How can we prepare our trainees to address health disparities?

Health disparities are differences in access to health care and overall health status between different population groups ¹. The root causes of these differences are often related to historical and systemic inequities beyond the control of the individual ². Providing education to medical residents and fellows has been identified as a critical step toward eliminating health disparities and preventing the recurrence of past medical misdoings. Therefore, the Accreditation Council for Graduate Medical Education’s (ACGME) Clinical Learning Environment Review (CLER) program has included, as an educational priority, a curriculum focused on addressing health disparities, with emphasis on social determinants of health and cultural competency ³. In addition, beginning in 2023, The Joint Commission standard LD.04.03.08: Reducing health care disparities is a quality and safety priority will be applied broadly. This standard requires that healthcare leaders and organizations actively address health inequity at the patient and community levels. Therefore, medical residents and fellows will need to be prepared to tackle the challenge of health disparities when they leave their training programs.

Recent studies have highlighted the barriers associated with incorporating this topic into clinical curricula ^1,4,5. One challenge is the lack of trained and knowledgeable faculty delivering the information. As curricula regarding health disparities are developed within departments, the faculty charged with presenting this material may not be adequately prepared to discuss complicated topics like culture, bias, and discrimination related to health disparities. To overcome this difficulty, specialized training for those doing the educating should be implemented ¹. If such training is not available at an institution, then there are excellent online resources available, for example, Stanford university’s “Anti-Racism Tool Kit” (Anti-Racism Toolkit | Manager Toolkit (stanford.edu). Another challenge is that there is no consensus on assessing the effectiveness of training methodology. The assessment aims to quantify the degree of improvement in awareness, attitude, knowledge, and skills ¹. Appropriately evaluating these educational initiatives is vital to achieving the desired outcomes. Programs may choose to create their assessment method using strategies such as projects or written reflection. However, there are published tools that may also be used. The Inventory For Assessing The Process Of Cultural Competence Among Healthcare Professionals- Revised (IAPCC-R©) is an example of an assessment tool designed specifically for clinical staff. While there may be no agreed-upon methods to evaluate the quality of education on health disparities, effectiveness checks should be conducted.

We want to close by offering suggestions for all who seek to teach about health disparities in a way that fosters cultural responsiveness and cultivates a sense of community connection among trainees:

1. Explicitly cover basic terms and definitions so trainees and educators can utilize a common language when discussing health disparities.
2. Incorporate the topic throughout the curriculum instead of limiting the discussion to a single lecture or special seminar.
3. Utilize case-based learning (CBL), where residents and fellows are presented with scenarios of caring for patients from minority groups that focus on implicit bias and train physicians to provide equitable care. In addition, CBL will serve to increase awareness of implicit bias and improve communication skills.
4. Focus on the significant inequities present in the community. Many health systems publish community health needs assessments (CHNA) which is a good starting point when investigating which disparities are locally prevalent.
5. Offer place-based experiences for trainees. It’s crucial to develop a sense of belonging to the community we serve. Therefore, we suggest organizing activities that improve the understanding of the culture and history of the community (e.g., tours, museum visits, etc.).

References

1. Brottman, M. R., Char, D. M., Hattori, R. A., Heeb, R. & Taff, S. D. Toward Cultural Competency in Health Care: A Scoping Review of the Diversity and Inclusion Education Literature. Acad Med 95, 803-813, doi:10.1097/ACM.0000000000002995 (2020).
   
   
2. Wheeler, S. E., Hasskamp, J. H. & Peck Palmer, O. M. Recognizing Laboratory Medicine's Collaborative Role in Identifying and Eliminating Health Disparities. J Appl Lab Med 6, 274-284, doi:10.1093/jalm/jfaa143 (2021).
   
   
3. Co, J. P. T., Weiss, K. B. & Committee, C. E. CLER Pathways to Excellence, Version 2.0: Executive Summary. J Grad Med Educ 11, 739-741, doi:10.4300/JGME-D-19-00724.1 (2019).
   
   
4. Dupras, D. M. et al. Assessment of Training in Health Disparities in US Internal Medicine Residency Programs. JAMA Netw Open 3, e2012757, doi:10.1001/jamanetworkopen.2020.12757 (2020).
   
   
5. Chin, M. H. et al. A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care. J Gen Intern Med 27, 992-1000, doi:10.1007/s11606-012-2082-9 (2012).