A checklist for advancing equity, diversity and inclusion in medical sciences and education, part one

Efforts to embed equality, diversity and inclusion in medical sciences and education are gaining momentum. In two parts, we present a checklist of six questions, created by a partnership of students and academics at the University of Exeter medical school, to help lecturers in medicine and medical sciences embed diverse and inclusive strategies within their curricula. 

We start here with the first three questions, which serve as a launchpad for academics to work towards dismantling systemic barriers, promoting health equity and fostering a sense of belonging among students.

1) Have you ensured all images and graphics used are representative and inclusive of protected characteristics? 

It is crucial to recognise the impact that images and visual aids have on student learning and the relatability of knowledge across diverse groups. So check if the images used in your teaching materials are inclusive of different protected characteristics. If not, actively search for visuals that represent the student population and wider community in which students will live and work. As institutions strive to train global citizens, they must expose students to diverse imagery to enhance their awareness and foster a sense of belonging within the curriculum. Students should feel “seen” and represented in the learning materials.

• Resource collection: How to achieve equity in higher education
• Medical teaching resources need to represent all skin colours 
• Resource collection: Decolonising the curriculum

For example, when studying emotion as part of cognitive and behavioural neuroscience, facial expressions are used to illustrate concepts of brain activity and emotion to students. Lecturers must ensure the images used represent a range of ethnicities, genders and cultures where emotions can be expressed differently, rather than relying solely on the most easily accessible faces surfaced by a Google search, which are typically white males.

Although images and graphics are helpful, they can also reinforce stereotypes and unrepresentative associations. Academics need to be mindful of avoiding implicit associations and ensure that graphics show a range of visually identifiable protected characteristics. Challenge assumptions behind image choices. For instance, is the image of a person in a wheelchair only used when discussing disability? How often do we represent people with disabilities in a celebratory or professional context, as scientists or professors?

Images play a profound role in shaping perceptions. It is vital to critically evaluate images we select to accompany teaching resources. 

2. Are the biopsychosocial and demographic models of diseases included in your module?

Diseases are expressed differently across cultures due to psychosocial factors. Students must be made aware of this and the impact of these perceptions on the delivery of healthcare. Models of disease cannot solely be grounded in Western medicinal values and data if we are to ensure effective and compassionate treatment for all.

Covid-19 highlighted disparities among black and ethnic minority groups, who experienced higher infection and mortality rates. Factors such as housing conditions, unequal healthcare access and public-facing occupations, including a greater likelihood of working in health and social care roles, are all believed to have contributed to these statistics.

Students need to understand how historic discrimination and poorer health outcomes can contribute to mistrust towards healthcare and vaccination programmes within some communities. This results in under-reported diagnoses and reduced participation in vaccination efforts, skewing disease data. Educators should illustrate how social barriers limit access to medical care for certain groups, preventing full understanding of diseases. For example, language barriers and lack of cultural competence in healthcare settings can deter marginalised groups from seeking medical care. Equity in medicine requires tailored treatment procedures for different groups, a principle that must be communicated to students.

Research techniques used to identify and treat diseases must be scrutinised because certain demographics can be overlooked. One example is that genome-wide association study (GWAS) analyses have been performed largely on people with European ancestry. This means that genetic variants that are associated with diseases in other populations might not be identified.

Where the genetic profiles of certain minority groups are not included, this could lead to inadequate and inefficient diagnoses or treatment options. It is our responsibility to consider these factors when teaching so that the next generation of researchers develop a more objective and inclusive mindset.

3. Do you communicate historical contexts of how knowledge was created or research conducted?

Much medical knowledge is founded on a dark history of injustice and exploitation by renowned scientists and doctors who contributed to health research. Medical educators should embrace a duality of purpose, contributing to the positive expansion of knowledge and progress in medicine while simultaneously communicating injustices and unethical practices. 

It is sometimes feared that speaking about injustices when showcasing famous scientists means erasing their impact on knowledge creation. However, the goal is not to evaluate scientific discoveries purely through this lens, but to acknowledge contextual origins when teaching students about health research.

A prominent case is that of gynaecological knowledge, stemming from the exploitation of black women. James Marion Sims, often referred to as the “father of modern gynaecology”, developed ground-breaking surgical techniques. His work was, however, highly controversial due to the unethical experimentation he conducted on enslaved African-American women without their consent or use of anaesthetics. Sims justified his inhumane research methods with the popular notion of the time that black people felt less physical pain than their white counterparts.

One of the landmark scientific discoveries of the 20th century, the discovery of the DNA double helix, was underpinned by gender discrimination, whereby Rosalind Franklin’s significant contributions were overshadowed by the work of Nobel prize winners James Watson and Francis Crick.

The more we know about our past, the better we can understand current injustices in medicine and research and push our students to be critical thinkers and build equitable futures. 

Musarrat Maisha Reza is a senior lecturer in biomedical sciences, and Mia-Rose Gillison is a neuroscience student, both at the University of Exeter.

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