Curricular changes are coming to every aspect of medical education, spurred by demands of Jacobs School student leaders
By the University at Buffalo
A new medical curriculum with anti-racism at its core is being designed and implemented at the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo.
Catalyzed in 2020 by the COVID-19 pandemic, as well as the George Floyd murder and global protests that followed, the evolving new curriculum is a result of the profound reckoning that these events forced among those studying and practicing medicine.
“I have never seen so much willingness to change,” observed Margarita Dubocovich, Ph.D., senior associate dean for diversity and inclusion, and one of four co-chairs of the Diversity, Inclusion and Learning Environment Committee. “This is the moment. This is the opportunity.”
While issues such as the social determinants of health have been part of the Jacobs School’s orientation and required courses, it was a student-written document and petition submitted in June 2020 that launched the comprehensive efforts now underway.
“The student petition changed the urgency,” recalled Linda Pessar, M.D., former director of the Center for Medical Humanities and now professor emeritus of psychiatry. “It demanded that the medical school quickly increase its attention to structural racism and social justice, to look at the ways that the curriculum creates and perpetuates racism by not attending to differences among people.”
Former dean Michael E. Cain, M.D., mandated that the requested changes be fast-tracked. His successor, Allison Brashear, M.D., vice president for health sciences and Jacobs School dean, who came to UB in December 2021, has redoubled those efforts.
“Medical education at the Jacobs School is undergoing fundamental changes addressing structural racism in medicine in an effort initially inspired by our students,” she said. “That fact speaks volumes about the depth of commitment that our students bring to this work collectively as they work with faculty to achieve health equity in every aspect of patient care.”
Recommendations included providing racial and socioeconomic context behind longstanding health issues in African American communities and directly acknowledging the effects of systemic racism and the threat of police violence on the physical health of people of color. They included teaching students how to be effective patient advocates and providing instruction in the history of anti-Blackness, discrimination against LGBTQ+ people and other marginalized communities, and how these issues have affected medicine and how it’s taught.
The petition also addressed increasing the diversity of faculty and staff, a goal to which the university as a whole has committed through the establishment of President Satish K. Tripathi’s Advisory Council on Race. Administrators acknowledge that such diversity is sorely lacking at the medical school, but that change is coming with new diversity requirements for search committees and an emphasis on holistic interviewing.
It is well-documented that having more diversity among instructors benefits all students and faculty, and that mentoring is key, a premise taken for granted throughout the medical profession.
In addition, the school has:
√ Recommended anti-racism training for professors and lecturers.
√ Pledged to protect students and applicants who speak out against social injustice.
√ Established a crisis response/bias advisory response team.
√ Undertaking a comprehensive case review
A key focus for curricular change is the patient cases that students are exposed to, both in the classroom and in the clinic, either with standardized patient volunteers or in the community with preceptors.
“We are taking a look at the entire inventory of cases across the curriculum,” said Jennifer Meka, Ph.D., associate dean for medical education and director of the Jacobs School’s Medical Education and Educational Research Institute.
Faculty have been revising and editing cases, and discussing ways to encourage students to reflect on implicit bias and structural racism.
“It really is a systemic look at the entire curriculum,” said Alan J. Lesse, M.D., senior associate dean for medical curriculum, who, with Meka, co-chairs the curricular revision subcommittee.
An early, critical change was the decision in fall 2020 to subscribe to a database that specializes in dermatological manifestations of disease and features a broad spectrum of representation, including many people of color.
Traditionally, most cases have featured patients who are white men aged 40-55, without any mention of race or economic orientation.
“We are working on guidelines to revise cases to better reflect the diverse population our local students will be working with,” Meka said. “The goal is to develop the racial competence, cultural humility and advocacy skills that are required for practicing medicine, to examine the intersectionality of race and its impact on health and wellness. We are also working with our faculty facilitators to go beyond the biomedical issues and to talk with patients about social determinants of health, incorporating respect for other cultures.”
More Diverse ‘Standardized’ Patients
The clinical practice of medicine course, which students take during their first two years, is a key focus. It relies on volunteers from the community who are trained to act as “standardized” patients with specific medical symptoms, who are then diagnosed by medical students.
“Most standardized patients are white,” said Tatiana Amaye-Obu, a member of the Class of 2024. “I had my first non-white patient last year in my second semester, but some students have never had a non-white standardized patient.”
Diversifying that pool of standardized patients will be challenging. “Minority communities are already distrusting of medicine,” Amaye-Obu said. “So, in order to improve that, we have to go out into the community and truly explain what we’re doing. That’s the whole point of doing standardized patients: caring for others in the future.”
Toward that end, the school introduced in 2018 the health in the neighborhood course as a pilot elective.
The course pairs medical students with members of the Hopewell Baptist Church congregation in Buffalo. The goal of the course is for students to become familiar with the realities of medical disparities and how they affect individuals.
“The intent of the course was to explore the effect of racism on the Black community and to engage with the African American community,” said David Milling, M.D., senior associate dean for medical education, who founded the course along with Pessar and Henry-Louis Taylor Jr., Ph.D., professor of urban and regional planning in the School of Architecture and Planning and director of UB’s Center for Urban Studies. “It had little to do with us providing care but instead had to do with listening to the community, to finding out what are the barriers to providing care and how can we be better physicians.”
The course has now been expanded to include a clinical component, blending what students are learning in the classroom with culturally sensitive interviewing as they work with clinical preceptors in underserved communities.
Instructors throughout the school have been incorporating anti-racism into their courses, not only for those pursuing medical degrees, but also for those in undergraduate and graduate programs in biomedical sciences.
Jennifer Surtees, Ph.D., associate professor of biochemistry, and David Dietz, Ph.D., chair of the department of pharmacology and toxicology, have explicitly integrated anti-racism into their ethics course, introduction to scientific investigation and responsible conduct (BMS 514LEC). One focus in the class engages students in addressing the attitude still prevalent among some scientists of “we don’t need to discuss this in science.”
Social Justice and Equity Administration Leadership Fellowships
Students urged school administrators to work to alleviate the burden of students of color who are affected by structural racism while also serving as the primary leaders of diversity and inclusion efforts.
These efforts led to the establishment of the Social Justice and Equity Administration Leadership fellowships launched last year by the Office of Inclusion and Cultural Enhancement. Funded initially by the Jacobs School’s Office of the Dean, the fellowships give medical and biomedical sciences graduate students a chance to work on specific projects that address social, educational or health care inequities while providing $3,500 each in scholarships, as well as funding for travel expenses.
Five fellowships were awarded in the first round and topics range from assessing the impact of the health in the neighborhood course and improving vaccine equity in communities of color, to developing a curriculum on the history of racism and ways to improve the learning environment for members of the LGBTQ+ community.
And while the institution has clearly embraced these changes, Lesse noted, they all still need to fit into the medical curriculum.
“The question is, we have four years right now to develop students into physicians,” Lesse said. “What do they need to learn when? These changes will make them much more aware of their roles as physicians in society.”
That is especially true in the required first-year course medicine and society, which focuses on the physician’s role. The course has been redesigned with a stronger emphasis on health inequities.
James N. Jarvis, M.D., clinical professor of pediatrics, who is of Akwesasne Mohawk ancestry and has worked on American Indian and Alaska native child health issues for more than 30 years, has addressed the class.
He told the students, “You can’t just say to Indigenous groups: ‘We’re here to help, this is what we think you ought to do.’ Instead, you need to spend time with them. Ask them what they think. Sit down with these communities. Be humble and listen.”
These principles, now an integral part of the Jacobs School curriculum, will ultimately benefit not just the individual students being educated, but also, by extension, all of the communities where they will eventually practice.