Bridging the gap: Development of an experiential learning–based health disparities curriculum

Abstract

Background

The increasing number of vulnerable populations served by the emergency department (ED) calls for developing and implementing curricula aimed at training residents to deliver quality care for the most marginalized groups.

Objective

We aimed to address this by developing and piloting a curriculum to introduce the unique challenges and disparities encountered by our diverse ED patient population using an experiential learning approach.

Methods

We engaged community partners in designing and implementing a curriculum for incoming interns. This curriculum addresses specific populations encountered within the ED including patients with psychiatric illness, patients with cognitive disabilities, intoxicated patients, violent patients, patients of various cultural backgrounds, non–English‐speaking patients, and LGBTQ patients. Experiential and active learning sessions with content experts and site visits to area organizations were arranged. Pre‐, post‐, and time‐delayed surveys were deployed to evaluate the pilot of this curriculum.

Results

Thirteen incoming interns participated in the orientation curriculum. Residents' comfort with each of these various patient populations as well as familiarity with community and ED resources was assessed before, after, and 1 year delayed from each session (response 13/13, 100%). Their scores increased significantly from baseline in the postsurvey and were maintained 1 year later (p < 0.05). Residents additionally provided narrative responses regarding what they learned and what was most helpful after completing their intern year.

Conclusions

This pilot curriculum demonstrates that implementing an experiential learning curriculum and engaging community leaders and resources is key to training residents to address health disparities within their unique ED patient population. As such, it is imperative that we seek to immersively introduce trainees to the unique needs of the patient population they will serve early in training.

BACKGROUND

Health disparities are differences in the incidence, prevalence, mortality, and burden of disease and other adverse health conditions that exist between specific groups. ¹ Recent evidence indicates that health disparities continue to exist across diverse populations and are on the rise nationwide. ² , ³ , ⁴ In fact, by 2060, it is estimated that 57% of the U.S. population will be composed of underrepresented groups, many of whom experience the consequences of disparities in health care. ⁵ Health disparities stem from a host of factors including conscious and unconscious biases held by providers that may be derived from a lack of education regarding the specific needs of different populations. ⁶ , ⁷ This can ultimately result in variations in care and health outcomes for patients. Thus, the increasing number of underserved and vulnerable populations in the United States calls for developing and implementing educationally sound programs aimed at training physicians to provide quality care for the most marginalized groups. ⁸ , ⁹ , ¹⁰

Given this, the ACGME, as part of the Next Accreditation System, which is designed to prepare physicians for practice well into the 21st century, included two pathways as part of the Clinical Learning Environment Review (CLER). These Health Care Quality Pathways provide expectations that trainees receive education on identifying and reducing health care disparities and receive training in cultural competency relevant to the institution's patient population. ⁵ , ¹¹ There have been calls across the medical community advocating for incorporating training regarding the social determinants of health (SDH) into medical education. ⁵ , ¹² Nowhere is this training perhaps more important than in the emergency department (ED) where, as the safety net of the hospital system, faculty and trainees encounter patients of different race, sex, identity, culture, ability, literacy, financial means, and housing status during each clinical shift.

NEED FOR INNOVATION

Recent articles have called for residency training programs to include broad, community‐based education that would allow for the opportunity to educate our residents to become socially competent emergency physicians. ⁵ , ¹³ , ¹⁴ To afford the necessary skills to residents during their training, intern orientation has been identified as a crucial time to introduce these topics as entering residents are likely moving from all over the country to a new area where they are unfamiliar with the patient population and the specific disparities they face. ¹⁴ To maximize content delivery, it is recommended to employ an experiential learning approach, which “infuses direct experience with the learning environment and content” as an effective adult learning method to approach the delivery of this content. ¹⁵ It is additionally important to form interdisciplinary community partnerships so that providers understand the resources available to combat these disparities. ¹⁴

While many have called for the implementation of educational programs to address the teaching of SDH and how to address health disparities, there are few published curricula demonstrating that emergency medicine (EM) residency programs are providing formal training in this area, particularly education regarding their unique ED patient populations.

OBJECTIVE OF INNOVATION

We sought to address the challenge of educating our incoming residents regarding health disparities by developing and piloting an intern orientation curriculum to introduce the SDH and the unique health disparities encountered by our ED patient population using an experiential learning approach within a previously defined curriculum development framework.

DEVELOPMENT PROCESS

We developed this curriculum based upon established instruction design methods using Kern's Six Steps for Curriculum Development in Medical Education ¹⁶ (Table 1).

TABLE 1.

Methodologic approach to developing the health disparities curriculum following Kern's Six Steps for Curriculum Development in Medical Education ¹⁶

General needs assessment	Targeted literature review Hasnain et al., scoping review, 2014 17 —16 programs (15 primary care, one surgery), almost exclusively didactic instruction Patow et al., 2016 15 —nine GME innovations using experential learning, no outcomes Chang et al., 2017 18 —EM bus field trip through Washington, DC, neighborhoods with community partners Balhara and Irvin, 2020 19 —Single‐session mural tour combining art of medicine and social context Cross et al., 2022 20 —Single‐day, multispecialty neighborhood walking tour covering community resources
Targeted needs assessment	Open‐ended survey of current residents (24 respondents) asking about What populations our residents were least comfortable with What specific populations they felt would be useful for incoming interns to learn about before caring for patients in our urban, academic ED Results included Residents less comfortable caring for patients of disparate backgrounds Consistent with needs assessments from other specialties 21 , 22 Specific patient populations included patients with mental illness, cognitively and/or physically disabled patients, patients with substance abuse disorders including alcohol, violent patients, patients from various cultural backgrounds, patients with limited English proficiency, and LGBTQ patients
Goals and objectives	Based on the results of our targeted needs assessment, we designed the health disparities curriculum to prepare residents to: Develop familiarity with the various perspectives on health care, disparities faced, and unique needs of each patient population included; and Identify the various hospital and community resources available to the patient populations they will encounter in the ED
Educational strategies	Active and experiential learning sessions as described in Table 2
Implementation	These sessions were delivered over 3 days of intern orientation in partnership with community members and organizations There was no cost associated with this curriculum as all community partners were willing to volunteer their time Any additional space and time was provided by the department for orientation‐related activities
Evaluation	Measured outcomes included deidentified and participant‐coded evaluation surveys, developed by our team in conjunction with our community partners and content experts Validity evidence was addressed via Messick's framework for validity 23 Content validity evidence: The evaluation survey was developed to match the content delivered in direct consultation with the content experts Response process validity evidence: The survey was piloted on second‐year residents (10 residents) and the residency education leadership team (three members) for clarity of the questions, relevance to the content covered, and grammatical errors with edits made based on critiques received from the respondents Evaluation surveys addressed two components: Each intern's self‐reported comfort with these patient populations Each intern's perceived knowledge regarding resources available to each of these patient populations in the ED or within the community

Goals and objectives

Based on the results of our targeted needs assessment, we designed the health disparities curriculum to prepare residents to:

1. Develop familiarity with the various perspectives on health care, disparities faced, and unique needs of each patient population included; and

2. Identify the various hospital and community resources available to the patient populations they will encounter in the ED.

IMPLEMENTATION PHASE

Educational strategies

To address the gaps identified by our targeted needs assessment in resident knowledge and comfort with these diverse patient populations, we developed an active and experiential learning curriculum to address these disparities for incoming interns as part of our orientation series. Active learning is defined as learning through building on prior knowledge and experiences. Experiential learning is defined as learning through reflection on doing. To deliver this content, this curriculum involved sessions presented by community partners recruited both from within the hospital and from the surrounding community. These sessions included active learning via highly interactive discussions with members of the community who identify with various groups and experiential learning sessions including hands‐on workshops and immersive site visits to various community organizations who work with these patient populations. The immersive site visits particularly engaged our interns with the patient population in their day‐to‐day lives or in their lived experiences. The workshops allowed the residents to practice various skills they were taught by the community experts. Each session, regardless of format, included narrative reflection as part of the evaluation process to encourage the residents to consider how they would integrate what they learned into their practice as they began residency. Each of the patient populations identified as part of the targeted needs assessment was addressed in a separate session using the described instructional methods (Table 2).

TABLE 2.

Content outline of health disparities with curriculum sessions, instructional methodology, and resources required for each session

Session topic	Instructional design	Resources needed
Cultural competence	Moderated panel discussion An interactive panel was convened with patients representing the African American, Hispanic, Hmong, and Amish populations within the community surrounding our academic ED. The panel was moderated by a university expert in cultural competence. Residents were able to ask questions and the panelists shared their experiences of the community and health care system providing concrete examples and discussing alternative approaches to their experiences with the residents.	Community partners who are often leaders in their respective cultural communities. If none apparent, you may wish reach out to local agencies serving these communities, community centers, or religious organizations within those communities. This session required a reserved space and 90 min for the panel discussion.
Limited English proficiency	Interactive lecture with expert and patient stories The director of interpreter services gave a brief lecture on resources available for patients with limited English proficiency including interpreter services and how to provide discharge instructions for patients who speak a different language or are blind. Patients with various language barriers including American sign language discussed their experiences with the residents. Residents were able to practice working with interpreters during this session with practice patients.	The hospital interpreter services office was integral to connecting with an expert to provide resources to the residents as well as arrange the discussion with patients who had experience with the ED. This session required a reserved space and 60 min for the lecture and interactive discussion.
LGBTQ patients	Workshop A local LGBTQ community partner gave a brief overview of the barriers their patients face in seeking care in the ED. Several members of the LGBTQ community then shared their experiences with the residents. Based on this, we broke up into small groups and had a role‐playing session regarding the topics discussed to improve resident comfort with addressing these disparities in their interactions with these patients.	Partnering with a local community agency for LGBTQ health issues is key to this session. While residents often feel they understand LGBTQ patient issues, hearing their experiences from the ED and having to walk through these scenarios can be eye‐opening. This session required a reserved space and 2 h for the workshop. This could be abbreviated or expanded based on your goals for the session.
Violent patients	Workshop Hospital security leaders provided a workshop to discuss nonviolent deescalation and self‐defense when working with violent patients. This session began with a brief lecture, followed by alternating brief demonstrations of scenarios and residents demonstrating how they would respond to each situation. It finished with basic skills to protect oneself when being attacked or held by a patient.	Hospital security is a frequently overlooked resource. These individuals often provide nonviolent deescalation training and have these workshops readily available. They are able to facilitate role‐playing and skill practice sessions as well. This session required a reserved space and 2 h for the workshop.
Alcohol and drug abuse	Interactive site visit Our ED sends patients to an alcohol and drug detoxification center on a routine basis. As part of this session, we visited that detoxification center. This included an interactive tour of the center and a practical discussion of resources available for patients once they are discharged from the ED and taken to this facility.	If you have a local center where you send patients for alcohol or drug detoxification, forming a relationship with that community partner and seeing the center is a valuable experience for the residents. Other options for partnering include dual‐diagnosis facilities or intensive outpatient treatment centers. This session took 2 h for the tour. Appropriate driving time on either end should also be considered.
Cognitive disabilities	Interactive site visit Our ED receives patients from one of the only remaining residential facilities for patients with complex cognitive disabilities. Given that we frequently see them when they are ill, getting a baseline sense of how they are functionally when they are well and the resources available to them is important. As part of this session, we toured the facility and talked with the interdisciplinary providers from physicians to physical, occupational, and respiratory therapists to orthotics consultants who care for these patients on a daily basis. We also were able to speak with the patients and sit in on sessions where they worked with providers at the facility and ask questions.	If you have a local center from which you receive patients with cognitive or physical disabilities, you may wish to partner with them. Other options include outpatient interdisciplinary clinics, respite centers, or special education centers that may be affiliated with local schools. This session took 2 h for the tour. Appropriate driving time on either end should also be considered.
Mental illness	Interactive Site Visit Our ED frequently receives patients from an inpatient forensic psychiatric facility. We also see a substantial number of patients with mental illness in our ED who are hospitalized at another part of this facility. As part of this session, we visited this mental health facility. This included an interactive tour of the center and a discussion of resources available for patients once they are discharged from the ED and taken to or returned to this facility. This included a robust discussion of both medical and psychiatric management as well as legal issues pertaining to court ordered treatment within the facility and its impact on ED management.	Many hospitals and EDs have community mental health partners. These partnerships should be made clear to the residents as should the community outpatient resources for mental health treatment. This session took 2 h for the tour. Appropriate driving time on either end should also be considered.

Evaluation

Surveys were developed as described in Table 1. These surveys were deployed before the curriculum to obtain a baseline; they were subsequently completed immediately following the 1‐month curriculum and again 1 year later. Each survey assessed two components: (1) intern self‐reported resident comfort with these patient populations by asking them to respond to the following statement: “I am comfortable caring for X patients in the ED” and (2) each intern's perceived knowledge regarding resources available to each of these patient populations or to them in working with these patients in the ED by asking them to respond to the following statement: “I am familiar with resources available in the ED and community for X patients.” These surveys employed a 5‐point Likert scale with the following anchors: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree in responding to both of these questions. Descriptive statistics of the mean responses to these questions in the pre‐, immediate post‐, and 1‐year postsurveys were compared. Paired‐sample t‐test analysis comparing baseline results from the presurvey against the results after the session and at 1 year was performed using statistical software (SPSS Inc. Version 16.0). with two‐tailed statistical significance predetermined at p < 0.05. Effect size was calculated using Cohen's d. Additionally, both the immediate postsurvey and the 1‐year postsurvey included qualitative, open‐ended responses regarding what they learned in the sessions and what was most useful over the course of the year in the ED, respectively. This pilot study was determined to be exempt by the University of Wisconsin Institutional Review Board.

OUTCOMES

Thirteen entering residents participated in this experiential health disparities curriculum pilot as part of their intern orientation month. There were nine men and four women. One identified as Latino and the others as White. All identified as cisgender. One identified as bisexual, and the remainder, as heterosexual. They ranged in age from 26 to 35. This pilot was performed at a single, urban, academic EM residency program. Each resident completed surveys prior to, immediately following, and 1 year after completing the curriculum. All 13 interns completed each survey for a 100% response rate.

We found significant increases in the interns' self‐reported comfort with various patient populations and significantly increased familiarity with community and hospital resources available for each of the populations covered in the sessions immediately following participation in the curriculum with p < 0.05 in all patient populations (Figures 1 and 2). Importantly, these gains were sustained 1 year later after each intern had worked an average of 5 months in the ED at a significant level with p < 0.05 for both questions across patient populations except for resources for language differences 1 year later (Figure 1 and Figure 2). Effect sizes for these gains were moderate and ranged from 0.27 to 0.53 with the greatest effect seen in psychiatric and violent patient populations.

FIGURE 1.

Average resident responses on 5‐point Likert scale ranging from 1 – strongly disagree to 5 – strongly agree regarding comfort with each patient population on the pre‐, immediate post‐, and one‐year post‐survey.

FIGURE 2.

Average resident responses on 5‐point Likert scale ranging from 1 – strongly disagree to 5 – strongly agree regarding familiarity with community and ED‐based resources for each patient population on the pre‐, immediate post‐, and one‐year post‐survey.

Each intern additionally responded to open‐ended questions regarding what they learned in the immediate postsurvey as well as what was most useful from the sessions over the course of the year in the ED in the 1‐year survey. A sampling of these responses is provided in Table 3.

TABLE 3.

Narrative responses to survey questions regarding what each resident learned from the sessions and what they found most useful working in the ED 1 year later

Session topic	What was learned	What was most useful in the ED
Cultural competence	“This was an excellent reminder that cultural differences play a role in patient preferences.” “Body language is important when interacting with patients who may be different than me.” “Family involvement in medical care is very important in many cultures.”	“It was so important to know about the differences in how Hmong patients make decisions with their families.” “I am so glad I knew to ask to be introduced to everyone in the room so I would know who was important in the decision‐making process.”
Limited English proficiency	“11% of our patient population does not speak English at home.” “I learned how to call for an interpreter, get a video interpreter on the line for sign language, and that we have a 24 h in‐person Spanish interpreter! How cool is that?” “I learned when interpreters are mandatory and why–we make so many assumptions, and many of those are completely wrong!”	“It was so helpful to know that our interpreters could translate written discharge instructions into a patient's native language.” “This is a golden resource in this hospital—to have 25 different languages offered, most of them in person, and to know how to get them to the ED or on the phone was invaluable to know up front.”
LGBTQ patients	“I had no idea LGBTQ patients were at such high risk for suicide.” “It is so helpful to know what specific needs our LGBTQ patients have—I had no idea about the increased risk of invasive meningococcal disease or the different incidences of illnesses in these populations.” “It is extremely helpful to know where to find a patient's preferred name and pronouns in Epic!”	“It became so much clearer to me over the course of the year how helpful this session was—knowing the different LGBTQ‐friendly primary care doctors, who to contact for various outreach efforts such as Wilma's Fund for homeless LGBTQ patients was so important.” “Knowing the various resources available for trans and transitioning patients in our ED was something I did not realize would be so important.”
Violent patients	“It is helpful to know when we can and cannot utilize security in the ED.” “How to get out of a ponytail hold!” “Anxiety can be a patient getting very quiet and may lead to future escalation and violence.” “I learned a ton of helpful nonviolent deescalation techniques.”	“Keeping at least 3 feet between me and a patient and knowing my exits saved me from getting attacked by several patients this year.” “The various techniques to respond to different levels of escalation were incredibly helpful. It was so true that stopping patients at verbal escalation and knowing how to do that almost universally prevented physical escalation or violence.”
Alcohol and drug abuse	“I learned when it is safe to send someone to detox from the ED.” “I learned what is expected of the physician for medical clearance prior to discharging a patient to detox.” “It is good to know that someone who is incapacitated can be placed on a 72 h hold in this state.”	“Knowing what medical resources were available in our detox centers saved me from discharging patients inappropriately to detox, which would have been potentially unsafe.” “Knowing to hold patients who are intoxicated and suicidal until sober for evaluation was so important this year.”
Cognitive disabilities	“How to contact facilities for those who are disabled to obtain information about their baseline and what kind of care they receive there.” “How to approach caring for nonverbal patients including examining them and obtaining information from relevant sources.” “I learned about the social model for disability.”	“Knowing to ask about a patient's baseline and what they act like when ill or in pain was incredibly helpful this year.” “Knowing the community resources for patients with disabilities was invaluable.” “Knowing how guardianship works and how to find out who a patient's decision‐maker is saved me so many headaches and so much time on shift.”
Mental illness	“Knowing how holds are placed and who needs to be involved since it varies by state.” “Knowing which inpatient facilities in the state with admit uninsured patients.” “I learned what is required for medical clearance from the ED as a physician.”	“Knowing how to approach disagreements with psychiatry or those responsible for placing holds for psychiatric reasons was so important as it was often gray in the moment.” “Having an intimate understanding of the medical clearance and psychiatric admitting process was a very valuable asset this year.” “Knowing where to find the resources for uninsured patients with mental health crises was so helpful.”

REFLECTIVE DISCUSSION

This pilot was a successful model for increasing resident comfort various patient populations encountered in our ED as well as increasing knowledge regarding community and ED resources for these patients. In light of recent events including the Black Lives Matter movement, ²⁴ an increasing body of literature regarding implicit bias among providers affecting clinical decision making, ²⁵ , ²⁶ and evidence that patients receive improved care from providers who are able to connect with the patient population they serve, ²⁷ , ²⁸ these and similar curricula are imperative to ensuring our trainees are prepared to serve our diverse ED populations. While this may not result in a standardized curriculum that can be implemented widely, it provides a model for a flexible and adaptable approach to the development of a curriculum that addresses the unique needs of a program's specific patient population.

Orientation provides protected time for interns to become acquainted with the varied patient populations served by the ED in which they will train. It also allows for them to learn about patient populations and resources available prior to carrying the burden of a large patient load on each ED shift. However, a curriculum like this can be implemented longitudinally as well during protected conference time or as part of residency retreat or other times when all residents are able to participate. The key to success is to engage community leaders and even patients to participate in educating our trainees. Utilizing active and experiential learning techniques provides an interactive, hands‐on, personal connection to these varied patient populations. This allows trainees to see how what they do affects their patients by hearing personal stories. It additionally gives them first‐hand experience with many of the resources available in the community with which they would not otherwise be familiar.

To ensure the longevity and sustainability of this successful pilot curriculum, we have developed an advisory board composed of the participating content experts as well as key members of our academic department and administrative team. Future planned evaluation techniques of this curriculum include a targeted objective structured clinical examination (OSCE) or direct observation in the ED to better characterize its educational impact on our trainees and the patients we serve.

LIMITATIONS

Limitations of this pilot include its small sample size of 13 interns. While this may limit generalizability to an extent, it is a pilot, and we intend to evaluate larger scale outcomes in the future. Second, the follow‐up survey at 1 year may be confounded by what our interns naturally would have learned while working with these patients in the ED. Third, we used surveys as part of our evaluation, which may not adequately reflect true learning regarding resources as the responses were subjective and outcomes lower order in nature when compared to the use of simulation. We will seek to implement higher‐order outcomes with future iterations of this work. Additionally, our patient population is not reflective of every patient population. Sessions will need to be altered and different community leaders engaged to reflect each individual residency training program's patient population. Finally, this pilot was performed in a single specialty. While the scope specifically addressed patient populations encountered in the ED, the approach would be translatable to any specialty who wished to engage community stakeholders and engage their residents in experiential learning to meet their patient population in a way that deepens understanding and affords a greater contextual approach to patient care in the clinical environment.

CONCLUSIONS

It is imperative that we as residency program leaders and EDs address the various health disparities faced by our diverse patient populations. Training residents utilizing experiential learning techniques and engaging community leaders and resources is key to training residents to address health disparities within the unique ED patient population they serve.

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.

Supporting information

Appendix S1

Caretta‐Weyer HA, Hess JM. Bridging the gap: Development of an experiential learning–based health disparities curriculum. AEM Educ Train. 2022;6:e10820. doi: 10.1002/aet2.10820