Lynette Reid introduces the work done at Dalhousie to diversify the case-based learning curriculum in the medical program.

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Medical educators in Canada have been implementing an accreditation standard around social accountability as part of de-coupling our accreditation process from the United States (achieved this past summer). In addition, medical practice and the medical sciences are rapidly changing in relation to issues of diversity and inclusion. The confluence of these influences was the stage for an important curriculum revision we undertook at Dalhousie in 2022-24.

Recently, I chaired a curriculum project—“case diversification”— that I’m going to describe in a series of blog posts.

Our medical students have three case-based learning (CBL) tutorial discussions a week in the first two years of their curriculum. Our working group used an anti-oppressive lens to revise the 200 CBL session materials (case narratives with discussion questions and tutor notes). The initial goals of the project were to diversify the patients portrayed in the clinical case scenarios used in CBL and to review the cases for dated and stigmatizing language and recommend revisions. But the work rapidly expanded.

Photo Credit: pxhere. Image Description: A photo showing a diverse group of health-care workers.

Anti-oppressive practice is a useful framework for incorporating the care of equity-denied groups into medical practice. It is now reflected in the Medical Council of Canada qualifying exam objectives. There are systematic and intersectional ways that people are privileged and disadvantaged (e.g. colonialism, racism, cishetoronormativity, sexism, ableism), and these affect health (as social and structural determinants of health) and healthcare. Clinically, anti-oppressive practice includes approaches like trauma and violence-informed care, inclusive practice (adaptation/universal design), and affirming care.

The project was highly collaborative. A key participant was Leanne Picketts, a medical education practitioner who worked on it full time. Leanne has a background in simulated patient education, curriculum design, and educational research. We met monthly with a committee that had interprofessional (social work), clinical, biomedical, ethical and epidemiological expertise, staff expertise in community engagement, program evaluation, and assessment, and of course students with lived and academic expertise, experience, and commitment to the work. The Faculty of Medicine invested in staff and faculty collaboration in the project and the recommendations of the working group came with an expectation from leadership that (for the most part) our assistance in updating cases would be accepted. This was distinctive of Dalhousie’s approach—in other schools, this kind of work has been done on a student-led basis, which sounds great, but in reality means downloading the work of faculty onto minoritized students (the “conscripted curriculum”).

A crucial insight that Leanne brought to the process was the link between presenting diverse identities and improving the patient-centredness of the cases. The students advocated for adding to each case an opportunity for meaningful discussion of the patients’ experiences of health and health care. Our visiting scholar from Social Work, Eli Manning—who very sadly passed away in the year after the project—brought rigour and a strong critical lens to our approach to weaving together the social and the biomedical sciences. When we piloted the approach with the tutors, they requested that we provide specific tutor notes for each case. And as we reviewed for language, we saw that behind language lay normative narratives and biases and assumptions built into the science. Our work extended from revising how the patient identity and clinical care were portrayed to updating the medical and clinical science that was woven into the cases. We used the expertise of persons in the group to revise the patient identities, edit the narratives, and add the discussion questions; we had library support for on-demand rapid lit reviews. We did some focused community engagement and invited experts outside our group to take part in specific cases. We accepted (and remunerated) offers of help when students saw what we were doing and wanted to see their communities better represented.

Most days I was as much a philosopher of science as I was an ethicist, although to be clear this work was not about my own de novo critique of medical science. It was translational work: bringing the most up-to-date resources on sex, gender, ability, and race/ethnicity to our case authors and curriculum leaders for their consideration.

A key goal of our anti-oppressive approach was to disrupt the normative assumption that, unless stated otherwise, the patient is a 70 kg white male (who is also urban, straight, cisgender and of medium to high socioeconomic status). Each case was provided with an upfront statement of the patient’s social identity (gender identity, sexual orientation, racialized identity, indicators of socio-economic status and disability; also religion and family formation). We increased representation of rurality and spread the cases better across the two provinces our medical school serves. We had targets for identities and audited as we went. We stated these dimensions of identity whether they were “medically relevant” or not, and whether they were normatively taken for granted or seen as “different”.

These opening identity statements were not intended to represent what you should gather in a social history or put in the patient’s chart. But in some ways these descriptions did “put patients in boxes.” We resisted this categorization by including descriptions of the ways that patients accepted or resisted these social identifying categories, or how patients found them relevant or not, or whether they would choose to share or not, and with whom; the intersectionality of these identities also offered some resistance.

In the following blog posts, I’ll reflect on some of the ways we approached dimensions of identity: race and ethnicity; sex, gender and sexual orientation; disability; socio-economic status; and Indigenous health.

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Lynette Reid is an associate professor in the Department of Bioethics at Dalhousie University