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Abstract
Introduction The COVID-19 pandemic has illuminated disparities and inequities in healthcare globally, making it a necessity to identify, and address social and structural determinants of people’s everyday lives. Medical schools and education need to respond to and address social justice in undergraduate education. Social justice in medical education has the potential to be a foundational block to support the initiatives that have or are being implemented in our health systems.
Methods We carried out a meta-synthesis and used an interpretative approach for the analysis. Searches were conducted of three databases: PsycINFO, Embase and Medline and were carried out in May 2021. We excluded articles that were not related to undergraduate medical students. The aim of this review was to explore literature on SJ teaching to elicit the experiences of learners to inform future SJ teaching and curriculum.
Results Using meta-synthesis methodology, four themes emerged: personal growth of learners and professional identities; developing commitment to working with marginalised populations in their environments; integrating traditional clinical skills with advocacy, interests in human rights and SJ work; learning processes and methods.
Conclusions Findings confirm that SJ in undergraduate medical education has an essential role. However, social justice in medical education was understood as a non-essential piece of professionalism, or as something to be learnt in the abstract method rather than as a part of everyday practice realities. Our findings suugest that creating globally competent doctors through a globally equivalent curriculum, which is balanced and with a locally invested training programme could lead to a supply or workforce that is fit for purpose for local populations.
- curriculum
- assessment
- medical education
- learners perspectives
- social justice
Data availability statement
Data are available on reasonable request.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Social determinants of health are embedded in medical education. However, discussions of social justice are often seen as too political or elicit discomfort. Therefore, discussions about social justice remain marginalised in medical education.
WHAT THIS STUDY ADDS
The core medical school curriculum should include compulsory training to enable students to recognise and redress adverse medically relevant social factors leading to health inequities. Findings confirm that social justice in undergraduate medical education has an essential role in reducing inequilities and is something that is learnt in the abstract method rather than as a part of everyday practice realities embeeded in the reality of the individuals everyday challenges.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Addressing health disparities requires medical students to attain skills in ‘assessing and intervening in the social and structural determinants of the individuals’ daily lives’ beyond the clinical setting and patient–doctor interface. Creating globally competent doctors using a globally equivalent curriculum with a locally invested training programme could lead to a supply or workforce that is fit for purpose for local populations.
Introduction
The primary purpose of medical schools is to educate future doctors who can care for the national population.1 However, doctors and healthcare professionals work in communities where many individuals live below the poverty line; face discrimination based on their race, gender, sexuality and class; have a significant amount of chronic health problems and medical disabilities; reside in geographically isolated areas; and lack a sufficient number of healthcare providers to meet their needs. These forms of discrimination often intersect, magnifying their negative effects even further. In this way, a single individual can be stigmatised and carry multiple disadvantages.2 Such patients have been historically underserved.3
Definitions of social justice
In medicine, social justice (SJ) is defined as equal access to quality healthcare and the universal right to health.4 This definition recognises, along with the Declaration of Alma-Ata, identified more than 30 years ago that gross inequalities in health status are politically, socially and economically unacceptable, and that health is a fundamental human right.5 The modern concept of social justice in health is derived from the 19th-century social medicine. For example, Virchow said that ‘The physician is the natural advocate of the poor’, adding that ‘medicine has imperceptibly led us into the social field and placed us in a position of confronting directly the great problems of our time’.6 The WHO defines the social determinants of health as the conditions in which people are born, grow, live, work and age, including the health system.7 These circumstances are shaped by the distribution of money, power and resources at global, national and local levels,7 which are themselves influenced by policy choices. The WHO states, ‘The social determinants of health are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries’.7
Biases against discussing social justice
Social determinants of health have long been embedded in medical education. For example, medical schools’ commitment to neutrality and objectivity, which are important values, nonetheless, discussions of social justice are often seen as ‘too political’ or elicit discomfort.8–10 Therefore, despite being increasingly recognised, discussions about social justice remain marginalised in medical education.8 These negative reactions should be resisted because educating doctors who can help reduce health disparities requires medical students to confront the social, political and economic realities which adversely impact health. As Virchow said, “Do we not always find the diseases of the populace traceable to defects in society?”9 Indeed, the ability to have discussions about social justice may necessitate a change in the culture of medical schools, and not just their curricula. To this end, there must be a recognition that medicine, like any other field, is political and that discussions about social justice are therefore entirely appropriate in medical school settings. As Virchow continues, “Medicine is a social science, and politics, nothing but medicine on a grand scale.”8
Teaching social justice
Hage and Kenny have describe one way of integrating social justice into education. Their ‘Social Justice approach to prevention’ has focused on empowering trainees and engaging them in community conditions through education, research, interventions and political processes.11 Curricular change often involves improving the structure of the teaching/learning environment (for example, seminars or problem-based learning groups instead of lectures), the content of courses and clerkships (the core set of knowledge, skills and attitudes that should be learnt), and how student learning of knowledge and skills is evaluated (in the sense that evaluation can help ‘drive’ the curriculum). These include self-reflection pieces, peer presentations, working with mentors and community members, community engagement, advocacy work, as well as direct action to redress the social conditions adversely affecting health. Accordingly, teaching the social determinants of health and health disparities in medical curricula require complementary and more innovative evaluation instruments. Thus, we wanted to systematically discover why and how social justice integration could be possible as part of the curriculum in undergraduate medical education. The aims of this review is to a) explore social justice literature on teaching assessments, b) report the experiences of undergraduate medical learners in the data, and c) to elicit how medical education leaders can integrate social justice into the undergraduate medical curriculum using the checklist generated by this research.
Methods
The proposed systematic review was conducted using a meta-synthesis methodology, using a line of argument synthesis.12 We used a meta-synthesis approach because it was an interpretative method of analysis used in broadening understanding of a particular phenomenon.13
Review objective/questions
The objective of our research was a) to identify the experiences of learners on social justice programmes and b) identify learning strategies that may act as the key methods to teaching a social justice curriculum.
Inclusion criteria
Participants
The populations of interest in this review were undergraduate medical students, educators and lecturers, and patient-experts, providing insights into their lived experiences. However, due to the retrieval of limited papers on this topic, we extended our search to the international literature for inclusion.
Phenomena of interest
The phenomena of interest included social justice, medical curriculum, with a focus on both assessment and teaching. We also included core curriculum, formative and summative assessments, incorporating the social sciences and experiences of the population of interest who are currently integrating aspects of social justice in the medical curriculum. Papers on postgraduate education and quantitative studies were excluded.
Context and setting
Studies were considered for inclusion if they comprised the population of interest for this research, who worked as educators within universities, hospitals, medical settings and community clinics where teaching, assessment and mentoring of undergraduate students take place.
Types of studies
The included papers were published in English and reported on qualitative studies including (but not limited to) ethnography, phenomenology, grounded theory, and action and feminist methodologies. We also included qualitative findings, from mixed-methods studies, case studies and case series.
Search strategy
The search strategy for this research aimed to locate both published and unpublished papers. Papers that were found in the grey literature and hand searched, were also used to identify text words contained in the titles, abstracts of relevant articles, and the index terms used to describe the articles. These were used to develop a full search strategy for our selected databases (see search strategy in the online supplemental material).
Supplemental material
Information sources
The following databases were searched: Embase, PubMed and PsycINFO.
Study selection
Following our searches, the results were imported into Mendeley, and duplicate citations removed. Two independent reviewers reviewed the titles and abstracts (SS and AS) to identify studies for full-text retrieval. In instances where reviewers did not agree, a third reviewer (NK) adjudicated on whether the study was retrieved. The two reviewers (AS and AS) then independently reviewed the full-text studies for inclusion with a third (NK) reviewer acting as an adjudicator in cases where the reviewers disagreed. Studies were considered for inclusion if they included undergraduate students or are those involved in teaching and assessment.
Assessment of methodological quality
The full-text papers were assessed by two independent reviewers (AS and AS) for methodological validity prior to inclusion in the review, using the British Sociological Association Criteria.14 Any disagreements that arose between the reviewers were resolved through discussion and with a third reviewer (NK).
Data extraction
Customised tables were created that were used to produce themes from the extracted data. All coded data from each included study, including details about the population, phenomena of interest, context, findings and illustrations, were extracted using NVivo, qualitative data analysis computer software. Data extraction and analysis were conducted by our research team. Themes were coded, extracted and tabulated for all papers rated as eligible for the review.
Data synthesis
Qualitative research findings were analysed using the meta-synthesis approach,13 using a line of argument synthesis.15 Meta-synthesis assists knowledge synthesis through a process of reconceptualisation of themes across a number of published qualitative studies.12 16 17 The analysis was undertaken in three stages: (1) creating a primary data synthesis, (2) exploring themes from studies and (3) evaluating the learners’ perspectives.
Results
The meta-synthesis included 36 studies (online supplemental table 1). Characteristics of the studies and contextual information on the included studies are presented in the online supplemental table 2.
Supplemental material
Supplemental material
The preliminary conceptual lens was developed for coding and analysis. We focused on generating social justice concepts which comprised 19 superordinate categories. These were used for the coding and analysis of emerging themes. The categories of social justice and their vote counts, indicating frequency of the concept being identified, are shown in table 1.
Social justice concepts
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram for the 36 papers is shown in figure 1. The 36 papers comprised qualitative studies (n=17) and mixed-methods studies (n=19). Most of the papers were mixed-methods evaluations of teaching programmes or interventions. The qualitative studies were mostly evaluations using qualitative methodology. The 36 papers described studies which were conducted in 10 countries: the USA (n=24), the UK (n=2), Australia (n=2), New Zealand n=1, Taiwan n=1, Scotland/UK n=1 and Canada (n=4). Two studies were conducted in collaboration of two countries: Israel/UK (n=1) and Colombia/Spain (n=1). The participants recruited were in various years of their medical education. Teaching and learning programmes were designed to deliver a few hours of core material through various methods (see Box 1).
Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 flow diagram,40 which included searches of three databases.
Teaching methods
Provided through reading texts
Didactic methods
Case discussions
Site visits
Several hours of experiential non-core activities applying core competencies
Individualised learning plan
Faculty advisor input
Non-core activities including community-engaged research
Service-learning activities
Other relevant experiences
Submission of a synthesis paper addressing pathway competencies
Students assigned to a community organisation for several days over a few weeks
Completing a minimum number of placement hours
Leadership-development activities
Specific lectures and
Large group discussions
Participation in small-group
Community projects
Guest lecturers’ perspectives on their experience
Reflective essay assignments
Technology and media
Film and role-play
Using games as a teaching activity
Assessment tools that provides assessment and instant feedback required in the learning process
The four themes that emerged from the learners’ perspective were as follows:
Personal growth of learners and professional development.
Developing commitment to working with marginalised populations in their local environments.
Integrating traditional clinical skills with advocacy, interests in human rights and social justice work.
Learning processes and methods.
Table 2 shows the main results from the meta-synthesis; level-one analysis included the primary quotes, level-two analysis included the synthesis of those findings from the learners’ perspectives and the level-three analysis includes the application of the synthesis of the social justice themes.
Main results from the meta-synthesis
Personal growth of learners and professional development
Our findings highlighted that along with professional development, personal growth as a skilled doctor was important to undergraduate medical learners. Personal development included the requirement to acknowledge the challenges existed for students at not only an academic level but also at an emotional personal growth level.
Emotion
The third year of medical school can be incredibly challenging on both an academic and emotional level. The de facto attitude on the wards is one of cynicism and exhaustion. HRSJ (Human Rights and Social Justice Scholars Program) has helped to demonstrate that medicine can be practiced according to a higher ideal.18 (p. 296)
There were also data in the papers that highlighted examples of complex learning and understanding related to the fact that individuals could encounter adverse experiences in what appeared to be obvious or safe choices for them. Knowing the full facts and context from individuals’ lived experience was an eye opener and led to better interactions and learning processes.
Complex learning
[The patient] taught me a lot about the conditions in SROs (single room occupancies). It is easy to assume that any housing is better than no housing, but I learned that people can feel even more unsafe in a building than they do outside. [The patient] experienced sexual violence in her SRO and genuinely fears the drug-related activity that occurs in her hallways.19 (p. 4)
The importance of experiential learning was a process, which linked students’ thoughts, feelings, concerns, and acted as a reflective tools as, a mechanism part self-selective teaching methods and programmes.
Experiential and service learning
I have volunteered both locally and internationally. What was different for me this time is that I kept a reflective journal to record my experiences, thoughts, feelings and concerns. At first, I felt that keeping a journal would be a burden. I soon realized that journaling during service-learning is the key to learning. I used the critical incident technique to explore how various events and experiences influenced my professional and personal growth. I learned how cultural views impact perceptions of health and illness, the struggles of poverty, and observed first-hand the necessity for health promotion. I learned more than I ever could have from lectures or from a textbook.20 (p. 979)
Developing commitment to working with marginalised populations in their environments
Developing commitment and eliminating apathy towards difficult situations and topics were highlighted in the data. Students reported feeling frustrated and powerless when there was little engagement or enthusiasm from peers, or colleagues. For topics that had far-reaching health, social and welfare concerns for certain groups with protected characteristics in the population.
Race and healthcare disparities
As another student, apparently frustrated by his/her own powerlessness to engage some of his/her reluctant colleagues in this topic put it: We dutifully learn about rare cancers which we will likely never see and genetic disorders only described in a handful of patients, which we will certainly never see and yet race, which we will see every day for the rest of our careers is a topic that only manages to draw a small group of students. I can’t help but feel that the apathy towards the subject of race … is a part of what has wrought the shocking disparities we are faced with today in healthcare.21 (p. 7)
There were also examples of positivity and enthusiasm from students, in ways of working that transformed what seemed to appear as a problem (for people with severe intellectual disability). Students worked through the real-life difficulties through a programme initiative, creating positive outcomes for individuals in the community.
The manager was excited by the conclusions we drew and the possibility of implementing the program (for people with severe intellectual disability),… she reported the next day that she had made a recommendation to the Chairman of Akim to promote the program nationwide. The fact that the program was received with such enthusiasm is exciting, and we are pleased we were able to take a real difficulty and translate it into practical program which can contribute deeply to the health of residents of the hostel and to the mentally disabled community in Israel.22 (p. 1448)
Furthermore, we found that educational programmes in our data that focused on service, reflection, led to inspiring learners, through a sense of encouragment and motivated students to work and make a commitment with underserved communities and their ‘real’ needs, reflecting a deeper understanding of context and background of individuals using healthcare.
SERVE [Service, Education, Reflection, Volunteerism Elective] inspired me to dedicate my future practice to underserved communities.23 (p. 300)
Integrating traditional clinical skills with advocacy, global health, human rights and social justice work
Moving teaching from singular lectures to more diverse methods of learning was reported to be an eye opener for students in highlighting the relevance of advocacy for vulnerable populations. This insight was important to understanding the social determinants of health as they were more real when seen in plain sight.
My experience broadened my understanding … concepts such as patient advocacy, vulnerable populations and the social determinants of health had seemed obscure in lectures, but were immediately relevant in this new environment … I have become more aware of the interaction between social issues and health care … that will direct my future learning and my approach to a career in medicine.20 (p. 979)
As important as local context was, we found that global health was also an important encounter for future work in the developing and ever-changing world of healthcare.
The evaluations have revealed that undertaking IPHC [International Primary Health Care] supports students because it: [provides the] opportunity to learn about diseases specific to 3rd world medicine. To gain an idea of the type of work I could do in the developing world in the future. …addresses many issues of healthcare that should be covered [sic] are not covered in the standard curriculum. In my opinion, IPHC should be made compulsory in [sic] as a 3-week component in 4th year.24 (p. 4)
Additionally, projects that lead to creation or finding resources for vulnerable populations and ways of working and advocating for positive outcomes, were a valuable learning process and led to a new understanding of concepts related to social justice.
My health care disparities project of mapping the Laotian population in Elgin showed me the importance of identifying health care resources for vulnerable populations and increasing access to these resources. Prior to this course, I thought much less about some aspects of increasing access to resources such as adequate public transportation as a part of advocacy. … Thus, I believe this course has expanded my definition of medical advocacy in quite a profound way.25 (p. 3)
Learning processes and methods
Findings reflected how students observed the importance of both the micro-lens and macro-lens of an individual’s problem and then understood them in the context of all the factors that could impact a wider scale, moving from individual local need to a wider public health focus.
When asked what they had learned students identified two key themes: the bigger picture of public health; and person-centered or individualized care. Participants recognized that ‘an individual’s health is multifactorial and public health can have a huge impact’. Furthermore, one stated: how small an impact medicine and direct biological intervention has upon someone’s overall wellbeing – there’s so many other factors on so many levels to consider.26 (p. 4)
There was an understanding that social problems, health and disease processes required multidisciplinary communication to make a significant or critical leap for positive outcomes.
It [Universidad de La Sabana] favours a dialogue of various disciplines: anthropology, sociology, public health and communication, seeking to understand and comprehend both the health process and disease… and to generate, from the discourse, critical thinking about social problems.27 (p. 271)
Inclusivity and diversity of professionals did not mean training more individuals to conform to the host population lens, but to allow room for professional identity formation to include the link to traditional medicine as well as Western practices and adapt to other more diverse contexts.
Personally, instead of just training more Native [medical] students to be fluent in Western medicine, I’d prefer to see the university reform itself and its systems of knowledge production to cultivate the emergence of an identity as an Indigenous doctor/health worker, skilled in both Western and traditional.28 (pp. 645–6)
Findings also showed that a mix of methods were preferred by learners, that a balance in information giving/receiving, via classroom and real-life work with individuals, was the best process for learning complexity.
The balance between interaction/participation, small group and lecture style teaching. The most valuable part of the content was the workshops and the skills they instilled in us for conducting history taking with a Māori patient.29 (p. 6)
This session was extremely useful to my learning/understanding of cultural considerations during medical interviewing - especially for students about to embark on their [Indigenous community] placements. It was indefinitely more useful than any pre-readings we could have gotten. Please keep this in the curriculum for next year!30 (p. 7)
The programme, teaching methods and evaluation from the studies included can be seen in the online supplemental table 3.
Supplemental material
Discussion
The WHO has defined the ‘social accountability of medical schools’ as ‘the obligation to direct education, research, and service activities towards addressing the priority health concerns of the community, region and the nation that they have a mandate to serve.’31 According to the WHO, social justice begins by recognising that health is a fundamental human right, and gross inequalities in healthcare are politically, socially and economically unacceptable.32 Social justice education, incorporating interdisciplinary knowledge and encouraging social, political and biomedical collaboration, will help medical students to become socially conscious and acquire the skills to deliver competent healthcare to all in the community.33 34
Our findings from the meta-synthesis suggest that, the core medical school curriculum should include training that enables students to recognise and redress adverse medically relevant social factors.3 This is because social issues such as poverty, illiteracy and discrimination deeply affect human health.35 Addressing these health disparities would require medical students to become skilled in ‘assessing and intervening in the social and structural determinants of the patients’ daily lives’ outside of the clinical setting35 and ‘looking beyond the patient–doctor interaction’ alone.9
This analysis also points to adopting a multifactorial lens as the best ways to impact positive outcomes were: (1) working in multidisciplinary, interprofessional teams; (2) understanding the role of doctors in health promotion, assessing health policy and health systems, providing culturally safe care, ‘thinking upstream prevention’ to develop a social justice programme; and (3) understanding that social determinants of health, include education, employment, culture, gender, housing, income, class and social status, and how these affect patients and communities.36 To accomplish this, our data indicates that medical students condsider professional identity that incorporated a ‘physicians-health advocates’ role to combat the propensity to see ill health as purely the outcome of poor lifestyle choices. As this belief ‘ignores the fact that social and economic status shapes a person’s ability to make healthy choices regarding housing, available food, safe neighbourhoods and the like.’9
Examples, such as the Social Justice Vertical Integration Group at the Geisel School of Medicine at Dartmouth, identified core social justice competencies with linked objectives3 and developed key topics in order to facilitate student achievement of these competencies and objectives. They also reviewed other medical schools’ diverse approaches to social justice teaching, examining ways by which both the classroom and the experiential components of the social justice curriculum can be integrated with important basic science and clinical curricular components. Creating multifaceted written and verbal student evaluation would be a critical component of the medical school social justice curriculum, as would adequate infrastructure support and ongoing assessment of the impact of students’ hands-on work with the communities they serve.3
Therefore, the goal of educating future doctors to care for the national population requires an adequate number of doctors who are properly distributed to underserved areas, and enough minority physicians in the workforce trained to allow for diversity and link both traditional and Western medicine with the needs of the local population served. The importance of this mission is underscored by an ever-increasing body of evidence of a wide range of health disparities affecting ethnic minority populations.37 These disparities often go unnoticed38 and reflect historical deep rooted inequalities in education, housing, employment and the related policies.39 Therefore, without discounting other potential causal factors, medical school curricula need to engage with the rich literature and evidence base which show that the conditions of life, with its various privileges and oppression, are strongly correlated with health or illness.
Limitations
The main criticisms of conducting a meta-analysis are that it blends various types of literature, disparate articles therefore the concluding result may overlook critical distinctions between studies. We have tried to minimise this by narrowing our focus, to look at learning interventions and programmes of social justice.
Conclusion
Our analysis suggests that the core medical school curriculum should include compulsory training, which enables students to recognise and redress adverse medically relevant social factors.3 Social justice in medical education should not be understood as a non-essential piece of professionalism. This is because social issues such as poverty, illiteracy and discrimination deeply affect human health.35 Addressing these health disparities would require medical students to become skilled in ‘assessing and intervening in the social and structural determinants of the individuals’ daily lives’ outside of the clinical setting35 and ‘looking beyond the patient–doctor interaction’ alone.9 Creating globally competent doctors through a globally equivalent curriculum which can be balanced and with a locally invested training programme could lead to a supply or workforce that is fit for purpose for local populations. To accomplish this, students must become ‘physician-health advocates’ and combat the propensity to see ill health as the outcome of poor lifestyle choices. 9 Findings confirm that social justice in undergraduate medical education is an essential component and has a role in the work of doctors, impacting healthcare and can be taught using various methods outlined in this research. In conlcusion, social justice can be learned as a part of everyday practice realities and should include the contemporary context of healthcare ineqaulities improvement focus and a social justice lens.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @DrKhan_do
Correction notice This article has been corrected since it was first published. Affiliation 1 has been updated.
Contributors Conception and design—NK, AR and SD. Screening—NK, ASe, SS and ASr. Extraction—NK, AS and SD. Analysis and interpretation of the data—NK and AR. Drafting of the article—NK. Critical revision of the article for important intellectual content—NK and AR. Final approval of the article—NK, ASe, SS, ASr, AR and SD. Specialist medical librarian support—MH. Guarantor—SD.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.