Academic medical centers are hard at work to build an ever more inclusive and equitable learning environment. In this blog we share one example of our work at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine. We applied a framework to address the multiple areas that lead towards a culture shift in anti-racism. We share one example of an engaging and successful initiative that is now incorporated into all first year medical students training: A book club created by first year students to increase cultural sensitivity and antiracism in their training.
Our nation has long been called into action to dismantle long standing inequities and structural racism in healthcare and health outcomes. Academic medical centers equally felt a sense of urgency to address inequities within the medical education culture. In February 2020, the Macy Foundation had convened leaders in Diversity, Equity and Inclusion (DEI) (1), and generated a series of 27 articles published in the December 2020 supplement issue of Academic Medicine (2). Programs shared institutional projects addressing different aspects of the health professions learning environment relating to culture change, listening to learners, and bias-free assessment and evaluation. The literature continues to expand with dedicated efforts to build programs towards an inclusive and equitable learning and working environment. The sum of the parts ultimately needs to add towards a culture of inclusivity, equity, and antiracism.
In How to Be an Antiracist, Dr. Ibram X Kendi (3) challenges us to take every opportunity and context to check our biases, beliefs, and stances on racism and antiracism. In particular, Dr. Kendi proposes that the opposite of racist is not not-racist, but instead is an active stance to combat racism at every opportunity. At our institution, we approached the work to address multiple initiatives to actively change our academic and healthcare setting to create a more inclusive, equitable, and thriving environment for all. For this blog, we will discuss how medical students also identified a space for students to engage in this conversation and grow professionally. Students created a book club to increase cultural sensitivity in medicine.
Such a large task can seem like setting off to boil the ocean. We applied J Mierke and V. Williamson’s 6-step framework (4) to achieve organizational culture change: 1.Identify the catalyst for change; 2. Strategically plan for successful change; 3. Engage and empower organizational members; 4. Cultivate leaders at all levels; 5. Foster innovation, creativity, and risk-taking; 6. Monitor progress, measure success, and celebrate (even the small changes) along the way.
Applying the framework to the book club looks as follows:
- Identify the catalyst for change: In 2000, the LCME created the requirement for medical schools to incorporate cultural competency training within medical school education. However, there are limitations to this concept. First, assuming “competency” in someone else’s culture is presumptuous and unobtainable. Second, in contrast to the concept of cultural competency, if one strives for cultural humility there is no end point, meaning that a person accepts there is need for continual reflection and does not become complacent in their knowledge. Furthermore, national events shook the medical school community to spring into action towards diversity, inclusion, equity, and anti-racism.
- Strategically plan for successful change: A student-run book club was created that selected literature centered on themes of cultural humility in medicine. During each session, students engaged in an open discussion about their takeaways from the book as well as how these lessons will apply to their future practice of medicine.
- Engage and empower organizational members: After each discussion, students would generate a list of actionable items. This list consists of questions to further students’ research into a topic, suggestions for political involvement, etc. Students were then encouraged to pursue any item(s) on the actionable items list that they felt would most benefit their learning and growth.
- Cultivate leaders at all levels: Students were self-driven to lead discussions on anti-racism and cultural humility, utilizing peer-level pedagogy to complement their curriculum-based education. Students engaged the Medical School leadership to support the initiative.
- Foster innovation, creativity, and risk-taking: After the summer of 2020, incoming students were eager to share anti-racism resources with one another, and the book club represented a creative way to structure conversations around the books to enhance understanding of the material. With the recognition that each individual is at a different point in their anti-racism path, the book club sought to challenge each student with difficult conversations about inequities in health care and their role as a future provider in the institution of medicine.
- Monitor progress, measure success, and celebrate (even the small changes) along the way: After implementing several successful sessions, with over two-thirds of the first year class attending at least one session, support was given by the administration to supplement the incoming class’s orientation with a book club session. Every student was provided with a copy of “The Spirit Catches You and You Fall Down” by Anne Fadiman and led through a discussion of the book by upperclassmen.
- An additional step of transparency in communication was determined to be critical from the start: Throughout the inception of the club, there was communication with the administration about the goals of the implementation and direction of the club. The club was met with enthusiasm and was adopted into the curriculum after its success.
The framework and process we have presented is centered on giving a voice to medical students and members of the academic community. The book club serves as an example of a manageable, impactful contribution towards a culture of anti-racism. Through representation in the steering committee and action groups, students and others are empowered to carry the responsibility of addressing specific issues that build an organizational culture of disrupting the status quo, questioning existing structures towards a more diverse, inclusive, equitable and anti-racist culture.
Monica Yepes-Rios, MD is Assistant Dean for Diversity Equity and Inclusion, Case Western Reserve University School of Medicine and Internist at the Cleveland Clinic Hispanic Clinic. She is passionate about investing in an inclusive learning environment and in the care of underserved communities. @MonicaYepesRios
Rachel Schafer: Originally from Cincinnati, Ohio, Rachel is a second year MD/MPH candidate at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. She is passionate about integrating anti-racism into the framework of medical school curricula and serves as a co-founder of her school’s book club student group. @
Jesse Fajnzylber: Jesse is a second year MD/MS candidate at the Cleveland Clinic Lerner College (CCLCM) of Medicine of Case Western Reserve University and is originally from Boston, MA. He is passionate about internal medicine and performed HIV/COVID research prior to matriculation. He is a fierce advocate for equity, focused on creating an atmosphere of antiracism in the curriculum, amongst peers and faculty, and he co-founded the book club at CCLCM. @JFajnzylber
- Humphrey HJ, Levinson D, Nivet MA, Schoenbaum SC. Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments: An Urgent Challenge. Academic Medicine. 2020;95(12S):S1. doi:10.1097/ACM.0000000000003679
- Ibram X Kendi, How to be an Anti Racist, August 2019
- Mierke J, Williamson V. A Framework for Achieving Organizational Culture Change. Library Leadership & Management. 2017;31(2). doi:10.5860/llm.v31i2.7216