Equity and justice in medical education: mapping a longitudinal curriculum across 4 years | BMC Medical Education

Equity and justice in medical education: mapping a longitudinal curriculum across 4 years | BMC Medical Education

During the 2020 US uprising for Black lives and concurrent increased awareness of national and global COVID-19 health inequities, our school set out to develop a comprehensive longitudinal ARDEI curriculum, spearheaded by students and bolstered by recommendations from our school’s Anti-Racism Task Force report [8]. The goal of this innovative curricular mapping was to discern ARDEI gaps in our program, engage faculty, and identify opportunities for sustainable curriculum development.

Building on existing US educational frameworks for structural and cultural competence, including the Association of American Medical College’s (AAMC) Tool for Assessing Cultural Competence Training (TACCT) [9], and Liaison Committee on Medical Education (LCME) [10] and American College of Graduate Medical Education (ACGME) DEI competencies [11], the team’s curricular goals were several. First, we recognized the need to build the curriculum upon a groundwork of psychological safety within our learning environment, which is a central tenet of learning in a competency-based medical education (CBME) framework [12, 13]. A second major goal related to deconstructing the racial essentialism that taints science and medicine both historically and in the present. Third, we focused on bolstering student skills toward active engagement in clinical and structural change toward enhancement of excellence and equity in healthcare and scientific discovery.

Setting & participants

In Spring 2020, faculty and administrative leaders at the Columbia University Vagelos College of Physicians and Surgeons (VP&S,) a four-year, urban medical school in the Northeastern US, made a number of commitments to anti-racism [8, 14]. One was creation of a faculty leadership position, Director of Equity and Justice (E&J) (author HC), within curricular affairs and linked to annual funding for five medical student E&J fellows. Additionally, faculty-student partnerships launched several urgently needed curricular enhancements to add critical content and strengthen learning environment psychological safety related to anti-racism discussions. To do so, we crafted student and faculty learning opportunities and structures to bolster growth mindset, student-faculty partnerships, and civil discourse regarding difficult topics such as systemic racism. These efforts included curricular initiatives to center skills that promote belongingness for all, particularly those underrepresented in medicine, as these are essential to wellness, high-functioning diverse teams, and are key to fostering cutting-edge scientific innovation [15].

Concomitantly, over 100 faculty leaders participated in longitudinal educational opportunities; also, individual bias-reduction consultation for educators was and continues to be widely utilized (> 50 consultations in academic year 2022–2023). Soon after these urgent initiatives were in place, the curricular mapping process began.

Identifying conceptual frameworks

Curricular mapping began using a backward design framework [16], with development of 10 ARDEI learning objectives. Several conceptual frameworks guided learning objective development, including the seminal schema published in 2020 by the Association of American Medical Colleges (AAMC) Group on Diversity and Inclusion (GDI) and Group on Faculty Affairs (GFA) [6] who recommended a pedagogy of anti-racism learning conceptualized as a pyramid with foundational awareness at the base of the pyramid, knowledge in the middle, and action-oriented leadership at the apex. We modeled our curriculum after this pyramid and added the concepts of both psychological safety and brave spaces [12] as the grounding on which the pyramid must be built. (Scholars conceptualize brave spaces of learning as those that merge psychological safety with encouragement for students to engage with ideas and skills that may be uncomfortable, with the understanding that discomfort may precipitate learning [17, 18].) The AAMC draft (later finalized) DEI competencies offered invaluable additional core conceptual support to our curriculum mapping journey [19]. These AAMC guidelines cover 3 domains – Diversity, Equity, and Inclusion – and catalog demonstrable competencies for medical professionals at each stage of training: beginning residency, entering practice, and faculty educator. Similarly useful in structuring our curriculum from awareness and knowledge to action-oriented skills was the 2021 anti-racism framework developed by Camara Jones: See, Name, Understand, and Act [20].

Building learning objectives

The equity and justice team used the domains of the AAMC DEI competencies and the developmental progression of the AAMC GDI/GFA framework as a starting point. These were complemented by relevant aspects of benchmarks from the TACCT, LCME, and ACGME and edited to eliminate redundancy and emphasize institutional priorities, to generate 10 draft ARDEI learning objectives in Fall of 2020. See Fig. 1 for key contributors to the ARDEI MEPO domain.

Fig. 1
figure 1

Anti-racism, diversity, equity, and inclusion MEPO domain: guiding frameworks and policies

Subsequent months were spent iteratively meeting with education leaders, including course and clerkship directors and finally our central curriculum committee, to gain perspectives, buy-in, and simultaneously map curricular activities. In fall 2022, during our school’s curricular revision process, the 10 ARDEI learning objectives provided a basis for development of the school’s new MEPOs, described below. The school’s central curriculum committee formally adopted the new MEPOs in spring 2023. See Fig. 2 for ARDEI MEPO domain creation timeline.

Fig. 2
figure 2

Timeline of anti-racism, diversity, equity, and inclusion MEPO domain development

Mapping the curriculum

Following iterative development of 10 ARDEI learning objectives by students and faculty educators, the E&J medical student fellows and director mapped the learning objectives to the curriculum, meeting with course and clerkship directors, reviewing preclinical and/or clinical course outlines, lecture objectives, seminar foci, and assessment tools. The review included analysis of 445 pre-clinical lectures, > 24 courses, 6 core clerkships, electives, and sub-internships. See supplemental materials 2 for VP&S Four-Year Equity and Justice Curriculum Activities Mapped by Learning Objective.

Fortifying the curriculum

To strengthen curricular longitudinality and address urgent content gaps, we added several foundational sessions. See supplemental materials 3 for curricular specifics.

Pre-matriculation summer reading curriculum

We first initiated an anti-racism pre-matriculation summer reading curriculum, including diverse texts designed to cover a broad topic range including a history of racism in medicine, racial essentialism, structural competency, health disparities, and implicit bias. These readings are debriefed longitudinally throughout the first year, within courses such as genetics, cardiology, and the longitudinal sociobehavioral medicine course.

This pre-matriculation curriculum not only introduced students to many foundational topics, but also laid the groundwork for community conversations about racism. As previously mentioned, psychological safety is a bedrock for CBME and it cannot be overemphasized with reference to anti-racism related topics. Thus, we launched our anti-racism curriculum with a seminar-style discussion based on the Courageous Conversations® framework [21], which is designed to foster skills to assist in discussion of difficult topics. To anchor the conversation, we utilized James Baldwin’s “A Letter to My Nephew” [22] for its strong themes of history, systemic racism, and humanity. To facilitate and deepen this conversation, we chose a narrative medicine framework for its power to foster narrative humility, multi-perspectives, and radical listening [23]. This session was bolstered by 6 h of faculty development for seminar faculty facilitators, designed in partnership with Columbia University Teachers College faculty. Encouraged by students to obtain expert co-facilitators, we additionally engaged graduate students from our Teachers College, social work, and public health schools who were experienced anti-racism facilitators.

Upstander Curriculum

To further support learning environment belongingness, recognizing that chronic racism creates stress that can impair learning as well as academic and team performance [12, 24], we launched a longitudinal upstander-skills curriculum. As an upstander is someone who intervenes on behalf of others [25], this curriculum offers students the opportunity to practice an advocacy intervention that may feel uncomfortable within a climate of non-judgement and support. Taught at three time points across four years, each session includes preparatory reading and interactive lecture, followed by small-group simulation during which students use sample cases to practice and discuss published strategies to utilize brave spaces for speaking and acting in support of others experiencing bias [26, 27].

Multi-course anchoring and assessment

Finally, we developed longitudinal, multi-course opportunities for anchoring and scaffolding knowledge and strengthening assessment. One significant curricular addition is an Anti-Racism at the Bedside session [28], which links pre-clinical content to concrete clinical tools. This two-hour workshop, designed for second-year students on the cusp of entering their hospital rotations, includes a number of exercises designed to mitigate bias, including practicing history-taking utilizing the structural vulnerability assessment [29]; utilizing the Visualdx.com skin of color diagnostic resource [30]; and practicing note-writing to minimize stigma [31]. To bolster assessment, we integrated multiple choice and short answer questions, and essays within our organ and disease-based pre-clinical courses. Additionally, we partnered with primary care clerkship faculty to develop an essay evaluation rubric for structural competency. Because mapping demonstrated a strong curricular foundation in structural competency, students and faculty felt comfortable with a graded assignment for this topic.

Developing an anti-racism program objective domain

In fall 2022, our medical school began an expansive curriculum re-imagining. This process was parallel to the ARDEI curriculum development and deeply informed by the work described above. As a first step to the curriculum re-imagining, the school revised its overall medical education program objectives (MEPOs). In addition to incorporating the six ACGME core competencies to develop our MEPO domains, we created a novel ARDEI MEPO domain based upon the 10 ARDEI learning objectives. The novel ARDEI education program objective domain consists of three competencies: (1) Recognize personal biases and their impact on those around them and on patient care, and apply strategies to mitigate the effects of these biases; (2) Demonstrate skills necessary to serve as an ally to others and to promote agency in others when there is historical injustice; (3) Articulate structural and historical inequities and apply strategies to mitigate systems of oppression in order to achieve equitable health care and learning environments. Several of the original 10 ARDEI learning objectives were also mapped to additional MEPOs domains that include the core ACGME/American Board of Medical Specialties competencies: inquiry and anti-racism, diversity, equity and inclusion. One example is the learning about racial essentialism (e.g., use of race in medical algorithms) which is addressed in the medical knowledge domain. Similarly, understanding the value of diverse teams is covered under the systems-based practice domain.

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