Paper Contribution D
Diversity Considerations in Health Professions Education
Jeffrey F. Milem, Eric L. Dey, and Casey B. White,
“Effective participation by members of all racial and ethnic groups in the civic life of our Nation is essential if the dream of one Nation, indivisible, is to be realized.”
—Justice O’Connor in Grutter v. Bollinger
The recent decisions by the U.S. Supreme Court in two cases that challenged the use of affirmative action in undergraduate admissions and in law school admissions at the University of Michigan helped to provide some clarity to an ongoing debate regarding the educational value of diversity, and specifically, racial and ethnic diversity, on our nation’s college campuses. In the opinion that upheld the constitutionality of the admissions process used for selecting law school students at Michigan, Justice O’Connor wrote that a majority of the court agreed that diversity served a compelling interest for institutions of higher education as well as for our society. The University of Michigan successfully demonstrated to the Court that diversity was essential in helping it to achieve its education mission because more diverse colleges and universities provide opportunities for teaching and learning that are not available in institutions that are less diverse. The university was able to make this case, in large part, because of the array of empirical evidence that it and other organizations provided that established how diversity enhanced the learning outcomes for students at Michigan and at colleges and universities across the country.
The primary goal of this paper is to examine the ways in which existing evidence about diversity in higher education and its effects on students, institutions, and society can be used to inform and improve the quality of education received by students in health professions. Published reviews of the literature on undergraduate college students clearly demonstrate that
various aspects of racial and ethnic diversity within higher education help promote benefits of assorted kinds (Milem, 2003; Hurtado et al., 2003; Milem and Hakuta, 2000; Gurin, 1999, Appendix A). These reviews indicate that diversity-related benefits are far ranging, spanning from benefits to individual students and the institutions in which they enroll, to private enterprise, the economy, and the broader society.
The benefits that accrue to individuals through enhancements to their educational experiences and educational outcomes (including process outcomes that help influence subsequent outcomes of these students; see Milem, 2003; Astin, 1991) are perhaps the most commonly recognized; diversity has been shown to enhance the ability of colleges and universities to achieve their missions—particularly as they relate to the missions of teaching, research, and service. Economic and private-sector benefits are reflected in the ways in which diversity enhances the economy and the functioning of organizations and businesses in the private sector. Societal benefits differ in that they transcend the boundaries of individual organizations and are related to the achievement of democratic ideals, the development of an educated and involved citizenry, and the ways in which underserved groups (e.g., low-income, elderly, those who lack insufficient health care) are able to receive the services they require. Recent original research efforts reinforce this viewpoint in higher education generally (Bowen and Bok, 1998), and specifically in medical education (Whitla et al., 2003).
It is important to note that research on the benefits of diversity indicates that these benefits do not automatically accrue to students who attend institutions that are, in terms of student or faculty composition, racially and ethnically diverse. Rather, if the benefits of diversity in higher education are to be realized, close attention must be paid to the institutional context in which that diversity is enacted. In other words, it is not enough to simply bring together a diverse group of students. Although this is an important first step in creating opportunities for students to learn from diversity, it cannot be the only step that is taken. Diverse learning environments provide unique challenges and opportunities that must be considered if we are to maximize the learning opportunities that they present.
If we are to change educational environments in ways that allow us to maximize the opportunities and minimize the challenges that are presented by diversity, we must first understand the conditions under which students are able to learn from diversity. In the pages that follow, we summarize the literature that does this. To begin, we review the literature drawn from studies of higher education generally, followed by a focused consideration of issues related specifically to health professions education (with an emphasis on medical education). To begin our discussion of higher education generally, we summarize and extend the key components of a framework for understanding campus diversity issues first developed by Hurtado and
colleagues (1998, 1999). This provides a useful frame for understanding the different dimensions of campus diversity and their importance. Having provided some conceptual definitions of diversity, we turn to research linking diversity and learning, emphasizing in turn cognitive and emotional development issues, contextual issues and learning environments, and pedagogy.
The focused discussion of health professions issues follows a similar logic, beginning with a consideration of the importance of diversity in these fields and unique characteristics of these fields of study (including goals, standards, and curricular structure). The status of current curricular approaches that support diversity-related education is discussed as are problems and issues with current approaches. An extension of cognitive and emotional development concerns related to health professions education is presented, followed by a discussion of how educational settings and learning environments can influence learning related to diversity issues, as well as pedagogy that can promote transformative learning. These two strands of work—higher education generally, and health professions specifically—are brought together in a set of recommendations intended to guide the transformation of education in the health professions so that students in these fields realize the educational benefits of diversity, and so that all members of our society will be better served by the professionals who provide them with health care.
In considering how we maximize the benefits of diverse learning environments, it is important to define precisely what we mean by diversity. Although other dimensions exist, for the purpose of this paper we will focus on diversity with respect to race and ethnicity. Recent work by Hurtado and colleagues (1998, 1999) provides a useful framework for conceptualizing and understanding the impact of various dimensions of the campus racial climate and documents the importance of an institution’s context in shaping student outcomes. This framework was first introduced in a study of the climate for Latino students (Hurtado, 1994) and further developed in syntheses of research done for policy makers and practitioners (Hurtado et al., 1998, 1999).
The campus climate described by Hurtado and colleagues differs from earlier research that defined the climate as reflecting common participant attitudes, perceptions, or observations about the environment (Peterson and Spencer, 1990). These common attitudes and perceptions are identified as malleable and distinguishable from the stable norms and beliefs that may constitute an organizational culture. Although this work has been important in distinguishing the climate from the culture of an organization, it is
most important in establishing that the climate is malleable and that the current patterns of beliefs and behaviors are amenable to planned efforts to change or improve the climate. The framework discussed by Hurtado et al. (1998, 1999) builds on this earlier work by expanding our thinking about climate by asserting that the psychological climate (perceptions and attitudes) is linked to a range of social phenomenon that have to do with structure, history, and actual interactions across diverse communities within the environment. Central to their conceptualization of a campus climate for diversity is the notion that students are educated in distinct racial contexts. Both external and internal (institutional) forces shape these contexts in higher education.
The external components of climate represent the impact of governmental policy, programs, and initiatives as well as the impact of sociohistorical forces on campus racial climate. The authors indicate that governmental contextual factors that influence the climate for diversity on college campuses include financial aid policies and programs, state and federal policy regarding affirmative action, court decisions related to the desegregation of higher education, and the manner in which states provide for institutional differentiation within their state system of higher education. Hurtado et al. (1998, 1999) describe sociohistoric forces that influence the climate for diversity on campus as events or issues in the larger society that are connected to the ways in which people view racial diversity in society. One recent example of this is the impact that the ongoing debate over affirmative action in college admissions had on the climate for diversity at colleges and universities across the country. Although these forces are usually initiated outside of the context of the institution, they frequently serve as a stimulus for discussion or other activity within the campus context. Because “[n]o policy can be isolated from the social arena in which it is enacted” (Tierney, 1997, p. 177), it is important to note that these two forces mutually influence each other.
The institutional context contains multiple dimensions that are a function of educational programs and practices. These include an institution’s historical legacy of inclusion or exclusion of various racial/ethnic groups; its compositional diversity1 in terms of the numerical and proportional
representation of various racial/ethnic groups; the psychological climate, which includes perceptions and attitudes between and among groups; as well as a behavioral climate dimension that is characterized by the nature of intergroup relations on campus. Hurtado et al. (1998, 1999) conceptualize the institutional climate as a product of these dimensions. These dimensions are not discrete; rather, they are connected with each other. For example, a historical vestige of segregation has an impact on an institution’s ability to improve its racial/ethnic student enrollments, and the underrepresentation of specific groups contributes to stereotypical attitudes among individuals within the learning and work environment that affect the psychological and behavioral climate. While some institutions take a “multilayered” approach toward assessing diversity on their campuses and are developing programs to address the climate on campus, most institutions fail to recognize the importance of the dynamics of these interrelated elements of the climate.
Historical Legacy of Inclusion or Exclusion
Hurtado et al. (1998, 1999) argue that the historical vestiges of segregated schools and colleges continue to affect the climate for racial/ethnic diversity on college campuses. Evidence can be seen in resistance to desegregation in communities and specific campus settings, maintenance of old campus policies at predominantly white institutions (PWIs) that best serve a homogeneous population, and attitudes and behaviors that prevent interaction across race and ethnicity. Duster (1993) argued that many campuses sustain benefits for particular student groups that go largely unrecognized because these institutions are embedded in a culture of a historically segregated environment. While some campuses have a history of admitting and graduating students of color since their founding (i.e., historically black colleges and universities), most PWIs have a history of limited access and exclusion (Thelin, 1985). These institutions have a longer history of segregation and exclusion than they do of inclusion. An institution’s historical legacy of exclusion has a significant impact on the prevailing climate that influences current policies and practices at the institution (Hurtado, 1992; Hurtado et al., 1998, 1999).
Institutions that are clear about their history of exclusion and the detrimental impact that this history has had may be able to gain broader support for their efforts to become more diverse through the use of affirmative action and other programs and services designed to improve the climate for diversity. Furthermore, institutions that acknowledge a history of exclusion may be able to demonstrate to people of color that the institution is willing to acknowledge its past transgressions and is working to rid itself of its exclusionary past.
Increasing the compositional diversity of an institution is an important initial step toward improving the climate (Hurtado et al., 1998, 1999). The distribution of students in a particular environment shapes the dynamics of social interaction in that environment (Kanter, 1977). For example, Chang (1999) has shown that the likelihood that students will engage with students who are different from them increases as the compositional diversity of the campus increases. Conversely, campuses with high proportions of white students provide limited opportunities for interaction across race/ ethnicity and limit student learning experiences with socially, culturally diverse groups (Hurtado et al., 1994).
Moreover, in environments that lack diverse populations, underrepresented groups are frequently viewed as tokens. Tokenism contributes to the heightened visibility of the underrepresented group, overstatement of group differences, and the alteration of images to fit existing stereotypes (Kanter, 1977). In addition, the fact that racial and ethnic students remain minorities in majority white environments contributes to social stigma that can adversely affect their achievement (e.g., see Steele, 1992, 1997, 1998; Steele and Aronson, 1995) and can produce minority status stressors (Prillerman et al., 1989; Smedley et al., 1993). Finally, an institution’s stance on increasing the representation of diverse racial/ethnic groups communicates to external and internal constituencies the importance of maintaining a multicultural environment (Hurtado et al., 1998, 1999).
Institutional leaders should not expect that they will substantially improve the campus racial climate merely by increasing the compositional diversity of their institution. As stated earlier, problems may arise if efforts are not made to address and improve other dimensions of the campus climate. However, if increased compositional diversity is accompanied by institutional efforts to become more “student centered” in approaches to teaching and learning (Hurtado, 1992; Hurtado et al., 1998, 1999), and if regular and ongoing opportunities for students to come together to communicate and interact cross-racially are provided (Chang, 1999), increased compositional diversity is likely to be beneficial. Increasing compositional diversity is an important first step in improving the campus climate.
The Psychological Climate
The psychological dimension of the campus climate includes individuals’ views of group relations and institutional responses to diversity, perceptions of discrimination or racial conflict, and attitudes held toward individuals from different racial/ethnic backgrounds. Increasingly, studies have shown that racially and ethnically diverse administrators, students, and
faculty are likely to view the campus climate differently. Thus, an individual’s position and power within the organization as well as her/his view as “insider” or “outsider” are likely to contribute to different views or standpoints (Collins, 1986). Hurtado et al. (1998, 1999) summarized this phenomenon by asserting that who you are and where you are positioned in an institution affects the way in which you experience and view the institution. These differences in perception of the college experience are significant because perception is both a product of the environment and a potential determinant of future interactions and outcomes (Astin, 1968; Berger and Milem, 1999; Milem and Berger, 1997; Tierney, 1987).
Research on the impact of peer groups and other reference groups is helpful in understanding another important aspect of the psychological dimension of climate on campus. Peer groups exert influence over the attitudes and the behavior of students through the norms that they communicate to their members. While faculty play an important role in the educational development of students, most researchers believe that student peer groups are principally responsible for much of the socialization that transpires (Astin, 1993; Chickering, 1969; Dey, 1996, 1997; Feldman and Newcomb, 1969; Milem, 1998). This is not meant to diminish the role that faculty play; rather, it suggests that the normative influence of faculty is likely to be amplified or attenuated by the interactions students have with their peers. Recent research on diverse friendship groups suggests that such dynamics are especially strong in areas where students are in the process of transforming their attitudes related to issues of race and ethnicity as well as those of their peers (Antonio, 2001).
The Behavioral Climate
The behavioral dimension of the institutional climate consists of general social interaction, interaction between and among individuals from different racial/ethnic backgrounds, as well as the nature of intergroup relations on campus. The prevailing view, particularly in reports forwarded by the popular media, is that campus race relations are poor and that segregation has increased on college campuses among minority groups. However, several research studies present a different picture of students’ actual interactions and relations on campus. For example, while in one study, white students interpreted ethnic group clustering as racial segregation, students of color described this behavior as their attempt to find sources of cultural support within an unsupportive environment (Loo and Rolison, 1986). Another study that examined the nature of cross-racial interaction among college students found that Mexican American, Asian American, and African American students reported widespread and frequent interaction across race/ethnicity in various informal situations (i.e.,
dining, roommates, dating, socializing), while white students were least likely to report engaging in these activities across race (Hurtado et al., 1994). Moreover, it is clear that the absence of interracial contact influences students’ views toward others, their support for important campus initiatives, and key educational outcomes (Hurtado et al., 1998, 1999).
However, students who have the opportunity to engage diverse peers in regular and ongoing structured interaction are more likely to show greater growth on a number of critical educational outcomes. The findings from research on the impact of campus initiatives that bring students from diverse groups together to engage in structured intergroup dialogues indicate that students who participate in these activities are more likely to report growth in their affinity for others. In addition, they are more likely to report enhanced enjoyment in learning about their own background as well as the backgrounds of diverse others. Moreover, these students are likely to report more positive views of conflict and to hold the perception that diversity does not need to be divisive in our society. Gurin (1999) argues that these are essential skills required of all citizens in an increasingly diverse democracy.
An important aspect of the behavioral climate involves the extent to which students have the opportunity to engage diverse others as well as diverse information and diverse ideas in their classes. These opportunities are enhanced in classrooms where faculty members use active teaching methods. In these classrooms, students are able to interact with peers from diverse backgrounds through class discussions, collaborative learning methods, and group projects. These activities contribute to a campus climate that is more supportive of diversity and leads to positive outcomes for the students involved (see, for example, Astin, 1993; Gurin, 1999; Hurtado et al., 1998, 1999; Milem, 2003; Milem and Hakuta, 2000; Smith & Associates, 1997). Clearly, there are some disciplines in which it is much easier for students to engage diverse information through course content (e.g., fields such as education, English, humanities, history, political science, psychology, sociology). However, when faculty are conscientious about incorporating active pedagogical methods into the courses they teach, students have frequent opportunities to learn from diverse peers—even in fields that do not appear to readily lend themselves to the incorporation of diverse content and subject matter (e.g., the physical sciences). As we will discuss later in this manuscript, the use of active learning or student-centered pedagogical methods in classes enhances a variety of important learning outcomes for students, including mastery of content in particular disciplines. However, the opportunities that students have to learn from diverse peers in classes that use these active learning methods, even in classes where the content does not deal explicitly with diversity issues, can help students to build bridges across communities of difference.
The Consequences of Diversity Climate
Within the context of an institution’s diversity climate, the effects of diversity play themselves out along a variety of dimensions. The works of Gurin (1999), Chang (1999), Milem (2003), and Milem and Hakuta (2000) argue that, in addition to compositional diversity, there are two additional types of diversity that can have an impact on important educational outcomes. Diversity of interactions is a second type shown to be influential in creating educational benefits and is represented by students’ exchanges with racially and ethnically diverse people and diverse ideas, information, and experiences. People are influenced by their interactions with diverse ideas and information as well as with diverse people. The final type of diversity is characterized by different diversity-related initiatives (i.e., core diversity course requirements, ethnic studies course/programs, diversity enhancement workshops, intergroup dialogue programs, and others) that occur on college and university campuses. While shifts or changes in the compositional diversity of campuses often provide stimulus for the creation and implementation of diversity-related initiatives (Chang, 1999), increasingly more colleges and universities are implementing these initiatives even though their campuses are quite racially and ethnically homogeneous.
These types of diversity are not discrete. We are most frequently exposed to diverse information and ideas through the interactions that we have with diverse people. Moreover, while diversity-related initiatives benefit students who are exposed to them—even on campuses that are almost exclusively white—their impact on students is much more powerful on campuses that have greater compositional diversity (Chang, 1999, 2002). Although each type of diversity has the potential to confer significant positive effects on educational outcomes, the impact of each type of diversity is enhanced by the presence of the others (Chang, 1999, 2002; Gurin, 1999; Gurin et al., 2002; Hurtado et al., 1998, 1999; Hurtado et al., 2003; Milem, 2003; Milem and Hakuta, 2000). Conversely, the impact of each type of diversity is diminished in environments where the other types are absent.
Chang’s work (1999, 2002) is very helpful in illustrating the three types of diversity we have discussed and the impact they have on students. Chang (1999) found that maximizing cross-racial interaction and encouraging ongoing discussions about race were educational practices that produced positive educational outcomes for students. The findings from Chang’s study revealed that socializing across race and discussing racial/ethnic issues had a positive effect on the likelihood that students would stay enrolled in college, be more satisfied with their college experience, and report higher levels of intellectual and social self-concept (Chang, 1999). However, Chang found that when the effects of higher levels of compositional
diversity were considered without involvement in activities that provided students with opportunities to interact in meaningful ways cross-racially, students of color were likely to report less overall satisfaction with their college experience (Chang, 1999). In other words, increasing only the compositional diversity of an institution without considering the influence that these changes will have on other dimensions of the campus racial climate is likely to produce problems for students at these institutions. This finding is consistent with scholarship on race relations, which indicates that as organizations become more racially diverse, the likelihood of conflict increases (Blalock, 1967).
Chang’s work also shows that students who attended more compositionally diverse institutions had more frequent opportunities to engage students from different racial/ethnic backgrounds. In other words, as compositional diversity increases, so does the likelihood that students will engage with students who are different from them. This work establishes that compositional diversity (represented by the enrollment of students of color at an institution) is an essential ingredient in providing opportunities for this interaction to occur.
LINKING DIVERSITY AND LEARNING
It is important to have a framework that helps us to understand the ways in which diversity can be connected to student learning. The most current and relevant framework for understanding the link between diversity and learning can be found in the material developed and tested as part of the Michigan legal cases (Gurin, 1999; Gurin et al., 2002, 2003) and is drawn largely from social psychological theories and research.
As part of the Michigan legal cases, Gurin (1999) argued persuasively that higher education institutions are uniquely positioned to enhance the cognitive and psychosocial development of students. Building on previous research and conceptual frameworks, she argued that students are at a critical stage in their human growth and development in which diversity, broadly defined, can facilitate greater awareness of the learning process, better critical thinking skills, and better preparation for the complex challenges they face as involved citizens in a democratic, multiracial society.
Conceptions of Development
Erikson’s work (1946, 1956, cited in Gurin, 1999) regarding psychosocial development indicated that individuals’ social and personal identity is formed during late adolescence and early adulthood—the time when many students attend college and graduate/professional school. Institutions of higher education can facilitate the development of individual identity. For
example, among the conditions in college that facilitate the development of identity is the opportunity to be exposed to people, experiences, and ideas that differ from one’s past milieu (Gurin, 1999). Moreover, as mentioned earlier, the learning environment in higher education is likely to accentuate the normative influence of peer groups. Diversity and complexity in the college environment “encourage intellectual experimentation and recognition of varied future possibilities” (Gurin, 1999, p. 103). These conditions are critical to the successful development of identity.
Gurin (1999) used the work of Piaget (1971, 1975/1985) as a conceptual and theoretical rationale for how diversity facilitates students’ cognitive development. Piaget argued that cognitive growth is facilitated by disequilibrium, or periods of incongruity and dissonance. For adolescents to develop the ability to understand and appreciate the perspectives and feelings of others, they must interact with diverse individuals in roughly equal status situations. These conditions foster a process of “perspective taking” and allow students to progress in intellectual and moral development. For “perspective taking” to occur, both diversity and equality must be present in the learning environment (Gurin, 1999).
While Piaget’s work was done primarily with children and adolescents, the applicability of this work to the development processes of college-age students was well documented in the work of William Perry. Perry’s (1970) work with college students laid a foundation for understanding development that occurs in the college environment. At Harvard, over a 15-year period in the 1950s and 1960s, Perry and his colleagues conducted a series of interviews with a population of men at the end of each year of college. From these interviews Perry and his team constructed a schema of cognitive and personal development involving a progression from viewing knowledge as right or wrong (dualism), to beginning to understand a dimension of uncertainty related to knowledge (multiplicity), to accepting knowledge as contingent and contextual (relativism; i.e., not only are there alternate views, but some may be better than others). In the final position, students make a commitment to living in a world with many answers, some good and some bad, and they reinforce this commitment by constructing their own values and opinions.
Perry’s model used an explicitly Piagetian perspective in tracing the development of students’ thinking about the nature of knowledge, truth, values, and the meaning of life and responsibilities (King, 1978). Specifically, Perry’s theory examined students’ intellect (how they understand the world and the nature of knowledge) and their identity (how they find meaning for their place in the world) (King, 1978). Key to the successful progression of students through the developmental stages in this theory is the ability to recognize the existence of multiple viewpoints and “‘the indeterminacies’ of ‘Truth’” (Pascarella and Terenzini, 1991, p. 29). The pro-
cess of developing these commitments is dynamic and changeable and is prompted by the exposure that students have to new experiences, new ideas, and new people. Perry (1981) argued that this developmental process extends over the entire lifespan.
Belenky and colleagues (1986) extended Perry’s model to include women. Through their study of women of different ages, cultures, and educational levels, Belenkyand colleagues created a model comprising five distinct epistemological positions, with transitions between them. “Silence” was described as an overwhelming sense of isolation and fear. Silent women, of whom none had a college education, had little sense of self and perceived their identity strictly through others’ opinions of them. “Received knowers” (whose epistemology was very similar to men who were at the “dualism” stage in Perry’s model) perceived those in authority as having the one and only truth. “Subjective knowers” found a voice and a sense of self, and although they still believed there was an absolute right and an absolute wrong, they also believed they had authority and could make their own decisions about who was right or wrong. “Procedural knowers” focused on processes to get to the truth, such as thinking, reflecting, and analyzing. Finally, “constructed knowers” made the self an object of study and sense making; they integrated their self, their mind, and their voice in meaning making and understood knowledge to be mutable and fluid.
In his exploration of “the mental demands of modern life,” Kegan (1994) included men and women in a study that explored coping and development in the different contexts of everyday life, including adolescence, parenting, work, and learning. He and his team charted five “orders of consciousness” through which individuals progress in the context of how they think, feel, and relate to themselves and others.
In the first order—running from infancy to about age 7 or 8—children make meaning (i.e., create knowledge) based on their perceptions. If their perception of an object changes, the object itself changes. The second order extends from around age 8 until adolescence and comprises the ability to construct “durable categories,” within which physical objects and other people possess characteristics separate from self. In the second order, children, seeing themselves as distinct, begin to develop a self-concept. The transition from the second to the third order begins during adolescence, and the third order is often achieved upon entry to college. In the third order, boundaries are extended beyond the self, and as the context of the self changes, so does the concept. Another way to say this is that individuals undergo a process during which they simultaneously learn to be autonomous and interdependent. Individuals in the third order are able to extend their thinking beyond their own world and to think more abstractly. A growing understanding of self and the ability or even necessity to live life full-time in one’s own context (rather than part-time in contexts created by
others) leads to a need for more independent thinking. The struggle to separate the self from what others expect occurs here.
Self-authorship is achieved in the fourth order. Individuals become the creators of their own lives, with their own sets of values and convictions to guide them. They are able to self-reflect, self-assess, and self-direct. Based on his research, Kegan theorizes that one-half to two-thirds of adults never reach the fourth level of consciousness, implying that this level is not commonly achieved in the traditional undergraduate college years, though it may occur during postgraduate studies.
Contextual Issues and Learning Environments
Within the span of human development stages and transformations, there are certain contexts and environments that are particularly suited to promoting student change with respect to diversity issues as conceptualized here. When a curriculum deals explicitly with social and cultural diversity, and when a learning environment encourages students to interact frequently with others who differ from themselves in significant ways, the content of what students learn will naturally be affected. Less obvious, however, is the notion that features of the learning environment affect students’ mode of thought, and that diversity is a feature that produces more active thinking and can inspire intellectual engagement and motivation. Both of these aspects of learning situations are important features of how diversity connects to learning.
Many terms in the social and cognitive psychology literature have been used to describe two basically different modes of thinking that can be thought of as being on a continuum of automaticity, from completely automatic thinking without any conscious control to more intentional and controllable mental processes (Manstead and Hewstone, 1995; Bargh, 1994). Research in social psychology in the past 20 years has shown that active engagement in learning cannot be assumed, confirming that much apparent thinking and thoughtful action are actually automatic, or what Langer (1978) calls “mindless.” To some extent, mindlessness is the result of previous learning routinized such that an individual can simply rely on automatically activated scripts or schemas, as opposed to active thinking.
Automatic thinking is pervasive in most aspects of everyday life, and in some instances it is a necessary strategy for coping with multiple stimuli in a complex environment. Bargh has shown that automatic thinking is often evident not only in perceptual processes and in the execution of skills such as driving and typing, but also in evaluation, emotional reactions, determination of goals, and social behavior itself (Bargh, 1994; Gurin et al., 2002). One of our important tasks as educators is to interrupt these kinds of automatic processes so that we can facilitate active thinking in our students.
Certain conditions encourage mindful, conscious modes of thought. Novel situations for which people have no script or with which they have had no experience do not allow them to rely on their routinized or automated scripts. Situations that promote active thinking can also be ones that are not entirely novel but not entirely familiar either; situations like these demand more than their scripts and experiences will allow people to grasp (Langer, 1978). Such situations, in which people have to think about what is going on and struggle to make sense of the situation, have been called complex social structures (Coser, 1975). These situations tend to be composed of many rather than a few individuals, people who are transitory rather than stable participants in the situation, and people who hold multiple, even contradictory, perspectives and expectations of each other, thus creating some instability, unpredictability, and discrepancy. In contrast, a simple social structure is one where a small number of familiar people interact with common perspectives over a long period of time. Coser’s work has shown that people develop both a greater sense of individuality and a fuller understanding of the social world when they are faced with complex rather than simple social structures.
The features of an environment that promote mental activity are compatible with cognitive-developmental theories. In general, those theories suggest that cognitive growth is fostered by novelty, instability, discontinuity, and discrepancy. To grow cognitively, we need to be in situations that lead to a state of uncertainty, and even possibly anxiety (Piaget, 1971, 1975/1985; Ruble, 1994a; Acredolo and O’Connor, 1991; Berlyne, 1970; Doise and Palmonaari, 1984). Diverse learning environments help to create these kinds of conditions and thereby stimulate active, conscious, nonautomatic thinking that stimulates cognitive development and identity.
The literature on transformative learning also provides another point of entry into understanding how students are affected by diversity experiences. Mezirow (2000a, pp. 7–8) describes transformative learning as a process that transforms “taken-for-granted frames of reference (meaning perspectives, habits of mind, mind-sets) to make them more inclusive, discriminating, open, emotionally capable of change, and reflective.” On a cognitive level, this perspective aligns well with Langer’s notions of mindful learning and links with aspects of identity development related to emotional maturity.
In contrast to informative learning that is focused largely on increasing what students know—a content orientation—transformative learning has as its goal a change in how students know (Kegan, 1994), facilitating the generation, among other things, of new perspective-taking skills that facilitate subsequent encounters with learning opportunities. Constructive discourse is key to helping students benefit from the experiences of others, and as a result attaining the goal of transformative insight (Mezirow, 2000a).
Many undergraduate efforts focused on diversity-related learning employ techniques that emphasize focused discourse surrounding issues of difference (Zuñiga and Nagda, 1993; Zuñiga et al., 2002).
Individuals transform their perspectives, or frames of reference, by becoming critically reflective of assumptions of themselves and others and aware of their context (Mezirow, 2000b). Similar context issues exist in all fields of study and provide both opportunities and challenges for those seeking to maximize the effectiveness of diversity as an educational tool. Of particular interest for health professions education is the potential for transformative learning to shape an individual’s orientation toward lifelong learning. Kegan (1994) argues that an individual’s transformative learning history is an important consideration in creating settings intended to create bridges to transformation, while also creating a path toward continuing transformation over the life course.
Creating the conditions for students to perceive differences both within groups and between groups is a primary reason that educators need to be concerned with ensuring that there are sufficient numbers of students of various groups in relevant educational environments. The most extreme kinds of racial imbalance from an educational perspective occur when a minority student or faculty member is alone as a solo or a token. Kanter’s (1977) pathfinding research underlies our understanding of token status in organizations, concluding that being a token in an environment was associated with three negative phenomena (i.e., heightened visibility, difference accentuation, and role encapsulation). Later research supports these conclusions (Yoder, 1994; Spangler et al., 1978), showing that solos (the only one) and tokens (a tiny minority) have negative experiences when they interact with majority group members.
Other conditions that can influence student learning are those created by faculty members and how they choose to structure their educational interactions in classrooms and other learning settings. The benefits of student-centered teaching practices are detailed in a comprehensive report by Chickering and Gamson (1987), who identified educational conditions that result in powerful and enduring undergraduate educational experiences and combat common criticisms of higher education (e.g., apathetic students, illiterate graduates, incompetent teaching, and impersonal campuses). The authors advocate that education should encourage cooperation and collaboration, rather than competitive or isolated learning situations. They believe that working with others and sharing ideas increases involvement and deepens understanding. This is supported by Johnson and Johnson’s (1989) comprehensive review of cooperative learning methods at the col-
lege level. The review concluded that cooperative learning groups increase productivity, develop commitment and positive relationships among group members, increase social support, and enhance self-esteem. In addition, research on peer-teaching indicates that both peer-teachers and learners benefit from the cooperative relationships generated and gain a better understanding of the subject matter (Goldschmid and Goldschmid, 1976; Whitman, 1988). McKeachie and colleagues (1986) found that cooperative teaching methods such as group projects and student-led discussions were more likely than instructor-dominated methods (e.g., lecturing) to improve the problem-solving, motivation, and leadership skills of students.
In addition, research by Astin (1984) and Pace (1984) on student learning and development emphasizes the importance of a student’s active involvement in the educational process. Their research suggests that the greater the student’s involvement in academic work or college experience, the greater the level of knowledge acquired. Pascarella and Terenzini (1991) suggest that the most influential educational component of student involvement is the instructional approach used. In a review of the literature, they found that alternative teaching methods, such as active learning, peer teaching, and cooperative structures, have substantial advantages over traditional teaching formats in eliciting active participation. In addition, Pascarella and Terenzini (1991) indicate that content learning and cognitive development is greater in classrooms where students are engaged by the instructional and learning processes. Furthermore, they assert that academic involvement—which is more likely to occur in cooperative situations—also increases psychosocial dimensions such as nonauthoritarianism, tolerance, independence, intellectual disposition, and reflective judgment.
Taken together, these perspectives (and supporting research evidence) underscore a number of general conditions through which campus diversity—if managed through effective, thoughtful processes—can positively affect student learning outcomes. One example of such an effort can be found in the University of Michigan’s Program on Intergroup Relations (IGR), which explicitly articulates these conditions and provides students with differing—and potentially conflicting—social identities opportunities to come together to understand and learn from their differences. Through courses and other learning opportunities, IGR helps students learn to talk across race and ethnicity (and across other differences as well) in a public way, learning to address group differences in a balanced and positive fashion. The conditions that facilitate this process include the presence of diverse peers, discontinuity from previous social background, equality among peers, discussion under rules of civil discourse, and normalization and negotiation of conflict (Zuñiga and Nagda, 1993; Zuñiga et al., 2002; Gurin et al., 2002).
A study based on data drawn from this program reveal that it is not simply diversity-related content that is influential in promoting student learning, but also the active learning techniques that are embedded in the program (Lopez et al., 1998). In contrast, postprogram actions were influenced not by content, but by the active learning aspects of the courses within the program. Providing students with content through lectures and readings alone does not generate this kind of learning.
While programs modeled after the IGR program at Michigan have begun to appear on other college campuses (e.g., Arizona State University, University of Denver, University of Maryland, University of Massachusetts at Amherst), they remain more the exception than the rule in higher education.
The Impact of Diverse Faculty on Teaching and Learning
Our discussion about the benefits of diversity up until now has focused almost exclusively on the ways in which having a diverse student body can provide important educational and societal benefits. However, it is also important to consider the impact that a diverse faculty has on institutions of higher education. In a recent study that examined the contributions made by diverse faculty to the research, teaching, and service missions of the university, Milem (1999) found that women faculty and faculty of color contributed to the diverse missions of the university in important and unique ways. Specifically, the study analyzed the relationship between the race/ ethnicity and gender of faculty members and a variety of variables related to the three central missions (teaching, research, and service) of higher education institutions.
Milem found that race and gender served as significant positive predictors of the use of active teaching methods in the classroom—methods that have been shown to enhance the learning of students in the classes in which they are used. Moreover, the use of active pedagogy provides students with opportunities to interact with peers from different backgrounds through class discussions, collaborative learning methods, and group projects. These activities contribute to a campus climate that is more supportive of diversity and lead to positive outcomes for the students involved (see, e.g., Astin, 1993; Gurin, 1999; Hurtado et al., 1998, 1999; Milem, 2003; Milem and Hakuta, 2000; Smith & Associates, 1997).
Milem (1999) also found that diverse faculty members provided students with more opportunities to encounter readings and research that address the experiences of women and members of different racial/ethnic groups. Interacting with diverse course content provides students with opportunities to understand the experiences of individuals and groups who differ from them in various ways. Moreover, by engaging diversity through
readings and class materials, students of color are given opportunities to see themselves and aspects of their experiences in the curriculum. Takaki (1993) has argued that the significance of providing these opportunities to students should not be underestimated. “What happens …meone with the authority of a teacher describes our society, and you are not in it? Such an experience can be disorienting—a moment of psychic disequilibrium, as if you looked into a mirror and saw nothing” (Takaki, 1993, p. 16).
Regarding the research mission of the university, Milem (1999) argued that faculty of color and women faculty expand the boundaries of current knowledge through the questions they explore in the research they do. They are much more likely to engage in research that extends our knowledge of issues pertaining to race/ethnicity and women/gender in society. Finally, Milem found that faculty of color and women were more likely to engage in service-related activities than their other colleagues.
To summarize, Milem (1999) argued that students who attend institutions with higher proportions of women faculty and faculty of color are more likely to be exposed to faculty who are student centered in their orientation to teaching and learning. They also are more likely to experience a curriculum that is more inclusive in its representation of the experiences and contributions of women and people of color in our society. Finally, students who attend institutions with more women and faculty of color are more likely to interact with faculty who are engaged in research on issues of race and gender. On the basis of these analyses, Milem (1999) argued that women and faculty of color play a distinctive and fundamental role in the teaching and learning process through the unique contributions that they make to the three missions of higher education (research, teaching, and service).
In summary, the higher education literature identifies a number of important issues that link diversity to student learning, including factors related to individual development and the environments within which students are educated. The literature suggests that individual development is enhanced when individuals encounter novel ideas and new social situations, forcing them to abandon automated scripts and think in mindful ways. Given the continuing pattern of segregation in American society, the first time that many individuals encounter racial and ethnic diversity is at college, creating a rich and complex social situation that can be effectively used to promote student learning and development. As the diversity of American society progressively increases, so does the opportunity to make educational use of diversity as does the importance of doing so.
Maintaining or increasing compositional diversity is an important first step for campuses to take in this area, but it is not sufficient to simply diversify an educational program. Intentional actions that create meaningful interactions between individuals and ideas through the formal curriculum and its implementation, as well as through peer-to-peer interactions in informal settings, help create conditions that enhance student learning. Crafted and managed carefully, such experiences can help transform the ways people learn not only about issues of racial, power, and social justice, but how they approach the learning task itself.
If the value-added educational benefits associated with diversity are to be realized, then institutions of higher education and their faculties must be actively involved in a process of institutional change and transformation (Chang, 2002; Smith, 1995; Smith & Associates, 1997). Earlier research that examined the impact of increased compositional diversity on college campuses indicated that as the representation of students of color increased on campus, institutions felt greater pressure to change. Evidence of these early pressures to change can be seen in the development of ethnic studies programs, creation of diverse student organizations, implementation of specific academic support programs, and presentation of various diversity enhancement programs (Treviño, 1992; Muñoz, 1989; Peterson et al., 1978).
Garcia and Smith (1996) argue that the pressure that institutions face to change themselves as they become more diverse goes to the heart of the educational enterprise in terms of what is to be taught, who is to teach it, and how it is to be taught. Those who view diversity as a stimulus for institutional change and transformation believe that institutions of higher education should be held accountable to basic democratic ideals that require that they be more equitable and inclusive. Diversity initiatives are transformational in nature because they challenge traditional assumptions about learning as well as other forms of privilege that are associated with learning (Chang, 2002).
Chang (2002) provides a helpful way with which to consider how educators and leaders at individual institutions view diversity. Specifically, he asserts that two primary forms of discourse dominate our thinking about diversity in higher education. He labels these as a discourse of preservation and a discourse of transformation. Somewhat paradoxically, a discourse of preservation has as its key (if not exclusive) focus, increasing the compositional diversity of campuses. Chang (2002) argues that a discourse of preservation is limiting because it overlooks the full historical development of
diversity-related efforts on college campuses, focuses on admissions as the primary goal, ignores transformative aims, and thereby underestimates the impact of diversity on student learning.
Chang argues that we should engage in a discourse of transformation when it comes to campus diversity, which is based not only on compositional changes, but also deeper kinds of institutional changes. However, this is very difficult because the transformative aims of diversity often clash with deep-seated institutional assumptions and values. The educational benefits of diversity emanate from institutional changes that challenge prevailing educational sensibilities and that enhance educational participation. Clearly, if the educational benefits that diverse educational environments offer are to be realized, we must be acutely aware of the context in which this diversity is enacted. When the discourse about campus diversity is transformative, important questions should shape the discussions:
Who deserves an opportunity to learn?
How is the potential for learning evaluated?
What is learned?
Who decides what is important to learn?
Who oversees learning?
What conditions advance learning for all students?
Although the discourses described by Chang are important to begin the process of transforming institutions, diversity must eventually become institutionalized as an integral and seamless part of the organizational fabric of our colleges and universities. However, evidence from scholarship that examines organizational behavior in higher education suggests that this is a task that is not easy. A number of organizational forces at work in institutions of higher education make it difficult to institutionalize diversity. In the section that follows, we describe some of the forces that can impede progress in institutionalizing diversity in institutions of higher education.
In a report that summarized the impact of affirmative action in employment, Reskin (1998) indicated that much of the race and sex discrimination that exist in the workplace are a function of the business practices of firms in which such discrimination takes place. To illustrate this concept, Reskin offered two examples of factors that contribute to employment discrimination. The first occurs when employers rely heavily on informal networks to recruit their employees. The second occurs when firms require job credentials that are not necessary to do a job effectively. Reskin (1998, p. 35) suggested that “structural discrimination persists because, once in place, discriminatory practices in bureaucratic organizations are hard to change.”
Reskin argued that bureaucratic organizations develop an inertia that tends to preserve these practices unless the organization is faced with genu-
ine pressures to change itself. These observations about the role of organizational inertia in the business sector suggest that similar forces exist in colleges and universities. This is very likely when we consider that colleges and universities, like many private businesses and firms, tend to be highly bureaucratic organizations. Moreover, organizations that provide health care also tend to be highly bureaucratic. Hence, it is important to examine the organizational behaviors that are likely to impede efforts to incorporate diversity as a central part of our institutional missions.
While the American higher education system is large, diverse, complex, and decentralized, it is also extremely homogeneous (Astin, 1985). This homogeneity can be seen in comparable approaches to undergraduate curriculum, great conformity in the training and preparation of faculty, and very similar administrative structures. This tendency toward conformity is complicated by the fact that most educators and educational administrators view the higher education system from an institutional perspective as opposed to a systems perspective. This tendency toward overreliance on an institutional perspective tends to lead to the implementation of policies and practices that weaken the system as a whole (Astin, 1985).
A related perspective on these processes can be found in the concept of institutional isomorphism, an idea first introduced by Riesman (1956). This concept also has been described as “institutional homogenization” or “institutional imitation” (Jencks and Riesman, 1968; Pace, 1974; DiMaggio and Powell, 1983; Astin, 1985; Levinson, 1989; Hackett, 1990; Scott, 1995). “There is no doubt that colleges and universities in this country model themselves upon each other…. All one has to do is read catalogues to realize the extent of this isomorphism,” Riesman (1956, p. 25) wrote. Riesman depicted the higher education system as an “academic procession,” which he described as a snake-like entity in which the most prestigious institutions in the hierarchy are at the head of the snake, followed by the middle group, with the least prestigious schools forming the tail of the snake. The most elite institutions carefully watch each other as they jockey for position in the hierarchy. In the meantime, schools in the middle are busy trying to catch up with the head of the snake by imitating the high-prestige institutions. As a result, schools in the middle of the procession begin to look more like the top institutions while the institutions in the tail pursue the middle-range schools. As a consequence of this type of organizational behavior, institutional forms become less distinctive, relatively little real change occurs in the hierarchy, and the system of higher education struggles to move forward. It is important to note the similarity in outcomes of isomorphic behavior to Reskin’s (1998) discussion of the consequences of organizational inertia. Namely, institutions of higher education are likely to resist efforts at change unless they are forced to do so. Jencks and Riesman (1968) suggested that strong economic and professional pres-
sures drive isomorphism in higher education and concluded that homogenization occurs faster than differentiation.
One consequence of this type of organizational behavior can be seen in its effect on admissions policies and procedures. When students are viewed as resources, there is immense pressure to rely on narrow definitions of individual merit and to make institutional admissions policies more selective. Under these circumstances, decisions to seek applicants with higher standardized test scores are not made for any compelling pedagogical or educational reasons; rather, based on this traditional view of merit, institutional leaders believe that higher standardized test scores bolster an institution’s reputation. Faculty and administrators come to view selective admissions policies as being essential to the maintenance of academic excellence or standards. As a result, institutional excellence is defined by the “quality” of the people who are admitted and not by the nature of the educational experiences that students have while attending the institution (Astin, 1985). Despite the tendency for many educational leaders and policy makers to think otherwise, this extremely narrow definition of excellence does not serve colleges and universities, their constituencies, or our society well.
HEALTH PROFESSIONS EDUCATION
It is important to note that much of the research documenting the benefits of diversity and addressing the campus climate for diversity has been conducted using data collected from undergraduate students. Although this might suggest a limited utility of the perspectives generated from the general higher education literature for health care education, we suggest that this literature provides a good platform for addressing the common as well as the unique aspects associated with training in health care professions.
Some of the health professions disciplines are centered in baccalaureate programs (e.g., nursing, some allied health fields), while others are postgraduate in nature (e.g., medicine, dentistry). Thus, while many students in health professions education are subject to the same or similar cognitive and developmental issues as students enrolled in other postsecondary settings, many may have achieved a more advanced stage.
Structurally, because much of health professions education occurs within the larger organizational setting known as higher education, it is subject to institutional forces similar to those found in undergraduate and graduate/professional settings. What is unique in most health professions educational programs is the body of learning that occurs outside the traditional educational settings (i.e., lecture halls, classrooms, and laboratories), and within the settings where health care is actually delivered. Although
this two-part educational model is essential to health professions education, the format and venue for the clinical components of the programs can limit the intended influences and outcomes of the programs.
Finally, but perhaps more importantly, goals that guide health professions education include educating students to interact with and care for patients. The higher education literature discusses the need to ensure “equal status” among students from different cultures in order to achieve and enhance learning outcomes. Health professions educators need to take this one step further by helping students understand the importance of equal status in the context of interactions between health-care providers and patients, where differences in professional status as well as culture greatly influence the quality of health care provided.
Structure of Medical Education
History and Traditional Pedagogy
In 1910 Abraham Flexner—a high school principal with funding from the Carnegie Foundation—published a report on the state of medical education in the United States and Canada (Flexner, 1910). In the report, which was actually an exposé on the disorganized state of medical education, Flexner outlined specific problems and recommendations for improvement. The medical schools that survived after his report were the ones that complied with its recommendations; this resulted in medical training that was very similar in format across many of the schools, and that remained largely intact for nearly 75 years.
In general, the first 2 years of medical education were composed of lectures offered by scientists in specific biomedical science disciplines (e.g., biochemistry, physiology, pharmacology, microbiology) and accompanying laboratory exercises, some with human cadavers and animals. There was also preclinical skills instruction, mostly consisting of students practicing basic physical examination techniques on each other and occasionally using mannequins under a physician’s guidance.
In the third year, instruction shifted from classroom lectures and lab exercises to an apprenticeship format. Students, known as “clinical clerks,” followed physicians and residents around the hospital wards. Patients were available day and night for the students to interview, examine, and present during medical teaching rounds. Physicians who were providing patient care and teaching residents instructed medical students as they rotated through clerkships in the basic medical disciplines (e.g., internal medicine, surgery, obstetrics/gynecology, pediatrics, psychiatry).
While over the years there was a significant decrease in laboratory exercises—especially animal-based physiology and pharmacology labs for
first- and second-year students—this format for learning how to practice medicine remained largely unchanged until the mid-1980s. At that time, the Association of American Medical Colleges (AAMC, 1984), with support from the Liaison Committee on Medical Education (the accrediting agency for U.S. medical schools), encouraged medical schools to reform their curricula to integrate more active methodologies as a way of ensuring lifelong learning skills in physicians. By the early 1990s, many medical schools had responded to this call by reviewing and revising their educational programs. Most of the major revisions have been limited to the first 2 years of the curriculum and consist of additional small-group discussions and an earlier introduction to caring for patients. Some schools, however, took a more dramatic step and adopted the problem-based learning (PBL) format that had been in place in a few medical schools for 20 to 30 years, because of a belief that it promised more effective outcomes by placing learning in the problem-solving context in which medicine would be practiced.
More recently, medical schools have been working to respond to healthcare concerns that result from an increasingly diverse patient population in the United States. These concerns have been translated into educational standards and goals by oversight agencies, including state licensing boards and AAMC. As a result, medical schools have begun to design, implement, and evaluate learning modules that address issues and topics such as communication skills, cultural competence, spirituality and health beliefs, palliative care, and approaches that integrate non-Western therapies with more traditional Western therapies.
To address the matter of integrating more active learning into programs that relied so heavily on lectures, medical educators looked to a few medical schools that had adopted PBL, a student-centered methodology in which small groups of students led by tutors learn through clinical problem solving. PBL programs, pure or blended with more traditional approaches, have been adopted in the first 2 (preclinical) years of medical education. However, few medical schools have implemented significant changes in the clinical clerkships that were created shortly after the Flexner report.
The PBL approach in undergraduate medical education had been established by Case Western Reserve Medical School in the 1950s and McMaster University (in Canada) in the 1960s. At McMaster, Barrows saw PBL as a way for medical students to integrate knowledge across subject boundaries and at the same time develop problem-solving skills (Maudsley, 1999). PBL assessment was innovative as well, involving tutors and peers as well as students assessing themselves. Barrows (2000) described “pure” or “authentic” PBL as “modeled on the skills and activities
that will be expected of students when they are practicing their profession. It avoids requiring any learning behaviors that are not of value to the students’ future role as physicians” (e.g., rote memorization and answering multiple-choice questions).
Years later, medical educators who are critical of PBL have highlighted the inconsistency in approaches taken to PBL across medical schools, PBL’s questionable effectiveness, and the paucity of longer-term sustainability of benefits. Maudsley (1999) reported that various claims had been made for PBL about gains in knowledge, understanding, and thinking, but the label PBL had been used to describe “heterogeneous” approaches to educational activities, and few medical schools have even agreed on the basic characteristics of the method.
Colliver (2000) conducted a comprehensive meta-analysis of research related to the PBL method, comparing the performance of students in PBL programs with performance of students in the more traditional programs. He found no or small effect sizes in the comparisons and concluded that while PBL programs might provide a more challenging, motivating, and enjoyable approach to medical education, the “educational superiority” of PBL relative to the more traditional approach taken in medical education had not been clearly established.
Medical Education Goals and Objectives
A common overarching goal of medical education is to educate physicians who are prepared to practice medicine. In addition to this and to their own more specific goals for medical student education related to achieving cultural competency, U.S. medical schools are guided by educational objectives and standards established by two prominent national organizations.
AAMC, as part of its “Medical School Objectives Project” (AAMC, 1998), has described attributes that graduating medical students should possess. High on this list of important attributes are knowledge of the biomedical sciences and an understanding of the power of the scientific method, as well as the ability to obtain medical histories and perform physical examinations. Other qualities identified by AAMC as being important are the ability to communicate effectively, both orally and in writing, with patients, patients’ families, colleagues, and others; knowledge of the nonbiological determinants of poor health and of the economic, psychological, and cultural factors that contribute to the development and/or continuation of maladies; and a commitment to provide care to patients who are unable to pay and to advocate for access to health care for members of medically underserved populations.
Educational Standards and Accreditation
In addition to the guidance provided by AAMC, each medical school in the United States undergoes an accreditation process every 7 years that is conducted by the Liaison Committee for Medical Education (LCME). In contrast to educational programs that are evaluated by other accrediting agencies that rely largely on self-assessment activities, medical schools are assessed by a group of external experts using a specific set of educational standards, which are outlined in a publication titled Functions and Structure of a Medical School (LCME, 2002). Schools are advised about what they need to do to meet these explicit accreditation standards. These include providing students with content in their curricula and other discipline-based learning opportunities for broader, proficiency-based content, such as preparing students for their role in addressing the medical consequences of common societal problems; ensuring that graduating students have an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments; and developing in students the ability to recognize and appropriately address gender and cultural biases in themselves and others.
External Assessments of Learning
An external measure of the knowledge and skills students acquire during medical school is the United States Medical Licensure Examination (USMLE), administered by the National Board of Medical Educators. Two steps of this three-step process toward licensure specifically assess medical student learning (the first two steps usually occur during medical school; the third step usually occurs during residency). Step 2 now has two parts (effective 2004), the second of which is a specific test of clinical skills, including communication skills (called the Step 2 CSE, or clinical skills examination).
Step 1 assesses whether students understand and can apply important concepts of the sciences basic to the practice of medicine, with special emphasis on principles and mechanisms underlying health, disease, and modes of therapy. Step 1 ensures mastery of the sciences that provide a foundation for the safe and competent practice of medicine in the present as well as the scientific principles required for maintenance of competence through lifelong learning. Step 2 assesses whether students can apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision with an emphasis on health promotion and disease prevention. Step 2 ensures that proper attention is devoted to principles of clinical science and basic patient-centered
skills that provide the foundation for the safe and competent practice of medicine.
Current Diversity-Related Pedagogy in Medical Education
Knowledge and Skills
In response to societal concerns and educational goals and standards set by state licensing boards and the medical school accrediting agency, there has been an increase in the number of courses and experiences designed by medical schools to teach medical students to be clinically competent in providing health care to a socially diverse society.
The cultural competency approach (Wear, 2003) described by several medical schools highlights the language and customs of particular minority groups, especially their beliefs related to health. Nuñez (2000) asserts that this method is designed to help students increase their understanding of cultural differences and similarities within, among, and between different groups. While students learn characteristics that differ from their own, this is usually done using broad groupings of people (e.g., Latino), rather than using characteristics related to Latino subgroups (i.e., Mexican American, Puerto Rican American, Cuban American) or other dimensions of difference (urban versus rural, lower versus higher socioeconomic status) that exist within these broad categories. Critics of this methodology note that it characterizes culture as a static, “distinctive set of beliefs, values, morals, customs, and institutions which people inherit,” rather than “a process in which views and practices are dynamically affected by social transformations, social conflicts, power relationships, and migrations” (Guarnaccia and Rodriguez, 1996). One obvious negative effect of this approach is its tendency to perpetuate rigid stereotypes about members of particular groups and their needs, beliefs, and behaviors (Taylor, 2003).
A second approach, the communication skills approach, helps students to elicit important and relevant information from the patient through use of the patient’s own words. An added benefit of this approach is that students who use this method are able to communicate better with all patients, regardless of ethnicity or belief systems. This approach considers individual patients and their experiences rather than adhering to a rigid checklist of ethnic traits (Chin and Humikowski, 2002). Kleinman and colleagues’ model (1978) is one example of how health-care providers can use this approach to solicit input from patients in explaining their complaint or illness in their own words, thereby providing information to the provider about the patient’s cultural, social, economic, and environmental context (Table PCD-1). The model, which can work effectively in the educational and practice settings, helps health-care providers develop a more thorough
TABLE PCD-1 Questions to Be Posed in Kleinman’s Explanatory Model
SOURCE: Kleinman et al., 1978.
understanding of how the individual patient is experiencing his or her illness.
A third approach to incorporating diversity-related content and pedagogy in medical education combines the previous two and recognizes “the dynamic and ever-changing nature of cultures that occur within cultural groups” using longitudinal paradigm of “key themes and components of culture in health care” (Tervalon, 2003, p. 573). Proponents of this approach assert that students should learn about core cultural issues rather than lists of traits or characteristics, and that it is important to explore with each patient her/his particular cultural belief systems. This combined knowledge/skills method is supported by medical educators who concur with Chin and Humikowski’s (2002) assertion that “although individualization of care is most important … it would be foolhardy not to take into account common beliefs and cultural issues in a community.”
The findings from recent survey data (Flores et al., 2000) indicate that only 8 percent of U.S. medical schools reported having a separate course to address cultural issues; 87 percent reported that learning was embedded in other courses (in 1 to 3 lecture hours); and 16 percent reported offering a separate elective (the percentages exceed 100 percent because some schools offer more than one format). Case-based (59 percent) and didactic (57 percent) designs were the primary teaching methods, which is consistent with the focus in medical education on acquiring accurate knowledge (transmitted through didactic lectures) and developing appropriate behaviors and skills (practiced using cases).
While most medical schools provided opportunities to learn about diversity-related issues in the first (84 percent) and second years (72 percent), surprisingly, only 6 percent of medical schools provided opportunities for
any formal learning about these issues in the third year (which is usually characterized by intensive clinical training). This finding suggests that the assumption is that the learning about diversity that occurs in the first 2 (preclinical) years of medical school will be transferred to the clinical setting in the third year. However, this approach provides inconsistent reinforcement of what students learn, which is essential to the long-term maintenance and continued improvement of knowledge and skills.
Although this survey did not address how and when learning is assessed by the medical schools that responded, assessment can play an important role in student learning. Through the use of assessment activities that require students to interact with a simulated patient (such as Objective Structured Clinical Examinations, or OSCEs), faculty observe and provide feedback to each student, or the simulated patient can be trained to do the same (Betancourt, 2003). If the OSCE is administered at the end of the third-year clerkships, as many are, this can be used to help reinforce what students learned in their first 2 years as well as during their clinical skills practice in the third year.
Embedded in the approaches that we have described so far are various efforts to address students’ attitudes about diverse cultures. These approaches assume that health-care providers need to be aware of their own biases, prejudices, and stereotypes about culture and the influence these have in health-care encounters with patients if they are to provide culturally competent health care. Some proposed methods designed to do this include the use of learning situations where students describe their own cultural identities (Carillo et al., 1999) and activities that help students identify the sources of bias, prejudice, and discrimination in their own personal experiences (Welch, 1998). Humility, empathy, curiosity, respect, and sensitivity are important attributes in the delivery of effective, culturally competent care. Learning methods that help to develop these attributes include reflective journal entries (Crandall et al., 2003), small-group discussions (Tang et al., in press), student role-playing specific cases with feedback from faculty, exercises with simulated patients (Betancourt, 2003), and guest speakers and tutorials (Beagan, 2003). However, efforts to shape or change student attitudes can be exceptionally difficult. This point is illustrated in the experience of one author who observed a tendency for students and faculty “to focus on content rather than self-awareness” (Beagan, 2003, p. 613), and another who argued that “efforts to change attitudes are labor-intensive, difficult, and complex to evaluate” (Betancourt, 2003, p. 562).
Negative Reinforcements to Learning
Despite numerous attempts to develop and implement diversity-related curricula, medical educators have documented an educational paradox: This paradox highlights the conflict that exists between the explicit curriculum as articulated and enacted in medical classrooms and the implicit or hidden curriculum that is part of the underlying culture of medicine (Hafferty and Franks, 1994). They observe that “only a fraction of medical culture is to be found or can be conveyed within those curriculum-based hours formally allocated to medical students’ instruction”(1994, p. 864). Most of what medical students internalize in terms of the values, attitudes, and beliefs comes from the hidden curriculum, and these messages frequently stand in opposition to the formal curriculum (Hafferty, 1998).
M.J.D. Good (1995) argued that the “hidden culture” of medicine can undermine formal learning. One of the processes by which medical students demonstrate their medical competence is through crafting clinical narratives that transform the language used by patients into the language used by physicians. Good reported that this process leaves no room for students to elicit cultural information from their patients. B. Good (1994) found that the clinical narratives were a systematic process of disregarding the patient’s story. Hafferty (1998) wrote that in exercises where medical students were encouraged “to create medically meaningful arguments and plots with therapeutic consequences for patients,” the psychosocial dimensions of patients’ illnesses were regarded as “inadmissible evidence” during medical rounds. Thus, medical competence is regarded by many medical professionals—and so also by medical students—as the real competence (Taylor, 2003). Hence, as taught and demonstrated, this leaves no room for patients to tell their story, which would allow them to provide important information to the health-care provider about their social/cultural context.
Educators express caution with another kind of hidden curriculum (which may be more accurately described as the “unintended curriculum”) that can undermine the primary curriculum by sending unintended messages to students through their content or format. In an analysis of patient cases integrated throughout first- and second-year courses at the University of Minnesota (these cases were not part of a cultural diversity course or sequence), Turbes et al. (2002) explored whether the cases supported or undermined explicit messages to the students about diverse patient populations. The authors reported that there was an underrepresentation of women in the cases (which was likely to minimize the importance of discussions about women’s health issues), little mention of racial or ethnic identifiers in the cases (which, the authors explained, occurred within a cultural environment in which whiteness is often assumed), and almost no mention of sexual orientation (which leads to an assumption of heterosexuality).
TABLE PCD-2 Examples of Advice Given to Health-Care Providers That Can Reinforce Stereotypes
Hafferty and Frank (1994) described a hidden and unintentional curriculum in classrooms or clinical settings where faculty unwittingly present case reports to illustrate concepts that may convey images perpetuating a variety of stereotypes. Stories and jokes shared by students and faculty are often part of the shared culture of medicine and can be an enormously influential component of medical education. As students move from the classrooms to the stressful, arduous clinical training environment, they may cope with their stress by dehumanizing patients, transforming them into objects of work and sources of antagonism and assigning disparaging labels such as “hits” and “gomers” to their patients.
Finally, there are times when advice given to health-care personnel, although accompanied by documentation, can unwittingly reinforce stereotypes or aim so low as to elicit a negative response from the recipients (examples of a few of these are listed in Table PCD-2). This advice, which is generally available to all faculty, staff, practitioners, and their students in academic medical settings, can undermine educational goals rather than foster efforts to appreciate and understand the diverse cultures and complex health care needs represented in the patient population.
The pedagogy that is currently in place in many U.S. medical schools to ensure that graduating medical students are culturally competent tends to focus on the acquisition of accurate knowledge, respectful attitudes, and appropriate behaviors for interacting with patients. Although some medical schools report approaches that are designed to help students reflect on how their biases and prejudices may influence the quality of care they provide to patients, (e.g., Tervalon, 2003; Crandall et al., 2003), by and large, the approach taken at most medical schools to teaching cultural competence is consigned to courses in cultural sensitivity or provider-patient communication (Chin and Humikowski, 2002).
Current Status of Medical Education
If internal and external goals and standards requiring graduating medical students to be culturally competent in caring for patients are to be
achieved, medical educators must grapple with a number of difficult challenges. Current medical pedagogy tends to underestimate or even ignore the power of the hidden and informal curricula, where “students learn about the core values of medicine and medical work” (Hafferty and Frank, 1994), which can be in sharp contrast to the core values underlying the formal educational goals of the curriculum. There can also be a “disconnect” between early clinical skills training where students learn about the importance of cultural competence and later clinical training where they learn that patients’ social and cultural contexts are irrelevant to competent medical practice (Good, 1994; Good, 1995).
While increasing numbers of women are now entering medical school—nearly half of the entering class in 2002 consisted of women, an increase from 42 percent in 1992 (AAMC, 2003), the majority of physicians are white men who were raised and educated in racially homogeneous environments where nonwhite cultures were not present or represented (Project 3000 by 2000, 1994). Whites continue to be the predominant racial group in entering medical school classes, representing nearly two-thirds of medical school matriculants in 2002 (AAMC, 2003). Given this underrepresentation of people of color in medical school and the use of existing diversity-related teaching methods in medical education that focus on knowledge and skills that enable students to communicate with cultures other than their own, students are likely to adopt a perspective called “othering” (Beagan, 2003), in which students lump individuals from diverse cultures and subcultures together, viewing them through a lens in which difference is tantamount to disadvantage. This view prevents students from recognizing the privileges and advantages that are inherent in being a member of the dominant culture, which is key to recognizing and understanding the perspectives of individuals from nondominant cultures (Beagan, 2003).
Finally, high standards have been set regarding the need to include diversity-related learning opportunities for students in medical education that require medical educators to do more than assist in the acquisition of knowledge, skills, and behaviors. The goals and standards for medical education that have been adopted insist that these experiences enable medical professions to demonstrate scrupulous ethical principles and the capacity to recognize and accept their own limitations (AAMC, 1998), an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness, and the ability to recognize and address gender and cultural biases in themselves and others (LCME, 2002). Achieving these goals requires that medical educators develop in their students attributes such as critical self-awareness and self-assessment, abstract thinking, understanding the perspectives of others, and the ability to understand and value diverse perspectives.
There is a substantial body of evidence already described in this paper on models of moral, emotional, and cognitive development from childhood through college and adulthood. Beginning with Piaget’s observations of children and continuing through the twentieth century to Kegan’s orders of consciousness (how we make meaning or create knowledge), educators have been interested in the intersections between and the mutual influences of developmental stage and learning.
Kegan’s model is particularly compelling for health professions educators because of its focus on self-authorship in the fourth order he describes and the strong connections between the qualities and characteristics demonstrated by self-authors and the expectations of those striving to deliver effective, competent, and compassionate health care. As Kegan wrote (1994, p. 169), “Self-evaluating and self-correcting demands an internal standard; it requires a theory or a philosophy of what makes something valuable, a meta-leap beyond the third order.” Self-authorship in practice includes the ability to function independently, construct one’s own vision, make informed decisions, act appropriately, and take responsibility for one’s actions (Baxter Magolda, 1999), all of which are characteristics that society expects of its health-care providers. AAMC, LCME, and many medical schools have institutionalized these expectations by articulating goals for self-assessment as a vital component for self-directed (and self-correcting) lifelong learning.
There is also an important interpersonal dimension woven centrally into Kegan’s concept of self-authorship. Bruffee’s (1993, p. 2) medical example nicely describes the importance of interweaving the two dimensions (cognitive and interpersonal): “There is a perception by many in the medical profession itself that although traditional medical education stuffs young physicians full of facts, it leaves their diagnostic judgment rudimentary and does not develop their ability to interact socially, with either colleagues or patients, over complex, demanding, perhaps life-and-death issues.” Given the importance of communication skills in effectively working across cultural and other differences, it is important to ensure that both of these dimensions are clearly evident in intention and practice.
Of particular interest to medical educators is Kegan’s belief that one-half to two-thirds of the adult population never reach the level at which self-authorship is possible. He does, however, provide insight into an approach to learning that can help students become self-authors. Kegan noted that educators can create learning opportunities and set expectations to help students become self-directed learners, understanding that in doing so, many of them will need to change the ways in which they understand themselves and everything in their world. He describes students who have
achieved self-authorship as “self-directed learners” who are able to “examine themselves, their culture, and their milieu in order to understand how to separate what they feel from what they should feel, what they value from what they should value, and what they want from what they should want. They develop critical thinking, individual initiative, and a sense of themselves as co-creators of the culture that shapes them” (Kegan, 1994, p. 274). Kegan cautioned that using training as a method for teaching individuals to respect diversity would run the risk of reducing respect to a skill. Paradoxically, this could send the message that respecting diversity (i.e., mastering the skill) means to “keep our negative attributions and characterizations to ourselves, rather than to learn that our negative attributions and characterizations are in themselves a failure to respect diversity” (Kegan, 1994, p. 196).
Through a process called “transformative learning” (Mezirow, 2000a), individuals can transform their perspectives, or frames of reference, by becoming critically reflective of assumptions of themselves and others and aware of their context. Transformative learning theory and principles are particularly compelling when they are viewed in light of recent reports by Tatum (2003), Maher and Tetreault (2003), and Vacarr (2003). These authors encourage and describe transformative frameworks for learning about diversity that are problem based and focused on social issues, including race and racism, prejudice, dominant cultures and voices, and positionality. As noted by Tatum (2003, p. 156), who developed strategies for promoting racial identity development and improving interracial dialogue in the classroom, “It is certainly common to witness beginning transformations in classes with race-related content.” Such principles are not inconsistent with Baxter Magolda’s research and resulting principles that underlie pedagogical efforts to help students achieve self-authorship. She wrote, “Promoting self-authorship is a matter of helping students transform their assumptions about knowledge and about themselves” (Baxter Magolda, 1994, p. 97).
Current medical education literature is not void of thought-provoking suggestions for medical curricula that combine active learning formats with deeper and broader levels of self-reflection and understanding so vital to true cultural competence. Wear (2003) describes an approach to educating medical students based on Giroux’s antiracist pedagogy—a pedagogy that extends beyond the limitations of “communicative competence” and the “celebration of tolerance.” This approach calls for students to analyze unequal distributions of power that advantage dominant groups, and the relevant policies, attitudes, and rituals (i.e., culture) within these groups,
including their own medical school and health care environment. West (1989) wrote about how central such an approach is to recognizing the culture of those who are oppressed, rather than focusing on what makes them different, which runs the risk of marginalizing them even further. Ayers (1998) calls this “teaching for social justice” and argues that it serves as the very foundation of cultural competency efforts. Such experiences are designed to help students understand themselves as individuals who are “positioned” (or situated) in specific social and economic contexts that influence every interaction they have with patients, by providing them with “opportunities to look at their biases, challenge their assumptions, know people beyond labels, and confront the effects of power and privilege” (Wear, 2003). As noted earlier, by creating experiences that allow students to engage peers from different backgrounds in ongoing, structured interactions, students show greater achievement of critical educational outcomes (Gurin, 1999; Gurin et al., 2003). Likewise, faculty can provide opportunities for these interactions by adopting active-learning and student-centered formats (e.g., learning groups, peer teaching, group projects) that provide the students from different cultures with important opportunities to build bridges across their differences.
Medical educators have been working for more than a decade to integrate more active learning into their curricula, so some of this information is not new to them. The long philosophical leap they are asked to make here is to consider reexamining the principles underlying current medical school pedagogy that are focused on helping students to master the knowledge, skills, and attitudes that will in theory make them culturally competent. The higher education and psychology literatures on development, social justice pedagogy, active and interactive educational formats, and transformative learning provide convincing frameworks for development and learning that are better matches with attributes for delivering culturally competent health care that all interested parties—particularly some members of society—believe medical school graduates and physicians should possess. Medical educators can synthesize these literatures to develop an ideology that will guide them in constructing experiences that address the particular challenges they face in ensuring that medical students can effectively achieve cultural competency.
Medical Student Composition
As mentioned earlier in this paper, in the University of Michigan’s affirmative action deposition to the U.S. Supreme Court, Gurin (1999) used Piaget’s work (1971, 1975/1985) to support the contention that diversity in the student body facilitates students’ cognitive and identity development. Specifically, when students interact with diverse individuals—in “safe” en-
vironments where all have an equal opportunity to participate and be heard—the process of perspective taking, which stimulates development, is fostered. However, there is a strong correlation between the ethnic/racial composition of the student body and the educational benefits to be gained from such diversity-related initiatives. For example, Chang (1999) provided evidence about the diminished benefits of diversity-related pedagogy and approaches when they are adopted with little or no change in student body composition. Currently, the number and percentage of medical school matriculants in the United States remains predominantly white, with little change in underrepresented minorities over the past 10 years. Given this, efforts to engage medical students from diverse backgrounds in educational initiatives to achieve goals for cultural competence will have diminished impact if student diversity is not increased.
Although our manuscript does not focus on admissions practices in medical school or health professions programs, deans and admissions directors should consider the connections that we have shown exist between a diverse student body and educational initiatives that help students achieve cultural competence as they reflect on the criteria they use for admissions to their programs. This is an important consideration to make in pondering ways to achieve greater diversity in these programs.
Bowen and Bok (1998) wrote about society’s increasing dependence on the character of the individuals who serve society in professional roles. Levin (1996) said, “Academic excellence must remain the most important single criterion for admission … but we should continue to look for something more—for those elusive qualities of character that give young men and women the potential to have an impact on the world, to make contributions to the larger society through their scholarly, artistic, and professional achievements, and to work and to encourage others to work for the betterment of the human condition.”
Recent reports detailing health-care disparities (e.g., Institute of Medicine, 2003) underscore the need to address more directly “the betterment of the human condition” by ensuring access to health care to certain populations in the United States. By achieving greater nonwhite diversity among their students, medical schools can play a key role in the longer-term solutions to these disparities. Studies conducted by Komaromy and colleagues (1996, reported in Bowen and Bok, 1998) and Keith and colleagues (1985, reported in Bowen and Bok, 1998) provide important evidence that black and Hispanic physicians are much more likely to treat patients in minority communities that include poor people and that minority physicians are twice as likely to treat patients in locations where there are health-care shortages (as identified by the federal government). Medical schools may want to consider documented outcomes like this or evidence about the
predictive value of admissions criteria as they contemplate increasing diversity in the medical student population.
For example, a recent analysis of predictors of medical school performance (White et al., unpublished) showed that for underrepresented minority students at one medical school, academic performance (i.e., the undergraduate grade point average) is a better predictor of academic performance in medical school (measured at three time points, progressively) than standardized test scores (i.e., the Medical College Admissions Test, or MCAT), which reliably predicted only scores on future standardized tests (i.e., USMLE Step 1 examination).
Extending the Transformation into the Clinical Years
We ask medical educators to consider how studies reported in the higher education and psychology literatures (and to a lesser degree in the medical education literature), many of which are presented here, can be used to develop approaches that ensure medical student achievement of cultural competence. The methods and pedagogies discussed in this paper can potentially help medical students transform their perspectives about diversity and at the same time progress toward achievement of self-author-ship, which provides a foundation for understanding the perspectives of those from other cultures and backgrounds.
However, in considering a comprehensive educational approach within the medical education context, the “negative reinforcement” issues also must be addressed. When students begin clinical training, they leave behind the sheltered environment of the classrooms and clinical skills laboratories, and the day-to-day influence of the faculty members who have taught them in the first 2 years. As they enter the clinics, hospitals, and operating rooms, the “hidden curriculum” (Hafferty, 1998) and “hidden culture” (Taylor, 2003) largely dictate the cultural norms students will need to survive or even thrive. As noted by Hafferty (1998), the values underlying these informal curricula might be in direct conflict with the values underlying the goals of the formal curriculum. The challenge for medical educators is how to extend learning into a very influential milieu over which they have limited control and which in fact may serve to undermine or undo learning that has occurred.
In this paper we have encouraged medical educators to contemplate connections between attributes associated with specific developmental levels and those associated with educational standards and goals for cultural competence. As noted, language in the standards describing desired attributes of physicians closely mirrors language that Perry (1970), Kegan (1994) and others use to describe a high (or in some cases the highest) level of cognitive and interpersonal development—one in which individuals be-
come the creators of their own lives, with their own sets of values and convictions to guide them, along with the abilities to self-reflect, self-assess, and self-direct. It might be reasonable to anticipate that students who have achieved self-authorship prior to being sent into the realm of the informal curriculum have in essence been “armed” with the capability to create and rely on their own value structures, thus possibly diminishing (at least in the short term, until they gain more professional autonomy) the undermining influence of the informal curriculum. Comprehensive assessments already in place in most medical schools can be used to monitor the longitudinal effectiveness of newly adopted pedagogies and approaches by measuring mastery of specific learning outcomes into and after one or both of the intensive clinical years.
It is also not impossible to imagine a health-care world where educational values correlate more closely with conflicting cultural values. Standards developed by the Joint Commission on Accreditation of Healthcare Organizations (2003) include quality of patient care, which many institutions are assessing through surveys of patient satisfaction. This process provides a direct evaluation link between health-care organizations and the individuals they serve and underlies efforts that can be made to modify and influence behavior of those who are providing health care. Whether such efforts can influence the “moral underbelly” (Hafferty, 1998) of health care organizations remains to be seen, but with regard to influence over student values related to cultural competence, they are a move in the right direction.
In this paper we have presented an evidence-based argument to support the importance and benefits of diversity in higher and health professions education. To understand specifically what we mean by “diversity in higher education,” we began with a description of the factors within college/university campus climates that impact educational diversity: historical legacy (resistance to desegregation and unrecognized, embedded advantages for dominant cultures), psychological climate (perceptions of discrimination and attitudes toward individuals from different cultures), behavioral climate (social and educational interactions among students and faculty), and compositional diversity (racial/ethnic composition of the student body).
In a discussion about linking diversity with learning, we presented information about college student cognitive and emotional development; approaches to learning that are active and student-centered and provide the discontinuity and discrepancy that stimulate development within a cognitive framework; and specific learning methodologies that encourage cooperation, deepen understanding, and enhance self-esteem.
Finally, we presented information on the increased benefits of combining student composition with educational initiatives, impediments to institutionalizing diversity-based programs, and principles that might guide thinking and action related to integrating diversity-based initiatives into college and university life.
We then linked this body of evidence to health professions education, in a specific medical education context, where the argument supporting the educational value of diversity is even more compelling given the goals and standards related to the competent care of patients in an increasingly diverse U.S. population.
Specifically, we presented a brief history and described the structure of medical education programs, and described external goals and standards that guide medical educators in developing specific institutional goals and learning outcomes. We explained current educational initiatives in the medical education literature designed to achieve cultural competence and suggested a potential “disconnect” between current approaches and educational goals and standards.
We linked student development to potentially effective pedagogies, building on the higher education research on transformative learning and adding information about social justice educational principles and pedagogies from the higher education and medical education literatures. Although not a primary concern of this paper because of the evidence that cautions educators about important connections between the racial and ethnic composition of student bodies and diversity-based initiatives to achieve educational outcomes, we briefly discussed the current composition of students in U.S. medical schools.
Finally, we recognized that changes in curriculum and composition alone will not address the negative reinforcements that can undermine educational goals and standards. We asked readers of this paper to think about how pedagogy and experience to help medical students achieve self-authorship not only yields benefits related to learning and autonomy, but might also serve to at least diminish the influence of negative reinforcements that can weaken efforts to achieve clinical competence.
To achieve these benefits and maximize the opportunities for teaching and learning that diverse learning environments provide, it is important to give careful consideration to the context in which the diversity is enacted. Merely bringing diverse people together in an institution or an educational program does not ensure that the benefits of diversity will be achieved. Although it is an important first step, it cannot be the only step that this taken. In reviewing the relevant literatures, we have attempted to identify some general principles that can guide efforts to enhance the goals of diversity in health professions education.
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