Engaging Diversity to “enlighten” Medical Education

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The word “education” has etymological roots that are both interesting and revealing. It evidently derives from the Latin “educo”, roughly translated “I lead forth” or “I raise up”. “Educatio” is “a breeding; a bringing up; a rearing”.

The word “education” has been defined in various ways, but definition that I prefer is simpler and more consistent with the origin and intent of the process; “an enlightening experience”.

In a previous article (http://meds.queensu.ca/blog/undergraduate/?p=1569) we explored the role of diversity as a component of that “enlightening experience”. The main points:

  • the environment in which education is provided can be as powerful as the instruction itself.
  • early adulthood is a critical time in the development of social and personal identity. Erikson wrote of that time being a “psychosocial moratorium”, during which they feel free to “sample” and experiment with various social roles for themselves before taking on a more fixed and permanent role.
  • early diversity experiences are both impactful and enduring, as evidenced by Newcombe and colleagues work with the Bennington College cohort, and both the Michigan Student Survey and Cooperative Institutional Research Programs.

Perhaps most importantly, higher education diversity experiences are most influential when the social milieu differs from the students home and social background. In the words of Gurin, it needs to be “diverse and complex enough to encourage intellectual experimentation and recognition of varied future possibilities.” Simply put, the real power to influence goes far beyond lofty mission statements and curriculum, and arises largely from developing an environment where students are able to interact both passively and actively with individuals who are “different” and therefore force new thought and new perspectives during this critical developmental phase.

Building on the last point, it would seem that any attempt to improve the educational environment from a diversity perspective must begin with an understanding of the pre-university home and social backgrounds of our learners. What do we know of the background of students undertaking medical education in Canada?

An important study by Dhalla and colleagues (CMAJ 2002:166;1029) surveyed 1223 first year Canadian medical students and found that, compared to the general population, medical students were:

  • Less likely to be of Black (1.2% vs 2.5%) or Aboriginal (0.7% vs. 4.5%) heritage
  • Less likely to hail from rural areas (10.8% vs. 22.4%)
  • More likely to have parents with master’s or doctoral degrees (39.0% of fathers and 19.4% of mothers, compared to 6.6% and 3.0% respectively)
  • More likely to have parents who were professionals or high level managers (69.3% of fathers and 48.7% of mothers compared to 12.0% of Canadians), including 15.6% of medical students having physician parents.
  • Less likely to come from households with incomes under $40,000 annually (15.4% vs. 39.7%)
  • More likely to come from households with incomes over $150,000 (17.0% vs. 2.7%)

These findings have since been substantially confirmed by Steve Slade and and his colleagues, who compile the Canadian Post-MD Education Registry (http://www.caper.ca/~assets/documents/CAPER_Poster_AAMC_Physician_Workforce_Conference_May-2012.pdf.), and more recently by Young and colleagues who surveyed 1,552 Canadian medical students (Academic Medicine 2012, 87; 1501), concluding that they are “overrepresentative of higher-income groups and underrepresentative of populations of Aboriginal, black or Filipino ethnicities in Canada.”

Our students have also weighed in on this issue. The Canadian Federation of Medical Students has published a position paper entitled “Diversity in Medicine in Canada: Building a Representative and Responsive Medical Community.” http://www.cfms.org/attachments/article/163/diversity_in_medicine_-_updated_2010__cait_c_.pdf. To quote their document:

“As medical students in a country that embraces diversity, we believe that our medical system should be representative of and responsive to the diversity within our communities. Unfortunately, the medical school admissions process has traditionally favoured students from high-income, urban dwelling, majority groups, thereby limiting the diversity of medical students across Canada and further marginalizing underrepresented patients and communities…An increased emphasis on diversity in medicine would help ensure that medical students and physicians are in tune with the needs of the communities that they strive to serve and represent.”

And so it appears that if we’re to develop this “enlightening” environment within Canadian medical schools, we’d be well served by facilitating entry of socioeconomically less advantaged population, and particularly member of our Aboriginal populations.

But how? An examination of the literature and our own local experiences seems in order.

Lessons from Other Programs

Recognizing that any attempt to encourage and support historically disadvantaged groups must begin very early in the educational process, the “cascading mentorship” model has been advocated by many. In their recent article Afghani and colleagues (Academic Medicine 2013; 88: 1232) describe a model they have developed at the University of California “in which high school students are coached by premed undergraduate students, who are in turn mentored by medical students, who are mentored by faculty.” The program expanded over a short period of time and both undergraduates and medical students reported very high ratings in self-confidence, motivation for a career in academic medicine, understanding different cultures, leadership ability, teaching ability and commitment to serve the underserved.

In “How leaky is the Health Career Pipeline?” (Academic Medicine 2009; 84: 797), Alexander and colleagues sought to explore how students from underrepresented minority (URM) groups performed in “gateway courses” (general chemistry, organic chemistry, general biology, introductory physics and calculus) required for application to California medical schools. They found that URM students received significantly lower grades in these courses, even after adjusting for prior academic performance (ie. poorer background in those subject areas). However, despite this greater academic adversity, URM students were at least as likely as white students to complete all the gateway courses and become eligible for application. They conclude that “interventions at the college level to support URM student performance in gateway courses are particularly important for increasing the diversity of medical and dental schools”.

In 2001, the Medical University at South Carolina embarked on an ambitious and aggressive strategic planning program to increase the diversity of their student population and faculty (Academic Medicine 2012; 87: 1548). At the admissions level, they provided “added value” to an application for certain characteristics intended to diversify the pool of qualified applicants. These included advanced community service, cultural experiences attending to the needs of underserved and underrepresented populations, sustained work experience, artistic/athletic achievements, overcoming adversity, and rural or inner-city backgrounds. In addition, individual Departments were called on to develop specific diversity plans, and financially supported to do so. Other initiatives included the development of pipeline programs and strategic partnerships with more than 40 colleges and universities to develop interest in the health professions among URM individuals. This comprehensive, multi-dimensional and leader-driven approach has proven highly successful in increasing the diversity of both student body and faculty over a 10 year follow-up.

Since 1973, the Sophie Davis School of Biomedical Education has been operating an innovative program within the City University of New York (Roman SA, Academic Medicine 2004;79:1175). They offer an innovative 5 year combined BS/MD program to promising high school graduates who express a definite interest in a medical career. Successful graduates of this program are guaranteed advanced transfer into the final two clinical years at one of five cooperating medical schools in New York State. The mission of the program “to expand access to medical careers to among talented inner-city youths and youths who have experienced educational disadvantages despite demonstrated evidence of high levels of academic achievements”. The program has been remarkably successful in providing access to socioeconomically disadvantaged students (27% of their students coming from families with incomes below federal poverty levels, and 70% eligible for state sponsored tuition support), underrepresented minorities (only about 15% of their students identified as “white”) while maintaining academic success (90% pass rate in USMLE Step1) and producing graduates who provide service in underserviced and underprivileged areas.

Current programs at Queen’s

Closer to home, Queen’s has had an Aboriginal Admissions Process since 1998. Under the process, applicants who self-identify and who meet reduced cut offs for GPA and MCAT scores have file reviews conducted by a team that includes members of the Aboriginal community. Interviews with selected candidates also involve members of the Aboriginal community. Since the program’s inception, data have been kept on the number of self-identified applicants, the number of offers and the number of acceptances.

MedExplore is a student-led program created in 2012. It provides opportunities for skill development, networking, and career exposure to students from disadvantaged groups that are under-represented in health care professions, so that they can make informed educational and career decisions. Queen’s medical students run workshops and serve as mentors to high school students from a variety of backgrounds, including

Altitude Healthcare Mentoring is a student-led initiative that has been operating at Queen’s since 2011. It provides mentoring and programming to first-year students from disadvantaged groups, including Aboriginal students and students of low socioeconomic means.

Queen’s University Accelerated Route to Medical School (QuARMS) has the potential to address the many barriers inherent in the medical school admissions process. Writing MCAT tests, submitting applications and attending interviews all involve significant cost. As well, low-income students may not be able to afford to take a summer off from working to prepare for the MCAT or to participate in volunteering and extracurricular activities that less financially constrained students employ to enhance their applications. QuARMS is available to students in all schools, from all parts of the country. Full travel bursaries are provided for students who demonstrate financial need. A student from an underrepresented group who applies through QuARMS therefore has the opportunity to access medical education on a more equal footing with higher-income candidates, avoiding many of the barriers that might otherwise deter them from applying to medicine.

Going Forward

In my previous article on this topic, I closed by posing the not-so-rhetorical question “Can we do better?” The home-grown initiatives noted above are certainly praise worthy steps in the right direction, but I think all would agree that they would benefit from more visibility and more structured, consistent support. Moreover, they would seem to fall short of the deep, institutional commitment typified by the programs like those described at South Carolina and the Sophie Davis School. For all these reasons, a number of initiatives are being brought forward within the School of Medicine to better define and bolster our approach to advancing Diversity.

  1. A Diversity Statement has been developed and approved by the MD Program Executive Committee that will be brought to the School of Medicine Academic Council for approval this week that statement reaffirms the university commitment to underrepresented groups and focuses the School of Medicine on two target populations, the Aboriginal peoples of Canada, and the socioeconomically disadvantaged.
  1. A Diversity Advisory Panel, consisting of interested students and faculty is being struck to develop and support initiatives to advance Diversity within our school, including those student led projects already underway. Dr. Leslie Flynn has agreed to take on the chairmanship of this panel, and no fewer than 9 student volunteers have already stepped forward to participate, and that group has its first meeting scheduled for later this month.
  1. A Diversity Fund has been developed that will be available to the panel for support of projects or initiatives it recommends.
  1. Dean Reznick has given high priority to the recruitment of a faculty Diversity Lead to coordinate our approaches.
  1. I will be asking our Admissions Committee to consider means by which they could more directly support our Diversity goals through modification of our current MD Program and QuARMS admission processes.

As always, your views on these and any other initiatives you’d like to bring forward are most welcome.

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

Many thanks to Sarah Wickett and Sandra Halliday, Health Informatics Librarians, Bracken Library, for their valuable assistance in the compilation of information for this article.

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