Report on Diversity Education in UK Medical Schools 6th May 2016

Summary

The DIMAH conference was considered a valuable way of sharing knowledge and experiences in diversity education. It showed that the majority of UK medical schools are actively engaged in diversity teaching, with 31 of 33 UK medical schools represented at the meeting. Key stakeholders from the GMC, RCP, RCGP, RCPsych, AMEE and ASME also participated.

Three main common challenges were identified:

1. Faculty engagement and development

2. Curriculum delivery

3. Assessment and evaluation

Through working together we may be able to resolve some of the challenges. Detailed notes of the group will be available on the website www.dimah.co.uk

Context and Background to Meeting

• DIMAH was formed in 2011 and set itself the following remit:
• Clearly define diversity and what diversity education is and also what it is not.
• Curriculum design – identify aims and learning outcomes for diversity education, and how these will be delivered and assessed.
• Developing some resources for students and teachers which would include an outline ‘curriculum’ (including a guide for aims and learning outcomes).

In the last five year it has achieved the following outcomes:

• Identified a working definition of “diversity” which has informed our work.
• Consensus around core curriculum and guidelines for its delivery.
• Published Association of Medical Education Guide.
• Website development (ongoing).
• Community of practice established (need to widen).

The Aims of Meeting Were:

For UK medical schools to showcase their diversity education.

To consider how schools can learn from other schools to improve on diversity education.

Highlight the work of DIMAH.

Attendance

Of the 76 people registered for the event, 65 attended with four sending apologies. All but two of the 33 medical schools in the UK were represented at the event. Also present were The Royal College of GPs, Physicians and Psychiatrists, key GMC staff, the Association for Medical Education in Europe (AMEE) and the Association of Study of Medical Education (ASME). All those present had some role in medical education.

The Content of the Meeting

Setting the Context

The meeting opened with the GMC perspective on the relevance and importance of diversity education given by Professor Terence Stephenson, GMC president. This was followed by an overview of diversity education given by Nisha Dogra, Chair of DIMAH (University of Leicester).

Workshop One

This was an opportunity for each medical school to present a poster on diversity education at their institution. The purpose was to discuss, share and explore different curricula around diversity and the potential challenges involved. After the presentations there was a broader discussion and groups were asked to identify the three key points they considered most important following their discussions.

Jon Ward (University of Birmingham and DIMAH) collated the points from each group and three main themes were identified:

1. Faculty engagement and development
2. Curriculum delivery
3. Assessment and evaluation

Components of the key themes:

1. Faculty Engagement and Development

1.1 Drivers and Leads

Diversity or aspects of diversity may suddenly become ‘popular’ for reasons other than education (an important issue within institutions) and this can be driven by striving for awards, e.g. Athena Swan Award or LGBT Scottish Youth Award. The issue of whether there is a need for diversity leads at each institution was raised. Having a lead for diversity in place at an institution can raise the profile of diversity but it can also mean that other faculty members avoid taking any responsibility for diversity teaching within their modules. There is considerable variation as to what happens across medical schools.

1.2 Inclusion of Clinical Teachers

Clinical tutors must ‘buy in’ to the concept of diversity education being an important element of training for students but as yet their engagement is variable.

1.3 Importance of Role Modelling and the Hidden Curriculum

This was identified as an important issue as what students see (in the clinical environments they are training in and also within teaching institutions) can have a significant impact on learning and understanding. There is also the experience that sometimes what students observe in the clinical context contradicts what they may have learned in the educational environment.

1.4 Staff Development (including Clinical Teachers)

This was highlighted as being particularly important with faculty members reflecting on their own experiences and biases. To get students to reflect on their own assumptions and biases, faculty members need to have the opportunity to do the same and also model this in practice.

2. Curriculum Delivery

2.1 Usefulness (and Necessity) of Mapping Exercises

A number of attendees expressed the view that having to produce a poster for the conference had made them investigate how diversity was situated within their institutions curriculum. Others felt that further mapping was required – especially in institutions where a lead for diversity had not been identified.

2.2 Integration into the Curriculum

Some institutions explicitly ‘badge’ diversity as an element within their curriculum, whereas others reported that diversity was integrated into the curriculum. Concerns were expressed that where it is sometimes said to be integrated, it actually may not be happening as it needs to and students may not realise the expectations of them. There may also be a danger that diversity just gets lost in the wider curriculum – the thought may prevail that “someone else does diversity in their module, so it is covered” without any certainty.

2.3 Content

Community involvement and partnerships with community organisations can be very useful in diversity teaching and learning, but there is a major issue relating to resources – how are links to community organisations built and maintained? Another resource issue is building and maintaining a simulated patient (SP) team who can represent patients from diverse populations. Institutions in London, Birmingham and Manchester may be able to recruit SPs from diverse ethnic backgrounds in a way that for example Cambridge, Newcastle or Dundee may struggle to do. Successfully representing patients with learning or specific physical disabilities can also be challenging.

There may be an issue with the scope of definition and the conceptual clarity of diversity within institutions. There was little reference to any specific models or explicitness regarding the educational approaches to diversity, indicating that institutions may be unsure about what constitutes diversity teaching. Students may have a negative perception of diversity teaching and may see it as clinically irrelevant. A reframing exercise may be required so that students can see the value to their clinical practice. An example cited was of poor student uptake for a transgender talk. However, it is important to be aware that the way the subject is taught may also be relevant.

It was suggested by some that a problem-based/case-based approach to diversity teaching would be required. The importance of encouraging students to be reflective, analytical and critical and to be able to question their own assumptions was discussed.

3. Assessment and Evaluation

3.1 Difficulty of Assessment

The difficulty of assessment in this area and how it is currently being done was a common theme. There was a great deal of uncertainty about how to assess diversity and part of this linked to the conceptual lack of clarity around how terms are used or interpreted as little of this is explicit. Several means of assessment were considered and it was considered that a ‘tick-box’ approach should be avoided. Portfolio and peer review/feedback should be considered.

3.2 Should Diversity Assessment Be Summative or Formative and Should Testing Be Implicit or Explicit?

Opinions varied as to whether diversity assessment should be summative or formative and also how should the testing of diversity be made clear to students? For example, if students are aware that there is ‘diversity station’, to what extent will they display the expected behaviours for that station to pass the exam but not address diversity appropriately in other stations? Issues around how to assess diversity if it is integrated into assessments, and included as a strand in OSCEs were raised. This discussion linked into discussions about integration into the curriculum (see 2.2 above) and to what extent diversity should be taught and assessed across all areas of the curriculum.

3.3 Translating Theory into Practice and Evaluating Behaviour and/or Attitudes in Practice

The questions of how institutions can help students to take their learning into clinical practice, and how they can effectively evaluate the impact of their diversity teaching on clinical practice and the patient experience were raised.

Assessment

There was then an interactive session on assessment in diversity run by Margot Turner (St George’s Medical School and Deputy Chair DIMAH). Margot presented some of the literature on assessment in diversity. Delegates were then shown a video clip of a student interviewing a patient who stated that she wanted the student to ensure that she was not treated by nurses who were from other countries as she felt they could not understand her.

Delegates were asked to consider how they might have rated how the student managed the station and also any issues that arose from the clip. There was little consensus as to whether it is possible to assess diversity issues using OSCEs. Some groups discussed the film clip that was shown while others discussed OSCEs more generally.

Points relating to the clip included:

1. It would have been useful to the mark sheet for the station viewed as participants to identify how a mark sheet for such a station might be formulated. The different domains being tested could also be clarified. Some felt the material was more useful for a teaching session than for assessment.

2. The task of challenging xenophobia set the tone for the station but it was felt that it might be more appropriate to assess students about managing expectations and needs of a ‘difficult’ patient as in practice it is often not appropriate to challenge patients.

3. As this was an OSCE station, there was no time for the student to step outside and have time for self-reflection about the case, which might have been possible in a real situation.

4. The scenario presented might be difficult to use consistently with diverse student populations; for example how might responses from the character as a simulated patient and/or the student play out if the student appeared to be an overseas student?

5. It was felt that there might have been a real patient safety issue to be resolved, i.e. what if healthcare professional and patient communication problems caused a genuine risk to the patient? The possibility of having to challenge a colleague’s behaviour/attitudes rather than those of a patient was suggested.

General points about use of OSCEs to assess diversity:

1. It was questioned whether it is possible to design any OSCE station that involves diversity as there was a view that for the OSCE there needs to be a single correct outcome and this is unlikely with diversity issues.

2. Some attendees struggled to see how OSCEs could be used for assessment of diversity issues and felt that a more reflective assessment method was required.

3. The difficulty of embedding diversity within OSCEs was acknowledged again. There needs to be clarity about what is being assessed; for example are we assessing knowledge or understanding of the law. We need to consider if we can test for students demonstrating ‘respectful curiosity’.

4. One of the challenges to running successful OSCEs including diversity issues would be the lack of available simulated patients (SPs) with diverse backgrounds (in terms of minority ethnic backgrounds and disabilities in particular). There was concern that this Report on Diversity might lead to a lack of standardisation within OSCEs. If diversity is to be included in OSCEs, examiners and SPs will need to be appropriately trained.

5. The pros and cons of different assessment methods were discussed and concerns were raised about the validity of OSCE assessment of diversity issues if the station is seen as a stand-alone diversity station. Having a diversity strand running through a number of stations might mean it is not adequately assessed overall and that the diversity components could become diluted. It was suggested that a combination of specific diversity stations and elements integrated into other stations may be the most viable option.

6. Longitudinal methods of assessment may be more useful for assessing diversity issues.

Faculty Development

Nisha Dogra then provided some context to faculty development and its importance in diversity education. Some findings from a European funded Erasmus Project C2ME were also presented. The challenges of online versus face to face training were mentioned and links to staff development opportunities given. These are:

• (http://www.coursesites.com/s/_C2ME_1) and click the option to Self-Enrol in this course and then you should be able to complete the course
• http://www.faculty.londondeanery.ac.uk/e-learning/diversity-equal-opportunities-andhuman-rights
• http://www.flyingstart.scot.nhs.uk/learning-programmes/equality-and-diversity/

Workshop Two: Moving Forward

This workshop focused on how we might take some of what we had learned at the meeting and move forward together, given we had representation from postgraduate medical education and the GMC present as the latter has medical governance responsibilities for undergraduate and postgraduate medical education. Aarti Bansal (University of Sheffield and DIMAH) and Enam Haque (University of Manchester and DIMAH) summarised some of the action points

It was noted by facilitators and through discussion that this workshop proved more challenging with some unclear about expectations of them. Others felt unable to commit their institution to any action as they felt they had little authority to do so. Post-meeting first look analysis indicates that 90 action points were generated from 34 organisations with considerable overlap between organisations.

Leadership of Diversity Education

Ten action points related to considering leadership of diversity education and the possibility of diversity lead posts for example reporting on the conference, identifying a diversity guardian and identifying how having a lead does not remove collective faculty responsibility
for diversity education.

Admissions

Two action points related to admissions about widening participation and clarifying the percentage of low income students and those with protected characteristics.

Mapping Diversity in the Curriculum

Eleven actions points related to mapping diversity teaching in the curriculum with plans to establish if it was taught, where it was included and there was a longitudinal theme.

Developing the Diversity Curriculum

Twenty-two action points about developing the diversity curriculum were generated including making explicit what is required of diversity teaching, refining and updating course materials, integrating across the curriculum, developing community projects, engaging students in curriculum development, reviewing the outcomes for the diversity teaching. Two of these action points were specifically about liaising with module leads and collaborating with colleagues teaching communication and/or clinical skills.

Assessment of Diversity

Twenty action points related to assessment were put forward; 11 of these related to inclusion of diversity in OSCE stations (this ranged from writing new stations for diversity assessment, blue printing for diversity and reviewing existing OSCE stations); 8 were about ensuring it was included in some other part of the assessment process and one about mapping diversity in the assessment schedule.

Evaluating Diversity

Seven action points related to evaluating/monitoring progress were generated including evaluation of students experience of equality and diversity teaching in the curriculum, in new cases review ethnicity/cultural spread, check effective report to ensure cultural contents are reflected and student led survey of value of diversity training before go into clinical years

Faculty Development

Twelve action points related to faculty development for example discussing a paper in journal club to developing, running clinical teachers’ workshop and inclusion in the Masters in Clinical Education.

Linking to Awards

Four action points related to linking diversity education with awards such as Athena Swan and Stonewall.

Joining DIMAH

Pete Leftwick (University of Liverpool and DIMAH) provided information on membership of DIMAH. Further information can be found on the DIMAH website at www.dimah.co.uk.

Outcomes of Meeting

It was agreed we would provide a report of the meeting within two weeks if possible. Many contacts were also made and we would encourage people to join DIMAH. We will of course follow up at an individual level to any requests made directly to any of us at DIMAH. The website has received a greater number of hits following the meeting indicating that interest for the network was generated at the meeting.

There was a great deal of enthusiasm and engagement with the subject at the meeting and we need to consider how to convert this into tangible outcomes. To date 17 feedback responses have been received although there has also been feedback through email communication. The feedback on the day and from those that completed the feedback survey is largely positive. The structure and format of workshop one was better received than workshop two. Some delegates found the afternoon workshop less structured and the informal coffee break unhelpful.

In response to questions about whether after attending the meeting colleagues felt more supported in their role teaching diversity, 59% (n= 10) reported a lot or very much so. One participant reported not at all.

In response to whether they would as a result of the conference make changes to expand or improve diversity education at their institution, 77% (n=11) said probably or definitely.

Most of those responding identified workshop one as the most useful part of the meeting but meeting colleagues and networking was also identified as important. There was less consensus around other aspects of the feedback with a variety of individual comments with some on how future meetings might be improved. One hesitation in taking on the challenges was the lack of resources

Examples of comments received include:

• The conference last week was a superb showcase of good practice and networking aimed at continually improving standards everywhere. Thank you.”
• “I thought the meeting was terrific.”
• “I really found the meeting very useful and I think that the College needs to be doing more in this area.”
• “Well done again on yesterday’s meeting. It was very interesting and will certainly trigger me to review some aspects of how we deliver diversity education in X.”

As a result of the conference the website has received increased hits with a rise in membership requests.

Possible future work could include:

1. A working group of DIMAH, assessment experts from medical education and the Medical Royal Colleges to identify specific assessments. The Medical Schools Council expressed interest in including diversity OSCE stations in their UK bank to promote discussion and
encourage development.

2. Exploration with ASME and AMEE as to how to expand the educational network and to generate high quality publications in the field.

3. Working with the Royal Colleges to build on developing partnership with DIMAH to ensure continued learning from each other.

4. A follow up meeting with participation from a wider range of stakeholders

Future meetings are planned as follows:

• 21.07.2016 – University of Liverpool
• 14.10.2016 – University of Bedfordshire
• 03.02.2017 – University of Manchester
• 11.05.2017 – University of Sheffield

However later venues may be changed to accommodate needs of new members.

Acknowledgements

We would like to thank the following for their help: The Medical Schools Council, especially Clare Owen for supporting this meeting and
providing the venue and catering for the meeting.

The University of Leicester for supporting the development of the website and funding the drinks networking reception. Jo Welch, University of Leicester for administrative support. All medical schools who so kindly supported this event through identifying colleagues to attend.

This report has been prepared by Nisha Dogra, Jon Ward, Margot Turner, Enam Haque and Aarti Bansal and DIMAH committee members have had opportunities to comment on it.