HOW EDUCATION FOR CHANGE WAS DEVELOPED:
Kerns Six Steps
We used Kern’s Six-Step Approach to Curriculum Development in Medical Education to create Education for CHANGE. We conducted both global and local needs assessments to inform the overarching curricular goals.
Each lesson was then designed with objectives that map onto these goals. Materials were cultivated from a variety of sources, both within and outside of the medical field—including the fields of education, social work, psychology; and from national organizations such as the National Museum of African American History and Culture, California Newsreel, Just Health Action, the National Equity Project, and more. This is a curriculum composed of both pre-existing and novel content. We were thrilled to draw from the many fabulous resources available.
Prior to starting the curriculum, and periodically throughout, learners with marginalized identities are encouraged to opt out if material is harmful or redundant, and we use intermittent affinity groups to create community. Learners without marginalized identities are encouraged to lean into discomfort, and given resources to support doing so such as their own affinity groups, additional learning, and modeling. Talking about racism and other forms of oppression is challenging. We sequenced some of the content to cumulatively build comfort and community prior tackling some of the most charged topics. A blend of active (eg, activities, discussion, written reflection, role play, etc.) and passive (eg lectures, videos, panels, etc.) were used as appropriate to the content and to maintain engagement.
In the development of this work, we made every attempt to: (1) center resources developed by and voices of people with marginalized identities; (2) create space for individuals within the institution who hold marginalized identities to be as involved and/or vocal as they wish to be; (3) not demand or expect those with marginalized identities to lead the work if that is not their wish. You will notice throughout the curriculum that there are many stories (audio, written, video, and visual arts) from individuals who hold marginalized identities AND have chosen to share these pieces of themselves publicly.
Each lesson was then designed with objectives that map onto these goals. Materials were cultivated from a variety of sources, both within and outside of the medical field—including the fields of education, social work, psychology; and from national organizations such as the National Museum of African American History and Culture, California Newsreel, Just Health Action, the National Equity Project, and more. This is a curriculum composed of both pre-existing and novel content. We were thrilled to draw from the many fabulous resources available.
Prior to starting the curriculum, and periodically throughout, learners with marginalized identities are encouraged to opt out if material is harmful or redundant, and we use intermittent affinity groups to create community. Learners without marginalized identities are encouraged to lean into discomfort, and given resources to support doing so such as their own affinity groups, additional learning, and modeling. Talking about racism and other forms of oppression is challenging. We sequenced some of the content to cumulatively build comfort and community prior tackling some of the most charged topics. A blend of active (eg, activities, discussion, written reflection, role play, etc.) and passive (eg lectures, videos, panels, etc.) were used as appropriate to the content and to maintain engagement.
In the development of this work, we made every attempt to: (1) center resources developed by and voices of people with marginalized identities; (2) create space for individuals within the institution who hold marginalized identities to be as involved and/or vocal as they wish to be; (3) not demand or expect those with marginalized identities to lead the work if that is not their wish. You will notice throughout the curriculum that there are many stories (audio, written, video, and visual arts) from individuals who hold marginalized identities AND have chosen to share these pieces of themselves publicly.
Piloting and Ongoing Refinement
Prior to launch with residents, all Pediatrics faculty were invited to participate in an intensive, rapid-paced pilot of the first year’s material, taking place for 2 hours per week over the course of three months. Fifteen faculty and one fellow (37.5% of whom identify as BIPOC) volunteered to participate and completed the course. Participants included leaders such as our program director, department chair, and both chief residents. These individuals provided feedback for ongoing curriculum refinement prior to use with residents, and many have subsequently participated as facilitators in delivery of the curriculum to the residents. Twelve of the participants also completed a post-then-retrospective-pre-test at the end of the curriculum, which provided additional information for refinement to ensure the curriculum was meeting desired objectives. Subsequently, since implementation in our own institution starting in 2020, we have collected formative feedback from participants. The materials have undergone iterative revision to include learner feedback, as well as to update content and ensure it remains current & engaging.
A note on identity and positionality from the curriculum leader
From Emily Ruedinger MD, MEd
I engage in this work as a white, cisgender, female, heterosexual, able-bodied, United States citizen. I was raised in a middle-class neighborhood by two college educated parents (including one with a PhD who spoke the language of academia). I have worked hard, but for the most part and aside from occasionally my gender, my identity and my background made things smoother and did not make things harder.
Near the end of residency, I was involved in the care of a patient who suffered a delayed diagnosis and mismanagement due to implicit biases based on her identity (race, age, weight status, country of origin) and cognitive biases (premature closure, anchoring). The realization that I could cause harm because of my biases was distressing. It stuck with me. I began to focus my academic work on bias, especially on educating myself and other physicians about the impact of bias on care and, more importantly, reducing this impact. During fellowship, this learning involved many workshops, self-directed reading, pursuit of a Master's Degree in Education, and mentored curriculum development in this area. After fellowship, I continued my academic work along this thread and was lucky to be part of a diverse group of faculty developing and delivering a course for medical students that encompassed many related topics: diversity, health equity, ethics, social determinants of health, professionalism (which is a pretty loaded word in and of itself), social justice, healthcare systems and more. I also had the opportunity to engage in deeper learning on the intersectionality of race, weight status, age, and class as director of our adolescent bariatric program. .
A turning point for me occurred when I took a course through the People’s Institute on Dismantling Racism a few years ago. A fellow class member, who was also white, asked “how do I talk to my family and colleagues about this stuff?” I will never forget the instructor’s response. She, a Black woman, responded quickly. “If you can’t talk to your own people about this, I can’t help you. I know how to talk to my people about racism." She continued, "It’s not my job to tell you how to talk to your people. Your people created this mess. It’s time for you to start fixing it yourselves. Me and my people have enough to do.” She wasn’t talking to me, but she may as well have been. I realized that I needed to stop waiting for someone else to lead me. Until that time, I had mostly been a supporting actor in social justice endeavors. It was time for me to be willing to take on the lead, especially in times when it would otherwise create an unwelcome tax on those with marginalized identities.
Very shortly after attending this workshop, I transitioned jobs. I joined the faculty at the University of Wisconsin in 2019 and became an Associate Program Director for our Pediatric Residency Program. Our program had a gap in resident education around social justice. After exploring who else was and wanted to be involved in this work, it became clear that it was time to leverage my influence, power, and talents to fill that gap. Each of us has a sphere of influence, holds certain types of power, and has talents. My sphere of influence is most obvious as in my role as an Associate Program Director; I also hold power in this role, as well as through being a physician in general; my talents are in education. So, with a good measure of internal discomfort and occasional external rebuke for being so focused on racism (nearly always from white people), I dug in. I am sure I have not done this perfectly. Although I have endeavored to elevate resources and voices of those with marginalized identities whenever possible, I cannot erase the perspective that my own identities confer onto my work. Indeed, I am sure that some of these topics skew toward "stuff white people need to learn about..."
Currently, most medical programs are predominantly white, ours included. This is something we would like to change. Without recruiting a workforce that better reflects our community, we will fail at achieving equitable health outcomes, we will have less creativity and innovation, and there will be less richness in our learning environment. As our program and others strive toward this goal, we can and must engage in this learning and action in a way that does not tax our faculty, staff and trainees with marginalized identities. It is unfair to assume that my colleagues who hold marginalized identities want to spend their time doing this work—there are lots of other things to be interested in and talented at, from cytokine research to quality improvement to electrophysiology and more. And, if someone who holds a more marginalized identity does want to do this, then it is my role to step back and support person.
Throughout the development and delivery of this course, I have tried to acknowledge that some of the content included will be painfully obvious to a subset of our learners, especially those with marginalized identities. Conversely, this content will be completely new to a fraction of folks. Most will be somewhere in the middle. Individuals with marginalized identities are invited to opt-out of any content that is redundant or harmful, and to spend time in affinity groups during the sessions. Those with more privileged identities are expected to remain present even when uncomfortable. These guidelines are self-enforced, no questions asked. It has not proven to be a problematic policy for us. Depending on the demographics at your own institution, you may find some content too basic or too advance; adjust accordingly. As we embark on the third year of this curriculum, I am already finding that I can go a little bit faster. I hope this curriculum someday becomes obsolete.
The timing around the launch of this curriculum warrants comment. After a year of development, we were ready to launch Education for CHANGE with our residents at the start of the 2020 academic year. This was the summer when COVID was gripping the world, the summer when George Floyd and Breonna Taylor were murdered by police. Marches, both peaceful and riotous, swept the nation. It was a summer of unrest. It was also when we switched to virtual everything, and I scrambled to translate the curriculum from an in-person to virtual format. But, the collective feeling of turmoil and urgency meant everyone was hungry for the content. My "bosses", including our Program Director and Department Chair, had (gratefully) embraced the work as soon as I started. But I cannot say if this work would have been as successful had we begun implementation a year or two earlier. As they say, timing is everything.
Finally, each institution is unique. A local needs assessment can help you determine what, if any, Education for CHANGE materials are the best fit for your institution. Factors to consider will include your local community, institutional resources & demographics, existing curricular components, and more.
I engage in this work as a white, cisgender, female, heterosexual, able-bodied, United States citizen. I was raised in a middle-class neighborhood by two college educated parents (including one with a PhD who spoke the language of academia). I have worked hard, but for the most part and aside from occasionally my gender, my identity and my background made things smoother and did not make things harder.
Near the end of residency, I was involved in the care of a patient who suffered a delayed diagnosis and mismanagement due to implicit biases based on her identity (race, age, weight status, country of origin) and cognitive biases (premature closure, anchoring). The realization that I could cause harm because of my biases was distressing. It stuck with me. I began to focus my academic work on bias, especially on educating myself and other physicians about the impact of bias on care and, more importantly, reducing this impact. During fellowship, this learning involved many workshops, self-directed reading, pursuit of a Master's Degree in Education, and mentored curriculum development in this area. After fellowship, I continued my academic work along this thread and was lucky to be part of a diverse group of faculty developing and delivering a course for medical students that encompassed many related topics: diversity, health equity, ethics, social determinants of health, professionalism (which is a pretty loaded word in and of itself), social justice, healthcare systems and more. I also had the opportunity to engage in deeper learning on the intersectionality of race, weight status, age, and class as director of our adolescent bariatric program. .
A turning point for me occurred when I took a course through the People’s Institute on Dismantling Racism a few years ago. A fellow class member, who was also white, asked “how do I talk to my family and colleagues about this stuff?” I will never forget the instructor’s response. She, a Black woman, responded quickly. “If you can’t talk to your own people about this, I can’t help you. I know how to talk to my people about racism." She continued, "It’s not my job to tell you how to talk to your people. Your people created this mess. It’s time for you to start fixing it yourselves. Me and my people have enough to do.” She wasn’t talking to me, but she may as well have been. I realized that I needed to stop waiting for someone else to lead me. Until that time, I had mostly been a supporting actor in social justice endeavors. It was time for me to be willing to take on the lead, especially in times when it would otherwise create an unwelcome tax on those with marginalized identities.
Very shortly after attending this workshop, I transitioned jobs. I joined the faculty at the University of Wisconsin in 2019 and became an Associate Program Director for our Pediatric Residency Program. Our program had a gap in resident education around social justice. After exploring who else was and wanted to be involved in this work, it became clear that it was time to leverage my influence, power, and talents to fill that gap. Each of us has a sphere of influence, holds certain types of power, and has talents. My sphere of influence is most obvious as in my role as an Associate Program Director; I also hold power in this role, as well as through being a physician in general; my talents are in education. So, with a good measure of internal discomfort and occasional external rebuke for being so focused on racism (nearly always from white people), I dug in. I am sure I have not done this perfectly. Although I have endeavored to elevate resources and voices of those with marginalized identities whenever possible, I cannot erase the perspective that my own identities confer onto my work. Indeed, I am sure that some of these topics skew toward "stuff white people need to learn about..."
Currently, most medical programs are predominantly white, ours included. This is something we would like to change. Without recruiting a workforce that better reflects our community, we will fail at achieving equitable health outcomes, we will have less creativity and innovation, and there will be less richness in our learning environment. As our program and others strive toward this goal, we can and must engage in this learning and action in a way that does not tax our faculty, staff and trainees with marginalized identities. It is unfair to assume that my colleagues who hold marginalized identities want to spend their time doing this work—there are lots of other things to be interested in and talented at, from cytokine research to quality improvement to electrophysiology and more. And, if someone who holds a more marginalized identity does want to do this, then it is my role to step back and support person.
Throughout the development and delivery of this course, I have tried to acknowledge that some of the content included will be painfully obvious to a subset of our learners, especially those with marginalized identities. Conversely, this content will be completely new to a fraction of folks. Most will be somewhere in the middle. Individuals with marginalized identities are invited to opt-out of any content that is redundant or harmful, and to spend time in affinity groups during the sessions. Those with more privileged identities are expected to remain present even when uncomfortable. These guidelines are self-enforced, no questions asked. It has not proven to be a problematic policy for us. Depending on the demographics at your own institution, you may find some content too basic or too advance; adjust accordingly. As we embark on the third year of this curriculum, I am already finding that I can go a little bit faster. I hope this curriculum someday becomes obsolete.
The timing around the launch of this curriculum warrants comment. After a year of development, we were ready to launch Education for CHANGE with our residents at the start of the 2020 academic year. This was the summer when COVID was gripping the world, the summer when George Floyd and Breonna Taylor were murdered by police. Marches, both peaceful and riotous, swept the nation. It was a summer of unrest. It was also when we switched to virtual everything, and I scrambled to translate the curriculum from an in-person to virtual format. But, the collective feeling of turmoil and urgency meant everyone was hungry for the content. My "bosses", including our Program Director and Department Chair, had (gratefully) embraced the work as soon as I started. But I cannot say if this work would have been as successful had we begun implementation a year or two earlier. As they say, timing is everything.
Finally, each institution is unique. A local needs assessment can help you determine what, if any, Education for CHANGE materials are the best fit for your institution. Factors to consider will include your local community, institutional resources & demographics, existing curricular components, and more.
Bibliography
Please see the bibliography for a list of resources included in this curriculum.
WHY YOUR INSTITUTION SHOULD INCORPORATE EDUCATION FOR CHANGE
tHE PROBLEM
Racism- defined as a “system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call ‘race’) that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources.”(1, 2) - is now recognized as a critical social determinant of health. (1,3,4) Other forms of oppression, meaning the “interlocking forces that create and sustain injustice,” (5) include forces such as sexism, ableism, heterosexism, xenophobia, weight bias, and gender normativity, among others. Social justice “refers to reconstructing society in accordance with principles of equity, recognition and inclusion… [and] involves eliminating injustice created when differences are sorted and ranked in a hierarchy that unequally confers power, social, and economic advantages, and institutional and cultural validity to social groups based on their location in that hierarchy.”(5) Achieving social justice is crucial to achieving health equity, and requires disruption to many of our society’s current systems—including healthcare.
Oppressed and marginalized groups experience higher rates of illness and death across a wide range of health conditions, including diabetes, hypertension, obesity, asthma, heart disease, and suicide, among others.(6,7) Race is a social construct, not a biological one. Yet, studies have shown that approximately half of white medical trainees believe false myths such as that Black people have thicker skin, have less sensitive nerve endings, have greater muscle mass, and a higher GFR than white people.(7,8) Building critical consciousness among physicians, including socio-political awareness, cognizance of power dynamics, deeper historical knowledge, recognition of race as a social construct and understanding how racism and other forms of oppression serve as social determinants of health are necessary to dismantling racism and other forms of oppression in the healthcare system.(4)
Physicians are, by virtue of our jobs, compelled to improve the health of our patients. And, we are well positioned to do so at both the individual and systems level. Doctors hold leadership positions within healthcare teams and institutions; are often viewed as leaders within their communities; have unique access to resources (research, time, personnel, funding and more); can influence policy through stories, data, and position; and perhaps most importantly, we are essential, principal elements of the healthcare system. We have the power to perpetuate the current system, or to disrupt it and re-build for the better. Physicians need the knowledge, skills and attitudes to serve as drivers of change.
Oppressed and marginalized groups experience higher rates of illness and death across a wide range of health conditions, including diabetes, hypertension, obesity, asthma, heart disease, and suicide, among others.(6,7) Race is a social construct, not a biological one. Yet, studies have shown that approximately half of white medical trainees believe false myths such as that Black people have thicker skin, have less sensitive nerve endings, have greater muscle mass, and a higher GFR than white people.(7,8) Building critical consciousness among physicians, including socio-political awareness, cognizance of power dynamics, deeper historical knowledge, recognition of race as a social construct and understanding how racism and other forms of oppression serve as social determinants of health are necessary to dismantling racism and other forms of oppression in the healthcare system.(4)
Physicians are, by virtue of our jobs, compelled to improve the health of our patients. And, we are well positioned to do so at both the individual and systems level. Doctors hold leadership positions within healthcare teams and institutions; are often viewed as leaders within their communities; have unique access to resources (research, time, personnel, funding and more); can influence policy through stories, data, and position; and perhaps most importantly, we are essential, principal elements of the healthcare system. We have the power to perpetuate the current system, or to disrupt it and re-build for the better. Physicians need the knowledge, skills and attitudes to serve as drivers of change.
- Trent M, Dooley DG, Dougé J. The Impact of Racism on Child and Adolescent Health. Pediatrics. 2019;144(2).
- Jones CP, Truman BI, Elam-Evans LD, et al. Using "socially assigned race" to probe white advantages in health status. Ethn Dis. 2008;18(4):496-504.
- Svetaz M, Chulani V, West K, et al. Racism and Its Harmful Effects on Nondominant Racial–Ethnic Youth and Youth-Serving Providers: A Call to Action for Organizational Change. Journal of Adolescent Health. 2018;63(2):257-261.
- Paradies Y, Ben J, Denson N, et al. Racism as a determinant of health: A systematic review and meta-analysis. PLoS One. 2015;10(9):e0138511.
- Bell L. Theoretical foundations for social justice education. In: Adams M, LA B, Goodman D, KY J, eds. Teaching for Diversity and Social Justice. 3rd ed. New York, NY: Routledge; 2016:5.
- McLaughlin KA, Hatzenbuehler ML, Keyes KM. Responses to discrimination and psychiatric disorders among black, Hispanic, female, and lesbian, gay, and bisexual individuals. Am J Public Health. 2010;100(8):1477-84.
- Racism is a Serious Threat to the Public’s Health. CDC. Accessed February 22nd, 2022. https://www.cdc.gov/healthequity/racism-disparities/index.html.
- How we Fail Black Patients in Pain. AAMC. Accessed February 22nd, 2022. https://www.aamc.org/news-insights/how-we-fail-black-patients-pain
(part of) the solution
After participating in Education for CHANGE, residents reported a statistically significant increase in the following arenas:
- Confidence in their ability to...
- examine their own worldview, biases, and prejudicial attitudes after witnessing or hearing about social justice
- talk to others about social injustices and the impact of social conditions on health and well-being
- raise others' awareness around systems of oppression, power, privilege and marginalization
- challenge or address institutional policies.
- identify and intervene when they witness a microaggression, and navigate microaggressions as a recipient
- lead or join colleagues in an effort to address social justice issues relevant to their role as a pediatrician
- Sense of personal responsibility to...
- try to change larger social conditions that impede well-being
- promote fair and equitable allocation of bargaining powers, resources, and obligations in society
- Intention to engage in social justice activities
HOW TO INCORPORATE EDUCATION FOR CHANGE AT YOUR INSTITUTION
faq
How long is each session?
Education for CHANGE sessions are designed to take about 50-60 minutes.*
What is the difference between a topic and a session?
Some topics contain multiple sessions. For example, the “History” section is broken down into six, one-hour sessions.
Can we combine or adapt sessions?
Sessions can easily be combined or adapted to fit your institution’s needs and your program’s educational structure. We'd love to hear about the creative ways you modify Education for CHANGE!
Do we need to use all of the topics? Or all of the sessions within a topic?
You can pick and choose topics, or even sessions within a topic, to fill the educational gaps in your home institution. You do not need to complete the curriculum in its entirety. Simply omit sessions that are redundant to content that is already being delivered, or determined to be unnecessary based on a local needs assessment! A couple of caveats:
Will more content be added? Will this content be updated?
Yes, we will add and update content periodically to keep this current and relevant.
Education for CHANGE sessions are designed to take about 50-60 minutes.*
What is the difference between a topic and a session?
Some topics contain multiple sessions. For example, the “History” section is broken down into six, one-hour sessions.
Can we combine or adapt sessions?
Sessions can easily be combined or adapted to fit your institution’s needs and your program’s educational structure. We'd love to hear about the creative ways you modify Education for CHANGE!
Do we need to use all of the topics? Or all of the sessions within a topic?
You can pick and choose topics, or even sessions within a topic, to fill the educational gaps in your home institution. You do not need to complete the curriculum in its entirety. Simply omit sessions that are redundant to content that is already being delivered, or determined to be unnecessary based on a local needs assessment! A couple of caveats:
- An initial session on institutional policies, community agreements, opting in/out, and other introductory topics promotes an atmosphere of growth and safety. If you do not use our session, we strongly urge you to do something similar.
- Our effectiveness data looked at the curriculum as a whole rather than individual sessions
- Some topics are best presented in sequence. For example, it is difficult to deeply examine power, oppression and intersectionality without first examining one’s own identity. Similarly, a foundational knowledge of the historical foundations of race is necessary to inform discussions around systems of power. While you do not have to use all Education for CHANGE sessions, we urge you to consider what educational scaffolding your learners need before delving into some of the more difficult content.
Will more content be added? Will this content be updated?
Yes, we will add and update content periodically to keep this current and relevant.
how we incorporated this content into the University of wisconsin pediatric residency program
We have successfully implemented the curriculum in a number of ways at our own institution. A group of fifteen faculty in our Department piloted the full curriculum by doing two, one-hour sessions each week for three months. In its initial year of delivery to the residents, we presented the entire curriculum using a combination of morning report (1 hour) and block education (3 hour) sessions.
We have now settled into a combination of sequential sessions (one class at a time) and 3-year-cycle rotating curriculum (for all residents together).
We have now settled into a combination of sequential sessions (one class at a time) and 3-year-cycle rotating curriculum (for all residents together).
- Intern only sessions: Our program’s educational structure includes once-weekly intern-only morning report, and we have devoted fifteen of these throughout the year to Education for CHANGE content.
- We also have weekly 3-hour block education sessions (in lieu of noon conference) for all residents. Two of these annually are devoted to Education for CHANGE. We have six total Education for CHANGE sessions that are delivered during this time. Thus, each resident receives each session once during their 3-year residency, albeit in a different order depending on where they ‘enter’ the cycle.
- Senior only session: Finally, our PGY-3 residents have a session on social justice into their future careers, which is incorporated into a PGY-3 professional development retreat.
| full_curriculum_cycle.docx |
* A handful of the sessions are designed for a 3-hour format, but could easily be broken into hour-long segments (options to “break” in the session are noted in the lesson plan).
www.uweducationforchange.com was officially launched on July 22nd, 2022.
Website last Updated: July 27nd, 2022