Equity, diversity, inclusion, and social justice in CanMEDS 2025

Introduction

Social justice in medicine upholds that each individual, regardless of the diverse communities to which they may belong, has the same right to health, wellbeing, opportunities and privilege as another.¹ Exclusions in all aspects of societal structure have been a means to secure power for the majority population in Canada, and have unequivocally impacted medicine both through the composition of the medical workforce² and the availability and quality of care provided to patients of diverse populations and communities.^3,4 The physician workforce is recognized to have underrepresentation of several populations including those defined by their sex and gender; their identity as an Indigenous person or belonging to non-dominant racialized, ethnic, cultural or religious groups; by various abilities; and by familial socioeconomic status.^5,6 The experiences of members of these and other oppressed populations throughout their medical training are of disadvantage, discrimination, and exclusion ⁷. Medical education systems have been constructed to reinforce meritocracy, support hierarchy, perpetuate differences between population groups, and promote the biomedical model to the exclusion of other knowledges.⁸ The Canadian health care system is founded on the principle of universal access, yet this is often not the lived experience of patients who necessarily assess the benefits of seeking available care against the harms of racism, sexism, genderism, ableism, and ageism among other forms of discrimination, and all their intersections,⁹ they suffer in the healthcare system. These patients are not afforded the same quality of care as others¹⁰ and suffer worse health outcomes as a result.¹¹ In some areas, the gap in outcomes is widening.¹¹

With the long call for changes in medicine now prioritized for action,¹² the existing CanMEDS physician competency framework requires evolution with explicit statements for expectations of physicians related to concepts of equity, diversity, inclusion and social justice.¹³ We review these concepts here and provide recommendations for incorporating these in the CanMEDS physician competency framework drawn from our experiences as leaders in equity and anti-racism initiatives in medical education (all authors), research (CB,ND,KOT), and clinical practice (all authors) as well as our lived experiences as persons of Indigenous (CB), African-Canadian (KOT), and racial minorities in Canada (JMM, SR, BMW), women in medicine (CB, ND), and disabled (ND). We direct readers to also refer to the manuscripts that speaks specifically on the topic of anti-racism.^14,15

What are equity, diversity, inclusion, and social justice and why are they important to physician competency?

Equity, diversity, inclusion, and social justice are to be considered outcomes of addressing discrimination. Distinct from equality (which is the same distribution for everyone), equity necessarily accepts there will be variations in actions required to attain fairness, as individuals encounter different structural and systemic barriers as well as reduced opportunities simply by virtue of their membership in a or many population(s).¹⁶ Diversity refers to enhanced representation of persons from all populations in a collective, limitless in variations and possibilities, and yielding the opportunity for perspectives and innovations arising from multiple knowledges and experiences.¹⁷ Inclusion speaks not only to the presence of but also the nature of the experience of members of diverse populations in a collective, and that they assess they are a supported and valued member of that collective.¹⁸ Social justice is conceptualized from a rights-based approach, valuing that each individual should have the same health, wellbeing, opportunities and privilege as another.¹ Concise definitions of these and related terms are provided in Table 1.

Table 1.

Glossary of terms that are closely related to equity, diversity, inclusion, and social justice.

Term	Definition
Ableism	Discrimination and/or prejudice against persons with any form of disability (e.g., physical, intellectual). Persons are defined by their disabilities, and are characterized as inferior to the non-disabled.
Ageism	Stereotyping, discrimination and/or prejudice against persons on the basis of their age, typically against older members of society.
Accessibility	Accommodations are made to remove barriers to participation, resulting in the ability for all to participate.
Anti-oppression	The strategies, theories, actions, and practices that challenge systems of oppression
Cultural Safety	An outcome of reflective and aware practice and policy, where providers and organizations address bias and barriers contributing to inequities. It is the recipient of care, and not the provider, who determines if cultural safety is present or not.
Decolonization	Regaining inherent rights and power for self-determination of societal structure, services and investments.
Diversity	The greatest possible representation of attributes are present within the collective.
Equity	Attainment of fairness and justice, with imbalances addressed.
Homophobia	Stereotyping, discrimination and/or prejudice against persons on the basis of being lesbian, gay, queer or bisexual.
Inclusion	Acts and approaches that ensure that all persons are equally welcomed, supported, valued and respected.
Intersectionality	Interactions or synergies which arise from being a member of multiple populations facing inequities, and which results in a unique experience.
Meritocracy	System of awarding opportunities and status on the basis of ability and performance, but which neglects acknowledging structural inequities that limit opportunities for all members of society.
Racism	Stereotyping, discrimination and/or prejudice against persons on the basis of their race.
Sexism	Stereotyping, discrimination and/or prejudice against persons on the basis of their sex typically against those individuals that identify as women.
Genderism	Stereotyping, discrimination and/or prejudice against persons on the basis of their gender.
Social justice	Approach promoting that each person has the right to the full spectrum of economic, political, and social rights and opportunities.

While there is increasing recognition of the power and privilege imbalances in both the physician workforce and the care provided to patients from diverse backgrounds, physicians are not intrinsically able to identify existing inequities, nor understand the complex contributors impeding progress towards social justice goals.¹⁹ Physicians need to develop the necessary skills to take informed and evidence-based action as allies for both physician colleagues and patients.²

How are equity, diversity, inclusion, and social justice represented in the 2015 CanMEDS competency framework?

There are inferences relevant to equity, diversity, inclusion and social justice related to both the physician workforce and patient care in the CanMEDS 2015 physician competency framework (Table 2A and 2B), but they are rarely explicitly addressed. Specifically, the competencies do not acknowledge the existence of discriminatory beliefs and/or practices rampant in medicine specifically and more broadly in society, and do not set out explicit expectations for physicians to be competent in supporting or leading activities that promote social justice. None of the existing competencies in ‘leader’ and ‘health advocate’ aspects related to upholding appropriate and empowering physician training and work environments. This further perpetuates exclusions in our profession and does not reinforce that equity initiatives are necessary to support recruitment and retention to achieve a diverse and inclusive medical workforce, nor contribute to dismantling the hierarchy inherent in medical education.⁸

Table 2.

Equity, Diversity, Inclusion, and Social Justice Competencies for the CanMEDS Physician Competency Framework.

A. CanMEDS 2015 Competencies directly applicable to Equity, Diversity, Inclusion, and Social Justice
Related to the Physician Workforce Communicator 1.3 Recognize when the values, biases, or perspectives of patients, physicians, or other health care professionals may have an impact on the quality of care, and modify the approach to the patient accordingly Collaborator 1.1 Establish and maintain positive relationships with physicians and other colleagues in the health care professions to support relationship-centred collaborative care 2.1 Show respect toward collaborators 2.2 Implement strategies to promote understanding, manage differences, and resolve conflicts in a manner that supports a collaborative culture Scholar 2.1 Recognize the influence of role-modelling and the impact of the formal, informal, and hidden curriculum on learners Professional 2.1 Demonstrate accountability to patients, society, and the profession by responding to societal expectations of physicians 3.2 Recognize and respond to unprofessional and unethical behaviours in physicians and other colleagues in the health care professions.
Related to Patient Care Communicator 1.1 Communicate using a patient-centred approach that encourages patient trust and autonomy and is characterized by empathy, respect, and compassion 1.3 Recognize when the values, biases, or perspectives of patients, physicians, or other health care professionals may have an impact on the quality of care, and modify the approach to the patient accordingly 1.6 Adapt to the unique needs and preferences of each patient and to his or her clinical condition and circumstances 2.1 Use patient-centred interviewing skills to effectively gather relevant biomedical and psychosocial information 4.1 Facilitate discussions with patients and their families in a way that is respectful, non-judgmental, and culturally safe Health Advocate 1.1 Work with patients to address determinants of health that affect them and their access to needed health services or resources 2.1 Work with a community or population to identify the determinants of health that affect them 2.3 Contribute to a process to improve health in the community or population they serve Professional 2.1 Demonstrate accountability to patients, society, and the profession by responding to societal expectations of physicians
B. CanMEDS 2015 Competencies partially related to Equity, Diversity, Inclusion, and Social Justice
Related to Patient Care Medical Expert 1.1 Demonstrate a commitment to high-quality care of their patients 5.1 Recognize and respond to harm from health care delivery, including patient safety incidents 5.2 Adopt strategies that promote patient safety and address human and system factors Leader 3.2 Facilitate change in health care to enhance services and outcomes
C. Suggested additions or modifications for the CanMEDS 2025 Framework related to Equity, Diversity, Inclusion, and Social Justice specific to the physician workforce
New or Modified Competency	Rationale for change
Collaborator
1.4 (New): Foster working and training environments that actively promote equity, diversity and inclusion principles.	It is an expectation that physicians are active participants and contributors to social justice aims within the medical workforce.
Leader
5. (New): Identifies inequities, gaps in representation, and exclusions in the physician workforce and implements initiatives to achieve equity, diversity and inclusion.	Reinforces an individual physician’s responsibility to improve workplace environments for all colleagues while also promoting broader involvement of persons from underrepresented groups.
Health Advocate
2.4 (New): Contributes to a process to support recruitment and retention of a diverse physician workforce	Evidence exists for the benefits of representation of physicians from communities that are underserved for attaining population health and improved patient care.
Scholar
2.2 (Modified): Promote a physically and culturally de-colonized safe learning environment that aims to acknowledge and eliminate racism, sexism, genderism, ableism, ageism and any other social injustice	Each physician must be competent in disrupting discrimination against learners, and ensuring teaching content does not promote stereotypes.
2.6 (Modified): Assess and evaluate learners, teachers, and programs in an educationally appropriate manner, with awareness and mitigation of personal biases.	Physicians must be aware of the implicit biases they hold, and ensure they do not impact assessment and evaluation of others.
Professional
3.3 (Modified): Participate in peer assessment and standard-setting, with awareness and mitigation of personal biases.	Physicians must be aware of the implicit biases they hold, and ensure they do not impact assessment and evaluation of others.
4.3 (Modified): Promote a culture that recognizes, supports, and responds effectively to colleagues in need, including when they are facing discrimination.	Each physician must be competent in identifying, disrupting and advocating against discrimination in all its forms.
D. Suggested additions or modifications for the CanMEDS 2025 Framework related to Equity, Diversity, Inclusion, and Social Justice specific to patient care
New or Modified Competency	Rationale for change
Medical Expert
2.4 (Modified): Establish a patient-centred management plan, demonstrating the ability to identify appropriate resources for the patient’s social realities.	Expand health support from a biomedical model to include psychosocial assessment and supports.
5. (Modified): Actively contribute, as an individual and as a member of a team providing care, to the continuous improvement of health care quality and patient safety, inclusive of cultural safety.	Explicitly expand the concept of patient safety to include cultural safety based on their membership in diverse communities.
5.3 (New): Adopt strategies that promote cultural safety and that counter all forms of discrimination and bias.	Require each physician to gain knowledge and skills in identifying and naming forms of discrimination, and providing healthcare environments that are respectful and supportive of diverse patients.
Communicator
1.1 (Modified): Communicate using a patient-centred approach that encourages patient trust and autonomy and is characterized by empathy, respect, compassion, and cultural safety.	Addition of element specific to diversity of patients.
1.7 (New): Recognize how historical, socio-cultural, political, and environmental factors can have an impact on quality of care, and modify the approach to the patient accordingly.	Expand health support from a biomedical model to include psychosocial assessment and supports.
4.4 (New): Identify power imbalances that may interfere with the physician-patient relationship and/or patient care and take action to minimize them.	Explicitly requires physicians to acknowledge and mitigate privilege and power they hold over patients.
Leader
1.2 (Modified): Contribute to a culture that promotes patient safety, cultural safety, access, equity, inclusion, anti-oppression, and social justice, while challenging and disrupting systems which promote and foster all forms of discrimination.	Physicians have a responsibility to social justice aims and a role to use their privilege in society to demonstrate that discrimination is unacceptable.
Scholar
1.1 (Modified): Develop, implement, monitor, and continuously revise a personal learning plan to enhance professional practice, including gaining specific knowledge and skills to identify and disrupt discrimination.	Physicians are not only responsible for biomedical knowledge, but also how to contribute to social justice aims.
4.1 (Modified): Demonstrate an understanding of the scientific principles of research and scholarly inquiry, diverse forms of knowledge, and the role of research evidence in health care	Include value of other knowledge systems such as indigenous ways of knowing in the practice of medicine.
4.2 (Modified): Identify ethical principles for research and incorporate them into obtaining informed consent, considering potential harms and benefits, and authentically engaging populations underrepresented in research.	Removing ‘vulnerable population’ language from the existing competency. Authentic engagement incorporates the need for appropriate and ethical research with populations who have historically not been included in medical advances, while promoting self-determination in research topic areas.
Professional
1.1 (Modified): Exhibit appropriate professional behaviours and relationships in all aspects of practice, demonstrating honesty, integrity, humility, commitment, compassion, respect, altruism, reflexivity, critical consciousness, respect for diversity, and maintenance of confidentiality	Addition of reflexivity and critical consciousness to reinforce continuous self-evaluation and learning.
2.2 (Modified): Demonstrate a commitment to patient safety, cultural safety, and quality improvement	Addition of element specific to diversity of patients.

In a paper published in this issue of the Canadian Medical Education Journal, Adam et al²¹ highlights how the term ‘patient’ is referenced in the CanMEDS role descriptions and competencies. While the role descriptions frequently position patients as partners in care, with the exception of the Health Advocate competencies, the key and enabling competencies of the other roles position patients as passive recipients of information and care. Viewed from this perspective, the competencies could be seen to exacerbate existing power-imbalances in a way that allows ongoing discrimination.

How can equity, diversity, inclusion, and social justice be better represented within the 2025 CanMEDS competency framework?

We recommend competencies explicitly related to equity, diversity, inclusion and social justice for the 2025 CanMEDS competency framework. Including such competencies will support professional development in this area that will help physicians to actively identify and combat inequities while promoting diversity and inclusion in the workforce. We also want to ensure physicians develop skills that allow them to effectively engage with patients belonging to equity-deserving groups to both improve the delivery of healthcare and assist in advocacy efforts for systemic and structural change. Existing CanMEDS competencies related to each of these aspects are outlined in Table 2A and 2B with suggested modifications in Table 2C and 2D.

Related to the physician workforce, we recommend new competencies under the Collaborator and Leader roles that reinforce the expectation that physicians act as agents of change to support diversity and inclusion in the workforce. A new addition to the Health Advocate role reflects evidence on the critical role of diverse physicians and care delivery to underserved communities.²² Modifications to the Scholar and Professional roles reinforce necessary activities to ensure safe learning environments for physicians in training and safe working environments for physician colleagues, while also calling on physicians to recognize and mitigate their personal implicit biases when assessing learners or peers.

We also make recommendations for new competencies that reinforce the responsibility of physicians to strive for social justice and enact strategies that support outcomes of equitable and culturally safe²³ patient experiences in healthcare. Specifically, we have suggested modifications that broaden the responsibility of physicians in care interactions to include psychosocial assessment and addressing inequities in the social determinants of health and structural factors. This will require specific skill development in interrupting discrimination, minimizing power imbalances in the physician-patient interaction, community engagement and partnership, and contextualizing care to the realities of each patient. Lastly, it will be important to address the framing of physician-patient interactions of the type described by Adam et al²¹ and shift towards incorporating languages that recognizes patients as active agents and partners in their healthcare.

The proposed additions and revisions to the existing CanMEDS framework to promote equity, diversity, inclusion, and social justice aim to address critical improvements needed in medical education. These changes will strengthen representation in the medical workforce while providing a supportive and safe work environment for practitioners, while also explicitly requiring enhanced skills to benefit patient care.

Funding Statement

Funding: This project was completed with logistical support from the Royal College of Physicians and Surgeons of Canada.

Conflicts of Interest

Osei-Tutu received a stipend from the Royal College of Physicians and Surgeons of Canada. Wong received salary support from the University of Toronto, Choosing Wisely Canada, and the Royal College of Physicians and Surgeons of Canada. Thoma received payments for teaching, research, and administrative work from the University of Saskatchewan College of Medicine, payments for teaching and administrative work from the Royal College of Physicians and Surgeons of Canada, honoraria for teaching or writing from Harvard Medical School, the New England Journal of Medicine, the University of Cincinnati Children's Hospital, and NYC Health + Hospitals, and research grant funding from the Government of Ontario and the Canadian Association of Emergency Physicians.