In July, 2020, the two of us became the inaugural co-directors of the University of California, Riverside, School of Medicine’s new Health Equity, Social Justice, and Anti-Racism (HESJAR) curricular initiative. Since then the teaching of health equity to medical students has been a journey of continuous renewal.
Publications about health equity emerge nearly every day. Each year’s student cohort provides new pedagogical challenges. Every module we teach raises new issues regarding learning and assessment. We can’t stand still.
Our first academic year (2020-2021) set the stage for our continuous renewal. We decided to devote that year to grounding ourselves in the challenges of health equity. Of course that meant immersing ourselves in both health equity scholarship and the pedagogical approaches that other medical schools have adopted. But we also decided that we needed to take a deep dive into local health issues as a foundation for constructing our curriculum.
Throughout that academic year we held a series of zoom sessions with community members of diverse backgrounds. Open to medical school faculty, staff, and students, those sessions featured community members being interviewed by students about their health care experiences, particularly their interactions with health care professionals. From those interviews came numerous insights. Two such insights became fundamental to our teaching efforts.
First, those sessions convinced us that community members needed to be included in our classroom modules. Students needed to hear their health care experiences, as well as their suggestions for more equitable treatment. For example, we built a second-year classroom session around disability, featuring Peter Benavídez, founding director of Riverside Blindness Services. As part of our classroom conversation, Peter walks students through the experiences of blind people when visiting medical offices and health care institutions. His experience-based exploration of health equity has made his session one of the most well-received in our entire curriculum.
Second, our learning journey into health equity scholarship, other institutions’ efforts, and community sessions dramatized the enormous range of topics that could be addressed under the broad HESJAR rubric. Yet we had to operate within an already- crowded medical curriculum. We were allocated four to five required two-hour classroom modules during each of the students’ first two years. Moreover, those modules are spread throughout the year, challenging our efforts to build continuous learning from one session to another.
We decided to follow Albert Einstein’s dictum,, “Try to make everything as simple as possible but not simpler.” If we tried to “cover” too much, our curriculum could easily become a distracting hodgepodge. So we decided to focus our curriculum on one central theme: patient-centered care. We would expose students to other important HESJAR topics through voluntary activities like invited speakers, book clubs, and student-organized conferences. However, we would use our limited required contact time to concentrate on helping students improve the health care experiences and outcomes for patients, particularly those from traditionally marginalized groups.
To support student learning about patient-centered care, we focused HESJAR’s first two years on specific themes. Our first-year theme is Developing a Health Equity Mindset. Our second-year theme became Engaging Divergent Health Care Experiences, using an anti-deficit lens to address health care perspectives arising from different individual and group identities and challenges. Moreover, each year we assess our efforts in implementing these themes and draw on this assessment to renew the following year’s curriculum with an emphasis on greater learning effectiveness.
With first-year students we address Developing a Health Equity Mindset through such themes as the neuroscience of diversity and the identification and elimination of privilege in clinical situations. In addition, to help students organize their thinking, we have adopted a mnemonic model based on the word, EQUITY. Developed by Dr. Osei during a year-long study program with Harvard Macy Institute, this model focuses on steps to enhance both critical analysis and clinical action.
E — Examine Assumptions
Q — Question Privilege
U — Uncover Biases
I — Investigate Context
T — Treat Equitably
Y – Yield to Patient’s Voice
For our second-year theme — Engaging Divergent Health Care Experiences – we address such topics as race, ethnicity, LGBTQ+ issues, disability, and the effective use of medical interpreters in clinical situations. Each year we observe students’ responses to the individual sessions and obtain student feedback to continuously renew those sessions and to determine where we may want to add other diversity perspectives. In the process we noted that second-year students respond particularly well to those who can speak from their lived experiences.
This brings us to the issue of assessment. How do we determine whether our HESJAR curriculum is having the desired impact on students, particularly regarding their behavior in patient-centered situations? Our medical school requires a brief multiple choice examination after each two-hour module. This helps us assess short-term learning and determine which basic concepts we need to reinforce in future sessions.
Moreover, each year we try to renew our assessment focus on how HESJAR has influenced student behavior in clinical situations. We do that through our medical school’s Observed Structured Clinical Experience (OSCE) standardized patient assessment program. Community members are trained both to perform as patients within designed health care scenarios and to assess student performances. This includes evaluating students’ abilities to communicate bi-directionally and make shared decisions involving health equity challenges. Each year we attempt to make HESJAR skills more integral to the scripted scenarios and student assessment.
During the students’ fourth year we turn our attention to critical reflection and participatory action research. The goal is to help students consider their possible career-long roles as health equity change agents. As we further develop HESJAR, we hope that students will complete this four-year process with both the dedication and the capacity to make our health care system more equitable and inclusive for all.
As we enter the fifth year of our personal HESJAR journey, we maintain our commitment to continuous renewal. Hopefully each year brings improvement as we massage our vision and update our curriculum, pedagogy, and assessment. Most important, we hope that constant renewal means that future student cohorts will go forth as more effective champions of health equity.
Photo by Hush Naidoo Jade Photography on Unsplash
Adwoa Osei is Co-Director of the Health Equity, Social Justice, and Anti-Racism curriculum, Director of Pediatric Undergraduate Medical Education, and Associate Clinical Professor of Pediatrics of the University of California, Riverside, School of Medicine.She has received multiple awards for clinical care and teaching excellence.Dr. Osei has developed innovative methods for involving diverse local communities to share their experiences in educating medical personnel for cultural competence.She leads the UCR clinic for Leadership Education in Neurodiversity and has served on expert panels on disabilities for the Centers for Disease Control and American Academy of Pediatrics.