February 2024

Money matters

Orr CJ, Turner AL, Ritter VS, Gutierrez-Wu J, Leslie LK. Pursuing a Career in Pediatrics: Intersection of Educational Debt and Race/Ethnicity. J Pediatr. 2023 Jan;252:162-170.  https://doi.org/10.1016/j.jpeds.2022.08.014

Reviewed by Molly Rideout

What was the study question?

What is the level of educational debt among pediatric interns based on race/ethnicity?

What personal, professional, and financial factors influenced pediatric interns’ choice of career and how are these associated with race/ethnicity and level of educational debt?

How was the study done?

Using a cross-sectional study design, authors examined data from surveys linked with pediatric interns’ in-training exams from 2018-2020. The primary focus was the association between race/ethnicity and educational debt. Secondary associations were examined for race/ethnicity, educational debt, and the importance of personal, professional, and financial factors in career choice. Chi-Squared and one-way ANOVA tests were used to examine these associations. Authors chose race/ethnicity groupings based on 2015 Census categories.

What were the results?

Among pediatric interns responding to the survey (n=7943; 91.5% response rate), 44% had educational debt over $200,000, and 20% reported no educational debt. Black/African American respondents had the highest number reporting over $300,000 in debt (33%), and Asian respondents had the highest reporting no debt (33%). The importance of mentorship in choosing pediatrics was highest among Black/African American respondents with no debt, and the importance of mentorship decreased as debt increased for all groups, a change greatest for Black/African American respondents. The importance of debt and earning potential increased as level of debt increased, a change also greatest among Black/African American respondents.

How can I apply this to my work in education?

The educational debt burden, since unevenly distributed among racial/ethnic groups, may hinder progress towards building a pediatric workforce that is representative of the increasingly diverse pediatric patient population in the US. While mentorship is essential, it is unlikely to fully buffer the negative effects of high educational debt. Advocacy for loan forgiveness and increasing Medicaid reimbursement (leading to increased pediatric salaries) could mitigate the debt burden, in turn attracting more students from underrepresented racial/ethnic groups into pediatrics, and ultimately improving patient care for children.

Editor’s Note: This study emphasizes the complex outcomes of America’s ongoing, often predatory, financial interaction with Black communities. Students with minoritized racial and ethnic identities are not a monolithic group, and multiple societal factors will affect what individuals consider to be important to their future as Pediatricians. Mentorship is essential and should continue to center the specific needs and values of the mentee. (AK)

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A field in need of cultivation

Rashid M, Nguyen J, Foulds JL, Dennett L, Cardinal N, Forgie SE. A Scoping Review of Indigenous Health Curricular Content in Graduate Medical Education.  J Grad Med Educ. 2023 Feb;15(1):24-36. https://dx.doi.org/10.4300/JGME-D-22-00180.1

Reviewed by Terry Kind

What was the study question?

What’s been published on the impact and challenges associated with Indigenous curricula for resident physicians?

How was the study done?

In this scoping review (using a PRISMA-ScR checklist), authors searched 9 databases for articles focusing on the impact and challenges associated with Indigenous curricula developed for residents. Articles of varying types and methodology were included with this focus, if in English, and if detailing more than a single experience or session. Date range was from database inception to April 2021. Authors extracted and presented data in tabular format and also prepared narrative summaries; they then analyzed these summaries thematically with a critical theory philosophical approach.

What were the results?

11 publications met the inclusion criteria, from 1557 individual records screened. 6 of the 11 were published in the US, 3 from Canada, 1 from Australia and 1 from New Zealand. The teaching methods allowed residents to engage, discuss, and think critically.  Curricula were typically optional and combined with other topics. Themes included 1) misunderstandings and cultural bias about Indigenous people by residents, 2) community driven partnerships as a key component to create safe environments for residents and Indigenous stakeholders, and 3) challenges implementing the curricula, such as lack of tools and knowledge expertise, funding, and time to plan and partner.

 How can I apply this in my work in education?

This is a sparse field of research, and rigorous program evaluation is needed regarding the impact of these curricula on residents, on care delivery, and on outcomes in Indigenous communities. Authors recommend core rather than elective curricula, increased interprofessional collaboration, and stable funding at the institutional level for residents and Indigenous partners to participate. Notably and distressingly, authors discuss that existing biases and gaps also contribute to the hidden curriculum strengthening a colonial agenda.  Medical student focused curricula were beyond the scope of this scoping review, so COMSEP members could consider what is and what should be taught in the medical school context, and can draw on these findings regarding how best (authentically, sensitively) to develop, implement, and evaluate such curricula.

Editor’s Note:  Many medical schools have recently incorporated land acknowledgements to bring awareness to the displacement of local Indigenous Peoples, a practice meant to create visibility and show respect. However, this study shows that we have yet to provide meaningful education to our future physician workforce on Indigenous populations and the significant healthcare disparities they face. As the authors mentioned, it is crucial for us to take additional steps to meaningfully partner with Native communities to truly effect change. (AK)

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Disparities from the ground up

Hanson JL, Pérez M, Mason HRC, Aagaard EM, Jeffe DB, Teherani A, Colson ER. Racial/Ethnic Disparities in Clerkship Grading: Perspectives of Students and Teachers. Acad Med. 2022 Nov 1;97(11S):S35-S45. https://dx.doi.org/10.1097/ACM.0000000000004914

Reviewed by Caroline R. Paul and Deborah Rana

What was the study question?

The study sought to understand what happens during clerkships and to discover factors which may contribute to grading inequity.

How was the study done?
Medical students and clerkship teachers at 3 U.S. medical schools in 2020 completed a demographic survey and a semi-structured interview. The constant comparative method was used to analyze transcripts by inductively developing codes, grouping codes in categories, and refining codes, descriptions, and group assignments to identify themes. Interpretations of and relationships among themes were iteratively discussed to develop a grounded theory which formed the basis of a theoretical model emerging from the data analysis.

What were the results?

The study screened 133 participants. From that group, they selected 20 medical students and 30 teachers (28 clinical faculty and 2 residents). Six key themes were found including the social milieu of medical education, societal influence, assessment processes, student characteristics and background, the learning environment, and student interactions and reactions. The researchers came to see the culture within medicine influenced by the inter-relationships of student interactions and the learning environment. As student backgrounds and characteristics were brought into the milieu, societal influence affected the assessment processes resulting in grade disparities in clerkship grades.

How can this be applied to my work in education?
Understanding how the clinical learning setting can invite biases in the milieu of relationships formed during the clerkship experience is illuminating in this qualitative study. The authors suggest tendencies toward bias may be best counterbalanced by applying ways to observe performance more consistently and objectively, to create assessment systems, and offer opportunities in systematic ways that would seek to more equitably encourage the development and the assessment of clinical skills in learners from all cultural and ethnic backgrounds, more particularly, those from backgrounds currently underrepresented in medicine. Lastly, the article serves as an elegant model for showcasing how grounded theory may be applied through a qualitative lens to study the context of the clinical learning environment within medical education.

Editor’s Note: The powerful quotes included in this article from learners and educators highlight the lack of inclusion of and access for students with underrepresented identities, as well as those whose personality traits may differ from the “prototypically engaged” student. A compelling paper by Greenwald and Pettigrew^* asserts that ingroup favoritism is a leading cause of discrimination in today’s society, more than hostile prejudice. This article should serve as a reminder for us to be more intentional in our interactions with all students so we create learning environments that are inclusive. (AK)