Discrimination in Medical Education Survey Report 2019

DISCRIMINATION IN MEDICAL EDUCATION SURVEY REPORT

IFMSA

The International Federation of Medical Students’

Imprint Standing Committee Directors Medical Education Catarina Pais Rodrigues Sexual and Reproductive Health and Rights incl. HIV & AIDS Iheb Jemel Human RIghts and Peace Idil Kina Layout Design José Chen

Associations

(IFMSA)

is

a

non-profit,

non-

governmental organization representing associations of medical students worldwide. IFMSA was founded in 1951 and currently maintains 136 National Member Organizations from over 126 countries across six continents, representing a network of 1.3 million medical students.

IFMSA envisions a world in which medical students unite for global health and are equipped with the knowledge, skills and values to take on health leadership roles locally and globally, so to shape a sustainable and healthy future.

IFMSA

is

recognized

as

a

nongovernmental

organization within the United Nations’ system and the World Health Organization; and works in collaboration with the World Medical Association.

Publisher

International Federation of Medical Students’ Associations (IFMSA) International Secretariat: c/o IMCC, Nørre Allé 14, 2200 København N., Denmark Email: gs@ifmsa.org Homepage: www.ifmsa.org

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© 2019 - Only portions of this

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publication may be reproduced for non political and non profit purposes, provided mentioning the source.

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views

contains of

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different

contributors, the opinions expressed in this publication are those of the authors

and

do

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reflect the position of IFMSA. The mention of specific companies or

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Introduction to IFMSA

Contents

Page 4

Overview of the Project Page 5

Survey Results Page 6 A. Overview B. Curriculum C. Learning Environment D. Students Perceptions

Conclusion and Recommendations Page 18

References

www.ifmsa.org

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Discrimination in Medical Education

Introduction to IFMSA IFMSA was founded in 1951 and is one of the world’s oldest and largest studentrun organizations. It represents, connects and engages every day with a inspiring and engaging network of 1.3 millions medical students from 136 national members organizations in 126 countries around the globe.

IFMSA envisions a world in which all medical students unite for global health and are equipped with the knowledge, skills and values to take on health leadership roles locally and globally. IFMSA unites medical students worldwide to lead initiatives that impact positively the communities we serve. IFMSA represents the opinions and ideas of future health professionals in the field of global health, and works in collaboration with external partners. IFMSA builds capacity through training, projects and exchange opportunities, while embracing cultural diversity. Our work is divided in four main global health areas: public health, sexual reproductive health, medical education, human rights and peace. Furthermore, each year, we organize 15.000 clinical and research exchanges programs for our students to explore innovations in medicine, and healthcare systems in different settings. IFMSA is also officially recognized by the United Nations as the voice of international medical students, and has official relationships with major UN agencies, such as the World Health Organization (WHO), UNESCO, UNAIDS, UNHCR and UNFPA, as well as key supporters like the World Medical Association (WMA). This has ensured that IFMSA is considered a major partner when it comes to issues relating to global health, internationally and locally.

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Overview of the Project Discrimination is the act to differentiate and separate. It enables us to classify information and to learn easier, however it can also act as a tool for us to set people apart from one another in order to maintain the power structures of the society and protect our privileges.

Being a recognisable social stressor that can adversely affect the health and wellbeing of individuals, the topic and context of discrimination should be addressed in the curriculum so that future healthcare professionals are able to recognise and battle discrimination and provide dignified healthcare for all.

However, currently, medical education does not adequately address discmination in medical curriculum and may actually in many settings, perpetuate it.

Medical education and discrimination- Problem statement: • Inadequate exposure of medical students to the human rights aspect of the science of medicine • Failure to adequately capacitate medical students into recognizing discmirnation and providing non-discriminatory health care • Hidden perpetration of discrimination through educators’ biases, discriminatory examples, outdated and pseudoscientific data • Non inclusive medical content, settling one demographic group as “normhuman”, stigmatization of “other” groups.

Objectives and Methodology With this project, IFMSA aims to to understand how medical education worldwide is addressing discrimination, particularly its implications in healthcare and whether it is adequately preparing the future health professionals to tackle different forms of discrimination against vulnerable groups. Through collaborations between our three standing committees (Medical education, human rights and peace, sexual and reproductive health including HIV and AIDs) a global survey was launched. The survey was divided in two parts in order to understand the curricular structure, as well as students’ perspective regarding the approaches to discrimination in Medical Education in order to understand the current situation worldwide and how medical students can lead the change towards a better education and healthcare professionals. A total of 173 responses was received. Qualitative data was also obtained through discussions with students during the General Assemblies of IFMSA. In order to raise awareness on the topic, a webinar was held for students. (here)

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Survey Results A. Overview 173 responses from more than 50 National Member Organizations around the world; An analysis of survey respondents reflected that most of the students are in their clinical years (3rd, 4th, 5th and 6th). Responses showed good regional representation with A bulk of responses was from Americas and Europe regions.

Interestingly, 70% of medical students identified as one or more of the vulnerable groups stated (migrants and refugees, people with disabilities, women, racial and ethnic minorities, religious minorities, LGBTQI+, non conforming gender identity, people living with HIV).

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B. Curriculum In this section we analysed to what extent medical curriculum addresses discrimination in healthcare of certain groups, including but not limited to migrants and refugees, people with disabilities, women, racial and ethnic minorities, religious minorities, LGBTQI+, non conforming gender identity, people living with HIV etc. The curriculum assessment tool developed (annex to the Advocacy in Medical Curriculum Toolkit which can be found in the SCOME Public Folder) was used to understand to what extent this is incorporated in curriculum, teaching methodologies used, and the general approach to assessment.

1. Curriculum content A general trend was observed- health of most vulnerable groups are not addressed in medical curriculum, particularly migrants & refugees, religious & ethnic minorities, non conforming gender identity and health of LGBTQI individuals.

On a positive note, health of people living with HIV, or with a disability, seemed to be addressed, “spread throughout curriculum�, suggesting an increased awareness around these groups.

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2. Teaching methodologies In order to better understand the settings in which health of vulnerable groups and discrimination is taught, participants were asked to reflect on teaching methodologies adopted in their schools. The most adopted approach was lectures followed by PBL and clinical tutorials, community based learning was rarely reported. This data is probably justified by the fact that these are the common teaching methodologies in most schools, however, it is also concerning because health of vulnerable groups and provision of nondiscriminatory healthcare should involve experiential learning opportunities for medical students to adequately learn to recognize the verbal and non verbal forms of discrimination that may arise, and learn to reflect non discriminatory behaviour through positive communication skills.[1] One of 20 responses received from students was, “My school does not provide any specific methods of teaching medical students about the general approach of vulnerable groups and discrimination�.

3. Assessment methodologies It is well known that assessment drives learning. Also, quality assessment ensures that medical students, who will be the future health professionals have developed the competencies required of them. An alarming finding was that health of all vulnerable groups was not assessed neither in theoretical nor clinical assessment settings. A few reported incourse & end of course assessment of the topics.

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An in depth analysis of assessment methods showed a skew towards written/ multiple choice (theoretical) exams (47%), and oral + clinical exams which can also be justified by the fact that these are the common assessment methodologies in medical schools. Very few reported assessment methodologies that involve reflection eg: reports etc which is again concerning because developing the required competencies in addressing health of vulnerable groups requires transformative learning which is rarely captured through route assessment methodologies which reflect only knowledge gain, rather than perspective & behavioural change. [2]

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4. Specific vulnerable groups in curricula To better understand the status quo of inclusion of specific vulnerable groups in curricula, group specific questions were asked; a. Migrants and refugees Summary of the majority of responses - The topic is not addressed in curricula (60%), topic not assessed (70%).

b. People living with disabilities Summary of responses - 35% of responses identified that the topic is not addressed in curriculum. The remaining responses showed a variation - some integration throughout curriculum, inclusion in clinical and pre-clinical studies, with a minority of responses reflecting that it is an elective course in their curricula. A majority of responses reported that it is not assessed.

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c. Women Summary of responses - a majority of responses showed inclusion of the topic in curricula (70%), mostly spread throughout curriculum and in practical or clinical studies. However, only 50% reported that it is assessed, mostly as continuous assessment or end assessments as well.

d. Racial and ethnic minorities Summary of the majority of responses - The topic is not addressed in curricula (50%) with the rest indicating that it is included in their curricula either throughout curricula or during pre-clinical and clinical studies. With regards to assessment, the majority (70%) indicated that it is not assessed.

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e. Religious minorities Summary of the majority of responses - The topic is not addressed in curricula (66%), topic not assessed (85%).

f. LGBTQI+ individuals Summary of the majority of responses - The topic is not addressed in curricula (66%), topic not assessed (85%).

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g. Non conforming gender identity groups Summary of the majority of responses - The topic is not addressed in curricula (66%), topic not assessed (85%).

h. People living with HIV/AIDs Summary of the majority of responses - A majority (85%) showed that the topic is included in their curriculum, mostly integrated longitudinally throughout the curriculum or in clinical studies. However a lower number reported its inclusion in assessments (60%), mostly as continuous assessment or end assessments as well.

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Discrimination in Medical Education

C. Learning Environment Aside from curriculum, learning environment has a strong influence on learning.

In this section we assessed: 1. The degree to which teaching and learning environments and the educators where inclusive and co-operative with vulnerable groups.

2. The degree to which learning environments where receptive to feedback by students 3. The degree of accuracy in terminology and approach of the educator towards vulnerable groups.

A significant trend was observed, learning environment was reported to be significantly less inclusive to the following groups; Non-confirming gender identity, LGBTQI+, religious minorities and refugees and migrants. We also asked an open ended question; How do you perceive your learning environment ?

Some of the interesting responses received where as follows;

“It isn’t based on teaching students about discrimination at all”

“Usually infringed with religion and a closed mindset with ethnic and religious prejudices due to lack of education. Sad to see medical students themselves belonging from such backgrounds.”

“The fact that my university is a catholic one severely restrains the topics we can cover and the way they must be talked about. Demographic minorities are touched upon as an afterthought, or a coincidence. When reviewing a case report the patients can belong to these groups, but they weren’t chosen because of it. And certain groups are covered but merely because they suffer diseases that they consider are under what medicine should cover.”

Question 1: Inclusion of vulnerable groups.

This question takes into consideration the inclusion of the vulnerable group in the examples and case studies shared or in learning materials. The concept of Dismissive (1) stands for the educator that ignores the existence of the group and only structures the environment around the “general population”. The concept of Inclusive (5) when the group is regularly mentioned by educators as well as the “general population”

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Question 2: Cooperation with vulnerable groups This question takes into consideration the cooperation, as the learning environment encourages fostering a relationship and support the vulnerable group. The concept of Disengaged (1) stands for the specific needs of this group not being taken into account and there is no environment to elaborate on such needs. The concept of Cooperative (5), the environment enables students to learn about the specific issues about this group and encourages the support of this group.

Question 3: Receiving and applying feedback Feedback reception and application is tested in this question. Rating 1 suggests the educators are not receptive and/or are condescending when given feedback.

Rating 5 suggests the educators listen and make efforts to apply the feedback

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Question 4: Accuracy and appropriateness of terminology This question seeks to measure the degree of accuracy of medical terminology used, Rating 1, would consider the approach as stigmatizing and contributes to discrimination(for eg. basing their approach on outdated scientific or medical data, such as stating homosexuality is an illness). Rating 5, would consider the approach as accurate and appropriate, the statements are not biased and usually based on recent scientific data with the societal consideration

D. Students Perceptions In this section, we explored the general perception of medical students towards discrimination in their medical curricula, whether they are satisfied with the current situation and when and where they’d like these topics to be included in curricula.

The majority of students reported that they were not satisfied with their medical schools approach to vulnerable groups and discrimination, with even higher trends with regards to individuals of non conforming gender identity and LGBTQI+. Responses also reflected that students would like to have these topics integrated longitudinally along curriculum.

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On the other hand, some students found the inclusion of “some” of these topics in medical curriculum irrelevant mainly because they did not see a societal need for this. Some of the responses we received are;

“My country does not have these communities”

“Currently, these issues have not posed a problem in my medical school or inside the country Regarding women: I do think that in my country, a positive and not discriminating behaviour on the part of the instructors, and generally a positive, non discriminating environment in university and in hospital, discouraging discrimination, is what is needed, rather than a separate topic/lecture/workshop/ (....) On addressing it; gender equity can be promoted effectively in this indirect way, I think”

“The hippocratic oath to be taken by all medical professionals mentions the lack of discrimination to be held by a physician and thus this should avidly cover the above topics. Formal teachings would not yield any benefits as these groups are not encountered frequently and when they are, basic human respect and dignity are given to them by members of the medical profession in keeping with the oath.”

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Conclusion and Recommendations In summary, this study reflected that most of the topics regarding vulnerable groups and discrimination are not addressed in curricula. Similarly, learning environments were not inclusive to these groups. There is a need to: 1. Acknowledge that human rights and medical education are undividable from each other. Diversity and inclusiveness should be a transversal concept in all stages of medical education; planning and delivery.

2. Ensure medical curriculum and learning environments are inclusive of knowledge about specific diseases and health problems impacting specific populations defined above. Suitable teaching and assessment strategies must be implemented to ensure medical students develop the required competencies when providing healthcare to vulnerable groups.

3. Raise awareness on the importance of provsion of non-discrimatory healthcare and how discrimination can be perpetuated by healthcare workers either directly through discriminatory behaviours and statements or indirectly through disregard of complaints of individuals from vulnerable populations, dehumanization and objectification.

4. Build capacity amongst educators on why this important, how to create a more inclusive learning environments, avoid stigmatization whilst being scientifically accurate and socially sensitive.

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References 1.

Pdfs.semanticscholar.org. (2019). [online] Available at: https://pdfs. semanticscholar.org/3b09/41478ea8b7f8ff1c0fb865c29e68e991fd5a.pdf 2.

Pdfs.semanticscholar.org. (2019). [online] Available at: https://pdfs. semanticscholar.org/52dd/33e3760a3b167dd816e3ba2a5300fecc437d.pdf

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IFMSA

International Federation of Medical Students’ Associations

Dominican Republic (ODEM)

Lebanon (LeMSIC)

Saint Lucia

Lithuania (LiMSA)

(IFMSA-Saint Lucia)

Ecuador (AEMPPI)

Luxembourg (ALEM)

Senegal (FNESS)

Egypt (IFMSA-Egypt)

Malawi (MSA)

Serbia (IFMSA-Serbia)

Malaysia (SMMAMS)

Sierra Leone (SLEMSA)

Aruba (IFMSA-Aruba)

El Salvador (IFMSA-El Salvador)

Mali (APS)

Singapore (SiMSA)

Australia (AMSA)

Estonia (EstMSA)

Malta (MMSA)

Slovakia (SloMSA)

Austria (AMSA)

Ethiopia (EMSA)

Mauritania (AFMM)

Slovenia (SloMSIC)

Azerbaijan (AzerMDS)

Finland (FiMSIC)

Mexico (AMMEF-Mexico)

South Africa (SAMSA)

Bangladesh (BMSS)

France (ANEMF)

Montenegro (MoMSIC)

Spain (IFMSA-Spain)

Belgium (BeMSA)

Georgia (GMSA)

Bolivia (IFMSA-Bolivia)

Morocco (IFMSAMorocco)

Sudan (MedSIN)

Germany (bvmd)

Sweden (IFMSA-Sweden)

Bosnia & Herzegovina (BoHeMSA)

Ghana (FGMSA)

Nepal (NMSS)

Switzerland (swimsa)

Greece (HelMSIC)

The Netherlands

Grenada (IFMSAGrenada)

(IFMSA NL)

Syrian Arab Republic (SMSA)

Albania (ACMS) Algeria (Le Souk) Argentina (IFMSAArgentina) Armenia (AMSP)

Bosnia & Herzegovina – Republic of Srpska (SaMSIC)

Niger (AESS)

Taiwan - China (FMS)

Brazil (DENEM)

Guatemala (IFMSAGuatemala)

Nigeria (NiMSA)

Tajikistan (TJMSA)

Brazil (IFMSA-Brazil)

Guinea (AEM)

Norway (NMSA)

Thailand (IFMSAThailand)

Bulgaria (AMSB)

Haiti (AHEM)

Oman (MedSCo)

Tanzania (TaMSA)

Burkina Faso (AEM) Cameroon (CAMSA)

Hungary (HuMSIRC)

Pakistan (IFMSAPakistan)

Togo (AEMP)

Burundi (ABEM)

Honduras (IFMSAHonduras)

Palestine (PMSA)

Canada (CFMS)

Iceland (IMSA)

Canada – Québec (IFMSA-Québec)

India (MSAI) Indonesia (CIMSA-ISMKI)

Paraguay (IFMSAParaguay)

Catalonia - Spain (AECS)

Iran (IMSA)

Peru (IFMSA-Peru)

Turkey – Northern Cyprus (MSANC)

Chile (IFMSA-Chile)

Iraq (IFMSA-Iraq)

Peru (APEMH)

Uganda (FUMSA)

China (IFMSA-China)

Iraq – Kurdistan (IFMSAKurdistan)

Philippines (AMSAPhilippines)

Ukraine (UMSA)

Ireland (AMSI)

Poland (IFMSA-Poland)

Colombia (ASCEMCOL)

Israel (FIMS)

Portugal (ANEM)

Costa Rica (ACEM)

Italy (SISM)

Qatar (QMSA)

Croatia (CroMSIC)

Ivory Coast (NOHSS)

Cyprus (CyMSA)

Jamaica (JAMSA)

Republic of Moldova (ASRM)

Czech Republic

Japan (IFMSA-Japan)

(IFMSA-CZ)

Jordan (IFMSA-Jo)

Republic of North Macedonia (MMSA)

Democratic Republic of the Congo (MSA-DRC)

Kazakhstan (KazMSA)

Romania (FASMR)

(IFMSA-Uruguay)

Kenya (MSAKE)

Denmark (IMCC)

Korea (KMSA)

Russian Federation (HCCM)

Uzbekistan (Phenomenon)

Dominica (IFMSA Commonwealth of Dominica)

Kosovo - Serbia (KOMS)

Russian Federation – Republic of Tatarstan (TaMSA)

Venezuela (FEVESOCEM)

Rwanda (MEDSAR)

Zimbabwe (ZIMSA)

China – Hong Kong (AMSAHK)

Kuwait (KuMSA) Latvia (LaMSA)

Panama (IFMSAPanama)

www.ifmsa.org

Trinidad and Tobago (TTMSA) Tunisia (Associa-Med) Turkey (TurkMSIC)

United Arab Emirates (EMSS) United Kingdom of Great Britain and Northern Ireland (SfGH) United States of America (AMSA-USA) Uruguay

Yemen (NAMS) Zambia (ZaMSA)

medical students worldwide