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J Gen Intern Med. May 2010; 25(Suppl 2): 160–163.
Published online Mar 30, 2010. doi:  10.1007/s11606-010-1283-3
PMCID: PMC2847114
A Strategy for Improving Health Disparities Education in Medicine
Paula T. Ross, MA,1 Crystal Wiley Cené, MD, MPH,2 Jada Bussey-Jones, MD,3 Arleen F. Brown, MD, PhD,4 Dionne Blackman, MD,5 Alicia Fernández, MD,6 Leonor Fernández, MD,7 Susan B. Glick, MD,5 Carol R. Horowitz, MD, MPH,8 Elizabeth A. Jacobs, MD, MPP,9 Monica E. Peek, MD, MPH,5 LuAnn Wilkerson, EdD,4 and Monica L. Lypson, MDcorresponding author1
1University of Michigan, 2600 Green Rd Ste 150B, Ann Arbor, MI 48105-5791 USA
2University of North Carolina, Chapel Hill, NC USA
3Emory University School of Medicine, Atlanta, GA USA
4David Geffen School of Medicine at UCLA, Los Angeles, CA USA
5University of Chicago, Chicago, IL USA
6University of California San Francisco, San Francisco, CA USA
7Beth Israel Deconess Hospital, Harvard University, Boston, MA USA
8Mount Sinai School of Medicine, New York, NY USA
9Stroger Cook County Hospital, Rush University Medical Center, Chicago, IL USA
Monica L. Lypson, Phone: +1-734-7643186, Fax: +1-734-7635889, mlypson/at/umich.edu.
corresponding authorCorresponding author.
Introduction
A health disparities curriculum that uses evidence-based knowledge rooted in pedagogic theory is needed to educate health care providers to meet the needs of an increasingly diverse U.S. population.
Description
The Health Disparities Education: Beyond Cultural Competency Precourse, along with its accompanying Train the Trainer Guide: Health Disparities Education (2008), developed by the Society of General Internal Medicine (SGIM) Disparities Task Force (DTF), is a comprehensive tool to facilitate developing, implementing and evaluating health disparities education. The curriculum includes five modules highlighting several fundamental concepts in health disparities, suggestions for teaching about health disparities in a wide range of settings and strategies for curriculum evaluation. The modules are Disparities Foundations, Teaching Disparities in the Clinical Setting, Disparities Beyond the Clinical Setting, Teaching about Disparities Through Community Involvement, and Curriculum Evaluation.
Evaluation
All five modules were delivered as a precourse at the 31st Annual SGIM Annual Meeting in Pittsburgh, PA and received the “Best Precourse Award”. This award is given to the most highly rated precourse based on participant evaluations. The modules have also been adapted into a web-based guide that has been downloaded at least 59 times.
Conclusion
Ultimately, the modules are designed to develop a professional commitment to eliminating racial and ethnic disparities in health care quality, promote an understanding of the role of health care providers in reducing health care disparities through comprehensive education and training, and provide a framework with which providers can address the causes of disparities in various educational settings.
Key Words: health disparities, medical education, faculty development
In order to improve the health of the diverse U.S. population, it is essential to develop and implement educational programs that teach physicians about the pervasiveness of racial and ethnic health disparities and help them develop strategies to deliver quality care to diverse and underserved populations.1,2 The Institute of Medicine’s Unequal Treatment: Confronting racial and ethnic disparities in health care (2002) defined healthcare disparities as “racial or ethnic differences in the quality of healthcare that are not due to access related factors or clinical needs, preferences, and appropriateness of intervention”.1 Nonetheless, pedagogy for health disparities education is still in its infancy and has received limited acceptance and implementation into undergraduate and graduate medical education curricula.36 Moreover, there is considerable variability in the design and implementation of health disparities curricula, and few curricula comprehensively address the various ways to eliminate health disparities. Many focus on cultural competence, in an attempt to increase understanding of cultural beliefs and to outline best practices for communication with minority populations. Some curricula highlight systemic barriers such as limited access, insurance and language; yet few use evidence-based principles to guide learners in developing meaningful clinical responses to overcome such disparities.1,7,8 The Institute of Medicine’s report highlighted the role of health care providers in addressing disparities in health care; thus the development of curricula specifically designed to educate providers seemed a logical step toward meeting this need.
The aim of this article is to briefly outline the materials developed by the Society in General Internal Medicine’s Disparities Taskforce, which represents a comprehensive curriculum for teaching and evaluating health disparities education. These materials can be easily incorporated into faculty development efforts to address issues of health disparities, or improve upon existing educational modules. We also describe the process of delivering the curricular content during a precourse at the Society of General Internal Medicine National Meeting in 2008.
Rationale
Members of the Society of General Internal Medicine (SGIM) recognized the need for an effective module for educating physicians on the underpinnings of health care disparities and ultimately formed the Disparities Task Force (DTF). This group includes volunteers from the Society of General Internal Medicine membership, many of whom have experience teaching ethics, health disparities, and cross-cultural care at their institutions. The contributing faculty were primarily junior and mid-level health professions educators, clinician-educators and clinician-investigators. Over the course of three years, task force members worked in small-groups, participated in conference calls, e-mail exchanges, and in-person meetings to develop the curriculum. A workshop based on the materials and how they might be used in training colleagues to teach with them was proposed and accepted for presentation at the 2008 SGIM national meeting.
The task force selected a train-the-trainer model since the goal was to provide materials and teaching strategies to SGIM members that they could use in their home institutions to increase the number of faculty members prepared to teach about health disparities at the bedside, in small group seminars, and through community-based projects.9,10 Further, as our aim was to develop a model that would be used to train individuals who would later train others, the active learning experience incorporated into this model is critical for developing teaching and improving facilitation skills.11,12
Curriculum Development
The curriculum as represented in the Train-the-Trainer Guide: Health Disparities Education Guide (2008) is a comprehensive curriculum, consisting of five modules, designed to facilitate developing, implementing and evaluating health disparities education. All participating Task Force members presented topics for inclusion in the curriculum; however considerations were only given to those topics that gave evidence of academic rigor, as evidenced by implementation and evaluation at another institution. These items were then discussed during a retreat and subsequent conference calls to determine the final content included in the curriculum.
Target Audience and Facilitator Skills
We anticipated that this curriculum would be applicable to a variety of health care providers, including physicians, nurses, dentists, and allied health professionals, who are responsible for teaching students in the various health professions. While the materials provide information, which is useful for a variety of learners who have a desire or responsibility to educate others, individuals with limited teaching experience or health disparities knowledge may need additional training to feel comfortable teaching a topic as multi-factorial and complex as health disparities. Although these modules can be used by individuals with varied experienced, optimally those teaching these modules should have prior training or experience employing active learning modalities (e.g., small group discussions, role-plays, and experiential activities). Additionally, we recommend that teachers have experience facilitating discussions on multicultural issues in health care as discussions about cultural difference, race, bias, and disparities can be emotionally charged and often raise complex ethical questions. It is also important to consider the learning environment in which these modules are presented (e.g. specialty, institution, practice, etc.), and allow for appropriate implementation.
Learning Objectives
The task force aimed to develop a health disparities curriculum to assist faculty who have an understanding of and a commitment to eliminating inequities in health care quality and racial and ethnic health disparities regardless of their level of expertise and knowledge in the area of health disparities.13 We encourage faculty to become familiar with the literature on the causes and scope of health disparities and disparities reduction. Faculty should also be encouraged to become effective facilitators able to lead discussions about health disparities in various settings and teach participants about ways to reduce disparities. Therefore, the task force recommended that faculty teaching health disparities curricula should meet the following learning objectives:
  • Understand attitudes such as mistrust, subconscious bias and stereotyping that practitioners and/or patients may bring to the clinical encounter
  • Attain knowledge of the existence and magnitude of health disparities, including the multi-factorial etiologies of and the multiple solutions required to eliminate them
  • Acquire the skills to effectively communicate and negotiate across cultures, including trust-building and the use of key tools to improve cross-cultural communication
Curricular Content
The SGIM Health Disparities Curriculum, which was distributed as a handout for the Disparities Precourse incorporated five modules spanning the various dimensions of health disparities in medical education: Disparities Foundations, Teaching Disparities in the Clinical Setting, Disparities Beyond the Clinical Setting, Teaching About Disparities Through Community Involvement, and Curriculum Evaluation. Each of these modules is briefly described below. The curricular modules can be used individually or collectively and can be delivered over a four-hour time span if run consecutively. Further detail on each module can be found in Table 1. The modules have been designed to use active, rather than passive, learning styles. Therefore, the majority of activities include participant discussion and interaction.14,15 The curriculum purposely incorporates various educational approaches, including experiential activities, didactic lectures, case presentations, and small group discussions.
Table 1
Table 1
Module Descriptions
Precourse Evaluation
The Disparities Task Force presented these modules as one of 14 pre-courses offered at the SGIM Annual Meeting in April 2008 in Philadelphia, PA. Evaluations were completed by 30 of the 32 participants as part of the SGIM annual meeting process and specifically focused on content, delivery and usability of the course materials (See Table 2). Those participating in the pre-course were primarily clinical educators and described themselves as having some prior knowledge of the subject, albeit not experts. According to these evaluations, attendees found the content and the novel tools meaningful to their future work.
Table 2
Table 2
Disparities Precourse Evaluation Results
There remains an ongoing need for institutions to implement health disparities into their curricula. The SGIM precourse was found to be an effective way to deliver the Disparities Curriculum. The SGIM Health Disparities Curriculum is uniquely designed to aid in that effort and develop well-trained health care providers who are committed and prepared to eliminate disparities in health care quality and promote an understanding of the health care provider’s role in addressing this pressing issue. The curriculum was made available as a downloadable document via the SGIM Education website (http://www.sgim.org/index.cfm?pageId=269) in July 2008. To date, the curriculum has been downloaded over 50 times as of January 2010.
Acknowledgements
Funding for the initial phases of this work was provided by the Society of General Internal Medicine (SGIM) Council. Dr. C. Cené is supported through the UNC Clinical Translational Science Award-K12 Scholars Program (1KL2RR025746-01). Dr. A. Fernández is supported by the Arnold P. Gold Foundation. Dr. M. Peek is supported through the Robert Wood Johnson Foundation Harold Amos Medical Faculty Development Program and National Institute of Diabetes and Digestive and Kidney Diseases (K23DK075006-04).
Footnotes
On Behalf of the Society of General Internal Medicine Disparities Task Force
Dr. C. Cené is supported through the UNC Clinical Translational Science Award-K12 Scholars Program (1KL2RR025746-01).
Dr. A. Fernández is supported by the Arnold P. Gold Foundation.
Dr. M. Peek is supported through the Robert Wood Johnson Foundation Harold Amos Medical Faculty Development Program and National Institute of Diabetes and Digestive and Kidney Diseases (K23DK075006-04).
Dr. A. Brown received support from the UCLA Resource Center in Minority Aging Research (#AG02004), the National Center on Minority Health and Health Disparities (#P20MD00148), and the National Heart Lung and Blood Institute (# NL079240).
Dr. C. Horowitz received support from the National Center on Minority Health and Health Disparities (R24 MD001691), the National Center for Research Resources (UL1RR029887) and the Centers for Disease Control and Prevention REACH-US (U58DP001010).
Dr. S. Glick is supported by the National Heart, Lung and Blood Institute (K07HL081429).
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