Continuous Quality Improvement Team Recommendations for Diversity, Equity and Inclusion

The Independent Student Analysis (ISA) was a questionnaire administered by students as part of Penn State College of Medicine’s 2017 LCME self-study process. The entire student body was surveyed and a student team analyzed the results and presented it to the faculty. Based on student survey feedback, the topic of diversity was described in the ISA in the following excerpt:

“Many students felt that there could be more emphasis placed upon teaching students and faculty about diversity. As a result, some students felt uncomfortable or anxious in the learning environment. Alongside this, some students felt that there was a lack of diversity in written sample cases, standardized patients, and their scripts. While some comments mentioned progress regarding diversity at PSCOM, they felt that additional steps could be taken to address minority races, religions, sexual identities, and sexual orientations.” (Page 9)

Creating a comprehensive curriculum to address the lack of diversity education was one of the four top-level recommendations for improvement made by students in the ISA. Furthermore, the ISA recommendation corroborates data gathered from the AAMC Graduation Questionnaire
(GQ). For the question, “I believe I am adequately prepared to care for patients from different backgrounds,” the number of students who strongly agree has increased from 39.8 percent in 2013 to 54.2 percent in 2018, with fluctuations within that range in the intervening years. This is still below the national average of 64.1 percent of students in strong agreement.

For the question, “My knowledge or opinion was influenced or changed by becoming more aware of the perspectives of individuals from different backgrounds,” the number of students who strongly agree has steadily increased over time from only 7.8 percent in 2013 to 35.6 percent in 2018, although still below the national average of 40.6 percent who strongly agree.

Lastly, the question, “How often did you see ‘respecting diversity’ demonstrated by medical school faculty,” 42.7 percent of College of Medicine students answered “always” in 2018, slightly above the national average of 40.7 percent answering “always.” While progress has been made at the College of Medicine, student data shows that there is still work to do.

College of Medicine students’ concern for their education in this area is no surprise since a growing body of literature in academic medicine indicates that this is a concern nationally. Numerous recent publications describe efforts toward designing curricula which includes cultural competency, examination of personal biases, and an examination of structural biases in healthcare disparities. ²

Student activism is part of this thrust; for example, the group White Coats for Black Lives released its Racial Justice Report Card, grading 10 top medical schools for specific steps toward racial justice – none of which received high marks. ³

Several medical schools publicize their own curricula related to DEI, such as the University of Michigan’s Curriculum for Health Disparities and the Underserved, the Health Care Disparities Curriculum at the University of Chicago, the Health Disparity Curriculum at The Warren Alpert Medical School at Brown University, and the Health Equity and Social Justice curriculum at Robert Wood Johnson Medical School at Rutgers University. These curricula describe an intentional, integrated approach which includes a study of the social determinants of health, including race, gender, sexual orientation, ethnicity, socioeconomic status, religious beliefs and a host of other factors.

As part of its work, the task force performed the following steps:

• Reviewed the AY 17-18 curricula of Penn State College of Medicine Phases 1 and 2 using the iSeek search tool. Curricular materials including handouts, PowerPoints, PBL cases, etc., that are stored in SIMBA, the course management system, were searched for intentional teaching about DEI. ⁴ The group did not search for representation of a diverse population of patients or physicians – a separate project, to be sure – nor for mere mentions of groups as “at-risk” populations for disease.
• Reviewed the College of Medicine’s latest data from the Tool for Assessing Cultural Competence Training (TACCT), which LCME describes as a tool for identifying where cultural competency training appears in the curriculum. The TACCT was most recently completed for the 2018 LCME self-study.
• Conducted a student workshop to gather input in the development of the diversity vision statement.
• Reviewed findings from two student focus groups held in early 2018 on how to improve College of Medicine diversity education. Facilitated by Dr. Lynette Chappell-Williams and Dr. George Blackall, two of the current task force members, these conversations further revealed student concerns with the curriculum. For example, the portrayal of patients in PBL cases was frequently described by students as problematic, containing stereotypes of certain population groups.
• Contacted other medical schools to gather ideas about DEI curricula, including New Jersey Medical School (Rutgers), which has an individual designated to oversee their DEI curriculum.

As part of its work, the task force created a vision statement for diversity, equity, and inclusion in the College of Medicine curriculum. This was a collaborative effort with student input. This vision statement was reviewed and approved by representatives from the physician assistant program and the graduate programs at the College of Medicine.

Vision

The vision at Penn State College of Medicine is to equip our learners with the knowledge, skills, and attitudes they will need to provide culturally excellent health care and research for an increasingly diverse U.S. population. Our vision for cultural excellence, diversity, equity and inclusion is embedded in our educational pillars of health humanities, biomedical sciences, clinical sciences and health systems sciences.

A thoughtfully planned and documented vision defines goals and creates a personal ownership and shared language for all individuals. One shared vision will allow leadership to collaborate, support and engage all individuals to accomplish the vision.

In order to accomplish the vision, it should to be plainly and consistently communicated to inspire a meaningful commitment from all. Each stakeholder should understand the vision and the work that is required of them in the overall effort. A clear vision will give prospective students, faculty, staff and others a picture of the College of Medicine’s shared values. This will encourage applications and contacts from people who share the vision of cultural excellence, diversity, equity and inclusion.

Incorporating diversity across the medical school curriculum requires attention and effort. Dedicated faculty time to oversee this process ensures that it will not “flame out” after an initial push. This faculty member can help to integrate these topics and avoid duplication of efforts across courses and clerkships.

Although the College of Medicine has diversity and inclusion expertise through the Office for Diversity, Equity and Inclusion, and have curricular expertise within the Office of Medical Education, assistance will be needed in this first significant effort to incorporate diversity throughout the curriculum in a timely and comprehensive fashion.

The College of Medicine should invest in a consultant or consultants who have experience integrating these areas to give perspectives on implementing an exemplary inclusive medical education curriculum.

The expertise could be a combination of efforts: organizations that could do a “deep dive” in areas where the College of Medicine has the least internal expertise but could be a growing area of development, such as utilizing the Tanenbaum Center for Interreligious Understanding to address religious sensitivity issues. Tanenbaum has created a free resource – Religious and Cultural Competence for Medical Students: Advancing Patient-Centered Care – that can be used by the Office for Diversity, Equity and Inclusion to assist the Office of Medical Education with general religious inclusion information, but the college could contract with the organization to provide more in depth information, such as through Trigger Topics: Where Religion and Health Care Connect.

The second aspect would be contracting with individuals who could identify specific educational areas where diversity can be incorporated. The recommendation is to do a benchmarking of those medical institutions that have successfully incorporated diversity into the curriculum and contract with one of these individuals to do the same for our curriculum. Individuals such as Dr. Elena Olson, executive director of the Center for Diversity and Inclusion at Massachusetts General Hospital, or Dr. Joan Reed, dean for diversity and community partnership and professor of medicine at Harvard Medical School, could be contacted for recommendations.

To launch the effort to develop a comprehensive curriculum that incorporates diversity, the team recommends establishing a two-day immersion experience for clerkship and course directors modeled after the Faculty Institute at Cornell University.

This would provide faculty an opportunity to engage in a dialogue about aspects of diversity in the curriculum and creating a network of faculty who become “master educators” for diversity so can serve as resources to other faculty.

The immersion program would consist of advance readings on diversity in the curriculum and facilitation by outside experts, and would provide an opportunity to explore learning modalities and pedagogical approaches that promote an inclusive classroom environment.

Talking – and teaching – about issues of diversity, equity and inclusion can feel emotionally charged, political or challenging to teachers who are not well-versed in the language. It is easy to inadvertently say the wrong thing, even for a well-intended individual.

Simultaneously, issues of diversity, equity and inclusion can come up in almost any educational setting – from bedside rounds to small groups.

For example, students reported in the ISA that at times their peers (other students) would make inappropriate comments in the small-group setting. When this occurred, students felt the facilitator often responded in a sub-optimal way.

If faculty members do not know how to respond then they may do nothing – which is less than ideal.⁵ The team therefore recommends ongoing training for individuals with teaching responsibilities; once is not enough if the College of Medicine wants to begin to cultivate lasting skills in educators.

The ISA conducted in 2017 indicates that Penn State College of Medicine students value diversity. Research from organizational and social psychology indicates that diversity facilitates innovation, creativity and complex problem-solving. While there is limited research on diversity in health care organizations and medical education, research from other organizations makes a strong case for continued efforts to increase the diversity of educators.

One of the conclusions of the McKinsey & Company report “Diversity Matters” states “… more diverse companies and institutions are achieving better performance.” Expanding the diversity of educators will only serve to enhance performance as a college of medicine.

The recruitment of a diverse faculty and assignment to key committees is being addressed in the diversity policy being developed as a collaboration between Medical Education, Human Resources, and the Office for Diversity, Equity and Inclusion.

(For this analysis, the team recommends using AY 2017-18 curricular materials as a baseline measurement for future improvement.)

The College of Medicine’s values involving diversity are communicated in the selection of images to use in PowerPoints and use of appropriate terminology in describing population groups. Furthermore, students should be educated in the complex relationship between demographic variables and health outcomes. For example, emphasizing a simplistic race-disease association (i.e., “African-Americans are at risk for sarcoidosis”) without explaining the underlying social factors does not help to develop students’ critical thinking and leads to increased errors and harmful delays in diagnosis. ⁶

The team recommends methodology used by Tsai et al. in their Academic Medicine publication, “Race Matters? Examining and Rethinking Race Portrayal in Preclinical Medical Education,” (2016)7, to review PBL cases, PowerPoints from courses and other materials available in SIMBA to give a baseline measurement of materials used in academic year 2017-18.

For example, Tsai et al. found that whenever race was mentioned, it was simplistically describing racial risk factors as being due to either an explicit or implied biological difference between groups rather than “acknowledging social determinants of racialized disease disparities” (page 917). Would the College of Medicine find the same?

To begin a longitudinal curriculum on the relationship between racial identity and health, students should be proactively educated in the social construction of race using evidence from anthropology and social sciences. ⁸

While race is only one aspect of diversity, structural racism has had an enormous and historical impact on the health of communities of color in the United States. The medical profession often adopts an epistemology of racial essentialism, approaching race as a biological determinant of health. Instead, students should be provided with the knowledge that they need to critically question this notion and to look to complex factors such as the interplay of the chronic stress of racism with environmental factors in health. ⁹

An early learning opportunity that educates students into the problems of racial essentialism should be a mandatory event, ideally with small-group discussion following.

Teaching toward diversity, equity and inclusion is not one faculty members’ job; it is every faculty member’s responsibility.

Just as the College of Medicine is moving toward more complete curricular integration between humanities, clinical sciences, basic sciences and health systems science, DEI issues should be integrated throughout the curriculum.

The humanities curriculum might discuss how medicine has used race as a construct for classification of human beings since the Enlightenment. The study of cardiology could be enhanced by critical questioning of the scientific evidence behind the FDA’s approval of BiDil for specific marketing to African Americans. ¹⁰

When learning how to use critical appraisal skills in an evidence-based medicine course, students could apply these skills to studies related to health care services for LGBTQ individuals. A problem-based learning case could include a learning objective related to culturally appropriate care for Muslim patients, since this can be an area of uncertainty for non-Muslim students.

Every content area contains possibilities for teaching toward diversity, equity and inclusion, and the College of Medicine should take advantage of these opportunities and document how it is doing so in every course. The pre-existing process followed by the Curriculum Evaluation Committee, in which every course and clerkship is reviewed on a regularly recurring basis, is a suggested place to operationalize this.

(This recommendation includes the recruitment of diverse standardized patients and attending to issues of diversity within case scenarios.)

The standardized patient program has increased the diversity of its standardized patient actors by partnering with a local program for graduates of international medical schools run by the Simulation Center and with the drama department at Penn State Harrisburg. Through these efforts, racial and ethnic diversity has increased from 9 percent to 25 percent of the standardized patient actors.

Efforts should continue to recruit standardized patients to include transgender people, people of various religious backgrounds and those from other diverse demographic groups. This will directly address students’ documented desire to be better prepared to care for patients of diverse backgrounds.

Approximately 30 percent of the preclinical curriculum for the MD curriculum track in Hershey is taught using problem-based learning, so cases should reflect the College of Medicine’s values regarding diversity, equity and inclusion.

Currently, most patient portrayals do not include a mention of race, ethnicity, sexual orientation, gender identity, religious beliefs or other demographic variables. Even in cases where the demographic variable is not somehow linked to the clinical condition that is the topic of the case, inclusion of a rich portrayal of diverse patients can help reduce bias, because research consistently shows that surrounding learners with counter-stereotypes will reduce their own stereotyping. ¹¹

Assessment drives learning, so assessment items and question stems should also reflect this principle. Otherwise, there is the risk of cultivating or maintaining a hidden curriculum. Assessment items, and the clinical vignettes used in them, should be examined for representation.

According to the U.S. Census Bureau, by 2044, the “minority” population will become the majority. As the population in the United States becomes more diverse, the importance of training medical graduates to be more aware and understanding of the values, beliefs and views of people from different cultures than their own becomes increasingly important.

Knowledge about health care disparities informs culturally responsive care, or cultural empathy, which calls on physicians to not only have awareness of the social and cultural factors that affect their diverse patient cohorts but use that knowledge to negotiate them to improve health outcomes.

To this end, this curriculum provides a unique opportunity to foster cultural empathy while on a path toward empowering the future health care workforce to provide culturally responsive care. Given the value of said curricula and innovation required, this should be an independent thread that is woven into all phases of the existing College of Medicine curriculum.

(This wording was taken from White Coats for Black Lives.) ¹²

The phrase “nothing about us without us” was first coined by a disability rights activist to convey that no policy should be formulated without participation of all stakeholders. Following this theme, patients are increasingly seen as partners in medical conferences, research and health policy.

Following in this same vein, diverse community members should be viewed as partners as the College of Medicine seeks to execute its diversity, equity and inclusion vision. Diverse community members could serve on committees and steering groups, hopefully positively impacting concrete decisions around curriculum design, assessment, etc.

This plan should include the following:

• Perform biannual evaluation of curricular offerings using the TACCT tool, using 2017 as a benchmark.
• Monitor yearly data related to diversity, equity and inclusion from the GQ.
• Have students document their knowledge and growth in this area in their graduating portfolio. This directly addresses competency MH9.1: “Demonstrate compassion, humility, and respect toward all persons regardless of their diverse identities, values, beliefs, and experiences.”
• Assess student knowledge in this area using a validated instrument such as the Structural Foundations of Health instrument. This might be done in a reflection and assessment week, or could be incorporated into a course such as Science of Health Systems.
• Add a question to student course evaluations to measure excellence in DEI-related education, such as “How well did this course integrate topics and issues related to diversity?”

Given the importance of diversity, equity and inclusion, assessing efforts at changes is paramount. Documenting the College of Medicine’s improvements and growth in this area could serve as a differentiator for its programs in attracting potential students.

There are existing sites that serve diverse populations nearby that have limited student presence. Utilizing these sites would be another opportunity to further expose College of Medicine students to diverse patient populations.

Penn State College of Medicine students’ educational experience includes being hosted at affiliate sites.

The students’ expectation is that anti-discrimination/bias policies are in force as they are at Penn State College of Medicine and Penn State Health sites. Unfortunately, students have reported incidents to the Office of Diversity, Equity and Inclusion in which they were treated negatively because of their identity.

Memoranda of Understanding frequently already exist with affiliate sites, and the team recommends that all existing agreements be modified to include language from policy 33, including: prohibiting discrimination by patients; the process for students to follow to address challenges to application of the policy; and language that prohibits bias, sexual harassment or discrimination by employees of affiliate sites against College of Medicine students.

For example, this document should be circulated to all students.