Diversity: Inclusive Perspectives in Medical Education

Introduction

In addressing diversity within the context of medical education, several elements warrant consideration. Gender, race, and ethnicity represent salient yet non-exhaustive aspects of medical diversity. Legal and societal categorizations may distinguish individuals of divergent orientations, gender identities, and disabilities. As medical trainees, students vary in their ethnicities and racial identities as well as their socioeconomic status. Other areas of patient diversity that may present in the exam room include cultural, linguistic, religious, geographic, and educational backgrounds. Moreover, the urban, suburban, or rural setting influences access to public health resources.

Patients inhabit intersections of these varied diversities, influencing their healthcare disparities and experiences of prejudice in health-seeking.

Efforts to increase medical inclusion mirror the growth of diversity movements in medical education and societal institutions. These have been facilitated by landmark national policies. In the context of gender diversity, the Civil Rights Act barred sex discrimination by government institutions. In numerous settings during the 20th century, unspoken agreements between deans governed institutional executive appointment procedures, enforcing a gendered status quo and preventing administrative accountability. Efforts to increase medical inclusion and end discrimination aim to dismantle various forms of power that underpin historical and current prejudice and include a broader identity than gender alone. Beyond mitigating bias and improving clinical outcomes for patients who encounter gender- or race-based marginalization, adopting an inclusive approach to diversity can also enrich the day-to-day learning experiences and perspectives of medical students, faculty, and staff. Community norms and expectations have shifted over time to accommodate the growing trend towards diversity and inclusivity.

The Importance of Inclusive Perspectives

Inclusive perspectives can advance education. Exposure to diverse ideas and methodologies enriches education, challenges biases and stereotypes, fosters critical thinking, and opens up new vistas for innovation in creating healthcare aids or discovering illness treatments and preventions. Medical students are educators of patients and clients; they need to hear different worldviews and become comfortable with different life perspectives. Inclusion is an ethical imperative. Medical educators have an obligation to encourage the success of all students equitably, and any student should find medical education and the path to a medical career open and free. Each student should walk into the classroom, skills laboratory, or clinical setting without bias, prejudice, or limitation; race, creed, sex, gender expression, age, disability, or sexual orientation must have no burdens. Inclusive medicine is needed to keep patients safe. If a curriculum includes everyone and their voices, then we consider all aspects of that patient, all the way from the first element of their interview to assessment, diagnosis, prevention, and treatment. Exploring medicine through an inclusive lens has been seen to improve patient satisfaction and allows the provider to form more invested and successful partnerships, aiding in the process and outcomes of care. Inclusive approaches actively support affirmative learning environments. All learners must feel safe, secure, and able to express themselves in the learning environment. This requires respect and a safe learning environment for experiences from each student’s perspective, and it helps to create a culture of kindness and inclusivity for every single student. A diverse and inclusive medical education gives students the best opportunity to learn how to work with others and provide clinical care that is culturally respectful and without prejudices. In summary, inclusivity is essential to advancing education and professional practice in this field. And that is a good thing!

Strategies for Promoting Diversity

To move the process of integrating diversity and representation in the medical student curriculum beyond the simple inclusion of perspectives, one must first understand the diversity within the community. A needs assessment, in the form of surveys or expert panels representing the populations one aims to include, can identify diversity and factors surrounding it. Appropriate curriculum changes based on the assessment can range from substantive revisions to minor modifications designed to include diverse elements that are already present in the curriculum.

One must first understand the nature of diversity to be able to incorporate it effectively into any educational institution. Similarly, one must be able to identify underrepresented or marginalized groups to appropriately dedicate resources and streamline recruitment efforts. Recruitment efforts might also target the institutions these students hail from directly, aiming for high school and college programs that might potentially mentor and nurture them towards a career in science. Training of institutional and local area staff in regular recruitment efforts should include specific competencies of comfort, open-mindedness, and an ability to understand systems and effects of discrimination. In order to function at any level with an unfamiliar cultural community or background, one likely needs to engage in continuous training. Thus, one must train and retrain faculty, staff, and students in these competencies and emphasize student training.

The development of mentorship programs that foster community relations, through involvement and engagement with the communities caring for specific schools, can also be another effective strategy for promotion. Generation of partnerships with organizations that have a representational similarity to the institutions in the area can show the institution's commitment to diversifying their student body, putting financial and influential support where their ideology exists, as institutional relations are more readily available. Close monitoring and reevaluation to assess the effect of the strategies must also be continuously repeated to ensure that the philosophy has been transferred to an activity within the institution. The intentional and purposeful creation of a safe and inclusive environment for all students, supportive of their needs and appropriate to their culture, age, and tenure in the school, may also foster improved student academic achievement.

Challenges and Opportunities

While there is manifest momentum for creating inclusive practices in medical educational experiences, particularly in the United States, Canada, and other 'post-industrial' Western country settings, there is relatively limited evidence confirming just how well or effectively these practices are achieved, adopted, or sustained. There are significant barriers to the implementation of inclusive practices in medical education experiences in institutions and society. Some barriers raised within the academic literature on the subject of workforce diversity have been found to remain as significant factors across a variety of Western societies more broadly. Principally, these systemic barriers associated with the implementation of inclusive equality practices encompass inaccurate early conceptions about role legitimacy; dominant cultural practices; population refill; intra-personal and inter-personal reasoning models suggesting individual motivation for constructed gender/race-based differences; and responses to bias or discrimination. Many educators and senior staff also encountered barriers as a result of entrenched bias and lack of willingness to change, as well as practical limitations (of staffing, resources, in particular time and finances). In other cases, those educators who have initiated 'best' equality practices are faced with insufficient funds, staff, or training to make their programs truly effective.

There was some evidence that institutions with the least funding directed at increasing the diversity of the student body are the least likely to continue these initiatives or are not well sustained. There is, however, likewise a complementary and related set of opportunities to these challenges: the moral imperative and the business case; the change in the culture of education and society more widely to value and recognize diversity; and the willingness of some staff and students themselves to engage in the politics of social justice issues. Also, the findings indicate some successes on key fronts. Despite systemic or structural barriers to the wider (egalitarian) medical inclusion movement, some good practices are in evidence. Some educators have been willing and able to challenge and overcome barriers such as entrenched bias. Processes of change and reform in some schools have also been initiated 'from the bottom' (i.e., through student activist efforts), representing a challenge to the status quo. Moreover, some newly appointed senior medical teaching/academic staff have adopted a strong, evidenced, pro-diversity profile, really committed to change and deconstruction of previous racial norms. Other traditionally powerful or well-interconnected policy actors within and outside of the higher education sector have also been notable for clarifying and stating their commitment to pro-diversity. The findings suggest that the effectiveness and efficiency of an 'organizational commitment to equality' will strongly depend on the existence of some sort of joined-up leadership: senior policymakers; engaged academics; and well-networked process facilitators.

Case Studies and Best Practices

In many respects, this document is a compilation of successful case studies. Each of the programs and interventions described herein exhibits one or more "best practices" in promoting diversity and inclusion. A variety of methods have been selected for achieving those goals, and the implementation of those methods varies among the six medical schools contributing to this discussion. Every model presented in this document is intentionally innovative. These approaches to fostering diversity and inclusivity in undergraduate medical education do not represent the norm. Each medical school has taken a risk by investing in one or more of these programs without knowing what kind of return to expect. While the initiatives themselves may or may not be replicable, the spirit of innovation, of pioneering new ideas and turning a vision into a program, is within the reach of every medical school. The development of these case studies involved a complex process of cross-institutional collaboration, information sharing, qualitative interviews, and quantitative assessments. As a result, the following success stories emerged.

In keeping with a "best practices" approach, this section was intentionally designed to present a series of case studies highlighting successful diversity initiatives at various institutions. Stakeholders, including students, faculty, and upper administration, at all of the schools that participated were able to offer and share valuable experiences reflecting and surfacing their own perspectives. In all cases, clear benefits were cited, both for medical students and for faculty members. Benefits included, in various combinations, heightened cross-cultural sensitivity, increased institutional prestige and competitiveness, increased access to and recruitment from diverse populations, improved health care quality, excellence in clinical care, basic and clinical research, community services, and improved communication skills for all physicians. Students from diverse backgrounds reported feeling a greater sense of community and diversity support in their respective institutions as a result of their predominant pipeline initiatives. Faculty cited these same initiatives as providing the satisfaction of "giving back" by being a part of the programs and making a personal difference. Every campus used specific information from their annual evaluation report. They indicated that they use qualitative evaluations within the initiative itself as well as quantitative indicators to continue quality control, such as student and faculty focus groups, informal campus pulse checks, written and formalized feedback, external grant site visit observations.

Did you like this example?

230

12