In the Nation's Compelling Interest Ensuring Diversity in the Health-Care Workforce (2004) / Chapter Skim
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Contribution D: Diversity Considerations in Health Professions Education
Contribution D: Diversity Considerations in Health Professions Education
Pages 345-390
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The university was able to make this case, in large part, because of the array of empirical evidence that it and other organizations provided that established how diversity enhanced the learning outcomes for students at Michigan and at colleges and universities across the country. The primary goal of this paper is to examine the ways in which existing evidence about diversity in higher education and its effects on students, institutions, and society can be used to inform and improve the quality of education received by students in health professions.
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To begin, we review the literature drawn from studies of higher education generally, followed by a focused consideration of issues related specifically to health professions education (with an emphasis on medical education)
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An extension of cognitive and emotional development concerns related to health professions education is presented, followed by a discussion of how educational settings and learning environments can influence learning related to diversity issues, as well as pedagogy that can promote transformative learning. These two strands of work -- higher education generally, and health professions specifically-are brought together in a set of recommendations intended to guide the transformation of education in the health professions so that students in these fields realize the educational benefits of diversity, and so that all members of our society will be better served by the professionals who provide them with health care.
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The institutional context contains multiple dimensions that are a function of educational programs and practices. These include an institution's historical legacy of inclusion or exclusion of various racial/ethnic groups; its compositional diversity1 in terms of the numerical and proportional 1Much of the relevant research describes this dimension of climate as structural diversity.
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(1998, 1999) argue that the historical vestiges of segregated schools and colleges continue to affect the climate for racial/ethnic diversity on college campuses.
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has shown that the likelihood that students will engage with students who are different from them increases as the compositional diversity of the campus increases. Conversely, campuses with high proportions of white students provide limited opportunities for interaction across race/ ethnicity and limit student learning experiences with socially, culturally diverse groups (Hurtado et al., 1994)
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. The Behavioral Climate The behavioral dimension of the institutional climate consists of general social interaction, interaction between and among individuals from different racial/ethnic backgrounds, as well as the nature of intergroup relations on campus.
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However, the opportunities that students have to learn from diverse peers in classes that use these active learning methods, even in classes where the content does not deal explicitly with diversity issues, can help students to build bridges across communities of difference.
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, and Milem and Hakuta (2000) argue that, in addition to compositional diversity, there are two additional types of diversity that can have an impact on important educational outcomes.
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. In other words, increasing only the compositional diversity of an institution without considering the influence that these changes will have on other dimensions of the campus racial climate is likely to produce problems for students at these institutions.
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Perry's (1970) work with college students laid a foundation for understanding development that occurs in the college environment.
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In the third order, boundaries are extended beyond the self, and as the context of the self changes, so does the concept. Another way to say this is that individuals undergo a process during which they simultaneously learn to be autonomous and interdependent.
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Based on his research, Kegan theorizes that one-half to two-thirds of adults never reach the fourth level of consciousness, implying that this level is not commonly achieved in the traditional undergraduate college years, though it may occur during postgraduate studies. Contextual Issues and Learning Environments Within the span of human development stages and transformations, there are certain contexts and environments that are particularly suited to promoting student change with respect to diversity issues as conceptualized here.
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. Diverse learning environments help to create these kinds of conditions and thereby stimulate active, conscious, nonautomatic thinking that stimulates cognitive development and identity.
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Of particular interest for health professions education is the potential for transformative learning to shape an individual's orientation toward lifelong learning. Kegan (1994)
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underscore a number of general conditions through which campus diversity -- if managed through effective, thoughtful processes -- can positively affect student learning outcomes. One example of such an effort can be found in the University of Michigan's Program on Intergroup Relations (IGR)
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Moreover, the use of active pedagogy provides students with opportunities to interact with peers from different backgrounds through class discussions, collaborative learning methods, and group projects. These activities contribute to a campus climate that is more supportive of diversity and lead to positive outcomes for the students involved (see, e.g., Astin, 1993; Gurin, 1999; Hurtado et al., 1998, 1999; Milem, 2003; Milem and Hakuta, 2000; Smith & Associates, 1997)
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The literature suggests that individual development is enhanced when individuals encounter novel ideas and new social situations, forcing them to abandon automated scripts and think in mindful ways. Given the continuing pattern of segregation in American society, the first time that many individuals encounter racial and ethnic diversity is at college, creating a rich and complex social situation that can be effectively used to promote student learning and development.
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. Earlier research that examined the impact of increased compositional diversity on college campuses indicated that as the representation of students of color increased on campus, institutions felt greater pressure to change.
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However, this is very difficult because the transformative aims of diversity often clash with deep-seated institutional assumptions and values. The educational benefits of diversity emanate from institutional changes that challenge prevailing educational sensibilities and that enhance educational participation.
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This is very likely when we consider that colleges and universities, like many private businesses and firms, tend to be highly bureaucratic organizations. Moreover, organizations that provide health care also tend to be highly bureaucratic.
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HEALTH PROFESSIONS EDUCATION It is important to note that much of the research documenting the benefits of diversity and addressing the campus climate for diversity has been conducted using data collected from undergraduate students. Although this might suggest a limited utility of the perspectives generated from the general higher education literature for health care education, we suggest that this literature provides a good platform for addressing the common as well as the unique aspects associated with training in health care professions.
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The higher education literature discusses the need to ensure "equal status" among students from different cultures in order to achieve and enhance learning outcomes. Health professions educators need to take this one step further by helping students understand the importance of equal status in the context of interactions between health-care providers and patients, where differences in professional status as well as culture greatly influence the quality of health care provided.
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Problem-Based Learning To address the matter of integrating more active learning into programs that relied so heavily on lectures, medical educators looked to a few medical schools that had adopted PBL, a student-centered methodology in which small groups of students led by tutors learn through clinical problem solving. PBL programs, pure or blended with more traditional approaches, have been adopted in the first 2 (preclinical)
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. Years later, medical educators who are critical of PBL have highlighted the inconsistency in approaches taken to PBL across medical schools, PBL's questionable effectiveness, and the paucity of longer-term sustainability of benefits.
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, administered by the National Board of Medical Educators. Two steps of this three-step process toward licensure specifically assess medical student learning (the first two steps usually occur during medical school; the third step usually occurs during residency)
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The cultural competency approach (Wear, 2003) described by several medical schools highlights the language and customs of particular minority groups, especially their beliefs related to health.
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indicate that only 8 percent of U.S. medical schools reported having a separate course to address cultural issues; 87 percent reported that learning was embedded in other courses (in 1 to 3 lecture hours)
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Although this survey did not address how and when learning is assessed by the medical schools that responded, assessment can play an important role in student learning. Through the use of assessment activities that require students to interact with a simulated patient (such as Objective Structured Clinical Examinations, or OSCEs)
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. Most of what medical students internalize in terms of the values, attitudes, and beliefs comes from the hidden curriculum, and these messages frequently stand in opposition to the formal curriculum (Hafferty, 1998)
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The pedagogy that is currently in place in many U.S. medical schools to ensure that graduating medical students are culturally competent tends to focus on the acquisition of accurate knowledge, respectful attitudes, and appropriate behaviors for interacting with patients.
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, which can be in sharp contrast to the core values underlying the formal educational goals of the curriculum. There can also be a "disconnect" between early clinical skills training where students learn about the importance of cultural competence and later clinical training where they learn that patients' social and cultural contexts are irrelevant to competent medical practice (Good, 1994; Good, 1995)
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, all of which are characteristics that society expects of its health-care providers. AAMC, LCME, and many medical schools have institutionalized these expectations by articulating goals for self-assessment as a vital component for self-directed (and self-correcting)
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. Current medical education literature is not void of thought-provoking suggestions for medical curricula that combine active learning formats with deeper and broader levels of self-reflection and understanding so vital to true cultural competence.
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Medical educators can synthesize these literatures to develop an ideology that will guide them in constructing experiences that address the particular challenges they face in ensuring that medical students can effectively achieve cultural competency. Medical Student Composition As mentioned earlier in this paper, in the University of Michigan's affirmative action deposition to the U.S.
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Although our manuscript does not focus on admissions practices in medical school or health professions programs, deans and admissions directors should consider the connections that we have shown exist between a diverse student body and educational initiatives that help students achieve cultural competence as they reflect on the criteria they use for admissions to their programs. This is an important consideration to make in pondering ways to achieve greater diversity in these programs.
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, many of which are presented here, can be used to develop approaches that ensure medical student achievement of cultural competence. The methods and pedagogies discussed in this paper can potentially help medical students transform their perspectives about diversity and at the same time progress toward achievement of self-authorship, which provides a foundation for understanding the perspectives of those from other cultures and backgrounds.
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CONCLUDING THOUGHTS In this paper we have presented an evidence-based argument to support the importance and benefits of diversity in higher and health professions education. To understand specifically what we mean by "diversity in higher education," we began with a description of the factors within college/university campus climates that impact educational diversity: historical legacy (resistance to desegregation and unrecognized, embedded advantages for dominant cultures)
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We explained current educational initiatives in the medical education literature designed to achieve cultural competence and suggested a potential "disconnect" between current approaches and educational goals and standards. We linked student development to potentially effective pedagogies, building on the higher education research on transformative learning and adding information about social justice educational principles and pedagogies from the higher education and medical education literatures.
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1998. Report I: Learning Objectives for Medical Student Education: Guidelines for Medical Schools.
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and Canadian medical schools. Academic Medicine 75(5)
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1999. Enacting diverse learning environments: Improving the climate for racial/ethnic diversity in higher education.
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A review of the concepts and a formulation of ground rules. Academic Medicine 74(2)
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medical schools. New En gland Journal of Medicine 331:472476.
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2003. Components of culture in health for medical students' education.
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