At SUNY Upstate Medical University, all first-year medical students take a case-based longitudinal course in health systems called Patients to Populations (P2P). First originated in 2016, the course has long included discussions of racism in medicine. In the summer of 2021, a group of rising second-year medical students enrolled in Upstate’s Curriculum Reform Elective with the express goal of improving teaching regarding racism in P2P. The students divided into three working groups, targeting student development, faculty development and the case materials. In this blog, P2P’s director and three students from the case materials group reflect on their process and plans for assessing the impact of antiracist language in the future.
Dr. Caruso Brown:
Five years, we introduced the Patients to Populations case-based learning course as part of a new preclinical curriculum. Over the course of the first year of the MD degree program, small groups of students meet with pairs of faculty facilitators. All case discussions begin at the level of the interaction between patient and physician and work outward through the socio-ecological model to explore how structural forces shape these interactions.
In our first iteration of the course, we asked students to dive into a discussion of pregnancy outcomes using our own county’s raw data. We quickly ran into one of the challenges of our format: students in our program come to us from diverse backgrounds and with diverse experiences. Some students entered medical school with the goal of advocating for social justice. Others had worked in healthcare and witnessed the impact of racism in healthcare first hand. And still others had spent their undergraduate years focused on biology and chemistry and had no vocabulary with which to discuss systemic racism, much less to do so sensitively.
In each year since, we have grappled with how to achieve our goals, refining our course materials, our faculty development, and our orientation for our learners, trying to meet each at the door. In the fall of 2020, we met with three students—Aniah McLeod (a co-author of this blog), Nneka Onwumere, and Stefano Gaspard—who raised concerns about how the approach to discussions of racism in their small groups negatively impacted students who are Black, Indigenous or People of Color (BIPOC). In collaboration with Lauren Germain, Director of Evaluation, Assessment and Research at Upstate and the director of the Curriculum Reform Elective for medical students, and Hannah Connolly, an MD/MPH/PhD candidate at Upstate and Syracuse University, we offered a section of the course specifically for rising second-year medical students interested in systematically tackling this issue from three angles: student orientation, faculty development, and case materials. Students were able to choose between receiving course credit or compensation (work-study) for their efforts. Each working group started by defining a problem and conducting a literature review, in order to ground their proposed interventions in the available evidence, and Dr. Germain worked with each group to develop an assessment plan.
Four students, Aniah McLeod, Sydney Klugman, Andrulisa Jones, and Joanna Berg, identified the need for more patient-centered and clearly antiracist language in the case materials and set out to revise the cases (which were previously published as a textbook, Bioethics, Public Health, and the Social Sciences for the Medical Professions: An Integrated, Case-Based Approach, in 2019). Aniah, Sydney and Andrulisa share their experiences and insights into this process below.
I served as the team leader for the student group revising the case language. Our group revised the language in four cases, three of which involved patients of color, and all of which had the potential to perpetuate racism when used in the small group setting. We referred to Krishnan and colleagues for guidance when assessing the extent of racism in the cases and failure to address social and structural determinants of health (SSDOH) and healthcare inequities . We also referred to Amutah and colleagues when revising the language of the cases . Our group plans to evaluate the impact of our revisions in the fall of 2021 using a modified version of DallaPiazza and colleagues’ validated scale (assessing self-reported learning with regard to racism) and ultimately to publish our work in an academic journal .
One of my responsibilities was to revise the case backgrounds and prompts (or case events) to correct misrepresentation of race. The prompts of the case tell the story of the patient as it unfolds. One theme in our revision included eliminating negative stereotypes from the prompts. All of the cases labeled Black patients with one or more of the following negative stereotypes: unemployed, impoverished, uninsured, a Medicaid patient, or an incarcerated individual. For example, one case had prompts that presented an unemployed Black male patient who was described by his employer as an unreliable worker. I revised the prompts to clarify that the patient was a part-time employee experiencing financial hardships and poor health because of SSDOH, racism in medicine, and healthcare inequities.
These language revisions are necessary because the presentation of patients of color using only negative stereotypes and harmful narratives contributes to implicit racial biases and perpetuates racism in medicine . Additional themes included revising the prompts to explicitly denounce the mistreatment of patients of color and encourage learners to practice cultural humility and compassionate evidence-based medicine with every patient and especially with patients of color.
One major focus of the group, when revising and rewriting the cases, has been the particular way the questions are posed. The phrasing of the questions throughout the case is important because, while many facilitators choose to use their own phrasing, the written questions can still set the tone for the discussion and lead facilitators to emphasize certain aspects of the case. We used a several guiding frameworks to help us analyze the questions and do our best to call attention to possible existing biases and minimize the furthering of bias . Our work has been done with the explicit goal of transitioning the case material to be anti-racist and we feel that the questions are an important facet to guide discussion and help students engage with both the material, and the other participants and encourage learning from one another.
We used a combination of ethical discussion questions, self-reflection questions, and questions that ask students to think through actions and consequences relating to the case blurbs. When editing the questions themselves (and not the information included in the responses), we looked for opportunities to shift the discussion towards systemic issues and away from individual blame. We also rephrased questions to focus on ways that students, as individuals, could contribute to changes. The changes are presented as opportunities for students to challenge their personal biases and work on recognizing where systemic issues intersect with interpersonal dynamics. In both questions and the provided responses, students are called to recognize the power—and responsibility—they have and will have in the future.
The responses to discussion questions in the P2P case materials are used as guides for the conversation between facilitators and students. The facilitators have access to these responses, which include up-to-date statistics and factual content, as well as contain sidebars called “Teaching Tips.” Teaching Tips provide ideas for facilitators to use when probing for different perspectives.
The goal of updating these responses was to interject more sensitive language, expand on the story of the patient’s situation, and ensure that students are viewing these cases through a lens of empathy and compassion . For example, in a case that discussed a patient from a low socioeconomic status background, one question dealt with the myths of poverty. The original response contained statistics and a list of myths about poverty but did not provide historical context regarding how the cycle of poverty began and has been perpetuated in the U.S. This response was updated to include, the definition and impact of generational wealth, the history of redlining, hiring discrimination, and how negative perceptions of impoverished people are reinforced by the fallacy of the American Dream [4-9].
Providing this context is meant to help students see the systemic and societal factors that were, and are still, in place and impact the patient’s situation. Updating these responses included conducting extensive current and historical research in order to promote a multifaceted level of understanding into these complex cases. This will help guide conversations in this course toward their goal of promoting a mindset of compassion and advocacy mindset—a mindset that is essential for the future of healthcare.
Though this project evolved from our commitment to valuing the education and learning experience of students of color at Upstate, we also firmly believe that doing so benefits all students and their future patients. Our group plans to evaluate the impact of our revisions in the fall of 2021 using a modified version of DallaPiazza and colleagues’ validated scale (assessing self-reported learning with regard to racism) and to publish our work in an academic journal .
Amy Caruso Brown, MD, MSc, MSCS (Twitter @aeCarusoBrown)
- Caruso Brown is an associate professor in the Center for Bioethics and Humanities and the Department of Pediatrics, Division of Pediatric Hematology Oncology at SUNY Upstate and the director of the Upstate Bias Checklist Collaborative. When not teaching, taking care of patients, or writing, she is usually rock climbing, hiking or skiing with her 9-year-old son.
Aniah McLeod, MS
- Aniah is a second-year medical student at SUNY Upstate. She is a proud Pitt alumna and is the inaugural recipient of the Global Health Certificate at the University of Pittsburgh. She enjoys putting her education to good use by creating and participating in initiatives that improve the lives of others, especially those belonging to underserved communities.
Sydney Klugman, BS
- Sydney is a second-year medical student at SUNY Upstate. She enjoys opportunities to use her interest in sociology while learning medicine and has been honored to be involved in this curriculum reform project. Outside of an academic setting, they enjoy rollerblading and embroidering.
Andrulisa Jones, BS, BA
- Andrulisa is a second-year medical student at SUNY Upstate. At the University at Buffalo, she obtained two bachelor’s degrees, one in biochemistry and the other in psychology. Her psychology background has helped tremendously as she strived to promote a patient-centered approach in curriculum revision. Outside of medical school, she enjoys latch hook crochet, hiking, bike riding and spending time with her dog.
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