Improving Inclusivity in Medical Learning Environments

There are many psychological, social, and instructional factors that influence inclusivity in medical learning environments. Implementing specific and actionable strategies would support students and improve learning, engagement, and inclusivity.

Psychological

Two significant psychological factors are 1) deficit thinking and 2) drink-from-the-firehose curriculum and teaching.

Deficit thinking shows up as language like “don’t waste a spot” or “this student isn’t devoted enough”. Deficit thinking places blame on students and can be harmful (McClure & Reed, 2022) for mental health. (You may be interested in Strength-Based Language for Medical Educators.)

Medical students must also navigate excessive information overload, known as “drink-from-the-firehose”. The workload affects students’ well-being and may contribute to stress or cynicism (Howick et al., 2023) or moral injury while medicine is supposed to be a caring profession. (Read about Why a Guaranteed and Viable Curriculum Matters for Medical Literacy.)

Social

Medical students benefit from positive social esteem related to being in a noble, high-achieving, and high-performing profession. However, the learning environment is also competitive.

The students occupy the lowest rank in the steep hierarchy of a high-stakes profession. Moreover, most have a family member who is a physician (Shipley, 2023), oftentimes a parent. For these reasons, medical students may be treated like children in the learning environment. Furthermore, some medical educators occasionally put students on the spot or humiliate the learners (Hamdy, 2023), which may also affect engagement.

Social dynamics are shaped by unempathetic role models (Howick et al., 2023) and peers who are scrutinous or punitive towards deviations from professional norms. A student who is too outspoken or hesitant may be met with a physician’s gaze or admonishment, or become the subject of gossip. To avoid scrutiny, students avoid drawing negative attention to themselves.

Some learners, such as first-generation medical students (Association of American Medical Colleges, n.d.), may not be accustomed to expectations in the culture of medical education. Students with various identities experience discrimination at Canadian medical schools related to race, disability, speech/language, physical appearance, or other differences (MacLeod et al., 2023). Medical schools’ exclusion of qualified applicants and overloaded curriculums preclude equity and inclusion in the learning environment.

Instructional/Curriculum

As medical information proliferates, more content is added to curriculum despite that “knowledge is expanding faster than our ability to assimilate and apply it effectively” (Densen, 2011, p. 51). At all levels of medical education, however, physicians maintain that the overloaded curriculum is necessary to “meet standards”, instead of making meaningful efforts to reduce cognitive load (e.g. with a Guaranteed and Viable Curriculum). Medical school lectures often include hundreds of PowerPoint slides in lectures and the quality of lectures may vary considerably.

Medical schools are effective at preparing students for multiple choice exams, as test items are covered in the course contents in different ways and in multiple modalities (Darling-Hammond et al., 2019), which promotes and reinforces learning for these topics. There is little evidence, however, that shows how the learning environments develop students’ “twenty-first century” skills in problem solving or critical thinking (Darling-Hammond, 2019) for real-world applications (relevant especially in Medical Literacy for Older Adults). Moreover, the overt and hidden curricula, stressful workloads, and unempathetic role models contribute to declining empathy in medical students (Howick et al., 2023). (See MedULingo’s student profiles for Teaching Empathy to Medical Students.)

Inclusivity Enhancements

The following strategies are recommended to improve inclusivity in medical learning environments.

Ensure that institutional leaders show support and commitment towards professional development activities (Colbert & Bierer, 2022) in a culture of continuous learning and growth (Carbaugh et al., 2015).
Address deficit thinking (McClure & Reed, 2022) by promoting asset/strength-based approaches (Reyes & Duran, 2021) among medical educators (e.g. with Strength-Based Language for Medical Educators). Empathetic role models are important in medical education (Howick et al., 2023) and educators require ongoing professional development of social-emotional skills to promote such capacities in their students (Darling-Hammond et al., 2019), (especially when Teaching Empathy to Medical Students). Interrogation techniques which humiliate learners (Hamdy, 2023) should be discouraged. Moreover, despite high-stakes scenarios, mistakes may be treated as learning opportunities (Darling-Hammond et al., 2019) in low-stakes settings.
Implement strategies for reducing cognitive load such as scaffolding (Darling-Hammond et al., 2019) or best practices for multimedia learning (Strom, 2015) to promote deeper understanding and engagement.
Train faculty and staff to better respond to disclosures related to student identities and requests for accommodations (Levin, 2024).
Implement Universal Design for Learning (UDL) where possible and provide students with flexibility and options to meet their needs and improve their experience as well as their performance (Gawron et al., 2024). UDL should disrupt discourse and challenge notions of normalcy in the learning environment (Gawron et al., 2024), and thus may promote critical thinking, problem-solving, or empathy in medical education.

Use these strategies to improve inclusivity and create more supportive and engaging learning environments in medical education.

References

Association of American Medical Colleges. (n.d.). Tools and Resources for First Generation Medical Students. AAMC. https://www.aamc.org/career-development/affinity-groups/gea/first-generation-students

Carbaugh, B. G., Marzano, R. J., & Toth, M. D. (2015). School Leadership for Results: Shifting the Focus of Leader Evaluation. Learning Sciences International.

Colbert, C. Y., & Bierer, S. B. (2022). The importance of professional development in a programmatic assessment system: one medical school’s experience. Education Sciences, 12.

Darling-Hammond, L., Flook, L., Cook-Harvey, C., Barron, B., & Osher, D. (2019). Implications for educational practice of the science of learning and development. Applied Developmental Science, 24(2), 97–140. https://doi.org/10.1080/10888691.2018.1537791

Densen P. (2011). Challenges and opportunities facing medical education. Transactions of the American Clinical and Climatological Association, 122, 48–58.

Gawron, K., Tomlinson, M., Mohan, N., & Van Puymbrouck, L. H. (2024). A scoping review of Universal Design for Learning in United States allied health & medical 18 education. Open Journal of Occupational Therapy (OJOT), 12(1), 1–14. https://scholarworks.wmich.edu/ojot/vol12/iss1/7/

Hamdy, S. (2023). The trauma of medical training in two webcomics: A call for multimodal citation. Medical Anthropology Quarterly, 37(3), 225–247. https://doi.org/10.1111/maq.12746

Howick, J., Dudko, M., Feng, S.N., Ahmed, A.A., Alluri, N., Nockels, K., et al. Why might medical student empathy change throughout medical school? a systematic review and thematic synthesis of qualitative studies. BMC Med Educ 23, 270 (2023). https://doi.org/10.1186/s12909-023-04165-9

Levin, S. A. N. (2024, March 1). Many Students Don’t Inform Their Colleges About Their Disability. That Needs to Change. EdSurge. https://www.edsurge.com/news/2024-03-01-many-students-don-t-inform-their-colleges-about-their-disability-that-needs-to-change

MacLeod, A., Fletcher, J., Brown, M., Parker, R., Luong, V., Kits, O., Burm, S., & Ajjawi, R. (2023). (rep.). Underrepresented in Medicine: A meta-ethnography of underrepresented students’ experiences of medical school . Social Sciences and Humanities Research Council. Retrieved from https://sshrc-crsh.canada.ca/society-societe/community-communite/ifca-iac/evidence_briefs-donnees_probantes/sdpm-edpm/macleod-eng.aspx.

McClure, B., & Reed, K. (2022). Hacking deficit thinking: 8 reframes that will change the way you think about strength-based practices and equity in schools. Times 10 Publications.

Reyes, H. L. & Duran, A. (2021). Higher education scholars challenging deficit thinking: An analysis of research informed by community cultural wealth. Journal of Critical Scholarship on Higher Education and Student Affairs, 6(1) https://ecommons.luc.edu/cgi/viewcontent.cgi?article=1171&context=jcshesa

Shipley, C. H. and J. (2023, April 3). Opinion: Nepotism’s deep roots in medical education. Medical News. https://www.medpagetoday.com/opinion/second-opinions/103839

Strom, M. (2015, October 21). Digital Spaces: 12 best practices for multimedia learning. Edutopia. https://www.edutopia.org/blog/digital-spaces-12-best-practices-michelle-manno

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