Using an Adaptive Listening Tour and Survey to Promote Faculty Reflection on Diversity, Equity, and Inclusion (DEI) in the Pre-clinical Undergraduate Medical Curriculum

Abstract

Descriptive studies regarding how to integrate diversity, equity, and inclusion (DEI) into medical education are lacking. We utilized the AAMC’s Key Steps for Assessing Institutional Culture and Climate framework to evaluate our current curriculum via listening tours (n = 34 participants) and a survey of the 10 pre-clinical block directors, to better understand the opportunities and challenges of improving DEI in the pre-clinical curriculum. Opportunities included diversifying cases and standardized patients, enhancing information on systemic racism and social determinants of health, and increasing racial humility and population genetics/epigenetics training. Faculty had issues with “correct ways” to incorporate DEI and time constraints.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01924-7.

Background

The sociopolitical unrest in 2020 led medical schools to initiate or renew their commitment to the principles of diversity, equity, and inclusion (DEI), and how to better incorporate them in coursework. This reaction was a bubbling-over of concerns felt by the medical community over the past several decades and was catalyzed by efforts from students on campuses nationwide. Action from trainees at several institutions brought concerns to the forefront and their efforts continue to drive change at medical institutions [1]. Recent studies emphasize sustained momentum and solutions to the identified problems [2]. Academic medicine, however, has not kept pace with curricular adjustments to consistently address antiracism in education, particularly in an integrated fashion.

In the literature, there is a paucity of stepwise approaches for understanding and developing DEI topics in medical education. Rather, publications emphasize the importance of these issues for educating capable doctors, but do not provide evidence for a systems-based approach to integrate DEI in medical curriculum nor implementation strategies [3–7].

To begin this process, the University of Nebraska Medical Center (UNMC) utilized the Association of American Medical Colleges (AAMC) Key Steps for Assessing Institutional Culture and Climate [3], referred to as “Key Steps” hereafter, to promote critical reflection of DEI in our curriculum. Our overarching goal was to understand the barriers course directors face as they evaluate the pre-clinical curriculum and incorporate more DEI in their coursework. Herein, we describe our initial steps and findings from faculty reflection about integrating more DEI in our curriculum.

Activity

The current UNMC medical curriculum is divided into 3 phases: Phase 1 is the preclinical foundation (18 months) divided into 10 blocks. Phase 2 is clinical application in six of the core disciplines of medicine (13 months). Phase 3 is career preparation, which provides individualized training for students in their specialty choice (13 months).

Our intervention focused on implementing the first three Key Steps in our Phase 1, pre-clinical curriculum, which integrates basic, clinical, and health systems sciences into 10 blocks, based on organ systems (Fundamentals; Blood, Defenses, and Invaders; Musculoskeletal and Integument; Circulatory; Respiratory; Renal; Neuroscience; Gastrointestinal and Endocrine; Genitourinary; and Multiorgan Systems). In each block, students learn about normal structure and function of each system followed by the pathologic and clinical manifestations of abnormal systems. The Key Steps are as follows: “Step 1: Reflective questions for personal exploration on relevant criteria, Step 2: Data collection processes and tools to capture the determinants of the culture of diversity and inclusion, Step 3: Synthesis and analysis to identify areas of strength and opportunities” [3].

Step 1 Reflective Questions: This was completed via a listening tour to assess institutional culture, policies, curriculum objectives, content, and structural issues that promote or hinder DEI integration into the curriculum. The listening tour sessions of approximately 1-h were recorded via Zoom and transcribed verbatim. Faculty attendees were either block directors (BDs) or individual faculty course instructors within the different blocks. Typically, a listening session involved BDs from one course but occasionally, due to overlapping responsibilities, faculty from different courses were in the same listening session. Listening tours were chosen as a way to build collaborative relationships between the faculty and the DEI office [8]. We had the following objectives:

1. Introduce the DEI education office,

2. Understand the Phase 1 curriculum and education process,

3. Identify current DEI material being taught,

4. Examine barriers and opportunities to integrate DEI material,

5. Identify the needs of faculty to integrate this material.

We met with directors from each of the 10 blocks (average 2–3 directors per block), with at least one director being a clinical educator and one being a basic science educator, for 10 listening tours.

Step 2 Data Collection: In addition to the qualitative data from Step 1, a survey was developed and sent to Phase 1 BDs to inquire about DEI and ethics-related content in their curriculum (full survey Supplement 1). For the purpose of this study, the questions related to DEI were analyzed. Survey questions about ethical professionalism were not included in our analyses as they do not directly involve DEI.

Step 3 Synthesis and Analysis: For the thematic analysis, guidelines established by Braun and Clarke [9] were used to identify patterns derived from the listening tours [10]. Two researchers reviewed the transcripts and reached consensus regarding themes and representative quotes. These were confirmed by respondent validation.

From the survey, dichotomous responses were summed, and percentages were calculated. Representative quotes are presented for a richer description of findings.

Results and Discussion

During the listening tour, we met with 34 faculty, including 21 BDs and 13 other Phase 1 faculty instructors. Faculty reflected upon how DEI topics were addressed in their courses and ways to improve the curriculum. Commonly, faculty desired to do a better job of addressing antiracism and recognized that there are many opportunities and challenges (Table 1). The BDs and faculty frequently acknowledged that their material did not consistently include DEI content because they did not feel equipped to teach on the topic, causing fear of mistakes (Table 1). This uncertainty underscores the need for simultaneous training for future physicians and educators. Furthermore, BDs and faculty consistently noted the challenge of limited time to teach an abundance of material, which could complicate incorporating DEI topics.

Table 1.

Themes from listening tour with block directors

How is DEI addressed in your Block?	More commonly addressed in professionalism, communication, SDoH- specific lectures, upper-level courses that deal with patient care, and gender-related topics
	More difficult in basic science/molecular courses, which is the focus of many courses early in the curriculum
	Minimal to no block objectives that specifically call out DEI topics
	Can do better
Opportunities	Can use more cases, standardized patients, patient panels, and small groups to bring in these topics
	Consider adding population genetics and more epigenetics
	Do a better job of clarifying when a disease is worse due to SDoH or environment (i.e., EBV in Africa due to malaria) rather than implying it is due to race
	Can do better and want to do better
	Many more opportunities related to SDoH and history of racism in medicine. History has a lot to teach us
Challenges	Uncertain how to teach this correctly – have previously been told NOT to discuss race since it is a social construct. Should we or shouldn’t we and if so, how? Fear and misconception
	Need to reinforce topics taught earlier so they do not seem superficial and like we are just checking a box
	Do we include race in background during documentation or not?
	For some diseases we do not yet know definitively if there is a genetic influence or not. How do we address this? Race is not genetic
	Want to do it correctly & what is “correct” changes
	Will take time during class, which is already limited
	Allowing students to give feedback related to DEI via anonymous survey is a promising idea but this survey will need faculty input/refinement and understanding on both sides, so students and faculty understand questions and responses

SDoH social determinants of health, DEI diversity, equity, and inclusion, EBV Epstein-Barr virus

One BD from each block responded to the survey, with most reporting that racial sensitivity was presented in their lectures but was not assessed (Table 2). More than half stated they discussed unconscious bias, and presented on race, gender, and sexual orientation. Not surprisingly, more discussions about gender and sexual orientation were specifically addressed in LGBTQIA+ -dedicated lectures or case-based discussions of gender. Most reported no discussion on ableism (Table 2). Slightly more than half want to add DEI content; however, similar to the listening tour results, time was a barrier for those who had not (Table 2).

Table 2.

Responses to block directors’ survey questions (n = 10 directors^a). Results are listed as number of respondents, followed by (%) of respondents. Abbreviated quotes are representative of the complete set of responses. Not all respondents added additional text to their yes/no response

Questions	No	Yes	Abbreviated quotes (yes responses)b
Is racial sensitivity presented in your block?	3 (30%)	7 (70%)	- When discussing SDoH - Using case-based materials
Is racial sensitivity assessed in your block?	7 (70%)	3 (30%)	- Only qualitatively - Formatively but not summatively
Is there any discussion about unconscious bias?	4 (40%)	6 (60%)	- During discussions of SDoH - During discussions of potentially sensitive issues (such as sexual history, abuse, vulnerable populations, etc.) - When we debrief after medical ethics - Using patient examples in lab
If so, to what extent?
Do question stems address different races, genders, or sexual minorities?	4 (40%)	6 (60%)	- Via cases - We discuss different genders - When we talk about LGBTQIA+
Is there any discussion about disabilities and ableism?	7 (70%)	3 (30%)	- We discuss autism and visual ability - Via a patient panel of patients with physical disabilities - We have PT faculty as guest speakers
If so, to what extent?
Are you interested in adding DEI/ ethical professionalism to your block?	4 (40%)	6 (60%)	- Block currently fullb - Would need to add to existing content rather than adding more/new contentb
In what ways do you encourage your block instructors to include DEI in their teaching?	n/a	n/a	- Areas of inequity related to patient care, disparities - Physiological or pharmacological differences between genders, races when relevant based on disease epidemiology or scientific literature - COVID-related lectures - Informally only, no formal requests - Food choices based on food deserts, transportation, SNAP, WIC - Difficult because our lectures are molecular, cellular, or at the tissue level

SDoH social determinants of health, DEI diversity, equity, and inclusion, SNAP Supplemental Nutrition Assistance Program, WIC Women, Infants, and Children Program, LGBTQIA+ Lesbian, Gay, Bisexual, Transgender, Queer and/or Questioning, Intersex, and Asexual and/or Ally +, PT physical therapy

^aA response was received from each of the 10 blocks, communicated by a director representing that block

^bIndicates that the abbreviated quote refers to those who selected “no” for this answer. All other abbreviated quotes refer to those who selected “yes”

Our results suggest that a listening tour coupled with a survey is an effective way to identify DEI integration barriers in the curriculum and promote candid reflections amongst educators. Faculty reflection and listening enabled the DEI team to build collaborative relationships, understand the current extent of DEI integration into the pre-clinical curriculum, and ascertain barriers and facilitators to integration. Common themes were that faculty felt uncertain of the “correct ways” to implement DEI, lack of available time during blocks, and the impression that this material is already covered during lectures dedicated to DEI. However, through our discussions, we found that DEI content was often isolated to lectures about systemic racism and SDoH. While BDs encouraged teaching faculty to address health disparities, most blocks had no DEI-related objectives or dedicated assessment. Also, gaps in the medical curriculum were often due to lack of clarity on when and how to include race in clinical case presentations and vignettes.

The faculty identified several opportunities to enhance DEI integration in their blocks, such as diversified cases, standardized patients, and small group content. Additionally, some faculty suggested highlighting the history of racism in medicine. Overall, there was an agreement that “we need to do better.” The concern for available time in the blocks can be addressed by non-time-consuming edits, such as using person-first language, representative skin tone images, and avoiding the use of race as a biological variable.

While several studies have identified DEI gaps in medical education and a need to address bias, systemic racism, and health equity in medical education [4, 6, 7], few have provided strategies on an initial approach to implement changes. Our findings highlight the need to first collaborate with medical educators and understand their concerns to better design tools for faculty to become effective in integrating DEI.

Our identified opportunities mirror proposed interventions in the literature, which include offering training for medical school staff, while others suggest a parallel curriculum for medical students throughout their medical education [11, 12]. In previous research, when either a single event or sporadic events addressing DEI were held for students or faculty, a self-reported increased ability to recognize concerns in vulnerable patient populations was recognized [13, 14]; however, data are lacking regarding if and how this awareness was integrated into curricular content by faculty.

Our study has limitations related to the small sample size and retrospective data analysis, yet it provides important insight into faculty engagement and opportunities of DEI integration in the pre-clinical curriculum. These results may not be generalizable, but the model of a stepwise approach of listening and reflecting could be utilized by educators who want to initiate curriculum change at their institutions.

As a result of this work, we have developed DEI objectives for the pre-clinical curriculum to enhance the education of DEI-related issues and their impact on disease outcomes (Table 3). We are designing faculty development sessions to improve confidence in addressing DEI, with an emphasis that all faculty, not just URiM faculty should contribute [15]. Furthermore, we are working with leadership for structural incentives to engage in these curricular enhancements such as protected time and inclusion of DEI activities in promotion criteria; time spent developing this crucial content should be compensated and recognized.

Table 3.

Phase 1 DEI objectives developed as a result of this work

Recognize where race as a sociopolitical construct influences disparities in disease incidence and outcomes

Identify health effects from exposure to racism, bigotry, or bias using current, recent, or historical examples that illustrate how breaches of equity and justice impaired health

Define the epidemiology of diseases that show disparities relating to marginalized, underserved, and minority patient identities and relate the risk, where appropriate, to structural inequity

Identify how diseases present differently in patients from different backgrounds and how elements of patient identity can negatively relate to health outcomes

Discuss marginalized patient populations and their backgrounds in a dignified manner

Identify examples of inadequate healthcare resources that predominantly affect patients from low- and middle-income countries, non-Western locations and discuss their conditions, while focusing on the patient as a person worthy of respect and empathy

DEI diversity, equity, and inclusion

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contribution

All persons who meet authorship criteria are listed as authors, and all authors certify they have participated sufficiently in the work, including the concept, design, analysis, writing, and revision of this manuscript.

Declarations

Ethical Approval

This curricular evaluation did not require IRB review as determined by the UNMC Institutional Review Board.

Conflict of Interest

The authors declare no competing interests.

Disclaimers

This publication’s contents are the sole responsibility of the authors and do not necessarily represent the official views of the University or any of its partner organizations.