Speaker’s Challenge: An Ethical Grounding for Medical Education

As the University of Miami Miller School of Medicine and other academic health centers work to transform medical education, it is critically important to consider everything through the lens of health equity, says Danielle Laraque-Arena, M.D., who has worked nationally and internationally on education and research addressing the needs of underserved populations.

“What is health equity?” Dr. Laraque-Arena asked at medical education grand rounds Thursday at the Gordon Center for Research in Medical Education. “You’ve heard of health inequalities, or gaps in health status experienced by disadvantaged populations. It leads us to a much broader scope. Those health inequalities, with a social justice equity lens, require more in-depth engagement with communities.

“I don’t mean the black community, the white community, the Latino community,” she continued. “I mean ALL of us.”

Dr. Laraque-Arena, who served as president of SUNY Upstate Medical University, is now professor of pediatrics, psychiatry and behavioral sciences, and public health and preventive medicine at SUNY Upstate and senior scholar-in-residence at the New York Academy of Medicine. Her research has focused on health equity and health disparities, especially relating to rates of violent injuries.

Equity is about the ethical grounding of medical education, she said, and recognizing that the structures of health care that lend themselves to biases and racism affect communities, and affect the formation of physicians.

UM President Julio Frenk, who introduced Dr. Laraque-Arena, led a seminal Lancet Commission report on “Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World” in 2010. The 10 years since the publication of that report have been a “very intensive decade of a lot of exploration in medical schools,” President Frenk said, and now “we have this once-in-a-lifetime opportunity to redefine the curriculum.”

Justice must be at the center of this redefinition, he said. “Inequities are inequalities that are avoidable and unjust.”

Dr. Laraque-Arena talked about the inequities that have existed historically in medical education. “When I started in medicine there was no discussion of population health, of ethical care,” she said. “I had trained at the top children’s hospital at the time (Children’s Hospital of Philadelphia), and then I went to Harlem Hospital, and I was told that the medicine I was taught at CHOP, that I believed in, didn’t apply.

“No after-hours care, no having that mother or father call me up because they’re worried about the two-month-old who’s ill at night,” she continued. “There was not an acceptance of the concept of equity — those families deserved the best. In the venue of medical education, we must be consistent in what we do and how we teach it.”

Social accountability is the frame for medical education and health care, Dr. Laraque-Arena said. The World Health Organization defines the social accountability of medical schools as “the obligation to direct their education, research and service towards addressing the priority health concerns of the community, region, or nation they have a mandate to serve.”

“How we frame the problem is critically important to what we value and how we evaluate the outcomes,” Dr. Laraque-Arena said. “Do we have the right frame? is the question you should ask. Determine which frame fits this place, this community, this university.”

Henri R. Ford, M.D., M.H.A., Dean and Chief Academic Officer, is leading the redesign of the Miller School’s frame for medical education. The NextGenMD initiative is creating a new curriculum to “empower our students to transform lives, and inspire them to serve our global community.”

Dean Ford talked about his collaboration with Dr. Laraque-Arena on a number of initiatives, particularly after the 2010 earthquake in their shared homeland of Haiti. They have worked together with other dedicated medical educators to rebuild the country’s medical education system.

The Dean expressed support when Dr. Laraque-Arena talked about the need for “enlightened agents of change” in transforming education. “Change is scary,” she said, but universities and society must look at their systems and be ambitious about change. That means more diversity among leaders and learners, and a focus on transformation of systems beyond health care.

“A shift to a more diverse and inclusive research community might result in research outputs that carry greater meaning and potential benefit for more people in more parts of the world,” Dr. Laraque-Arena said. “That is transformative.”

During her distinguished career, Dr. Laraque-Arena has been a leader at the Mount Sinai School of Medicine and Maimonides Infants and Children’s Hospital of Brooklyn, and a faculty member at the College of Physicians and Surgeons at Columbia University and Harlem Hospital Center. As director of the Harlem Pediatric Resource Center, she pursued community-based research in the areas of injury prevention, child maltreatment, and adolescent high-risk behaviors.

The challenges can seem insurmountable, she said, because “we have the most complex health system in the world, and we don’t have the outcomes we should.” But transformation will be possible if we engage the community, make sure everyone is at the table, incentivize change, and develop metrics to measure whether the new curriculum has resulted in the desired health workforce and health status goals.

“I start with the why,” she said in conclusion. “Why am I a physician? I wanted to do something meaningful in my life.

“I did learn by being president that change is really hard. I hope you guys take on the challenge of leadership at every level. Move the system to be more equitable, so your efforts lead to equity that is just and fair.”

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