https://orcid.org/0000-0003-3486-5515
ABSTRACT
Background
Simulated cases are widely used in medical education to develop clinical reasoning skills and discuss key topics around patient care. Such cases present an opportunity to demonstrate real world encounters with diverse patient and health provider identities, impacts of social and structural determinants of health, and demonstrate a generalist approach to problems. However, despite many calls-to-action for medical schools to better incorporate equity, diversity and inclusion (EDI) and generalism, it remains difficult to evaluate how well these goals are being met.
Methods
A quality improvement project was completed at a single medical school to evaluate the domains of generalism and EDI within simulated cases used in the preclinical curriculum. Generalism was evaluated using the Toronto Generalism Assessment Tool (T-GAT). EDI was evaluated using a locally developed novel tool. Analysis included descriptive statistics and Pearson correlation coefficient.
Results
A total of 49 simulated cases were reviewed. Twelve generalism and 5 EDI items were scored on a 5-point Likert scale, with higher scores indicating better demonstration of generalism or EDI within a case. Average generalism score across all cases was 45.6/60. Average EDI score across all cases was 11.7/25. Only 21/49 cases included representation of one or more diverse identity categories. The most common diverse identity represented was non-white races/ethnicities, and the identity represented the least was diversity in language fluency. Generalism and EDI scores demonstrated a weak positive correlation (R2 = 0.25).
Conclusions
Quantitative evaluation of simulated cases using specific generalism and EDI scoring tools was successful in generating insight into areas of improvement for teaching cases. This approach identified key content areas for case improvement and identities that are currently underrepresented in teaching cases. Similar approaches could be feasibly used by other medical schools to improve generalism and EDI in teaching cases or other curricular materials.
Introduction
Simulated patient cases are widely used in medical curricula at different levels of training, but many do not address important concepts of medical generalism and do not demonstrate adequate approaches to concepts of equity, diversity and inclusion (EDI). Medical generalism refers to a philosophy of care that looks at a patient as a whole person in their context, and includes actions and behaviours beyond medical expert clinical decisions alone [Citation1]. An intentional EDI approach to curriculum requires ensuring that curricular materials, such as simulated cases, represent real world identities and social contexts to provide exposure for students to diverse patients and situations with a goal of improving equity in healthcare broadly [Citation2]. Simulated cases are used widely throughout medical schools, particularly in the preclinical curriculum, as opportunities for students to engage in clinical reasoning exercises and to develop fundamental critical thinking skills and key content knowledge. The degree to which these cases are targeted to a generalist level of medical knowledge (incorporating generalist principles and philosophy of care), and the degree of representation of diverse patients, health providers, and social contexts (without leaning on bias and stereotypes) is largely unknown [Citation3].
Over the past decade, there has been an increasing emphasis on the value and importance of patient-centered care as a key component of high quality healthcare [Citation4], including recognition of the complexities of each individual patient and their medical and social contexts. Medical training programs are working to determine how EDI is being incorporated into program structures and curricular content, as EDI is a critical concept in preclinical training. Future physicians must be able to respond to the needs of the community, with a particular increased focus on anti-racism and better supporting the health of equity-deserving and underrepresented groups [Citation5,Citation6]. Incorporating examples of and discussion points for social accountability and social justice into the preclinical curriculum provides opportunities to correct past injustices promulgated by the medical system. Despite the many calls-to-action for medical schools [Citation7–10] to incorporate components of EDI and anti-racism into their curricular content, it remains very difficult for programs to formally evaluate their current curricula to determine how well it is meeting these goals.
Frequently used pedagogical approaches that rely on simulated patient cases include problem-based learning (PBL) or case-based learning (CBL) [Citation11,Citation12]. During these sessions, students frequently follow a case from an undifferentiated initial presentation through to diagnosis and management. The simulated cases used in these settings include variable levels of detail when describing the personal backgrounds, sociodemographic factors, and other details of patients, families, and health providers to provide context for the clinical case and stimulate discussion. With the increasing societal focus on EDI in medical education, medical training programs need to continue exploring methods to evaluate and improve the teaching cases being used.
Several groups have developed curriculum innovations regarding healthcare disparities [Citation13–16], and others have developed strategies and tools to review teaching cases for diversity and inclusion [Citation17,Citation18]. One standout example was Krishnan et al. [Citation19], who reviewed the content of teaching cases used in the commercially available Aquifer platform (https://aquifer.org/) widely used by North American undergraduate medical programs. The authors utilized an evidenced-informed framework to analyze their virtual teaching cases for ‘effectiveness of the presentation of race and culture’ and identified 6 main themes of common mistakes noted in the cases: 1) cases did not distinguish between race as a genetic or biologic risk factor and social or structural causes of racial health disparities; 2) etiologies of diseases centered around individual behaviours and characteristics only and not potential upstream factors, and language used prevented understanding of root causes of health disparities; 3) patient descriptions included reductionist and essentialist portrayals of non-Western cultures and people of color; 4) cases portray a sense of futility or ignore addressing social and structural causes of illness; 5) cases lacked critical reflection on health disparities and implicit bias in medicine; and 6) cases did not consistently portray minority identities among patients or health providers. From these 6 themes, they developed a ‘Race and Culture Guide for Editors of Teaching Cases’ with 6 sections, including suggested case edits and exemplars of how to better incorporate content and discussion topics targeting the deficient areas from the themes. This guide formed the basis for the locally-developed EDI scoring tool used in this project.
Similarly, there are many calls for medical schools to examine their programs and look to better incorporate a focus on generalist practice into the curriculum. The notion of generalism in medical education has existed for some time with the goal to better meet the needs of the complex patient in a holistic manner [Citation1]. Generalism has been defined as ‘a philosophy of care that looks at the whole person in the context of his or her life, with a commitment to the person, as opposed to the disease itself, and to providing continuous and coordinated care in collaboration with the larger health care team’ [Citation20]. The generalist approach has long been championed by physicians in family medicine, and it is well recognized that the global healthcare system is currently experiencing a significant crisis in primary care [Citation21–23]. In 2021, Nutik and colleagues [Citation20] developed a framework to quantify the principles of generalism within curricular materials. The Toronto Generalism Assessment Tool (T-GAT) was developed as a method to score curricular materials on the degree of representation of key elements of generalism, including: 1) portrayal of the whole person in the context of their family and social environment; 2) importance of the doctor-patient relationship; 3) respect for the role and scope of generalist practice; 4) early presentation of undifferentiated problems; 5) management of uncertainty and tolerance of risk; 6) consideration of multimorbidity and chronic disease; 7) emphasis on prevention and health promotion; 8) continuity and coordination of care; 9) importance of multidisciplinary team care; and 10) including advocacy in patient care. This tool was found to be easy to use and had an overall reliability score of 0.48 and internal consistency of 0.92, using a group of new faculty raters and a random sample of 21 teaching cases from their undergraduate medical curriculum. The T-GAT was thus selected as the basis for evaluating generalism in this project.
Our undergraduate medical education program has utilized simulated cases as part of our ‘Discovery Learning’ small group sessions (pedagogy on the spectrum between PBL and CBL) in the preclinical curriculum for over 20 years. As part of the goal of continuous quality improvement of our curriculum, this project included two key aims: 1) to determine the current generalist focus of simulated case content and identify content that may be too subspecialized at the preclinical stage of training; 2) to identify the current state of our simulated cases and degree of content focused on EDI domains, and identify specific content and topics within the cases for updates and future improvements.
Methods
Context
A quality improvement project was conducted at a single medical school to quantify the degree of generalism and EDI constructs presented in the narrative simulated cases used in the program’s structured Discovery Learning (DL) small group sessions. Our undergraduate medical program is a 4-year program, with 2 years of preclinical training followed by 2 years of clinical training. During the preclinical years, DL sessions are held three times per week (total duration 5 h per week) across all 11 system courses, with students running through a single case per week. Each course includes between 3 to 7 weekly cases. Group sizes range between 8–12 students and sessions are taught by either physician or non-physician tutors, with the same tutor assigned to a group for the duration of a system course where possible. All sessions are considered mandatory for students to attend and participate in.
This project is reported according to the SQUIRE-EDU guidelines [Citation24], a collection of best practices and recommendations for increasing the quality of reports aiming to improve healthcare and healthcare education (see checklist in Supplemental Materials).
Intervention
The narrative simulated cases included student-facing content and tutor-specific content. Student-specific content included case vignettes, investigations, and patient outcomes as the cases progressed. Tutor-specific content included tutor guides with additional case details, background information for the clinical conditions, and prompting questions for discussion. All components of each case were reviewed independently by two raters (TS, KH), both second-year medical students who had recently completed the preclerkship curriculum and thus had lived experience of participating in the cases being evaluated. The raters were required to justify each of their scores for the cases and this was then reviewed by a faculty member (JY) for agreement and consensus. All cases were assigned quantitative scores using the measures described below. A detailed report of these scores and specific narrative feedback for each case was provided to course faculty coordinators for review upon completion of this project for future implementation of targeted improvements to individual cases.
Measures
The Toronto Generalism Assessment Tool (T-GAT) developed by Nutik et al. [Citation20] was used to evaluate each case and provide a generalism score. This rating scale included 12 questions addressing the generalism framework domains and cases were scored on the degree of inclusion of the following major themes: portrayal of the whole person in the context of their social environment, importance of the doctor-patient relationship, respect for general practice, undifferentiated problem presentations, management of uncertainty, consideration of multimorbidity and chronic disease, emphasis on prevention and health promotion, continuity of care, multidisciplinary team care, and advocacy. All questions were scored on a 5-point Likert scale, with 1 = not at all present and 5 = extensively demonstrated. A maximum score of 60 was possible, and higher scores indicated more extensive coverage of generalism domains.
No validated or previously described tools were available to quantify the EDI domains of each simulated case. Using the structure and scoring system of the T-GAT tool as a framework, we utilized the 6 key themes described in Krishnan et al.’s ‘Race and Culture Guide for Editors of Teaching Cases’ [Citation19] to develop a novel scoring tool for this project. Each of the 5 initial themes identified in the guide were converted into a scoring item or question (see ). All items were scored on a 5-point Likert scale similar to the T-GAT, producing a total score of 30, with higher scores indicating stronger demonstration of EDI domains within the case. The sixth theme from the guide regarding the diversity of representation within the simulated cases was scored categorically as yes/no, with the specific representative demographics identified as present or not present. The scoring tool was piloted by the student raters with 4 cases initially, then discussed with faculty for any revisions prior to completing the remainder of the reviews.
Table 1. Scoring rubric for equity, diversity and inclusion domains of simulated cases; adapted from Krishnan et al.’s ‘race and culture Guide for editors of teaching cases.’ SSDOH = social and structural determinants of health.
Analysis
All cases were independently scored by each student rater (TS, KH) initially, using both tools described above. Highly discrepant scores (defined as score differing by 3 or more points between reviewers) were reviewed and discussed by the student raters regarding their scoring rationale, and subsequently changed if specific content was felt to have been missed or inappropriately scored. If scores remained highly discrepant following review, the case was reviewed independently by a faculty reviewer (JY) and further discussion among all three reviewers was had to reach consensus on the final score. Descriptive statistics were used to calculate an average sum generalism score (total 60 points) and average sum EDI score (total 25 points) for each teaching case. An average score for each specific generalism and EDI question was also calculated across all cases. Pearson correlation coefficient was calculated between the average generalism score and average EDI score across all individual cases to assess for potential correlation. Parametric statistics and calculations were chosen for analysis according to methodology as described by Norman [Citation25]. All calculations were conducted using Microsoft Excel.
Ethical considerations
No human or animal subjects were involved in this project. This project was a local quality improvement project for the educational curriculum, utilizing simulated patient cases. An ethics review was not required.
Results
A total of 49 simulated teaching cases were reviewed, comprising all mandatory cases used within the DL curriculum of year 1 and year 2 in the University of Alberta undergraduate medical program (see ). A total of 931 individual scores were recorded and only 12 individual items (1.3%) were found to be highly discrepant (difference greater than 3 points) between reviewers; these 12 items were resolved by consensus as described in the methods.
Table 2. Total number of simulated cases reviewed. Number of cases is proportional to course duration.
Generalism scores
For generalism, the highest average score was for question 1: ‘Is the case relevant to common problems seen in primary care’. The lowest average score was in question 2.10: ‘Advocacy’. This suggests that, overall, the case presentations were highly relevant to common presentations in primary care, but that the depiction of Advocacy within the narrative information was weaker. The scores for each individual generalism question averaged across all cases are shown in . The overall average generalism score per case was 45.64 (SD 6.62) out of possible 60 points.
Figure 1. Average generalism score by question, averaged across all 49 cases.
Equity, diversity and inclusion (EDI) scores
Regarding EDI domains, the average score was highest on question 3: ‘Patient history centers around unique circumstances and not racial/cultural stereotypes’. Average score was lowest for question five: ‘Case discusses implicit bias and critically reflects on racial/cultural disparities’. The scores for each individual EDI question averaged across all cases are shown in . The average total score per case was 11.74 (SD 3.31) out of 25.
Figure 2. Average equity, diversity and inclusion (EDI) score by question, averaged across all 49 cases. See table 1 for question details.
Regarding diversity of representation within the simulated cases, only 43% (21/49) of the DL cases represented any of the diversity categories outlined earlier (see ). The categories with the highest representation were as follows: 1) non-white races/ethnicities (11/49 cases); 2) diversity in urban/rural patients (7/49 cases); and 3) diversity in national origin (4/49 cases). The category with the lowest representation was diversity in language fluency (0/49 cases). Four additional categories were represented in a single case each: multiracial couples, non-binary gender identity, diversity in disability, and diversity in religious beliefs and traditional dress.
Figure 3. Number of cases where each category of diverse identity is portrayed. Note that only 21/49 cases included at least one category; some cases represented multiple categories.
Correlation between generalism and EDI
A weak positive correlation was identified between the average generalism and EDI scores (R2 = 0.25), suggesting that a case with high generalism scores was somewhat more likely to also have a high EDI score, and vice versa. No clear pattern or overt clustering of cases was evident by course (see ).
Figure 4. Scatterplot of EDI scores (Y-axis) and generalism scores (X-axis), with each individual point representing one case. The trendline represents the correlation between the X and Y axis. The R2 value of the trendline is equal to 0.25. Circular points represent first year courses, while square points represent second year courses. Point colours correspond to the course to which they belong, depicted by the legend.
Discussion
Critical appraisal of existing curricular materials is an important aspect of continuous quality improvement for all medical schools. With an increasing need to focus on the social accountability mission of medical education programs [Citation5], it is imperative that core curricular materials provide appropriate generalist perspectives and narratives that promote principles of equity, diversity and inclusion. Our analysis of mandatory teaching cases used within the preclinical curriculum identified where individual cases sat along the spectrum of poorly or strongly demonstrating generalism and EDI concepts. Cases with high average generalism or EDI scores were identified as useful examples for developing future cases or for modeling how current cases could be changed to better emphasize these principles. Cases found to have low average generalism or EDI scores were highlighted as key cases for improvement or redesign.
This project utilized an existing and validated tool to evaluate simulated cases for generalism [Citation20]. The T-GAT scoring scale emphasizes many aspects of generalism that are important for real-world clinical practice, which are often independent of clinical specialty area. Some key components of generalism include health promotion, tolerance of risk, longitudinal care, multidisciplinary team care, advocacy, and highlighting the importance of a strong doctor-patient relationship to ensure positive health outcomes. Based on the aggregated results from the T-GAT scoring scale, our teaching cases scored quite well across almost all questions, suggesting that each component of generalism was portrayed strongly and clearly for students in the cases. The one exception to this was the advocacy domain, which received the lowest average score amongst all components of the T-GAT. During review of the case narratives and tutor guides, it was clear that advocacy was intended to be flushed out more in group discussions. However, the lack of explicit examples of advocacy in the case narrative or in any prompting questions or discussion points within the tutor guide led to this domain receiving the lowest overall score. While it is not necessary for every case to extensively demonstrate advocacy, a higher proportion of specific cases should be identified to explicitly demonstrate advocacy and optimize opportunities for student exposure and discussion of this important concept.
The EDI scoring scale used was developed as a novel tool for this project by adapting the key themes and categories from Krishnan et al.’s ‘Race and Culture Guide for Editors of Teaching Cases’ [Citation19] and the scoring system used in the T-GAT. While the existing guide provided useful examples to case authors, the use of a quantitative scoring system allowed for a more global evaluation of the current state of EDI representation in our curricular materials, provided objective comparison across cases and courses, and allowed us to identify specific cases to prioritize for revision in the near future. Following Kane’s validity framework [Citation26], our tool had the intended use of identifying which cases were most in need of immediate changes, thus allowing the prioritization of resources to implement these updates. The scoring items were developed from an existing evidence-informed source (Krishnan’s editors guide), and the rubric used (Likert scale and anchors) had been shown to be reliable in a similar tool (T-GAT). As a proof-of-concept quality improvement project, we chose to use consensus decisions in scoring rather than a large sample of raters to trial this tool. We therefore were not able to formally measure psychometric properties of this EDI tool, but were able to identify exemplar simulated cases as well as deficient cases from our review, which could then be used to guide future curricular content changes and updates. There was consistency amongst the student and faculty reviewers across a large number of data points, thus showing evidence of generalisability for the scoring tool to evaluate EDI across many different simulated cases. Future work to quantitatively evaluate rater reliability and consistency would be beneficial for further validation of this tool.
Other Canadian medical schools have utilized different methods to evaluate teaching cases for EDI content, which have been presented at conferences but not yet formally published [Citation27,Citation28]. Stone et al. similarly used the Krishnan et al. framework to review their medical school teaching cases and found that discussions surrounding social and structural determinants of health (SSDOH) and unconscious bias were lacking [Citation27]. However, without a scoring system, measuring curriculum improvements after edits to cases may be more difficult. Our approach allows for re-assessment and the potential for further quantitative comparison of changes to case content. Similar to Stone et al., our results showed that our local teaching cases could benefit from more in-depth discussions of bias or racial/cultural health disparities. We found that all cases consistently had low scores in 4 themes from Krishnan’s case editor guide: 1) relationship of SSDOH to racial/ethnic health disparities; 2) relationship of SSDOH to patient health behaviors; 3) SSDOH addressed in treatment plans; and 4) reflection on implicit bias and racial/cultural health disparities. Appropriately integrating these concepts into curriculum would serve to better prepare future physicians for practice in today’s complex sociocultural medical landscape.
Other groups have had similar goals of assessing medical school cases to be more inclusive and representative of a diverse patient population [Citation17,Citation27,Citation28]. St-Georges et al. used an equity checklist to address specific disparities in medical school curricula [Citation28]. Their checklist highlighted several important inequities previously found in medical curricula, including the lack of depiction of dermatological processes on multiple skin colors, and the pervasive and dangerous error that black patients may experience pain differently. Other categories in this checklist included clinical measurements, genetics, epidemiology, language, and imagery. Future research could aim to incorporate this checklist-style approach and the EDI scale used in our project to develop a more consistent and validated teaching case scoring system.
Next, we found that less than half (43%) of the cases included a diverse range of identities. The patient population that students are training to serve will inevitably include individuals with diverse identities, including diverse racial, cultural and language backgrounds, disability status, socioeconomic status and gender identity. Minorities that are under-represented in medicine should be of particular interest for depiction in teaching cases, not just as patients but as the health professionals in the cases, so that students are able to further develop cultural awareness and cultural competency prior to beginning their clinical work. A study by Lee et al. emphasized the importance of including diverse identities such as race, ethnicity, gender and sexual orientation in clinical case vignettes as failing to do so would perpetuate the cycle of cultural blindness [Citation18]. However, while there is an impetus to include more diverse representation in curricular materials, it is important to ensure that appropriate context is provided as inclusion of different identities without such context may only serve to reinforce pre-existing biases and stereotypes [Citation29] and fail to recognize the impact of SSDOH on the outcomes of individuals and particular communities [Citation30].
Finally, a novel and interesting finding in this project was the weak positive correlation between generalism and EDI scores. This correlation was not surprising as many of the key domains of generalism used in the T-GAT tool did seem to overlap with the key EDI domains. For example, cases that scored low in generalism frequently had low scores for advocacy, and similarly scored low in the EDI domain of addressing SSDOH in a treatment plan. This positive correlation also suggests that curricular improvements to either generalism or EDI or could result in overall better scores in both domains. Medical educators striving to bolster their curriculum may benefit from targeting specific inclusion of SSDOH details into the case narratives, including examples of advocacy to overcome SSDOH barriers, thus improving both generalism and EDI domains.
Limitations
This project did include a few limitations. Cases were primarily scored by student reviewers, with limited faculty review only in discrepant cases. However, only 1.3% of the individual items scored were found to be highly discrepant during the initial independent student reveiws and required further faculty review and consensus discussions. This suggests that our approach is feasibly implemented by student reviewers. A larger committee of case reviewers may have provided wider perspectives regarding some scores, however, using students who had just completed the existing curriculum provided a unique lived experience from which to score and critique the simulated case narratives and tutor guides. As a local quality improvement project, our smaller project team was better able to conduct this review in a timely fashion to deliver changes and suggestions to the curriculum. While this approach prevented formal psychometric analysis of the novel tool, the low incidence of highly discrepant scores from the initial reviews provides early proof-of-concept validity evidence for the use of this tool. Further research to trial this EDI tool with a larger sample of student and faculty reviewers would be beneficial in future to provide more concrete psychometric data to assess the reliability and internal consistency of this tool. Lastly, our scoring method for diversity identity categories was binary yes/no, which limited evaluating the depth of representation in the clinical vignettes. Future work to provide better context for this finding could include looking at correlating the presence/absence of diverse identities within the simulated cases to the other 5 key themes identified by Krishnan et al. and scored in the tool, to ensure that inclusion of diverse identities is not simply a checklist item but done with intention and balance to reduce bias and stereotypes.
Conclusions
Simulated patient cases are an essential tool for medical education, but all such curricular tools should be critically evaluated for their representation of important concepts of generalism and equity, diversity and inclusion. Our novel scoring system for EDI content and combining scoring for generalism was useful in providing insights and feedback to identify key areas for simulated case improvements in our local undergraduate medical program, which will allow our teaching faculty to prioritize the most essential cases for immediate revision and improvement. Further work to validate this EDI tool and to explore the relationship between principles of medical generalism would be beneficial to any medical school looking to identify and target curricular materials for improvements in the generalism and EDI domains, with the ultimate goal of furthering the social justice mandate of all medical schools.
Supplemental Material
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No potential conflict of interest was reported by the author(s).
Data availability statement
The data that support the findings of this study are available from the corresponding author, JCY, upon reasonable request.
Supplementary material
Supplemental data for this article can be accessed online at https://doi.org/10.1080/10872981.2024.2331852.
Additional information
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