How medical school curricula perpetuate inequality

In Curricular Injustice: How U.S. Medical Schools Reproduce Inequalities, I describe how the medical profession, in its attempt to integrate the humanities and social sciences to develop humane and equitable future physicians, often failed to do so. Clinical faculty members, in their capacity as curricular designers and implementers, were at the heart of these failures. Their limited understandings of the critical and reflective contributions of these fields patterned their delivery of the material. Failure happened at each step in the process of knowledge application, which in this case was their process of transforming the potential of the humanities and social sciences into actual curricular practices in medical school classrooms.

From decisions about placement within the overall curriculum to choices about what substantive content to include and exclude from these fields of knowledge, clinical faculty members’ good intentions were rarely realized. Instead, medical students received lessons about how the social sciences and humanities could be relevant for clinical practice—but in ways that continued to implicate the medical profession in the creation and maintenance of social inequalities. Thus, this book matters for our understanding of how medical educators make decisions that continue to uphold the white, elite status quo of their profession while dismissing, marginalizing, or problematizing the people and ideas that deviate from it. And the stakes are high, with humane and equitable care on the line.

In this excerpt from chapter 4, readers will be brought into the classroom—with clinical faculty at the helm of instruction. In chapter 4, I draw attention to the problems that occurred with instruction, which emanated from the clinical faculty members’ limited expertise with the social sciences and humanities. These were not neutral problems but rather curricular injustices—the clinical faculty engaged in curricular practices that were inaccurate, placating, and unequal.

Given the decisions made by the curricular designers at each medical school, much of the context for curricular injustice was set before students encountered the content in the classroom. To introduce the forms of failure that occurred in the context of everyday instruction, I will introduce Sam, a white female medical student. During our discussion, Sam recounted this “awkward” memory of a clinical faculty member trying to facilitate a conversation in their practice of medicine (POM) small group. Sam told me that the white male clinical faculty member started the lesson by describing a hypothetical clinical case: “OK, you have a patient who needs to lose weight with diabetes or whatever and you want to go over different foods that they can eat … He goes, ‘[W ]ell you can’t just tell them to cut out carbs because they’re eating, like, fajita bread and this is their normal diet … so you have to work with them.'” As she was telling the story, Sam kept pausing to double-down on the awkwardness of this pedagogical scene. She noted how the clinical faculty member’s inability to utilize the appropriate term of “tortilla” and instead using “fajita bread” underscored the poor delivery and cultural stereotyping. Sam went on to recount another example from this educator’s facilitation: “I remember that as one example of the Hispanic population, we watched a video and a lady’s crying because she can’t get enchiladas. You feel awkward for watching.” This awkward moment was the only time Sam could remember learning about the Liaison Committee on Medical Education (LCME) Standard 7 on social sciences.

With regard to the humanities, Gyi, a South Asian male medical student, took a “Literature in Medicine” elective at his school because he wanted to engage with the humanities. When I asked what kinds of books he read, he demurred, saying that the way his clinical faculty member led the course, it was “essentially group therapy.” Clinical faculty members and students alike often offered accounts of how humanities operated in the classroom—as tools or spaces that allowed medical students and faculty to relax and enjoy one another’s company; play with something fun; and contemplate how the book, art, or music made them feel. The humanities, when implemented by clinical faculty members, were transformed into a “social, a nice stress relief kind of thing.” They were therapeutic curricular practices rather than critical ones.

These examples from Sam’s and Gyi’s experiences with their required and elective courses are revealing in a couple of ways. First, and per- haps most vividly, in using the passive language of “awkward”—rather than calling the clinical faculty member’s example what it was, which was racist—Sam was showing the fruits of her facilitator’s educational labor. She did not have the language for or awareness around racism. Gyi also did not have a takeaway from the humanities elective beyond it being therapeutic. While student reception will be the focus of chapter 5, the second point this example from Sam in particular elicits is the broader issue with (mostly white, mostly clinical) medical educators in the classroom: they lack expertise. As Sam’s clinical faculty member’s use of the term “fajita bread” demonstrates, clinical faculty members’ limited understandings produce curricular practices that diverge from the curricular dreams of critical and reflexive doctoring. Not only do they fail to address the LCME standards and the equity problems undergirding them, but they do so in ways that reify social inequalities.

While clinical faculty members lacked social scientific and humanistic expertise, they had an abundance of clinical expertise, which patterned their approach to enacting curricular practices in the classroom. Via their clinical witnessing, clinical faculty members valued patient cases and lived experience rather than systematically researched bodies of knowledge, thus affecting how the social sciences were taught in the classroom. And by centering their own experiences with the difficulties of their clinical work, clinical faculty members viewed the humanities as tools to help them cope with their jobs. In both cases—social sciences and humanities—clinical experience served as a proxy for social sciences and humanities expertise. And in both cases, there were significant consequences for how curricular practices were enacted in the classroom: as I will show, the central curricular injustices occurring with in-classroom instruction were curricular practices that were inaccurate, placating, and inequitable.

Lauren D. Olsen is a medical sociologist and author of Curricular Injustice: How U.S. Medical Schools Reproduce Inequality.