Presenter: Mark C. Henderson, MD, MACP, Associate Dean of Admissions, University of California Davis School of Medicine

[The following blog was generated by Susan Ely and Doug McKell]

Creating a Diverse Class of Learners via Socially Accountable Admissions

The Learning Objectives for this first Spring 2024 IAMSE Webinar series on Teaching and Learning in Medical and Health Professions Education include the following: First, evaluate the paradigm of social accountability in medical education, including the relationship of representation of increased diversity of health professionals to health equity of underrepresented, underserved, and marginalized patient communities. Second, examine trends in the composition of the US physician workforce, including the percentage of physicians from underrepresented groups compared to their percentage of the population and the changes over time. Third, discuss the UC Davis holistic admissions process, which has increased the diversity of their medical student population despite the 1977 passing of California Prop 209 banning affirmative action.

Dr. Mark Henderson discussed the underrepresentation of marginalized groups in medical schools and the inequities in medical education, emphasizing the need to address these inequities. He stressed the importance of implementing holistic admissions strategies to increase diversity, including long-term changes in the admissions process, cultural support, and peer mentorship. He spoke about the UC Davis School of Medicine and its process over the last 15 years to admit increasingly diverse medical school students. Dr. Henderson began by discussing the paradigm of social accountability as it applies to medical education, specifically medical school admissions, focusing on the current medical student application process that results in the excess or deficit selection of students from some groups compared to their proportional representation in the general population. This negatively affects health equity access and increases health disparities among several underrepresented patient populations. He presented a conceptual model demonstrating why proportional health professional representation and diversity are essential to health equity since individuals and practitioners from disadvantaged groups are more likely to have cultural and language concordance with their patients. This leads to better communication, better trust amongst marginalized communities, and greater health advocacy for such communities, with more health practitioners working in the communities where they are needed.

Dr. Henderson presented data showing that in the United States, the racial/ethnic background, educational advantages, and family income proportions of the demographic composition of physicians who practice in the United States don’t match the United States population as a whole, except for the white population. For example, for the Latino population, which is now almost 20% of the United States, only about 7% of physicians are Hispanic or Latino. There is a similar disparity with the African American population, although it’s not quite as severe, where 6% of physicians are black compared to 13% of the US population. Finally, there is an overrepresentation of Asian subpopulations, where almost 22% of practicing physicians are from Asian subgroups, while Asian Americans comprise only 6% of the US population. Dr. Henderson pointed out that while the US population became much more diverse, with the number of individuals from underrepresented groups living in the US almost doubling from 66 million to over 105 million, and the number of medical schools grew by over 50% between 1997 and 2017, our future physicians do not reflect the US population. Based on the family income of students in medical school today, your chances of being admitted to medical school based on your family’s income are directly proportional to your family income. This means a lower- income student is less than half as likely to be admitted to medical school as a higher-income student.

Dr. Henderson then paraphrased Dr. Martin Luther King’s statement that as capitalism has grown, there are specific segments of the population that have been left out and, in a sense, have exploited impoverished black and white individuals and communities of color. His point was that the inequities he presented dealing with the lack of a representative physician workforce and diversity in the workforce overall were present before last year’s Supreme Court decision that banned affirmative action in the United States. He stated that based on affirmative action bands in California as well as seven other states after those bands were put in place, the racial and ethnic representation in medical schools got much worse. He expects the same thing will occur across the United States unless there’s attention focused on this issue.

Dr. Henderson then described how to make the necessary changes to create a more diverse and representative medical student population. The most crucial step is to have a sense of urgency. The UC Davis School of Medicine was directly affected by the state-wide affirmative action ban enacted in 1997. In 2005, they began a series of process changes, and the enrollment of underrepresented groups has tripled over about 15 years. Many structural elements are present, as alluded to earlier, e.g., privilege, class, and racism. These elements tend to preserve the status quo. Inertia is another factor, as is the fear of lawsuits, even before the recent SCOTUS decision. What is most important is an institution’s mission. Dr. Henderson stated that it is essential to ask your medical school the following question: What medical education goals is the institution trying to accomplish? He argued that the mission of medical education is to train physicians to meet the health needs of society. Fundamentally, it is a social mission. The first step at UC Davis School of Medicine was to adopt a mission focused on meeting society’s needs: socially accountable admissions. This meant that the mission of the UC Davis School of Medicine was to matriculate future physicians who will address California’s diverse health workforce needs.

The UC Davis School of Medicine admissions office shifted its operation to include input from a diverse group of faculty, students, trainees, and patients. They use multiple mini- interviews blinded to several biasing elements that favor the admission of individuals from privileged backgrounds or those who have had more excellent educational opportunities. Using a holistic review is an important paradigm involving choosing students who fit within a school’s mission. It’s about more than just their grades or test scores, which don’t tend to correlate necessarily to the mission. Dr. Henderson emphasized the importance of previous healthcare experiences, whether personal experiences or work experiences within the healthcare system. 45% percent of UC Davis School of Medicine students are the first in their families to graduate from college, which results from applying more inclusive selection criteria to create a more comprehensive economic representation of enrolled students. Finally, Dr. Henderson explained that UC Davis School of Medicine has developed several partnerships with local high schools, local community colleges, and other medical schools that share a similar mission.

Another critical way the UC Davis School of Medicine has approached its mission is to develop inclusive programs focused on community health needs. The Community Health Scholars program comprises almost a third of enrolled students. Most of these students are first-generation-to-attend-college individuals from low-income backgrounds and are often from underrepresented groups. Admissions criteria for these programs prioritize individuals from these communities. The first one, established in 2007, is called Rural PRIME. It is meant to address the maldistribution of physicians in California. Another program, TEACH-MS, focuses on the underserved urban population. The Central Valley REACH program is concentrated in the Central Valley, the agricultural hub of California. The Accelerated Competency-based Education Primary Care program is a 3-year MD degree pathway for Primary Care physicians and is the beneficiary of several external funding sources. Lastly, a program focused on California Native American/American Indian communities was established in 2022.

Dr. Henderson then described the long-term outcome of the residency program match for UC Davis School of Medicine students. Based on data from 147 students over the last ten years, about 80% come from groups underrepresented in medicine. Most students are matched into specialties of need in California, with 43% going into traditional primary care. If ob-gyn, pediatrics, emergency medicine, and internal medicine are included, about 75% of the students would go into some form of primary care.

Dr. Henderson stressed that this level of success requires looking at your applicant pool differently. UC Davis School of Medicine developed a tool called the data scale, which is a metric derived from each student’s application. It incorporates several socio-economic variables to form a score from zero to 99. A high score on this scale means the student has experienced significant socio-economic distress. A low score would mean they’ve experienced very little hardship. The variables include income, parental education, working during college, or growing up in an underserved area. Because traditional measures of excellence or merit tend to be confounded by educational opportunity, we use this scale to provide context to those other measures. Because it’s a number, it tends to nudge our committee members to be more holistic and dive deeper into every applicant’s application. Dr. Henderson indicated that he believes this correlates to resilience or grit and the ability to overcome obstacles, i.e., essential qualities in future physicians.

Dr. Henderson focused on three programs that help ensure medical student success. The first program is their Community Health Scholar program called ACE PC, which admits eight students a year, all of whom have primary care experience before medical school admission, either as an emergency medical technician, a medical assistant, an ancillary health provider, or someone who worked in a healthcare center. 85% of these students are first-generation college graduates. They are admitted to medical school with lower grades and lower MCAT scores, but they finish in three years instead of four, and almost 90% of them match into a primary care residency. They get a full tuition scholarship because accumulated medical school debt discourages many students from pursuing primary care.

The second program is a community college-to-medical school Pathway Program. It turns out that about half of the Latino family residents came through the community college system, and a third of the black family residents went to community college. This is a significant pathway for underrepresented students. The problem is that many community college students don’t finish, or they don’t transfer, or it takes them quite a bit of time to transfer. About 2.5% transfer within two years of community college, and only a quarter within four years. This program aims to build bridges between community colleges and the UC Davis undergraduate campus. Once the students are at the undergraduate campus, they provide additional health professions career advice and help them address gaps in their educational preparation.

The last program is a partnership with Oregon Health Sciences for a tribal health medical school pathway program called Wy’est. This residential post-baccalaureate program accepts Native American students who have applied to medical school but have been unsuccessful. They spend ten months in Portland. If they meet the requirements of the post-baccalaureate program over this period and the Wy’est program requirements, they receive conditional acceptance into UC Davis School of Medicine, Oregon Health Sciences University School of Medicine, or the Washington State School of Medicine. This program has been quite successful over the last eight years. The students from this track enter the Tribal Health Community Health scholar program when accepted at UC Davis School of Medicine.

Dr. Henderson concluded his presentation by repeating his main point that the mission of medical education is to train physicians to meet society’s health needs. He reported that supporting students with additional academic advising resources and financial aid has additional costs. At the same time, he was optimistic that other advances in medical education, such as AI, may make the holistic admission process more equitable despite concerns about fairness and potential misuse.

Presenter: Thirusha Naidu, PhD, Clinical Psychologist, Associate Professor Department Behavioral
Health, School of Nursing and Public Health, University of Kwazulu-Natal, South Africa

[The following notes were generated by Michele Haight]

Refracting Lenses Seeing Women of Color in Global Health

This presentation includes my reflection on the entire “One World, One Health: Tackling the Global
Health Crisis” IAMSE webinar series. It also includes artwork created by Faith Ringold and other artists,
whose work depicts the content of the presentation and provides a visual representation of ideas.

My historical identity in South Africa is connected to my ancestors who were slaves/indentured servants
from India, forced to leave their home due to the ongoing extraction of goods and resources from the
Asian continent by the British colonizers. I grew up in South Africa during apartheid and attended
segregated schools. I have been a recipient of the global health experience, and I position my research
through the lens of a recipient rather than a provider. All these aspects of my identity inform my
positionality and have influenced the way I think about and conduct my research.

The following are my reflections on the prior webinars presented during this series.

Baenziger: Global Health Electives: Impact, Challenges and Best Practices This perspective speaks from
the Global North (GN) to the Global South (GS), intervening, talking, and acting toward the GS. It is
critical to understand how GS researchers experience this. The flow of global health training is not
bidirectional in an equitable way. Most GN trainees go to the GS for training, not vice versa. Training and
intervention occur in the GN. Knowledge flow goes from the GN to the GS, whereas extraction goes from
the GS to the GN. Work needs to be done to level extraction and exchange, learning and ideas. Critical
questions: Are we teaching white saviorism or respecting local knowledge and agency? What is the
global health archetype student we are creating?

Richardson: Impact of Climate Change on Global Health. Climate change is not experienced equally.
Africa and African women disproportionately experience the negative effects of climate change.
Because African women are tied to the land, climate change impacts their lives more severely. These
impacts include agricultural production, food nutrition, food security, and health impact on water,
energy, disaster migration and conflict. Climate change must address the needs of women in the poorest
parts of the world in order to be relevant. People in political and economic power are making decisions
as to how climate change needs to be addressed and dealt with. Critical question: Whose perspective
and interests are we focusing on in climate change conversations?

Rashid: Global Approaches to Medical Education: Who Wins? This presentation deals with accreditation
and how the WFME sets global standards for medical/health professions education. Clinical standards
are set by Euro-North American methods, and do not really reflect the context of the training in other
countries. The WFME is skewed towards Western interests, perspectives, and ideas of how people
should be trained. The WFME system promotes the credibility of Western ideas and content while
keeping silent about, even ignoring the fact that there are other methods of teaching health professions
education in the world. Methods for teaching health professionals are relevant to the context in which they are taught. However, the educational methods of the GS are not given credibility because the
powers lie with the GN.

There has been a feminization of the health professions in the GN but not in the GS where fewer health
officials are women. Women get a worse deal in health systems because these systems are structured
according to a male dominated health system. We need more women in the health professions to
provide experience and perspective to properly address the needs of women. We need to develop plans
to train more women. Critical questions: Are we teaching a masculine curriculum that epitomizes male
thinking? Who is determining the basic criteria for standards and what ways of thinking do they base
their determinants on?

Cianciolo, De Jong, & Ramani: Culture and Practices for Global Inclusion in Health Professions Education
(HPE) Publishing: What Can Work? The leaky pipeline in medical education (Kusurkar, 2022), shows how
knowledge production in publishing occurs in medical education where low- and middle-income
countries (LMIC) are not part of the knowledge conversation. This creates a lack of diversity among
reviewers who do not see what is important for researchers in these countries. The knowledge system is
designed to rely on methods that are structured by Western epistemology. Editorial boards lack diversity
as well and further marginalize differing perspectives and epistemologies. There needs to be deepened
partnerships between the GN and GS, widened access to publications, and diverse types of papers that
are published. Critical questions: In medical education publishing, whose voices are we hearing most?
Who is controlling access to knowledge production?

GS authors identified three different categories of difficulty in getting their papers published: practical,
academic, and transformational.

Modern medicine is an artifact of colonialism because the science it underpins emerged from Western
knowledge structures that are based on a history of colonialism. The colonial roots of medicine include
colonization, colonialism, and coloniality. Coloniality has outlived colonialism and is preserved in our
books and our criteria for academic performance.

Quijano (2000) has proposed a colonial matrix of power that consists of a triad of colonialism, racism,
and patriarchy. He stated that this matrix permeated the colonial world and has cascaded down into the
modern world; it continues to dominate our knowledge and subjectivity.

Maldonado-Torres (2007) noted that coloniality is not over, it is all over, everywhere; it is ubiquitous.

In Zero Point Hubris, Castro-Gomez, (2021) points out that our behaviors and decisions continue to be
influenced by coloniality through our internalized colonizer. The information problem in global health is
that we are all victims of this mindset.

If we focus on women of color in the world who experience the most difficulties and challenges, we will
get it right for everyone else. By attending to women of color we can enhance global health and health
for all.

Medical education presents ever-changing opportunities and challenges for learning communities and institutions. In the past five years alone, learners and educators have confronted a global pandemic that temporarily ended in-class content delivery, the advent of Pass/Fail score reporting on USMLE Step 1/COMLEX Level 1with dramatic effects on residency placement for both US and foreign medical graduates, and the expanding use of Artificial Intelligence in clinical practice and medical education. The Spring 2024 IAMSE Webinar Series will address strategies to expand and enhance a dynamic culture of teaching and learning for our educators and learners. This five-part series will begin with a consideration of how best to serve an increasingly diverse group of learners and promote the expansion of diversity at all levels. The webinar series will explore the importance of maintaining and enhancing a culture of professionalism, then generational differences within learning communities will be addressed, reflecting the three or more generations represented by learners and faculty at most medical schools. Another session will examine approaches to promoting wellness and mitigating burnout among all learning community members in the context of educating future clinicians on the importance of work-life balance. The series will conclude with a consideration of the “hidden curriculum”, perceived by many learners as a parallel curriculum. The goal of the series is to encourage and enable participants to embrace change and foster innovative approaches to teaching and learning as we conclude the initial quartile of the twenty-first century.

Empowering Minds: Fostering a Dynamic Culture of
Teaching and Learning

Join us for each one-hour session beginning Thursday, March 7 at 12 PM EST. Sessions in the Spring 2024 series include:

• March 7, 12 PM EST – Creating A Diverse Class of Learners presented by Mark Henderson
• March 14, 12 PM EDT – Moving beyond Professionalism to Professional Values Integration in Medical Education
  presented by Carrie Tibbles
  Please note that Daylight Savings begins in the United States on March 10. Please be sure to check the presentation times with your local time zone.
• March 21, 12 PM EDT – Exploring Best Practices in Health Professions Education for Gen Z Students presented by Shannon Jiminez, Sarah Lerchenfeldt, and Kara Sawarynski
• March 28, 12 PM EDT – Student Motivation and Well-Being in Medical School and the Resilient Mindsets in Medicine Initiative presented by Kenn Barron, Zachary Himmelberger, and Yoi Tibbetts
• April 4, 12 PM EDT – Navigating the Hidden Curriculum in Health Professions Education presented by Megan Brown

As always, IAMSE Student Members can register for the series for FREE! Email support@iamse.org for more details.

Presenters: Anna Cianciolo PhD, Professor Medical Education, Southern Illinois School of
Medicine, Editor in Chief, Teaching and Learning in Medicine, Peter de Jong PhD, Senior
Adviser/Researcher, Center for Innovation in Medical Education Leiden University Medical
Center, Past Editor in Chief Medical Science Educator, President IAMSE, Subha Ramani
MBBS, PhD, MPH, Associate Professor Medicine, Harvard Medical School, President AMEE.

[The following notes were generated by Michele Haight]

Culture and Practices for Global Inclusion in Health Professions Education (HPE)
Publishing: What Can Work?

Global inequities exist in the STEM literature and likely in the HPE literature as well. The MEJ
24 is a list of 24 predominantly European and North American journals identified as the core
seed set of journals comprising the field of medical education. Only 3 of the top ten journals
listed are located in the Global South, representing 4.2% of authors. 62.8% of authors come from
the US, UK and Canada, which are in the Global North. 

85% of the world’s population lives in the Global South. There is a disconnect between global
knowledge production and global knowledge dissemination. Scholars from the Global South are
excluded from knowledge conversations. This leads to a lack of confidence in their capacity to
be included in knowledge conversations, which leads to a lack of representation for
disseminating knowledge as peer reviewers and editorial board members.

Global South is a term used by government and development organizations to describe
developing low- and middle-income countries that are typically former colonial entities.
However, this term has been challenged because it does not represent the nuances and
complexities of the countries and peoples it is proposed to describe.

HPE publishing uses the Global South delineation to promote inquiry and discussion. Doing so
can serve to interrupt entrenched thinking and practices in order to create a space for
participation and innovation. This term can also stimulate discussion about the agency of
individuals and organizations in achieving global inclusion.

For HPE publishing, applying an Inclusive Excellence Framework based on Shore’s (2011)
Inclusion Framework can mitigate some of the aforementioned challenges. Inclusive Excellence
occurs as the result of high belongingness and high value in uniqueness. Because this is most
easily achieved in small groups, publishers and editors are encouraged to create micro
communities within the larger publishing communities.

Adapting DeLuca’s (2013) Interdisciplinary Framework for Educational Inclusion to HPE
publishing is a practical model for education and inclusion. In its current practice, the HPE
publishing world is moving away from a unicentric perspective in which European and North
American principles, rules and regulations have dominated the publishing space. HPE publishing
is mostly gravitating towards a beginning and sometimes approaching an advanced multicentric
perspective. The overall goal for HPE publishing is to transform to a concentric perspective.

Strategies adapted from Danowitz & Tuitt, (2011) for creating a practical framework for
Inclusive Excellence are as follows:

• Programmatic focus on the intellectual and social development of members
• Engagement in purposeful development and utilization of all resources, especially human resources
• Celebrating of cultural differences and publishing about them
• Creating welcoming communities, small and large
• Embracing all diversity to enhance student, staff, and organizational learning.

The following are strategies that journals and authors can utilize to promote Inclusive
Excellence.

Journals:

• Make editorial boards and peer reviewers more diverse.
• Establish international advisory boards.
• Provide workshops and conferences to support publishing.
• Create internships for editorial boards.
• Provide English language support.
• Invite authors from different regions to participate in special issues.
• Waive article processing fees.
• Develop and train editorial board, reviewers and viewers.
• Introduce double-blinded peer reviews.

Authors:

• Carefully choose the target journal.
• Be attentive to instructions to the author; if unsure, connect with the journal.
• Find and collaborate with co-authors.
• Review the international literature.
• Explain the study’s context and why the manuscript is special.
• Explain the study’s relevance and implications.

Striving for inclusion in HPE publishing is not a matter of being altruistic. It is a necessary
endeavor to achieve a scholarly dialogue that will improve the practice and understanding of
HPE publishing. Promoting scholarly efforts and publishing infrastructure outside of the Global
North are also essential actions to attaining Inclusive Excellence. This is the work that is
currently being done by the International Network for Advancing Science and Policy (INASP)
and the Global Health Scholarship Community of Practice Program.

As always, IAMSE Student Members can register for the series for FREE!

Presenter: Ahmed Rashid MD, Professor of Medical Education, Vice Dean (International) of Medical Sciences, Director of Faculty Development for Medical Education Collaborations, University College of London’s Medical School (UCL)

[The following notes were generated by Michele Haight]

Global Approaches to Medical Education: Who Wins?

This presentation examines the intersection of globalization, global health, and medical school regulation. It poses the question about who wins when we move to a global regulation process for medical schools.

At UCL, disruptive thinking has been the status quo since 1826. It was the first university in London to welcome women and students of any religion or social background. This progressive, egalitarian approach continues at UCL to this day. UCL is London’s global university.

The team at the UCL Centre for Medical Education Collaborations (CIMEC) is involved in supporting the development of new medical schools across the world. This includes developing tailored medical education programs and designing contemporary administrative and learning environments. This work is mostly concentrated in the Global South.

The World Federation for Medical Education (WFME) is an organization that exemplifies the different issues, challenges, and priorities that faculty members and medical education leaders face in different parts of the world. There is a mismatch between the priority and recognition of this agency across the world. Those in the Global North are not necessarily aware of the existence of the WFME, whereas those in the Global South are preoccupied with its existence.

The WFME is a tiny organization with virtually no staff. The decision-making body of the WFME appears to be its Executive Council. The voting members on the Executive Council include the six presidents of the representative medical education groups for each continent (AMEE, AMSA, PAFAMS, SEARAME, AMEEMR, WPAME), two founding members (WHO, WMA), and three executive members (IFMSA, JDN, ECFMG). The structure of the WFME makes sense, but the inclusion of the ECFMG, which represents a single country (US), is problematic.

ECFMG is the gatekeeper for physicians who train outside the US and wish to do a residency in the US. Completion of residency training in the US is considered prestigious and highly desirable around the world. 

In 2010, ECFMG created a policy that as of 2023 (now 2024 due to the pandemic), all medical students wishing to train in the US had to graduate from a medical school accredited by an agency that uses globally accepted criteria such as those put forth by the WFME. The additional requirement that a medical school can only be certified by ECFMG if that school is accredited by an agency that is recognized by the WFME launched the WFME into the global consciousness. To be clear, WFME does not confer accreditation. Rather it recognizes certain accreditation agencies, and schools that are accredited by those agencies meet the requirement. This policy decision had a tremendous global impact that has been likened to the “butterfly effect” (Lorenz, E.N., 1972).

The predominant issue is that a single agency from the US (ECFMG) developed this policy, and another US organization (FAIMER) developed the mechanics for implementing the policy. Essentially, the US has singularly developed the conceptual framework and the technical infrastructure for a policy that has a worldwide impact. The following three articles provide a closer examination of the issues associated with this policy.

Altruism or Nationalism: Exploring Global Discourse in Medical Education (Rashid M.A., 2023) This article provides a critical discourse analysis of 250 papers. The analysis revealed two contrasting discursive positions: altruism and nationalism. Altruism is informed by endorsement and modernization discourses. Each of these discourses contributes to a policy narrative that aligns with key global principles for modernizing and improving medical education across the world.

The second position is nationalism (referring to American interests), which is informed by discourses of protection and control. Protection is described as twofold. It refers to protecting the American public\ from the threat of foreign doctors, and it also refers to protecting American citizens who train outside of the US from poor quality medical schools. Control refers to the need for the US to monitor and manage the quality of all medical training. 

The article proposes that both discourses are present in the policy, each one appealing to a different audience. The article concludes that it is important to highlight the tension between the WFME, a global facing agency and the ECFMG, a single country-facing agency.

Examining the WFME Recognition Programme at 10 years (Tackett et al., 2023)
This research paper produced the following observations. 

• Most of the countries that supply the most international medical graduates (IMGs) have agencies that have applied to the WFME program. So far, only 41 out of over 150 agencies around the world have applied to WFME.
• There is no formal or informal evaluation of the WFME program.
  
• The motivation for agencies to apply or not is unclear.
• A global market for accreditation has emerged and perhaps this is the most troubling observation. There are no rules to stop accreditation agencies from operating in multiple countries, and there are no rules for multiple accreditation agencies to operate in a single country. As a result, accreditation can become a highly political and commercial endeavor.
• There is a lack of transparency and no research.

Reconsidering a Global Agency for Medical Education: Back to the Drawing Board?
(Rashid, et al., 2023a)
This article postulates that the world deserves a different model for medical education.
The article points out that six white male presidents have helmed the model, even though the majority of medical schools are in the Global South. It further points out that the agency’s offices are mostly located in Western Europe and North America, not the Global South. The policies promoted by this agency legitimize standardization and westernization, and promote the values, priorities and policies of the Global North. Finally, there is a lack of transparency, democracy and evaluation in the current model.

Envisaging an alternative model might include the following characteristics, “…local rather than global, contextual rather than general, cooperative rather than hierarchical, supportive rather than judgmental, flexible rather than rigid, and developmental rather than a single snapshot…”(Rashid et al. 2023b).