In 2020, we were nearing the end of our first year of medical school while witnessing one of the most isolating and tumultuous times in our nation’s history:
- March 11, 2020: COVID-19 was declared a pandemic
- March 13, 2020: Breonna Taylor was murdered by police in Louisville, KY
- May 25, 2020: George Floyd was murdered by police in Minneapolis, MN
We waited for our college of medicine to acknowledge that while some saw these events as abstract news headlines, others were reeling in fear and anger. Instead, the silence was deafening. So we messaged our cohort:
“We’ve been aware of the protests in response to police violence and murders that have recently and historically targeted Black communities. How can we let our administration know that education centered on patient advocacy and anti-racism is needed?”
Our efforts became a response to real threats that minoritized members of every medical institution and broader society bear daily. We began crowd-sourcing concerns drawn from lived experiences of those across our college to write an open letter to our medical school leadership. The cover page was a call to intentional action; the sixteen pages following were explicit requests to amend and bolster diversity, equity, and inclusion (DEI)-centered deficiencies in our coursework, admissions process, faculty recruitment and retention, and financial resources. We desired to call explicit attention to our landscape as one that permits ongoing injustice. This challenge remains just as urgent today, as recent Supreme Court decisions which enable continued injustice (e.g. the stripping of Affirmative Action policies; the empowering of prejudiced business owners) are set to fuel a new era of attacks on equity.
Our work was borne of real-world frustrations. We were frustrated by the informal and inconsistent dance around difficult topics of disparity in healthcare, presented in isolation from the core of our medical education, and viewed primarily as detached history. We challenged our college on the idea that scattered one-hour discussions about topics like implicit bias were sufficient preparation for our future clinical practices serving diverse patients. We called on colleagues and teachers to name the roots of injustice and ignorance, to explicitly draw attention to “racism,” “sexism,” “ableism,” “transphobia,” and “White supremacy.” Our institution needed to acknowledge that we are part of a system that actively contributes to the disempowerment, underrepresentation, and marginalization of vulnerable populations.
We demanded specific, achievable curricular changes, such as increased diversity in images of skin, and requested new long-term goals for the college including a curriculum focused on evidence-based medicine when discussing the higher disease burden facing marginalized and underserved patient populations. Our efforts to enact curricular change were part of a broader movement in the wake of the COVID-19 pandemic to increase attention to the role of disparities in our society. Many medical educators felt a call to action to ensure students develop an understanding of and appropriate approaches to biases, health inequities and disparities, and social determinants of health (SDOH).With support from the college’s leadership, our letter ultimately transformed into major curricular changes and the formation of a Health Equity and Advocacy Thread (HEAT), which formalized a commitment to integrating equity-centered content thoroughly and thoughtfully throughout our curriculum. We embraced the power of hundreds of voices speaking together for systemic change and were finally breaking ground. But the question remained: would our efforts be enough to institute lasting change?
Integrating Diversity, Equity and Inclusion in a Traditional Curriculum
To implement new DEI-related content, our college leadership chose a competency-based assessment framework. The goal of competency-based medical education is to identify the outcomes or competencies desired to drive the design and implementation of educational processes, ensuring that competencies are reached through targeted assessments. We worked alongside leadership to modify and add competencies for the college to reflect a greater focus on health equity and social determinants of health. Below is an example in the patient care domain of our college’s original and updated competencies:
Original version: “Address disease prevention and health promotion strategies for individual patients or populations.”
Updated version: “Address disease prevention and health promotion strategies for patients and communities from diverse backgrounds with consideration for historical contexts, their lived experiences, and social determinants of health.”
Our central goal was for students to learn to provide comprehensive, equitable, and inclusive medical care to diverse patient populations as part of a spiral four-year DEI curriculum.
Encountering Barriers
Despite sincere efforts by many stakeholders in our college to integrate DEI-related content across our curriculum, we face the same barriers that stymie progress toward equity in society at large. Much of the burden of the thread’s success has hinged on faculty willingness and ability to effectively incorporate DEI-related content into their existing instructional time. Given time limitations within courses, many smaller changes to established didactics were made rather than creating new dedicated sessions, to both increase buy-in and center the idea that health equity permeates all aspects of our medical education.
While the majority of faculty and students have embraced this more systematic approach to DEI teaching, some among us are opposed to diverting from the traditional, science-only focus. Importantly, such pushback has historically served as a means by which racist and whitewashed realities can endure, leaving necessary topics out of view and without the same scrutiny that is afforded to other scientific disciplines. Our ongoing challenge is not just to incorporate DEI-related content but to strongly advocate for imperative self and structural examination. We have found that students’ attitudes about the importance of equity-centered content have not changed substantially as they progress in training; essentially, they either care or they do not.
Successfully engaging these detractors requires a fundamental change in personal worldview, which thus far has been difficult for us to systematically enable. For example, one student argued in a survey comment that because White people can be poorer than others in some parts of the country, “the focus [on] race and ‘marginalized’ groups is detrimental to the overall education” of our medical students, functioning “simply to appease the mass hysteria associated with this alarmist propaganda.”
It is heartbreaking, though it comes without surprise, how dismissive and even repellent some future physicians remain to hold health equity education in regard. How do we reach those who view DEI-related topics as “busy work” impeding their “real” training, or as work which serves to brainwash rather than liberate? Certainly, Students of color face negative impacts by often finding themselves in the position of having to advocate for the inclusion of their lived experiences against such pushback.
As we consider our path forward, we are left to reflect on what opportunities might have been lost in translating our call for radical curricular reform into our traditional competency-based framework for medical education. Yet, we believe our goal remains an important one—to apply a comprehensive health equity curriculum throughout medical students’ education. This necessitates vulnerable conversations, a willingness to see beyond ourselves, and a shared desire to understand each other more fully. We aren’t there yet, but we are somewhere better than before, so we remain hopeful.
Hina I. Iqbal, 4th year medical student, University of Kentucky College of Medicine, @hinaiqballin
Claire D. Clark, PhD, MPH professor, University of Kentucky College of Medicine, @ClaireClarkPhD
Anna-Maria South, MD, professor, University of Kentucky College of Medicine, @AnnaMariaSouth
Alan M. Hall, MD, professor, University of Kentucky College of Medicine, @AlanHall_UKHM
April R. Hatcher, PhD, professor, University of Kentucky College of Medicine
Jackie Pope-Tarrence, PhD, professor University of Kentucky College of Medicine
Lillian Sims, PhD, professor, University of Kentucky College of Medicine, @lilliansims