Social Justice Curriculum: One Step Toward Change

by Santina Wheat, MD, MPH, Northwestern University Feinberg School of Medicine, Department of Family & Community Medicine; Katherine M. Wright, PhD, MPH, Northwestern University Feinberg School of Medicine, Department of Family & Community Medicine, Chicago, IL; Deborah Edberg, MD, Department of Family Medicine, Rush University, Chicago, IL

Introduction

Our health care system perpetuates health inequity¹ through institutional and individual acts of oppression.² Evidence of implicit and explicit biases among health care providers negatively impacts patient care^3,4 and affects interactions and retention of all members of the health care team.^5,6 Teams must take ownership of personal biases that impact patient care decisions.^7-10

We developed a social justice curriculum to enable resident physicians to recognize personal and health care system biases. This study aims to evaluate learner reactions to the curriculum and identify areas of improvement.

Methods

We outlined an eight-session curriculum to address bias within individuals and the health care system (Table 1). To evaluate the curriculum, we developed a 22-item survey measuring participants’ perception of the impact of bias, membership in oppressed groups, and knowledge of terminology. Additionally, we measured skills recognizing and addressing bias, discrimination, and microaggressions on interpersonal and institutional levels. Finally, we measured attitudes about accepting and addressing personal biases and impact at the institutional level.

Table 1: Curriculum Components and Activities

Topic	Learning Objectives	Description/Activities
Racism	● Discuss instances and implications of oppression/racism in broad and personal context	● Two distinct 3-hour discussions about racism at the interpersonal level as well as historical context via laws within the healthcare system as well as throughout society including education, real estate, drug usage, policing, uneven enforcement of laws, etc. ● Group breakouts/debriefing sessions to discuss ideas/emotions elicited through the session
LGBTQ Discrimination	● Recognize specific incidents of homophobia and transphobia and impact on individuals ● Recognize impact of homophobia and transphobia in healthcare and medical education	● 3-hour workshop covering the history of LGBTQ discrimination/civil rights, group exercise exploring gender roles and stereotypes ● Small group breakout/debrief session to discuss ideas/emotions elicited through the session ● 3-hour session with physician who described personal experience with bias and successfully integrated LGBTQ curriculum at GME level
Gender Bias and Sexual Harassment	● Recognize specific incidents of gender bias in medicine ● Recognize the impact of bias and harassment on careers and an organization ● Learn strategies to interrupt bias	● 3-hour workshop on gender bias/sexual harassment presenting data, workshopping cases and debriefing
Microaggressions	● Recognize impact of racism, sexism and sexual prejudice during healthcare history ● Identify situations of microaggressions ● Practice tools to call-in situations	● 3-hour discussion on microaggressions, the historical context of medicine, and its role in discrimination and violence against people of color
Ableism	● Recognize types and impact of ableism on people with different abilities. ● Identify ways a health care provider can advocate for a person with different abilities through the health care system and externally	● 3-hour discussion on ableism and the role of the health care provider as well as the health care system in discrimination of people with different abilities
Interrupting bias (with a focus on residency recruitment)	● Consider how to prioritize and “rank” applicants taking bias and systemic oppression into account	● 1.5-hour workshop reviewing sample applicant files from various backgrounds, academic records and life experiences through the lens of diversity/oppression and opportunity
Incorporation into curriculum	● Recognize how bias impacts all areas of medicine/education	● Incorporate discussion of race/gender into journal club/didactics ● Incorporate discussion of bias into precepting sessions/inpatient rounding

Results

Fifty-eight residents and 10 faculty participated. Completion of evaluation surveys was voluntary; 48 participants completed the precurriculum survey (70.59%) and 23 participants completed the postcurriculum survey (33.82%). Postsurveys indicated greater awareness of bias. Among a smaller subset of matched pre/postsurvey respondents, 69% reported an increased frequency of recalling discriminatory actions or words (n=13, z=-2.48, P=.01), discussing systems of oppression with patients (z=-2.88, P<.01), and addressing bias when it occurred in a professional setting (z=-2.00, P=.049) as depicted in Table 2. Respondents reported a greater understanding of the impact of race and ethnicity (z=-2.12, P=.03), physical and mental ability (z=-2.41, P=.02), gender (z=-2.33, P=.02), religion (z=-2.59, P=.01), and citizenship/documentation status (z=-2.12, P=.03). There were minimal, nonsignificant changes in self-reported attitudes.

Table 2: Changes in Pre- and Postcurriculum Survey Measures

	Z Score	P Value
I can recall a time that I noticed words or actions that were discriminatory in a healthcare setting.	-2.48	.01
I can recall a time when I actively employed a strategy to mitigate the impact of my own bias when evaluating colleagues.	-1.40	.16
I can recall a time when I have discussed systems of oppression (eg, racism, sexism, homophobia, ableism) with my patients.	-2.88	<.01
I can recall a time when I openly addressed bias when it occurred in a professional setting such as a meeting or patient encounter.	-2.00	.05
I can recall a time when I took ownership of my actions or words when someone pointed out that I impacted another – intentionally or unintentionally – due to my bias.	-1.90	.06
I believe that policies and guidelines should be designed with the majority in mind.	-1.56	.12
I believe that the best way to ensure fairness is to apply evaluation criteria to everyone equally.	-1.13	.26
I feel confident in my ability to alter my behavior to minimize the impact of implicit bias in my work.	-0.91	.37
I think that my personal bias regarding characteristics such as race, gender, sexual orientation, ability, or religion has a profound impact on the work that I do as a health care professional.	-0.31	.76
I trust in my ability to recognize when implicit bias is impacting an interaction.	-0.90	.37
I have an understanding of the impact of the following characteristics on my patients. and colleagues:
Race and ethnicity	-2.12	.03
Physical and mental ability	-2.41	.02
Sex (as it relates to sexism)	-1.63	.10
Gender	-2.33	.02
Sexual orientation	-1.51	.13
Religion	-2.59	.01
Education level	-1.13	.26
Income and economic status	-1.41	.16
Citizenship/documentation status	-2.12	.03
Class	-1.41	.16

Discussion

This curriculum trains residents to address biases that impact health equity. Although no educational best practices currently exist, thought leaders emphasize either changing (a) “hearts and minds” (ie, attitudes) or (b) laws, policies, and procedures that support the status quo. We believe the two strategies are intertwined.

Learners demonstrated a heightened knowledge of and ability to recognize bias; however, attitudes did not change significantly. Generally it’s easier to impart knowledge than to change attitudes supported by a lifetime of messaging. The biggest hurdle may be self-reflection in identifying our own roles in supporting the status quo.

The debriefing sessions enabled residents to process emotions. A balance of historical and contemporaneous facts describing discriminatory laws and practices alongside personal stories were critical to provide context and draw connections. We recommend required readings and conducting an ongoing needs assessment identifying where residency and clinical partners stand on awareness and readiness to change scale.

This curriculum series met a mixed reception, amplified by a distinct difference in learned vs lived experiences. Residents did not all work together and may not have felt safe enough to be authentic. Race caucusing and debriefing within programs may allow more honest conversations. Another issue may have been the perceived buy-in from leadership as some core faculty did not attend. We know from bias training research that without clear support from leadership, programs may backfire.

Conclusions

The curriculum achieved positive results as more open dialog occurred among residents about microaggressions. Awareness of bias improved and changes were made to minimize the impact of bias in recruitment. Residents and faculty informally reported small changes in patient care practices with more awareness of how bias and discrimination could impact care. This curriculum shows promise for progress and implementation elsewhere.

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