Abstract
Background
Residents must understand the social drivers of health in the communities they serve to deliver quality care. While resident orientation provides an opportunity to introduce residents to social and structural drivers of health, inequity, and care delivery relevant to the patient population in their new communities, many graduate medical education orientation curricula do not include this content.
Objective
To report the development and implementation of a novel, patient-centered health equity orientation curriculum, including initial feasibility and acceptability data as well as preliminary self-reported outcomes.
Methods
The curriculum was developed by academic faculty in collaboration with institutional and local health equity champions. Content centered on the history of inequities and racism within the local communities and included didactic presentations, asynchronous video, and virtual site visits to community resource groups. The curriculum was administered to all 2021 incoming Vanderbilt University Medical Center medical and surgical residents (N=270) over 2 half-days, both in-person and via Zoom. Data were collected anonymously via pre- and post-surveys.
Results
A total of 216 residents (80% response rate) provided pre-survey response data, but only 138 residents (51.1%) provided post-survey data, including self-reported demographics (eg, underrepresented in medicine status) and level of agreement with 10 competency-based statements coded as pertaining to knowledge, skills, behaviors, or attitudes (KSBAs). Primary outcomes included improvement in residents’ KSBAs from pre- to post-survey. The greatest increases in percentages occurred with content that was specific to local history and population.
Conclusions
In a class of incoming residents, this study demonstrated feasibility, acceptability, and pre-post curriculum improvement in self-reported KSBAs when addressing health equity issues.
Introduction
Social and structural drivers have a greater impact on health than do health care services.1 The Institute of Medicine2 and Association of American Medical Colleges3 recommend prioritizing curriculum and training for residents to recognize and address health inequities. Strong recommendations have also been issued to address the history of racism and racist practices embedded in our health care system and to develop resident competency in this area to impact the health of our patients.4-6 Early introduction of conversations around racism and health inequities primes residents to deliver more thoughtful care for individual populations,7,8 and focusing these conversations on the local community might better equip residents to deliver equitable care that is specific and effective for the patients they will see.
Whereas most residency orientations focus on logistics, resident bonding, and institutional needs, some residency programs have designed orientation around health inequities and community engagement. These have included a week of experiential learning for an obstetrics and gynecology residency, including time in the community and hearing patient stories9; an immersion tool for learning social determinants of health (SDOH) inserted into intern orientation10; and a 2-day poverty immersion experience in a community residency program.11 However, we did not find published evidence of similar endeavors involving a curriculum that includes the whole institution or that were specific to the local community and its history.
To address this gap, we developed an orientation curriculum for all incoming residents at a large academic medical center to describe present and historical structural inequities and their impact on patients, and to identify existing community partners and resources that address those SDOH. We measured the feasibility, acceptability, and preliminary self-reported outcomes.
Methods
Setting and Participants
This was a pre-post study of the 2021 incoming resident class at Vanderbilt University Medical Center (VUMC) as part of an American Medical Association-funded Reimaging Residency Project titled “Goals of Life and Learning Delineated” (GOL2D). The GOL2D curriculum was developed by VUMC academic faculty and is grounded in Kern’s 6-step approach, Miller’s Prism of Clinical Competence, and Bloom’s Taxonomy. A description of the curriculum, including learning objectives, appears in Table 1. The study sample comprised 195 residents across 19 specialties.
Table 1.
Description and Objectives of Health Equity Curriculum
| Activity | Description | Objectives |
| Half-day 1 | ||
| Unidirectional didactic lectures |
|
|
| Asynchronous content between sessions | ||
| Asynchronous video | In-depth introduction to the neighborhoods of Nashville, including relevant social determinants of health, presented by VUMC Community Navigator and Vanderbilt Instructor |
|
| Half-day 2 | ||
| Unidirectional didactic lecture | Overview of the VUMC resident guide to addressing patient social determinants of health, presented by VUMC faculty |
|
| Virtual site visits | Representatives from 6 community resource groups provided a virtual tour of their organization followed by a brief question-and-answer session Organizations included:
|
|
| Interactive case studies | Hypothetical patient scenarios that were accompanied by 1 to 3 questions prompting residents to incorporate community resources, presented by VUMC faculty Topics included:
|
|
Abbreviation: VUMC, Vanderbilt University Medical Center.
Interventions
The orientation consisted of 2 half-days of in-person and virtual content. The overarching goal of the orientation was to introduce incoming medical and surgical residents to the community and patients they will serve, and to prime and empower them to screen for and address SDOH.
The first half-day included in-person talks on health equity, the history of racism in Nashville and at VUMC, and institutional efforts to promote racial equity and anti-racism. During the second half-day the residents were divided into 2 groups and participated in an interactive session to introduce general concepts of structural inequities and SDOH over Zoom. See Table 1 for additional details on curriculum objectives and content.
Outcomes Measured
To assess the educational impact of the module, we looked at pre- and post-module differences in residents’ perceived knowledge, skills, behaviors, and attitudes (KSBAs). Surveys were developed with input from GOL2D faculty. Residents were asked to respond to 10 statements (see Table 2) using a 5-point Likert-style response scale ranging from “strongly disagree” to “strongly agree.” The instrument also collected demographic data (see online supplementary data), such as underrepresented in medicine (UIM) status (ie, individuals identifying as Black/African American, Hispanic/Latinx, and/or Indigenous American). We collected these data to study potential differences in KSBAs by UIM status to determine if any biases were apparent that might help inform future educational initiatives (see online supplementary data). Study data were collected on the first and second half-days and managed using REDCap electronic data capture tools hosted at Vanderbilt University.
Table 2.
Pre- and Post-Survey Difference in Strongly Agree and Agree by Statement
| Statement |
Pre-Module
Survey, n (%); N=216 |
Post-Module
Survey, n (%); N=138 |
Pre-Post
Difference: Agree and Strongly Agree, % |
| 1. I can describe social determinants of health common to the general population (K) | 184 (85) | 134 (97) | ↑12 |
| 2. I can describe social determinants of health common to the Vanderbilt University Medical Center patient population (K) | 111 (51) | 131 (95) | ↑44 |
| 3. I can identify potential barriers to addressing social determinants of health (S) | 183 (85) | 131 (95) | ↑10 |
| 4. I recognize how my own privilege and power affect my clinical practice (S) | 182 (84) | 133 (96) | ↑12 |
| 5. I recognize the importance of considering insurance status and other financial/resource constraints when developing a plan of care (S) | 169 (78) | 131 (95) | ↑17 |
| 6. I can describe programs and services for addressing social determinants of health, such as access to addiction and mental health care, at Vanderbilt University Medical Center (eg, addiction psychiatry, Bridge Clinic, etc) (S) | 73 (34) | 125 (91) | ↑57 |
| 7. I can describe programs and services for addressing social determinants of health, such as food stability, transgender health, and access to affordable, quality care, for external community resources (eg, Shade Tree Clinic, Clinic for Transgender Health, etc) (S) | 74 (34) | 125 (91) | ↑57 |
| 8. I am equipped to ask my patients about social and economic factors contributing to their health (B) | 146 (68) | 130 (94) | ↑26 |
| 9. All patients deserve the same level of care regardless of their illness (A) | 196 (91) | 134 (97) | ↑6 |
| 10. Large institutions, such as hospital systems, have a duty to evaluate the ways in which their practices may lead to health inequities (A) | 204 (94) | 136 (99) | ↑5 |
Abbreviations: K, knowledge; B, behaviors; S, skills; A, attitudes.
Analysis of the Outcomes
Data were collected anonymously, and pre-post responses could not be linked at the participant level. Descriptive statistics were calculated on demographic drivers and SDOH. Frequencies and percentages were stratified by pre- and post-intervention. Stacked bar graphs were created to assess relations between underrepresented status and SDOH. Chi-square tests were calculated to understand similar associations. Significance was determined at the alpha 0.05 level. All analysis was conducted using SPSS V28.0 (SPSS Inc, Chicago, IL).
VUMC Institutional Review Board (IRB) submission (#220907) was completed. The study did not fit criteria for research, and IRB approval was not required.
Results
We obtained 216 of 270 pre-surveys from incoming residents (80%). A total of 138 residents responded to the post-survey, a response rate of 51.1%. Table 1 depicts the difference in agree and strongly agree responses across the 10 competency-based survey statements. Statements are coded as pertaining to knowledge (K), skills (S), behaviors (B), or attitudes (A).
Data were also analyzed by UIM status. There were no significant differences between responses by UIM status at post-curriculum, and Phi ranged from 0.001 to 0.103 indicating a very weak effect. As with the overall findings, the proportion of agree and strongly agree responses increased from pre- to post-module for all respondents. For more detail on analyses, please see online supplementary data.
Acceptability and Feasibility
Acceptability was suggested by responses to 2 post-module qualitative survey items: 68.8% (95 of 138) of participants identified at least one aspect of the curriculum as “most valuable,” whereas less than 1% (1 of 138) of participants identified any aspect of the curriculum as “least valuable.” The graduate medical education (GME) manager is supported by the GOL2D Grant and had time protected for this work. The GME program manager who was scheduling orientation had minimal change in her job to assist with logistics. Additional faculty volunteered. The community visits were virtual, efficiently utilizing our community partner time and were reimbursed at $150 each hour for non-VUMC partners ($900 total). Although not formally assessed, the curriculum was sustained over the following 2 years as well as implemented at a partner institution.
Discussion
The results of this curriculum evaluation revealed that it is feasible to deliver an educational intervention focused on the local history of racism and inequality, as well as resources to address these SDOH that results in pre-post change in KSBAs for all incoming residents at a large academic medical center.
These findings are consistent with prior studies that describe addressing SDOH in orientation but take them to a larger scale.9,11 These findings also suggest that the medical schools represented by the residents who participated in the study are largely providing an adequate foundation in the general principles of SDOH and the attitudes necessary to incorporate these into practice. This foundational knowledge of SDOH allows institutions to move forward with history and tools specific to the local environment rather than focusing on introductory content. Changes in percent agreement for questions 2, 6, and 7 (Table 2) demonstrate effective knowledge gain after the curriculum intervention.
Limitations included the lack of a link between pre- and post-responses which limited statistical analyses, and the lack of follow-up to assess durability, recency bias,12,13 and retention of KSBAs.
Conclusions
This novel, patient-centered health equity intervention for medical and surgical residents was feasible to implement during orientation. We demonstrated improvement in KSBAs around racism and health equity topics after the intervention for both UIM and non-UIM residents. The greatest knowledge increase was around SDOH specific to VUMC patients and community services available to bring upstream solutions.
Supplementary Material
Funding Statement
Funding: The authors report no external funding source for this study.
Footnotes
Conflict of interest: The authors declare they have no competing interests.
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