Balancing the curriculum

For most of its history, the School of Medicine was a place where young white men learned from older white men. Those days are gone. Black men and women trickled into the medical school in the middle of the 20th century. By the 1990s, women made up half of each medical school class and the presence of minority students was increasing.

Still, attitudes, biases, and stereotypes have lingered in the curriculum. Across the country, medical schools are recognizing that lab tests and vital signs don’t tell the whole story; and that to provide the best care, doctors must understand how race, gender, sexual orientation, poverty, and access to health care affect their patients’ health—as well as their own inherent biases.

This concern is not just academic. Knowing about patients’ lives has consequences for their care. “If we are ever going to get to the point of closing health care disparities, physicians of tomorrow must have a much better understanding of the people they are treating,” said Darin Latimore, MD, deputy dean for diversity and inclusion.

A fourth-year MD-PhD student on the Committee for Diversity, Inclusion, and Social Justice put it more forcefully. “People are dying and suffering due to lack of appropriate care that can stem from providers’ biases and false or inaccurate information from their medical training, like race-based medicine,” said Sahana Kribakaran.

For years, students have been advocating for a curriculum that recognizes the importance of social determinants of health. Their efforts bore fruit at a town hall in November 2015 with Dean Robert J. Alpern, MD, Ensign Professor of Medicine, when led by the organization NextYSM, students voiced their concerns. In addition to changes in the curriculum, they highlighted the need for more support for minority students, more minority faculty, reporting on bias incidents, and recruitment of a diversity officer.

The Dean’s Committee for Diversity, Inclusion, and Social Justice was created as a result, and the school’s Educational Policy and Curriculum Committee (EPCC) began looking into the curriculum. In March 2018, an EPCC subcommittee recommended enhancing opportunities for health equity research, creating a certificate in health justice, promoting professional development, establishing a social mission statement, and showing a commitment to faculty diversity. Two key elements of the plan were weaving a health equity thread throughout all four years of medical school and creating a requirement for community service.

The subcommittee, chaired by Marcella Nuñez-Smith, MD, MHS ’06, associate professor of medicine (general medicine), and of epidemiology (chronic diseases), and director of the Equity Research and Innovation Center, interviewed students, faculty, and representatives of community-based organizations.

“We reviewed the curriculum to see how it covered issues of social determinants of health, not only in terms of where they are covered, but the quality of that coverage,” said student and committee member Ram Sundaresh. “There were some areas where it was covered adequately, but we identified a lot of areas for improvement.”

“The concept of race in the curriculum and clinical care is raised all the time, but we don’t really teach it in a rigorous way,” said Nientara Anderson, a fourth-year medical student on the committee. “Race-related terms aren’t talked about in ways that are up to speed with current scholarship.”

Anderson said it’s not just a matter of how patients are treated. People of color and varying sexual identities and orientations are present in today’s classrooms. “Every time these issues are treated in an ignorant, incorrect, insensitive, discriminatory, or biased way, there are people in the classroom experiencing discomfort, alienation of professional identity, a sense of not belonging in the classroom, a sense of being singled out or insulted by the way things are being taught,” said Anderson.

Both the diversity thread and community engagement are works in progress. The medical school has hired a community-based experiential learning coordinator and is interviewing for the post of equity thread leader. The school is coordinating with community groups and neighboring universities whose students are also engaged in health projects in New Haven.

“Students from many colleges and universities volunteer in the greater New Haven community. It is unrealistic for us to assume that a local nonprofit would know which projects are best suited for an undergraduate versus a pharmacy student or medical student, for example. Part of our task is to create an effective method of pairing our students with community agencies that will benefit from the unique skills and knowledge that medical students bring to the table.”

Latimore said that while the school is in the early stages of “figuring out what the curriculum should look like,” the goals are clear.

“When a student takes a history, if they ask, ‘Do you have food hunger?’ and they hear ‘yes,’ I want them to say, ‘Here are agencies that can help you,’ ” he said. “If the students only learn that African Americans experience certain diseases at a higher rate, or that the LGBTQ community faces certain diseases at a specific rate, but do not ask the deeper questions about the patient’s ‘lived experiences,’ we will not have met the mark. We hope that our students will leave with a curiosity about and understanding of the complexity of the individual sitting before them, with the humility to learn, and with a knowledge of the resources that they can offer that person.”