In July, 2020, the two of us met for the first time as inaugural co-directors of the University of California, Riverside, School of Medicine’s new Health Equity, Social Justice, and Anti-Racism (HESJAR) curricular initiative. The school handed us those six words. The rest was up to us.
We started by looking and listening. We looked at what other medical schools had done. While we found some useful ideas, this strategy had built-in limitations. No other medical school that we encountered had triangulated those three intersecting but disparate ideas: health equity; social justice; and anti-racism. We had to address all three and integrate them into a coherent curriculum.
We also decided to listen. So we set up a number of discussion sessions with faculty, staff, and students, as well as a year-long series of community conversations in which medical students interviewed diverse community members about their health care experiences. Aided by this looking and listening, the two of us ultimately developed a four-year curricular model unlike anything we have seen at other medical schools.
Our basic goal is to educate our medical students to go forth as champions of health equity, committed to social justice, and dedicated to anti-racism. We aim to do this through a curricular model organized around three major concepts.
***Health Equity Framework
We decided to focus our curriculum on health care systems, culture, and structures (SCS). In what ways do these three health care components contribute to health equity or disparities? What steps can be taken to make these components more responsive to health inequities and supportive of social justice? In what respects has the idea of race been misused within health care and in what respects has it failed to receive sufficient attention? The SCS Trifocals became the foundation of our first-year curriculum.
The second-year curriculum increases the emphasis on relationships between health care professionals and patients, as well as their families. Central are three ideas: understanding; communication; and advocacy. These include a consideration of cross-cultural and cross-lingual perceptions and interactions. By addressing the critical role of advocacy, we hope that, by the time of graduation, our students will be effective cross-cultural communicators and will view themselves as champions for their patients within the health care system.
Health Equity Framework:
Because of the intensity of the four-year medical school curriculum, the number of HESJAR modules is necessarily limited. Therefore, we quickly recognized that much of our success would depend upon how deeply HESJAR values and thinking penetrated school-wide pedagogy. So we decided to try to integrate HESJAR into the school’s emphasis on case-based learning (CBL) and clinical settings. The CBL approach permeates the first two years of the curriculum, while intensive clinical experiences dominate the third and fourth years.
To integrate our curriculum within the school’s pedagogical approach, we developed our Health Equity Framework (HEF). That Framework posits a single foundational question, which we are encouraging all faculty to ask and apply in each of their classroom cases and clinical situations. The question: in this case or situation, what personal, systemic, cultural, or structural factors may exist that could facilitate or complicate the pursuit of health equity for the patient?
If all of our classroom and clinical faculty continuously pose that question with students, HESJAR can become central to school culture and student thinking. However, for faculty who want to push further, we also suggest three follow-up questions that delve into the three dimensions of HESJAR:
***Health Equity (HE): What intersectional dimensions of the patient may be relevant to the pursuit of equitable health outcomes?
***Social Justice (SJ): What structural, systemic, or situational factors may be relevant to the case?
***Anti-Racism (AR): What race-related factors, if any, should be considered?
To implement this approach, the two of us now offer monthly training sessions for faculty in how to use our Health Equity Framework in their classroom case discussions and in clinical settings. Simultaneously we introduce those questions to students so that they recognize the centrality of HESJAR to their education and become aware of school expectations that they engage with HESJAR ideas.
We harbor no illusions about the challenge of implementing such a curriculum, particularly the Health Equity Framework as a basis for discussions. In the “gotcha” culture of today’s college campuses, with widespread knee-jerk, shoot-from-the-hip accusations of racism or microaggressions, both faculty and students may naturally be hesitant to engage in vigorous discussions of challenging diversity issues. It’s safer to remain silent and avoid being fingered..
But we are optimistic. We have created an educational model that treats health equity and health excellence as vital, inseparable partners. We are trying to make the school an encouraging space for robust conversations about difficult diversity issues. In the process, we envision a transformed school culture in which faculty, staff, and students not only feel capable of engaging in constructive conversations about diversity and health care, but also become eager to do so.
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