Diversidade em Educação Médica

The New Diversity in Medical Education

Mark A. Attiah, B.A.

N Engl J Med 2014; 371:1474-1476 October 16, 2014 

DOI: 10.1056/ NEJMp1408460

During my pediatrics rotation, the mother of a patient waited until the attending physician had left the room before she lowered her voice, smiled, and asked, “Are you wearing your hoodie for Trayvon?” She didn't know what city I was from, what faith I belonged to, or what tax bracket I was in. She just knew that I was black, like her. This race-based camaraderie between patient and physician can improve patient satisfaction,1 and patients from racial minority groups tend to seek out physicians of their own race if given a choice.2 As a black medical student, I can attest that the sort of “diversity” that you can see — that allows you to be counted in a crowd — can significantly influence interactions with peers, instructors, and patients.

For the past few decades, medical education's definition of “diversity” has largely remained the same, as has the social mandate to increase it. With roots in the Civil Rights Movement, diversity initiatives have focused primarily on racial groups that had been implicitly and explicitly denied access to the field. Efforts to increase the numbers of blacks, Hispanics, and Native Americans served a moral imperative: it was the right thing to do. Such efforts have had mixed results: the proportion of Hispanic medical school graduates increased by 4.1 percentage points from 1978 to 2012, whereas the proportion of black graduates increased by only 1.8 percentage points during the same period (see Perspective article by Iglehart, pages 1471–1474). Moreover, this “good intentions” approach fails to critically examine diversity's true meaning and strips it of its potential to advance the field of medicine.

Enter “Diversity 3.0.” The term, coined by IBM, reflects a new way of thinking about diversity in education and the workforce. Building on the 1.0 model, in which diversity was seen as a necessary evil, and the 2.0 version, in which a diverse population was recast as a nice thing for the majority to have around, the current vision defines “achieving the full potential of this diversity [as] a business priority that is fundamental to our competitive success.”3 This reframing is not lost on Marc Nivet, chief diversity officer of the Association of American Medical Colleges. “1.0 is where diversity is competing with excellence,” Nivet explains. “Diversity 2.0, which is where we are, has not been viewed as central to the institution's drive for excellence.” In addition to integrating diversity into institutions' core missions, the 3.0 version, Nivet has written, “requires a focus on differences beyond race and ethnicity,”4 the traditional emphases of multicultural affairs offices.

Under this model, medical-student diversity becomes a prerequisite for an optimal learning environment, where various ideas, opinions, and experiences create a breeding ground for innovative solutions to problems. Version 3.0 can thus bridge the gap between initiatives that make black students feel more welcome in medical schools and those that harness the power of a diverse workforce to improve patient care.

Perhaps most immediately, the new vision provides a model for cultural competence in doctor–patient interactions that can improve patient satisfaction. Medical students, for example, can benefit from observing encounters between “standardized patients” (actors hired to play patients) and classmates whose backgrounds may be more similar to those of the hypothetical patients than to their own. My class met one such standardized patient whose religiosity was meant to render her “difficult” — and did have that effect for some students. But having grown up in Texas around many very religious people, I could readily engage in a rather pleasant conversation with her. The classmates who observed it may now approach a similar future patient with greater confidence. Indeed, white graduates of diverse medical schools report that they're better equipped to care for minority patients and have stronger convictions about inadequate access to care.3 Long after graduation, other benefits of racial and ethnic diversity are evident: black and Hispanic physicians are more likely to practice in areas with larger proportions of black and Hispanic residents, and they see a larger proportion of Medicaid and uninsured patients.5

People's worldviews may diverge for many reasons — owing to the experiences of military service, for example, or to sexual orientation or the language one speaks. All such characteristics and experiences figure into the new diversity, which acknowledges that shared experience in this country no longer tracks simply with race. Diversity is not so black and white anymore.

Despite the push for other forms of diversity, medical schools still place a certain premium on “visual diversity” — that of race and sex. This emphasis is understandable: such diversity is easily measurable, and concern about it is a legacy of systemic discrimination. That history, coupled with certain classroom and hospital experiences common to medical students from underrepresented minorities, creates a shared narrative that has supported a collective consciousness for decades. Some minority students may feel that the new diversity puts this shared identity at risk. And as we aim to translate earlier versions of diversity into something serving medicine's core missions, it's worth remembering that, as with the mother from my pediatrics rotation, I've often quickly built a rapport with a patient simply because we were both black.

But all diversity, visual or not, holds value. It's not just a numbers game or an annual administrative experiment. Diversity is a process that exists outside the admissions cycle and promotional photos. It's a mindset that extends into the classroom and the hospital. If the ultimate goal of diversity in medical schools and residency programs is to improve patient care, a good first step is to create a world where all trainees can feel supported while learning and working to the best of their ability. That goal can be achieved only with a wholehearted commitment to diversity that is inseparable from an institution's identity.

When I started college, I felt drawn to sit with other black students in the cafeteria. But establishing an inclusive learning environment means that people from different walks of life can not only have a seat at the same table but also be comfortable in their chairs. Although embracing this new diversity may mean broadening an institution's outlook from primarily underrepresented racial minorities, efforts targeted at those groups still serve an important mission. Diversity efforts can build on the existing model and borrow from their track record of progress toward creating better medical schools and hospitals for all groups.

When I arrived at medical school, I sought a place where I could be myself. Medical schools pursuing Diversity 3.0 would do well to remember that everyone with a unique story to tell wants the same. The ideal diversity initiative would therefore be a climate control of sorts, striving to create an atmosphere where everyone feels included in the larger dialogue. Only then will the conditions be ideal for creating a workforce that's willing and well-equipped to address the needs of an increasingly diverse population.

References

1 Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA 1999;282:583-589
CrossRef | Web of Science | Medline

2 Saha S, Taggart SH, Komaromy M, Bindman AB. Do patients choose physicians of their own race? Health Aff (Millwood) 2000;19:76-83
CrossRef | Web of Science | Medline

3 Rometty VM. IBM's commitment to diversity (http://www-03.ibm.com/employment/us/diverse/equal_opportunity_commitment.shtml).

4 Nivet MA. Commentary: Diversity 3.0: a necessary systems upgrade. Acad Med 2011;86:1487-1489
CrossRef | Web of Science | Medline

5 Marrast LM, Zallman L, Woolhandler S, Bor DH, McCormick D. Minority physicians' role in the care of underserved patients: diversifying the physician workforce may be key in addressing health disparities. JAMA Intern Med 2014;174:289-291
CrossRef | Web of Science

Dados de pesquisa

Updated: 4 Scales Every Researcher Should Remember!

by Zontziry Johnson 

 

 

One of our most-viewed articles is an article about four scales every researcher should remember. Since that post was written, some changes have taken place that have affected the four scales, so we figured it was time for an update! Here, we’ll dive into a bit more about considerations behind which scale or question type you should be using, as well as an update on the most powerful questions that can drive insight into what your respondents are thinking.

The First Rule of Research

The first rule for any research project – whether it’s a one-time project or a customer feedback survey distributed regularly – is this: focus your project to the one primary purpose or question you want to have answered. This will automatically help you narrow down what type of scale or question to use for your survey. For example, let’s say your focus is a feedback survey. The primary question might be: are our customers having a good experience in our stores? From there, choose the primary 3-5 items that you want to measure as related to the question. In this example, they might be: products easy to find; helpful staff; clean store. Now, you’re ready to check out the scales and questions that could provide you the best insight into these questions.

Four Types of Data to Measure

There are four types of data. Any data falls under one of these categories. They are all used for different purposes and are analyzed differently.

Nominal: names, labels. Examples include days of the week, colors, and geographic area names. These are difficult to analyze using most statistical methods. Basically, you are limited to count, or frequency of distribution.

Ordinal: order of items, but no measurable difference in numbers between the items in the list. Examples include satisfaction ratings and importance ratings. Analysis includes median (midpoint of distribution, rather than the average distribution) and count.

Interval: numeric values for which a difference in value is measurable, but no true zero exists (a point at which the quality being measure does not exist). Examples include time and temperature. Analysis includes most statistical measures, but not any that would include multiplying or dividing values.

Ratio: numeric values for which a difference in value is measurable AND a true zero exists. Examples include age and height.

Now that we understand the difference between the types of scales, let’s look at some of the most used scales!

Types of Measurement

There are two types of measurement: comparative and non-comparative. They are pretty straight-forward.

Comparative measurement: As the name implies, comparative measurements typically involves two brands, or two things, being compared against each other. One example would be comparing one brand of smartphone against another brand of smartphone to determine what people like better about one or the other.

Non-comparative measurement: Again, the name says it all. The scales we’re going to review today all fall in the non-comparative realm of measurement, where only one item or one brand is being measured.

The Four Question Types/Scales You Should Know

 

1.  Likert Items

A Likert scale is technically the sum of a list of Likert items. What makes a question a Likert item? There are equal numbers of positive and negative options in the scale; Likert items always have a central neutral option, which means there will always be an odd set of answers available to the respondent – typically, a Likert item has a total of seven answer options. Likert items measure ordinal data.

2.  Unipolar scales

Where Likert items are bipolar, meaning the respondent has to decide between opposing items, unipolar scales are more streamlined, allowing users to instead focus on the absence or presence of a single item. The scale is still measuring ordinal data, but research has shown that unipolar scales generate more accurate answers. An example of a unipolar satisfaction scale is: not at all satisfied, slightly satisfied, moderately satisfied, very satisfied, and completely satisfied.

3. Slider Scales

Slider scales (also known as continuous rating scales) allow the survey designer to measure ordinal data (using a categorical slider), or interval or ratio data (using a numeric slider). For example, a slider scale could be used for a unipolar satisfaction question, allowing a respondent to perhaps more precisely define their feeling about an item. A slider scale could also be used to let respondents answer questions about how much time they expected to wait for an order versus how much time they actually waited for the order. Based on what type of data you are gathering using the slider scale is the type of analysis you can conduct with the data. If you’re gathering interval data, you can calculate averages, standard deviations, etc. If you’re gathering ordinal data, however, be sure to stick to frequencies and medians to analyze your data.

4. Side-by-Side Matrix

The side-by-side matrix remains another highly-used item for measuring ordinal data. The side-by-side matrix allows a respondent to respond to two qualities about an item. The most common use is to determine a respondent’s opinion about the importance of an attribute and the satisfaction of their experience with that attribute. This helps a company determine if perhaps there are items they are focusing on that respondents don’t find terribly important, versus items that the respondent finds important, but unsatisfactory.

The most common analysis tool used with the side-by-side matrix is a Gap analysis, which is actually pretty self-explanatory – it shows where there are gaps between the two attributes measured, using the first attribute listed (in this case, importance) as the primary attribute to measure against. In this example, you can see that the red arrow indicates the greatest gap exists for the topic On-time Arrival. For the best impact, this would be where this organization should focus, as this item is important to respondents but has the lowest satisfaction rating.

Cooperação científica

Desafios da cooperação internacional em pesquisa

Por Heitor Shimizu, de Munique

“Se realmente quisermos cooperações instigantes em pesquisa científica e projetos conjuntos em que se pense o até então impensável, não é suficiente apenas colocar cientistas de um país em contato com os de outro, ou apenas permitir que se visitem”, disse Enno Aufderheide, secretário-geral da Fundação Alexander von Humboldt, durante a FAPESP Week Munich, simpósio promovido pela FAPESP e pelo Centro Universitário da Baviera para a América Latina (Baylat) em Munique, na Alemanha, de 15 a 17 de outubro.

 

“Temos que tornar possível que os pesquisadores permaneçam em outros países. Temos que permitir que eles tenham a perspectiva das pessoas que vivem lá e com quem eles trabalharão, de modo que haja uma interação real entre os dois lados”, disse Aufderheide.

 
Brito Cruz, Aufderheide e Varela falaram sobre os incentivos às colaborações entre pesquisadores de diversos países (foto: H.Shimizu)

Aufderheide foi um dos palestrantes no painel “Colaboração científica internacional, networking e excelência em universidades – Boas práticas”, ao lado de Christian Müller, diretor do Departamento de Estratégia e Gerenciamento do Conhecimento do Serviço Alemão de Intercâmbio Acadêmico (DAAD); de Torsten Nyncke, diretor regional para Europa, Brasil e Israel da Associação Fraunhofer; e de Carlos Henrique de Brito Cruz, diretor científico da FAPESP. O painel teve como moderador José Arana Varela, diretor presidente do Conselho Técnico-Administrativo da FAPESP.

Fundada em 1953 e com 15 pesquisadores com prêmio Nobel, a Fundação Humboldt oferece auxílios que possibilitam a pesquisadores de outros países passarem períodos em uma instituição alemã. Segundo Aufderheide, a instituição tem construído uma rede global de excelência em pesquisa que conta atualmente com 26 mil pesquisadores em quase 140 países, que têm ou tiveram apoio em algum momento de suas carreiras.

“Essa rede apoia colaborações multilaterais em várias disciplinas, beneficiando tanto indivíduos em sua busca de conquistas científicas como países que querem se tornar parte do empreendimento global de adquirir conhecimento”, disse.

Segundo Aufderheide, as necessidades e oportunidades para a colaboração internacional em pesquisa têm aumentado enormemente na última década. “E países que não estão bem integrados em redes internacionais correm o risco de perder oportunidades importantes para recrutar talentos”, disse.

Müller falou sobre a longa história de cooperação com instituições brasileiras, especialmente agências de fomento à pesquisa. Com a FAPESP, por exemplo, o DAAD mantém um acordo de cooperação desde 1988 – por meio do qual já foram concedidos mais de 130 auxílios e bolsas.

Nyncke falou sobre a estratégia de internacionalização da Fraunhofer, que se baseia na adição de valor científico para a associação alemã e nos efeitos positivos tanto para a Alemanha como para o país parceiro advindos da colaboração.

“O Brasil tem sido um parceiro importante para a Fraunhofer. Mais de 30 institutos da associação tem participado de cooperações com parceiros brasileiros. Dois centros de projetos da Fraunhofer, um deles no Estado de São Paulo, demonstram o comprometimento de longo prazo na colaboração científica com o Brasil”, disse.

Brito Cruz destacou o programa de internacionalização da pesquisa feita no Estado de São Paulo, apoiado pela FAPESP por meio de mais de 100 acordos de cooperação com instituições de outros países e por diversos instrumentos de fomento.

“Ciência é um empreendimento social. Não é apenas um empreendimento individual. Assim como a ciência depende do gênio individual, ela também depende da comunicação e do trabalho conjunto, especialmente entre os melhores pesquisadores no mundo. Esse é um dos motivos por que procuramos desenvolver a colaboração internacional em pesquisa. Queremos que os melhores cientistas em São Paulo trabalhem mais do que o fazem atualmente em conjunto com os melhores cientistas no mundo”, disse.

O diretor científico também destacou que, além de permitir que pesquisadores de São Paulo possam ir a outros países para participar de projetos binacionais ou internacionais, a FAPESP tem possibilitado a vinda de pesquisadores de outros países ao Brasil.

“Trouxemos o equivalente a um pesquisador por dia de trabalho [na semana] em 2013 e queremos aumentar para dois pesquisadores por dia”, disse. “Também no ano passado, 20% das bolsas de pós-doutorado da FAPESP foram concedidas a estrangeiros.”

“Há muitas iniciativas para a internacionalização da pesquisa brasileira e estamos trabalhando duro para isso, mas é claro que há diversos obstáculos. Um deles é que no Brasil nós falamos português, uma língua não dominada no resto do mundo. Outro ponto é que o país está distante dos principais centros científicos mundiais”, disse Brito Cruz.

 

“Na FAPESP, temos criado incentivos e oportunidades que permitam que esses obstáculos sejam superados e os resultados têm sido muito bons. Em 2005, por exemplo, tínhamos dois ou três auxílios da FAPESP em parceria com organizações de outros países para financiar o trabalho colaborativo de pesquisadores. Hoje, são cerca de 200”, disse Brito Cruz.

Ensino tradicional

When Should We Lecture?

By Maryellen Weimer, PhD

There are purists among us who would say that we should never lecture, but I don't think that's terribly realistic, and I'm still not ready to totally rule out lectures. As faculty, we bring expertise to learners and having an expert around when you don't know something can be very helpful. Do most teachers still talk too much? They do. Are lectures fraught with well-established impediments to learning? They are.

What's missing from the conversation are guidelines that teachers might use to determine when they should lecture. And that's what I'd like to propose in this post. Please consider the questions posed here as an initial exploration, which can be deepened and made more meaningful with your ideas, insights, and experiences. 

Should the decision of whether to lecture be influenced by what we are teaching in class that day? Are some kinds of content better explained by the teacher than discovered by the students? Is it complex content that you know from previous experience often causes students to struggle? Can the teacher's explanation lay the foundation, set the parameters, or provide the context so that students can start dealing with content from a place that expedites understanding? Is a lecture the best way to clarify what students find confusing?

Should we use lecture to present threshold concepts, those building blocks in the discipline which, if understood correctly from the start, provide stability for the knowledge structures built upon them? If we do, we should test how effectively the lecture established those foundations. We should collect data from students and use it to ascertain the level of their understanding as compared with their learning via other methods.

Can you determine when a lecture might be needed by watching the learning experiences of students? If they are attempting something that is challenging, if they are working hard, but still not getting it, if levels of frustration are rising, is that the time for a teacher to step in? Most of us know firsthand that sometimes learning can be so frustrating, emotions so strong and raw, that insight and understanding escape us. This is what some call just-in-time teaching. When students experience a learning impasse, the teacher steps in to provide the answer or additional information—or tells students where they should look for it.

Sometimes lecturing is simply the most efficient way to share information. We don't give student blank copies of the periodic table and let them try to fill it in. We don't let them try to set the basic principles of accounting.

Maybe we know when to lecture by ascertaining what will best convey the content. Does it need to be: explained clearly, maybe from different perspectives; illustrated, with examples or visually represented; structured with main and supporting points differentiated; or positioned to connect to what's come before and linked to what will come after? What the content doesn't need is to be transferred—passed from teacher to student. "Don't be a mother robin—chewing up the text for the students and putting it into their beaks through lecture," Richard Paul and Linda Elder admonish.

Should we use lecture when students don't think they care about the content, don't think it's interesting, or don't think there's any need to know it? A lecture where the teacher peppers the content with spicy facts, intriguing questions, colorful anecdotes, and relevant details can cultivate student interest. Teachers talking about how they connect to and with the content, why they love it, and why they think everyone else ought to also can be very motivational.

So we still have lots of questions when it comes to lectures, but we do know that we shouldn't use lecture as the default instructional method. We need to decide when lecturing makes sense so that it's a conscious, purposeful choice. And then there's the matter of length for any given segment of teacher talk. As I review these possible justifications for lecture, I'm hearing a call for mini-lectures, not lengthy expositions that take all or most of a class session.

Now it's your turn. How do you decide when a lecture is in order? Or, taken from the opposite direction, how do you know when what's needed to promote learning is not a lecture?

Saúde dos estudantes

Student mental health: the situation is more nuanced than it seems

If the media portrays student life as a hell on earth with no support available, it will only make students feel worse

Alan Percy

The increase in students using university welfare support should not be oversimplified. Photograph: Kproeith Morris/Alamy

There has been much publicity and concern about student mental health in recent months. This partly reflects the rise in students accessing university welfare support and counselling services, with most services experiencing a large increase year on year.

A significant proportion (between 5-10%) of the student community at universities in the UK uses the counselling services, according to the Heads of University Counselling Services (Hucs). However, it would be incorrect to accept overly simplistic explanations for this phenomenon.

It is obvious that in many ways life is extremely pressurised and stressful for university students today, but this is not just caused by the demands of academic life or the lack of support from universities. It is equally simplistic to say that this is all due to increased tuition fees and the pressures they put on students to succeed academically, so they can then go on to get a good job.

That is not to say that the uncertain economic future does not amplify the pressure on young people.

One of the ironies of increased student fees is that they can heighten student expectations (often unrealistically) about the support services at their institutions.

Although students are contributing more, the reality is that there has been no real increase in university funding, as central government funding to higher education has been dramatically cut.

A negative consequence of this cut could be for universities to cut back support services or replace experienced and effective counselling services with generic “wellbeing support workers”.

Social and mass media: driving unrealistic life expectations

There is a whole range of cultural and sociological issues affecting young adult psychological development today.

Social and mass media often promote unrealistic life expectations and engender a persecutory perfectionism within young adults. This can create a self-bullying mentality which can make students feel dissatisfied with their own achievements and experiences while also heightening expectations of others.

Unrealistic perfectionism is a key driver for more serious problems such as depression, anxiety, self-harm and eating disorders. Despite being more connected in a virtual way, many students feel more isolated, as they believe they have to hide their true self and present a perfect image to others.

Changes in secondary education have made the transition to learning at higher education much harder and more emotionally challenging for many students.

Real learning at degree level often involves going through periods of not knowing, being confused, until new knowledge emerges. However, some students may sense that if they don’t understand something immediately they are failing or being failed by their tutors.

Changes in family structure and parenting styles often lead to closer, friendlier and more positive relationships between parents and young adults, but this can also generate mixed messages for young adults, sometimes leading them to feel more anxious about separating from their parents and facing the challenges and risks of the outside world.

Using labels such as “depression” can make young adults feel trapped in a “passive sick role”

There is greater awareness – but not necessarily understanding – of mental illness. This often leads to an over-medicalised and symptomised view of normal life difficulties, challenges and struggles. Much of the data cited by student journals has no statistical validity. Figures are usually based on impressionistic and subjective questionnaires rather than rigorous clinical evidence or diagnosis.

Many students can feel they are “depressed” in a common-sense way when they are going through difficult life struggles, but this is different from clinical depression and anxiety disorders. The use of labels such as “depression” or “anxiety disorder” can have the effect of making young adults feel trapped in a “passive sick role” rather than helping them to develop the internal skills and resources to cope with life challenges.

According to psychological and therapeutic models, the way people make sense of their experiences has a fundamental effect on how they feel and act. Seeing life in simplistic “all or nothing” categories can have a detrimental effect on how people feel, as it stops them from understanding and engaging with the complexities of life.

If student life is constantly portrayed as being some kind of hell on earth, where most students are depressed with no one to help them, this creates a self-fulfilling prophesy making students feel worse and reluctant to seek help.

University counselling services are highly effective

University counselling services have been developing evidence-based therapeutic interventions, and using professional clinical experience, for many years.

 

Evidence from university counselling services across the UK demonstrates that they are highly clinically effective, with rates of significant and reliable improvement at 75% or above for service users. This not only reduces distressing psychological symptoms but also helps students to function better at university.

After using their universities counselling service, the majority of students report they are less likely to withdraw from their course, feel better able to study and feel better equipped to seek future employment. Evaluation of counselling services by students, through local and national studies, such as the national student barometer survey, show very high levels of satisfaction rates of above 90%.

Obviously not all students will find counselling services beneficial, but those who do not form a relatively small proportion of service users. Through a variety of interventions, such as individual and group counselling, psycho-educational workshops, and interactive self-help resources, university counselling services can help students in a professional, empathetic and non-judgmental way gain insight and awareness into their difficulties.

From this perspective students can then make realistic life changes and build the internal skills which will enable them to develop the emotional resilience required to face the normal difficulties and challenges of life.

The vast majority of students have a largely positive experience at university, although at times they will face very difficult and distressing periods.

Doing a degree should be a challenging process as young adults develop knowledge, skills and resources. But it should be a largely enjoyable and creative time. However, if students are having a distressing time there is a great deal of support available, both through professional clinical services and also the many student-led support groups.

It is always best if students who are having difficulties reach out for the support available, sooner rather than later. Counselling and support services cannot take away all life problems, or make people happy all the time, but they can provide the appropriate support that for many students will make all the difference.

* Alan Percy is head of counselling at the University of Oxford and media spokesperson for the British Association of Counselling and Psychotherapy: Universities and Colleges.

• This article was amended on 17 October to correct a statistic that said 80% of students showed significant improvement from attending university counselling services across UK higher education. The correct figure is 75%. The 80% figure is the average across the Russell Group universities.