[The following notes were generated by Michele Haight, PhD.]

Presenter: Janet Coffman, PhD, Professor of Health Policy, HealthForce Center, Philip R. Lee Institute for Health Policy Studies, Department of Family and Community Medicine, University of California, San Francisco, Co-Associate Director for Policy Programs, Institute of Health Policy Studies

Breaking Barriers for Racial/Ethnic Groups Underrepresented in the Health Professions

Why are we here?

• The racial/ethnic diversity of the US population is increasing.
• Native Americans, Blacks, Latino/as, and some Asian/Pacific Islander ethnic groups are underrepresented in most health professions that require a college or graduate degree.
• As the required educational level increases, the diversity level decreases.

We need to better understand the barriers faced by persons from these racial/ethnic groups to implement more effective strategies to create a more representative workforce.

Racial/ethnic concordance with providers is necessary for building trust with patients.

Barriers to Increasing Racial/Ethnic Diversity in the Health Professions

Structural Racism consists of multiple, interconnected levels of racism in societal structures: institutional, personally mediated, and internalized; all of these are socially mediated.

Institutional Barriers

BIPOC students (Black, Indigenous and People of Color) are more likely to:

• Have attended poorly resourced public schools with inadequate preparation for STEM courses and less extensive education in written and oral communications.
• Attend community colleges and state universities that may lack adequate resources to enable students to complete courses in a timely fashion, or to provide adequate pre-health advising and sufficient psycho-social support.
• Work during college due to the cost of higher education which limits the amount of time available to attend school, adequately study and is prohibitive to participating in internships, especially unpaid ones. This impacts their ability to earn good grades and participate in extra-curricular activities that are important for admission to medical school and other health professions’ programs.

The length of education in medicine and other professions that require a graduate degree compounds the cost and perception of unaffordability of attending professional school.

Institutional leadership does not necessarily have a demonstrated commitment to diversity.

There is a lack of role models concordant with students’ race/ethnicity.

Personally Mediated Barriers

• Overt bias
• Microaggressions
• Lack of guidance and support from professors/TAs in gateway courses and lack of pre-health advisors.

All of these send messages to BIPOC students that they do not belong.

There must be zero tolerance for personally mediated racism through anti-bias training and support for learners who experience racism from faculty and patients.

Internalized Barriers

• Stereotype threat, especially negative stereotypes about the intellectual capacity of BIPOC students. These can negatively impact students’ performance.
• Lack of a sense of belonging by BIPOC students.

Framework for Increasing Racial/Ethnic Diversity of Health Professions Students

• Form institutional partnerships.
• Provide tailored student support to create academic success: academic support, psychological support, social support, and financial support that focuses on scholarships and paid internships rather than loans and provides assistance with childcare and transportation.

 For example, Berkeley Biology Scholars Program.

• Engage faculty in institutional change.

Strategies for Undergraduate Institutions

• Improve remediation practices to create more intensive courses, emphasize thinking not memorization, and provide psycho-social support. Build confidence and independent thinking. For example, CUNY START program.
• Commit to Diversity, Equity, and Inclusion by establishing a Chief DEI Officer and Vice Chair for DEI positions and provide sufficient protected time and resources for DEI officers to do the work.
• Invest in mentoring for BIPOC students.
• Develop communities of practice and partnerships across colleges and professional schools. Establish recruitment partnerships with pre-health student associations and provide opportunities for campus visits, conferences, enrichment programs, etc.

For example, UC Davis Pre-Health Conference and California Medicine Scholars (which is focused on increasing the number of community college students who pursue careers in medicine).

• Create Post-baccalaureate Programs focused on those who unsuccessfully applied to medical school.
• Combine and condense undergraduate and graduate education.

 For example, the Sophie Davis Program which is a 7-year joint BS/MD degree program.

1. Transfer to medical school with advanced standing.
2. Progression to medical school is based on performance in medical courses instead of pre-med courses and MCATs.
3. Implement an accelerated, year-round curriculum that enables students to complete medical school in 3 years. These programs can be focused on BIPOC students.
4. Change Admissions requirements.

Breaking barriers for BIPOC students in the health professions requires multiple strategies that:

• Address all forms of racism
• Partner with K-12, college, and professional schools.
• Focus on more than health professions education.
• Encompass collaboration across all levels of education.

One example of a multi-level approach is the UCSF Latinx Center of Excellence.

[The following notes were generated by Michele Haight, PhD.]

Presenter: Caroline Harada MD, Associate Professor Internal Medicine, Leader of Geriatrics Consult Service and Assistant Dean for Community Engaged Scholarship at the Heersink School of Medicine at the University of Alabama at Birmingham

Lauren Parker MA, Director of Programs at the University of Kansas School of Medicine

Learning Communities: Creating Structures for Peer Support
The Learning Communities Institute is an organization of health professions schools that has the mission of building connections in medical education and serves as a valuable resource for developing learning community programs within health professions schools.

Framing Student Success
Elucidate the connections between learning communities and student success.
Acknowledge that setbacks are normal and work on the growth and development of students.
Student progress is a collaboration among many faculty in many departments. This shared effort is based on the following principles:

• Flexibility
• Inclusivity
• Interconnectivity
• Collaboration

These principles are critical operational processes necessary for achievement, implementation and desired outcomes.

Institutional commitment is a shared vision by all stakeholders in the university who are responsible for student success as measured through implementation and impact, and the ability for continued growth and development. These values are representative of the institutional culture.

Learning Communities 101
A learning community is an intentionally developed longitudinal group that aims to enhance students’ medical school experience and maximize learning. The goal is to foster among students a higher level of engagement and intellectual interaction with peers, faculty and the curriculum.

Increasing student engagement facilitates retention and success.
Learning communities came about because of learning development theory which seeks to understand students’ moral identity, their process of developing identity and dealing with challenges and getting support through those challenges.

Learning communities are well established in higher education, but relatively new to medical education.

Functional Areas in Learning Communities for Peer Support

• Student Support Systems
• Small Group Curriculum Delivery
• Professional Identity Formation

There are many different ways to structure a learning community. The structure of a learning community varies widely as each is tailored to the individual institution. Learners are generally assigned to their learning communities at the very beginning of medical school. Typically, students remain in these same learning communities for all four years.

Benefits of learning communities include the following:

• Better clinical skills
• Increased student satisfaction with advising systems and wellness programming
• Improved student interpersonal relationships
• Greater student connectedness to faculty in small group learning
• Enhanced faculty satisfaction

Learning Communities as Peer Support

Encourage community building as an investment in the future.

• Students with strong support networks enable faculty to identify students with difficulty earlier
• and provide earlier interventions.
• A support system prevents students from getting into difficulty because they are happier and
• well supported through strong relationships.
• Assigned space is useful for community building.

Peer advising/coaching/mentoring/tutoring

• Mitigate feelings of inadequacy, anxiety, and social isolation.
• Provide opportunities for near peer support.
• Structure activities into the academic calendar.
• Learning community leadership undergoes mandatory training.
• Leadership group meets monthly .

Programming to support group development

• Build connections, collegiality and respect at orientation to establish the culture of the
• learning environment.
• Engage in activities that cultivate an awareness and collective value for inclusion and belonging
• and an appreciation for differences within the context of student success.

Resources

• Institute for Inclusive Teaching at the University of Michigan social and personal identity exercises
• StoryCorps civil discourse conversation guide

[The following notes were generated by Michele Haight, PhD.]

Presenter: Michael Redinger, MD, MA, Co-Chair Department of Medical Ethics, Humanities, and Law, Interim Chair, Department of Psychiatry, Associate Professor Psychiatry, Western Michigan University, Homer Stryker MD School of Medicine

Mental Health and the Struggling Learner

The goal of this presentation is to assist educators in understanding how mental health difficulties can interfere with student success, both academically and professionally, and provide strategies for preventing and remediating failures attributed to mental illness.

The challenging issue is how to work through when a learner has been identified as having a mental health issue and is struggling either academically or professionally in the curriculum.

Recognizing Mental Illness in the Struggling Learner

• As a population, physicians and medical students are under increasing stress that has been exacerbated by COVID, and they are experiencing high levels of occupational burnout, depression, and anxiety.
• Physicians and medical students are also poor at self-care, seeking assistance for themselves or colleagues, and assuming the patient role.
• Students who have had significant exposure to adverse childhood experiences (ACE) are significantly more likely to report a moderate to significant effect on their mental health compared to their peers.
• Students who come from other disadvantaged circumstances are more likely to experience ACE and might require more support.
• A significant number of medical students compared to other graduate level students develop mental health issues over the course of their training. This indicates that there is something about medical school training that predisposes students to some type of mental health issues.
• External stressors and not patient interactions are the primary drivers of medical school stress.
• There are observable signs and behaviors that might signal the onset of the conditions described in the DSM-5. Mood and anxiety disorders are the most common conditions in medical school. Substance-Related and Addictive Disorders are not uncommon in medical school.

Psychiatric Fitness-for-Duty (FFD): Ascertaining if someone is in a position to do the job with reasonable skill and safety, which might otherwise be impaired by illness or injury.

• Impairment: The inability to practice medicine with reasonable skill and safety as a result of illness or injury.
• Psychiatric illness includes substance use disorders (SUD).
• Consultation is often triggered by inappropriate or problematic behavior BUT these behaviors do not always result from disability or impairment from psychiatric illness.

Fundamental Questions:

• Does a psychiatric illness exist?
• If so, does that illness impair specific functions?
• To what degree do impaired functions impact job performance?
  (All three of the above need to be present before one is considered impaired.)
  Can functional impairment be mitigated to allow for successful job performance, and, if so, how?

Physicians as a population are not identical to the general population in terms of their cognitive abilities.

• Measures of the intellectual performance of medical students and physicians on standardized tests of intelligence historically have found that intellectual performance is approximately one to two standard deviations above the mean of the general public.
• 7%-10% of practicing physicians may be classified as impaired, and 16% may be classified as underperforming.
• Data on the impact of test-taking anxiety is weak, regardless of the assessment tool.
• Data regarding the impact of mental illness on academic performance is more robust for college and high school students, not medical students.
• In one study, physicians who were referred for competency (fitness-for-duty) evaluations scored lower than their colleagues, but not necessarily different than the general population.

Medical student cognitive norms are different than the general population.

• Medical students who are impaired may be functioning at the mean of a population-wide sample, but are impaired compared to physicians as a whole.
• Medical students don’t have to necessarily score at a level that is worse than the general population to be considered impaired when compared to their colleagues. This is an important consideration when thinking about accommodations and/or sending a student for cognitive assessments.

Mental Illness and Academic Performance

• There is insufficient, low-quality data to draw strong conclusions regarding the degree of impact specific mental illnesses have on medical student academic performance.
• We can infer from other populations that mental illness is likely to impact medical student academic performance for at least some students. The degree of impact remains an open question.

Mental Illness and Professionalism Impairment

• Most FFD evaluations are triggered by problematic behavior that occurs across specialties and demographics.
• The seeds of these behaviors are seen early in the course of one’s medical career.
• Personality disorders are significant contributors to maladaptive behaviors, but are much more difficult to diagnose.
• Studies suggest correlations between prior grades and test scores and professionalism scores and future disciplinary actions. (Cuddy et al. 2017, Papadakis et al., 2004, 2008) This is an indication that there might be the potential to intervene early.
• Research also suggests that students with flourishing mental health are less likely to commit even minor professional lapses.

At what point should a physician training program remove students or residents?

• Medical schools graduate 97% of matriculated students.
• Unprofessional behavior during medical school was associated with a threefold increase in subsequent disciplinary action by a medical board (Papadakis, 2005).
• Can we do something about this? Or should we be more judicious about those who we pass through the curriculum?

An Approach to Professionalism Remediation

• Responses to professionalism lapses need to be holistic and include mental health evaluations.
• Remediation goes beyond a mandated mental health evaluation.
• Consider what further efforts can be made to help students access these support and reverse this process?
• Appraise to what degree different services are mandated or enforced prior to having students return to the curriculum.
• Look at professionalism through a “just” culture, systems lens when considering remediation or discipline.
• Consider how we can reverse this.

In Summary:

• Mental health is a positive contributor to professionalism lapses and later misconduct.
• Treatment of SUD seems to be the mental illness most amenable to remediation.
• Depression and burnout are worth addressing. This may help with addressing and minimizing academic difficulties.
• Behavior change is hard, particularly for those with certain personality traits/disorders.
• Determining correlation versus causation is difficult in individual cases.
• No one knows how to do this really well.

[The following notes were generated by Michele Haight, PhD.]

Presenter: Jason Walker, PhD, Assistant Dean of Transformational Learning, Associate Professor Physiology, Philadelphia College of Osteopathic Medicine South Georgia

The Off-Cycle Curriculum: Intention vs. Impact

Even though curricular change is a constant in undergraduate medical education (UME), the structure of medical education has not substantially evolved since the Flexner Report of 1910.

The 2020 Pandemic served as a catalyst for both chaos and change in UME.

Lessons Learned:

Increased interest in medical school

Increased and creative use of hybrid learning

Learning medicine takes a community (Learners felt isolated)

Struggling learners were allowed to progress (Implemented supports to advance struggling learners)

We are rebuilding our learners after the pandemic.  In this process, we need to continuously ask ourselves if we are building students on sand or on bedrock.

What is a decelerated curriculum?

• Deceleration is an alternative distribution of the preclinical courses that allows student to complete the first and second year curricula in three years.
• Deceleration may allow students to decompress their curriculum or repeat a course or courses in which they have deficiencies.
• Deceleration: Mandatory vs. Voluntary (based upon student, environment, and institution)

Considerations when placing a student on academic suspension:

• What happens when a student is placed on academic suspension?
• What resources does a student have access to while on an academic suspension that are provided by the institution?
• What expectations are placed on a student when they return from academic suspension? What are the expectations and accountability faculty, administrators, the institution?
• Are there any programs in place to track or check in with a student while on academic suspension? We must remember that the student has “failed” and is deeply feeling that sense of failure.
• What is the financial impact on the student who is placed on academic suspension?

Creating an Off-Cycle Program: To provide engagement to separated students to keep them connected to the institution.

Student Needs

1. Academic structure
2. Improvement of Knowledge Base
3. Improved Study Habits
4. Confidence Rebuilding

Implementation

1. ScholarRx (short bites of information)
2. Creation of Modules (post Module 30-40 item quiz)
3. Creation of a Book Club (all campuses; Make it Stick)
4. Bi-weekly small group advising with faculty
5. Monthly “authentic” small group sessions

As faculty, we need to consistently address the question of “Why am I here?” for our students in order to help them better understand how to create individual change from the inside out.

Small group interactions resulted in the creation of a strong support group for all of the off-cycle learners.

When the assessment supports that were implemented during the pandemic were removed, a new group of struggling students was identified. This prompted the following:

• Creation of an Off-Cycle Curriculum Council (OCC) to recommend candidates for the Off-Cycle curriculum.
• Provision of counseling for the candidates and review of the Off-Cycle curricular requirements: withdraw from basic science courses, stay enrolled in small credit courses to keep financial aid, fully audit all M1 courses, and engage in all labs.
• Clarification that the student makes the final decision to participate in the Off-Cycle curriculum and must agree to sign a contract.

Off-Cycle Accountability

• Off-cycle curriculum plan will be maintained in the permanent program record.
• Off-cycle students will be evaluated each term within the off-cycle curriculum plan.
• Off-cycle students must achieve an assessment average of 75% during each M1 term they are recapturing.
• Off-cycle students who fail to meet academic or professional standard while decelerated may be dismissed from the program.

Limitations of the Off-Cycle Curriculum:

• Lack of student motivation to extend medical school.
• Insufficient data on Off-Cycle student progress and outcomes.
• Lack of reliable and valid procedures for student outcomes and readiness prior to leaving the Off-Cycle curriculum.

Diagnosis of Deficiency

We make assumptions based on: MCAT scores, race/ethnicity, previous academic history, time management, study plan. We make decisions based on what we think we know.

Truth will determine the Real Impact: family issues, undiagnosed medical issues, undiagnosed disabilities, trauma, Nobody Ever Asked!!!!

Process for determining academic deficiency:

Deficiency in Assessments>Development of Remediation Strategy>Remediation with deliberate repetition, feedback and reflection>Reassessments>Reintegration into Regular Curriculum

OR

>Integration into the Off-Cycle Curriculum>Diagnosis of Deficiency

Considerations for creating a 5-year curriculum:

Identify at risk matriculants prior to first day of the first year of medical school based on the following:

• Learners’ discretion at understanding how they learn
• Socioeconomic status
• Mental Health concerns
• Non-Traditional Students

Potential external challenges: Accreditors, Institutional finances, Space accommodation

It is time to re-imagine remediation as Restructure, Integrated, Supplemental Education or RISE.