are not new, but contemporary advocates for reform decry an academic product that fails to emphasize concepts of justice, courage and truthfulness. Some methodological innovations, such as the advent of the flipped classroom, have challenged canonical didactic learning. Nonetheless, it is increasingly recognized that traditional medical education does not necessarily guarantee the attainment of entrustable levels of independent knowledge, skills and attitudes.

The phrase entrustable professional activities (EPAs) has been used for decades in medical education to describe specific tasks, skills and procedures that vary over time in the degree or manner in which they are supervised and evaluated. The concept, if not the phrase, is familiar to all who participate in medical education. Trainees are expected to skillfully accomplish certain activities with increasing independence as they proceed through their educational process. Supervisors must trust the ability of trainees to do so. In the current political climate, we may do well to consider how we can raise the level of trust in medical education from the communities we serve as well.

In the process of teaching and assessing EPAs, educators are tasked with assessing higher order reasoning skills. To achieve this, faculty rely on surrogate measures of proficiency: testing raw knowledge and determining how much supervision a given trainee requires at a given developmental stage. Unfortunately, neither a shared nomenclature nor a shared model exists among educators to translate competency frameworks to real-world medical practice.

Novel modes of collaboration could involve community testimonials paired with expert commentaries. In this manner, altruism, compassion & integrity all may be captured as meaningful learning objectives.

Despite calls to assess more complex and abstract attributes, knowledge acquisition remains the most common measuring stick of proficiency and entrustability. Community input is left out of the assessment equation. The unique juxtaposition of science and commitment to meaningful engagement at the level of the individual demands socially accountable medical education, yet how EPAs align with the priorities of the communities that medical schools serve is rarely asked.

EPAs also encompass such attributes as professionalism and empathy that defy readily quantifiable measures. Further, consensus among faculty is lacking regarding the actual level of entrustment needed to certify a given EPA. Educators are constrained by the public demand for proof of quality.

Endorsing EPAs is a process hampered by inadequate outcome measures of quality. Moreover, endorsing EPAs fails to account for the importance of mentoring and of role-specific education. At the same time, it fails to engage the community in assessing trainees’ sensitivity to cultural and socioeconomic priorities. And because assigning entrustability is a values-based activity without community involvement, granting the right to unsupervised practice fails to live up to the EPA’s promise of safe care defined by local standards.

This burden on educators carries the danger of a reflexive embrace of a posture of unassailable authority when advancing trainees down the path of entrustability, potentially at odds with community values. EPA assignment without community input may even place specific groups of patients at risk, leading to inequality on, for example, socioeconomic status.

Educational curricula concerning the social determinants of health, including unemployment, immigration status and homelessness, may be prone to implicit bias when neglecting pluralistic input.

Solutions

Properly designed learning strategies involving the community can inform practice-based learning and provide the foundation to redress institutional racism. Further, improved community and population health are higher-level educational outcomes that specifically aim to correct injustices in our social and medical systems. To achieve this, training programs need to emphasize an awareness not only of hard science but also of “contemporary and historical social injustices.”

On a global level, this has been ad­dressed, for example, by administratively involving Indigenous communities in medical education. In Australia, rural community health is taught to third-year medical students who live for the entirety of that year within the community that they serve. In Canada, local Aboriginal and Francophone communities participate in medical student selection. And in the Philippines, medical students work in the community to solve public health problems, such as improving access to clean water.

Community-based review processes currently employed in the research arena, such as community-based review of research protocols, could equally lend themselves to implementation within the arena of medical curricular development.

Another novel strategy emphasizes the potential of artificial intelligence (AI) and machine learning. AI methodology is able to identify a discrepancy in understanding that exists between two parties, for example, the trainee and the faculty or the trainee and community. AI is particularly suited to the assessment of clinical reasoning by virtue of the ability to compute maps of thought processes and to allow feedback on knowledge gaps immediately.

This serves two goals. First, it functions as a measure of learning because it serves to discriminate between two groups over time. By capturing the strength of alignment between trainees and faculty, critical-thinking skills can be assessed. 

Second, maintaining a record of the discrepancies captures systemic errors that need to be addressed for purposes of future quality improvement efforts. Machine learning may be leveraged to assess trainees with respect to community identified standards in addition to textbook learning.

At the level of the trainee, illuminating discrepancies in medical reasoning reflects systems-based learning, because it requires seeing interrelationships,
recognizing dynamic complexity and, ultimately, a refinement of medical meaning-making. At the institution level, it reflects practice-based learning and improvement, because it functions as a performance audit of the system that itself may serve to reveal implicit bias. If a group of trainees systematically treats one cohort of patients differently than another group, such an audit of behavior may reveal unconscious bias. At the community level, alignment of thinking between trainee and the local population, brings citizen power to medical education by providing attention to issues of marginalization and difference.

A third strategy concerns implementing reflection into curricular learning activities that specifically examine human rights abuses. This strategy can then be used as a mechanism for exposing class-based inequality.

A fourth strategy could provide a new format for educational conferences. Novel modes of collaboration could involve community testimonials paired with expert commentaries. In this manner, altruism, compassion and integrity may all be captured as meaningful learning objectives. These characteristics lend themselves to operationalization in this new format because the altruism and integrity per se are compatible with a compassion training effect.

In Sum

Social unrest is a reminder that medical education has a role in dismantling racial and ethnic division. This perspective piece aims to reorient the traditional curricular worldview.

Implementing a learning model for medical education that includes the community it serves requires a new vision for how the medical education system functions as a community (i.e., academia) and within a community (i.e., the public).

Citizen engagement in learning lends itself well to education efforts simply by virtue of embracing two-way, as opposed to top-down, hegemonic, communication. Embedded in this learning-community structure is value for cultural diversity and an acknowledgment that trainees must consider the interface of science and policy, as well as be able to communicate clearly and succinctly to diverse audiences in a variety of formats.

Interdisciplinary problem-solving experiences with multicultural input serve to encourage trainees to think critically and creatively, communicate with others and be intellectually flexible.

As we embrace new notions of curricu­lum development we should continue to ask: Are we capturing the authentic need of the community that medical education serves, and can we demonstrate that we are truly working to overcome racial and ethnic disparities in care?

James D. Katz, MD, is a senior research physician and the director of the Rheumatology Fellowship and Training Branch for the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH), Bethesda, Md.

Emily Rose, BS, is a participant in the Medical Research Scholars Program (MRSP), conducting research with the Grayson Lab in the Vasculitis Translational Research Program for NIAMS.

Katlin Poladian, MD, is a resident physician at the Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, N.C.

Sharon L. Kolasinski, MD, is a professor of clinical medicine at the University of Pennsylvania Perelman School of Medicine and chief of the Division of Rheumatology at Penn Presbyterian Medical Center, Philadelphia.

Karina D. Torralba, MD, is chief of the Division of Rheumatology and the rheumatology fellowship program director for Loma Linda University Health, California.

Declarations

This effort was supported by the Intramural Research Program of the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health. This effort was made possible in part through the NIH Medical Research Scholars Program, a public-private partnership supported jointly by the NIH and contributions to the Foundation for the NIH from the Doris Duke Charitable Foundation, Genentech, the American Association for Dental Research, the Colgate-Palmolive Company, and other private donors. The manuscript herein is not an official statement of the NIH or NIAMS. The authors appreciate the thoughtful comments of Laura Lewandowski, MD, and Robert Lembo, MD, who pre-reviewed the manuscript.

References

1. Bailey RJ, Baingana RK, Couper ID, et al. Evaluating community-based medical education programmes in Africa: A workshop report. Afr J Health Prof Educ. 2015 May;7(1 Suppl 1):140–144.
2. Betsch C, Böhm R. Cultural diversity calls for culture-sensitive health communication. Med Decis Making. 2016 Oct;36(7):795–797.
3. Braveman PA. Swimming against the tide: Challenges in pursuing health equity today. Acad Med. 2019 Feb;94(2):170–171.
4. Bromley E, Jones L, Rosenthal MS, et al. The National Clinician Scholars Program: Teaching transformational leadership and promoting health justice through community-engaged research ethics. AMA J Ethics. 2015 Dec 1;17(12):1127–1135.
5. Brown DR, Warren JB, Hyderi A, et al. Finding a path to entrustment in undergraduate medical education: A progress report from the AAMC Core Entrustable Professional Activities for Entering Residency Entrustment Concept Group. Acad Med. 2017 Jun;92(6):774–779.
6. Burrows GL, Calleja P, Cooke M. What are the support needs of nurses providing emergency care in rural settings as reported in the literature? A scoping review. Rural Remote Health. 2019 May;19(2):4805.
7. Carlson ER, McGowan E. A foundational framework for andragogy in oral and maxillofacial surgery I: General considerations. J Oral Maxillofac Surg. 2019 May;77(5):891–893.
8. Ellaway RH. Postmodernism and medical education. Acad Med. 2020 Jun;95(6):856–859.
9. French H, Arias-Shah A, Gisondo C, Gray MM. Perspectives: The flipped classroom in graduate medical education. Neoreviews. 2020 Mar;21(3):e150–e156.
10. Garofalo M, Aggarwal R. Obstetrics and gynecology modified Delphi survey for entrustable professional activities: Quantification of importance, benchmark levels, and roles in simulation-based training and assessment. Cureus. 2018 Jul 25;10(7):e3051.
11. Hebert-Beirne J, Hernandez SG, Felner J, et al. Using community-driven, participatory qualitative inquiry to discern nuanced community health needs and assets of Chicago’s La Villita, a Mexican Immigrant neighborhood. J Community Health. 2018 Aug;43(4):775–786.
12. Karches KE, Sulmasy DP. Justice, courage, and truthfulness: Virtues that medical trainees can and must learn. Fam Med. 2016 Jul;48(7):511–516.
13. Katz JD, Haile-Mariam TW, Roth K, et al. Teaching suffering: The testimonial-commentary method. Psychol Health Med. 2012;17(6):629–635.
14. Katz JD, Mamyrova G, Guzhva O, Furmark L. Random forests classification analysis for the assessment of diagnostic skill. Am J Med Qual. 2010 Mar–Apr;25(2):149–153.
15. Linganna RE, Goldhammer JE. OMG! Andragogy for millennials. J Cardiothorac Vasc Anesth. 2020 May;34(5):1250–1251.
16. Matwick AL, Woodgate RL. Social justice: A concept analysis. Public Health Nurs. 2017 Mar;34(2):176–184.
17. McBride B, Brewer C, Bricker M, et al. Training the next generation of renaissance scientists: The GK-12 ecologists, educators, and schools program at The University of Montana. BioScience. 2011;61(6):466–476.
18. McBurney CA, Vina ER. Racial and ethnic disparities in rheumatoid arthritis. Curr Rheumatol Rep. 2012 Oct;14(5):463–471.
19. Meyer EG, Chen HC, Uijtdehaage S, et al. Scoping review of entrustable professional activities in undergraduate medical education. Acad Med. 2019 Jul;94(7):1040–1049.
20. Moore AC, Anderson AA, Long M, et al. The power of the crowd: Prospects and pitfalls for citizen science in occupational health. J Occup Environ Hyg. 2019 Mar;16(3):191–198.
21. Ngunyulu RN, Sepeng N, Moeta M, et al. The perspectives of nursing students regarding the incorporation of African traditional indigenous knowledge in the curriculum. Afr J Prim Health Care Fam Med. 2020 Apr 16;12(1):e1–e8.
22. Osborne ML, Fields SA. Training physicians for the future US health care system. Future Hosp J. 2014 Jun;1(1):56–61.
23. Pedersen R. Empathy development in medical education—A critical review. Med Teach. 2010;32(7):593–600.
24. Pratt B. Constructing citizen engagement in health research priority-setting to attend to dynamics of power and difference. Dev World Bioeth. 2019 Mar;19(1):45–60.
25. Radonjic A, Yarkhani E. Balancing health disparities through socially accountable medical education. Educ Health (Abingdon). 2019 Sep–Dec;32(3):133–134.
26. Reeve C, Woolley T, Ross SJ, et al. The impact of socially-accountable health professional education: A systematic review of the literature. Med Teach. 2017 Jan;39(1):67–73.
27. Salhi BA, Brown PJ. Teaching health as a human right in the undergraduate context: Challenges and opportunities. Health Hum Rights. 2019 Jun;21(1):191–202.
28. Shenkman E, Hurt M, Hogan W, et al. OneFlorida Clinical Research Consortium: Linking a clinical and translational science institute with a community-based distributive medical education model. Acad Med. 2018 Mar;93(3):451–455.
29. Shore N, Ford A, Wat E, et al. Community-based review of research across diverse community contexts: Key characteristics, critical issues, and future directions. Am J Public Health. 2015 Jul;105(7):1294–1301.
30. Siega-Sur JL, Woolley T, Ross SJ, et al. The impact of socially-accountable, community-engaged medical education on graduates in the Central Philippines: Implications for the global rural medical workforce. Med Teach. 2017 Oct;39(10):1084–1091.
31. Strasser R, Worley P, Cristobal F, et al. Putting communities in the driver’s seat: The realities of community-engaged medical education. Acad Med. 2015 Nov;90(11):1466–1470.
32. Strasser R, Hogenbirk J, Jacklin K, et al. Community engagement: A central feature of NOSM’s socially accountable distributed medical education. Can Med Educ J. 2018 Mar 27;9(1):e33–e43.
33. Ten Cate O, Taylor DR. The recommended description of an entrustable professional activity: AMEE Guide No. 140. Med Teach. 2020 Nov 9;1–9. doi: 10.1080/0142159X.2020.1838465. Online ahead of print.
34. Toward a global consensus on quality medical education: Serving the needs of populations and individuals. Proceedings of the 1994 World Health Organization/Educational Commission for Foreign Medical Graduates Invitational Consultation. Geneva, Switzerland, October 3–6, 1994. Acad Med. 1995 Jul;70(7 Suppl):S1–S90.
35. VanLangen KM, Meny L, Bright D, Seiferlein M. Faculty perceptions of entrustable professional activities to determine pharmacy student readiness for advanced practice experiences. Am J Pharm Educ. 2019 Dec;83(10):7501.
36. Ventres W, Dharamsi S. Socially accountable medical education—The REVOLUTIONS framework. Acad Med. 2015 Dec;90(12):1728.
37. Weingartner LA, Sawning S, Shaw MA, Klein JB. Compassion cultivation training promotes medical student wellness and enhanced clinical care. BMC Med Educ. 2019 May 10;19(1):139.
38. Wear D, Zarconi J, Aultman JM, et al. Remembering Freddie Gray: Medical education for social justice. Acad Med. 2017 Mar;92(3):312–317.