Understanding Faculty Perspectives on Health Equity Curriculum Implementation in Graduate Medical Education: A Qualitative Study

Understanding Faculty Perspectives on Health Equity Curriculum Implementation in Graduate Medical Education: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Understanding Faculty Perspectives on Health Equity Curriculum Implementation in Graduate Medical Education: A Qualitative Study Krys Foster, Dhruvi Shah, Quinn Plunkett, Randa Sifri This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4830646/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Nov, 2024 Read the published version in BMC Medical Education → Version 1 posted 4 You are reading this latest preprint version Abstract Background Despite increased awareness of persistent healthcare disparities, integrating health equity education into medical residency curricula needs urgent expansion. The Accreditation Council for Graduate Medical Education (ACGME) mandates addressing healthcare disparities and social determinants of health, but implementation remains insufficient due to pervasive barriers. Objective To explore residency faculty perspectives at one institution surrounding implementing a health equity curriculum within their programs. Methods Between November 2022 and April 2023, qualitative interviews and focus groups were conducted with residency faculty participants (n = 13) from a large academic medical institution. Participants were recruited via an internal email list directory of program directors. Semi-structured sessions explored faculty perspectives on health equity curriculum implementation. Data analysis utilized template analysis and thematic coding. Results Faculty perceived barriers included limited time for teaching health equity, challenges in prioritizing health equity content within the curriculum, lack of formal training and expertise, discomfort in leading discussions, and institutional barriers such as resource allocation and lack of buy-in. Conclusions Findings underscored the need for institutionally supported faculty development and protected learning time for health equity education. Despite participant recruitment and representation limitations, the study provides valuable insights for addressing curricular challenges. This study highlights critical areas for improving health equity curriculum implementation in graduate medical education. Addressing these faculty barriers can enhance resident competency in identifying and addressing healthcare disparities. Trial Registration: The study received ethics approval from the Thomas Jefferson Institutional Review Board (IRB #22E.762). Graduate Medical Education Health Care Disparities Health Equity Faculty Curricular Barriers Residency Faculty Perspectives Introduction Health inequities and the impact of implicit bias on healthcare disparities remain prominent issues despite numerous national calls to address these matters, reports on their impact on patient health and mortality, and increased awareness of social determinants of health. [1– 3] To address this public health need, clinicians must have the knowledge and skills to detect and reduce health care disparities in their patient populations. In 2017, the Accreditation Council for Graduate Medical Education (ACGME) introduced a mandate requiring all United States medical residency programs to include healthcare disparities and social determinants of health in their curriculum. [4] Creating an environment where trainees develop skills and expertise to provide equitable care through specifically designed curricula is one way to support appropriate education. [5] Several graduate medical education (GME) programs include defined health equity education in their training, however, no standardization exists across programs. [6–9] For example, a scoping literature review performed by Atkinson et al exploring cultural competency curricula in GME identified a diversity of curricular designs and competency assessment tools, highlighting the variable and individualized approaches programs take to address the mandate. [7] Moreover, the lack of consensus on how to teach health equity makes implementing curriculum difficult. [7] Faculty are often tasked with creating educational material for topics and behaviors they were not taught, making it difficult to teach, evaluate programming and assess learner’s competency. [9] Therefore, we sought to better understand the current implementation of residency health equity curricula across a large academic medical institution. Specifically, this study explored faculty and resident perspectives on current health equity related curricular experiences through qualitative inquiry. Methods Setting and Participants This study was conducted between November 2022 and April 2023 at a single, large, urban academic institution in the Northeast comprised of 21 residency specialties. Faculty participants were recruited using an internal email directory of program directors. Program directors were encouraged to share the initial email with their core residency faculty. In this email, interested faculty were asked to complete a voluntary Qualtrics form detailing their name, email address, and specialty, which was then utilized for outreach. Using stratified sampling, we aimed for at least two-thirds of program representation to ensure diverse perspectives on health equity curricular implementation. Twelve total interviews and focus groups were conducted with faculty participants. Participating faculty received an emailed copy of the consent form before the formal meeting. Verbal consent was requested from participants before starting an interview or focus group. Interviews and focus groups were semi-structured, 45–60-minute virtual sessions conducted by a professional facilitator (KF) and a research coordinator with prior experience with focus groups. Sessions were audio recorded and professionally transcribed using an external transcription agency, REV©. Notes were taken during each focus group and interview to augment the transcript. Participants were given $ 50 gift cards as an incentive for their interviews. The study received ethics approval from the Thomas Jefferson Institutional Review Board (IRB #22E.762). Interview & Focus Group Moderator Guide The moderator guides were developed by KF in consultation with experienced qualitative researchers in the department and an expert from the institution who have conducted similar interviews. The guides were iterative, informed by a needs assessment, and questions were tailored to the participants. The guides were supported by a priori themes and studies that sought input from faculty regarding GME curricula. The guides included questions on curricular experiences related to health equity, interest, barriers, and facilitators to curricular implementation, and the feasibility of implementing a formalized residency curriculum addressing health equities across the institution. Code Book and Data Analysis Researchers performed template analysis to identify significant patterns, or themes, within the data, for exploration and interpretation of the specific research questions. [10] Interview and focus group transcripts were used for the coding process. An a priori codebook was developed to utilize NVivo© software for thematic analysis. Three researchers (KF, DS, QP) independently coded all transcripts using the same codebook with NVivo© software. Codes were organized into a coding template; the codebook evolved as the analysis progressed, new codes were added as themes emerged, and existing ones were refined as needed. The process was iterative, with continuous review of revising, combining, or splitting codes. After consensus was reached for codes pertaining to the main topics, the codes relegated to “quotes of interest” were discussed to decide how they should be coded. Results Eleven interviews and one focus group were conducted with 13 unique faculty participants with one faculty who participated in both. These included ten program directors and three assistant program directors from 11 specialties (Table 1). Participant names and personal information were de-identified and stored appropriately to preserve participant anonymity with only internal researchers having access to this data. Other demographic information (i.e. race) was not collected. Table 1: Participant Faculty Roles and Specialties (N = 13) N (%) Faculty Role Program Director 10 (77) Associate Program Director 3 (23) Department Dermatology 1 (7.7) Diagnostic Radiology 1 (7.7) Emergency Medicine 1 (7.7) Family Medicine 1 (7.7) Internal Medicine 2 (15.4) Neurology 1 (7.7) Obstetrics and Gynecology 1 (7.7) Pathology 2 (15.4) Pediatrics 1 (7.7) Physical Medicine and Rehabilitation 1 (7.7) Radiation Oncology 1 (7.7) Throughout the analysis, themes and subthemes collapsed and expanded as they evolved. The themes emerging from the qualitative interviews related to faculty perceived barriers to implementing health equity curricula fall under the themes of faculty time, faculty knowledge and expertise, faculty discomfort, and institutional barriers. These themes, subthemes, and illustrative quotes are further described below and in Table 2 . Table 2 Quotes Illustrating Main Themes and Subthemes Regarding Faculty Barriers for Health Equity Curriculum Implementation Main theme Subtheme Faculty Illustrative Quote Faculty Time (N = 17) Lack of time to teach (N = 12) I think for formal curriculum, honestly, it's a time thing. They have so much to learn...and there's only so much time we have to deliver it. - Diagnostic Radiology ...I think often we're very focused on, okay, they've got to keep doing the surgeries and they've got to keep seeing patients and treating the pneumonias because that's what they're here to learn. And the other stuff happens when it happens. - Physical Medicine and Rehabilitation I think it's somewhat variable...I think some people, they compensate for the residents or they don't take the time to really delve into it, and I think some of that is also because it frustrates the residents when I sidetrack them for five minutes because they just want to get to their next patient resident clinic... - Dermatology Curriculum prioritization (N = 5) There's a group of pathology educators...and they're coming up with a DI curriculum. That's supposed to be modular, that could theoretically slot into any pathology curriculum in the US, which we'll use once we get there...I don't know what I'm going to bump in order to fit that in. - Pathology And the challenge is, that is a huge amount of material. So what is the stuff that's most important that all residents need to learn? Because I can't teach my residents all of what they need to know about the medicine. - Emergency Medicine I feel like our residents have so much that they need to know. If I'm going to add something real to the curriculum, I want to know what they're getting out of it. - Pathology and Genomic Medicine Faculty knowledge and expertise (N = 28) Lack of formal training in health equity topics (N = 8) There has been no formal education for many of the faculty. We know this is a thing, we know it impacts, but we don't have the skills taught and we don't know how to get right to the core of the issue with a skillset that isn't there. - Internal Medicine ...all our lectures are delivered by attendings, but they might not feel they have expertise in that area or they don't have time to really research it and delve into it to change their lecture. - Diagnostic Radiology Our biggest barrier is lack of internal expertise in this manner, which I don't think surprises anybody...We've done our best to lean on certain faculty who have interest in this issue, which you wish it was everyone. And everyone has an interest, and everyone feels that it's a problem, but having the expertise to teach is the barrier. - Physical Medicine and Rehabilitation Lack of skills to address healthcare disparities (N = 5) ...you've heard this lecture, you found this information and you want to put it into practice in clinic, but the attending that you're working with doesn't know what you're talking about or hasn't really thought about it or hasn't done anything. And so it's great to teach residents, but we also need the education for the attendings... - Pediatrics Lack of knowledge of how to implement health equity curriculum (N = 15) What should we be doing? Saying, "Well, there's inequity happening," and pointing it out, but then we keep going about our day because we have to [...] Or, should we be teaching how to solve the inequity, which that's really daunting. I don't know how to do that. So then I get afraid to do, I don't know, to do anything. - Physical Medicine and Rehabilitation I mean, other than evaluating each resident on their evaluations, where we have sections regarding, of course, patient interactions, interactions with family, professionalism, we don't have, say, an examination assessing cultural competency and knowledge of disparities and all these things. - Diagnostic Radiology Faculty discomfort (N = 24) Discomfort in faculty leading conversations (N = 10) I also was going to have a movie screening for that movie Aftershock that came out, and I just couldn't find the right time and space to do it. Then again, I got nervous about being the person to facilitate the conversation, and needed a co-facilitator and couldn't schedule that. - Obstetrics and Gynecology Discomfort in creating uncomfortable experiences for residents (N = 4) Sometimes I struggle with creating educational opportunities that are going to be really important for my White residents, without alienating, or relying too much on my Black residents, to give their perspective, or their experience, or also traumatize them from things that may be affecting their friends and family, and potentially themselves at some point. - Obstetrics and Gynecology Discomfort with "teaching up" and "doing it wrong" (N = 10) It's so hard to teach something to our young people, who are better at this than we are. - Physical Medicine and Rehabilitation Discomfort with "teaching up" and "doing it wrong" (N = 10) The train to teach me, and those that are clinicians and doing fine, to be health inequity experts seems like such a darn lift. And so I'm fearful that the learners are always going to be ahead of faculty until we all retire. - Physical Medicine and Rehabilitation So I think challenges are [...] we don't want to do it wrong, we want to do it in a real way that is appropriately sensitive. - Pathology and Genomic Medicine Institutional barriers (N = 17) Resource allocation (N = 6) When everybody's already so busy or have the different hats that they wear and you don't have the financial support of it, I think there's desire there, but the reimbursement is not. - Internal Medicine Institutional barriers (N = 17) Resource allocation (N = 6) Funding again, would be an obstacle just for those other opportunities we had mentioned earlier, just getting them outside the borders of Philadelphia specifically and looking at other places and what being underserved or what inequities are there that are maybe different than the types that we see in Philadelphia. - Internal Medicine I think one of our biggest challenges is, or I have someone who's willing and able, and wants to teach, and is well respected by residents, patients, nationally, but doesn't have time. Time, because her job is clinical, and the way that she's compensated, and her time is structured, there's no opportunity other than her volunteering. And at some point, she gets... You have to say no, right? You can't do everything, or you won't, or you'll burn out. - Obstetrics and Gynecology ...I don't think that enough time is given because I think it is perceived as a bit of an energy time and resource sink. - Internal Medicine Lack of buy-in (N = 7) I think we run the gamut from people who are interested but don't have knowledge, to people who actively feel attacked a little bit by some of the things that are talked about in these spaces. So just buy-in is a problem. - Pathology I think it is not the highest priority because it does not come with the dollars that I think the institution desires...Things that make money, the procedures, the healthy patients with support cycle through in and out, that makes things happen. - Internal Medicine Faculty diversity (N = 4) If we are successful as a department in recruiting more diverse faculty, I think again, that would bring in new perspective, new life and new mentorship in terms of promoting these topics. - Internal Medicine I think also having a less than diverse faculty...I think when your faculty all has a somewhat similar point of view of the world and the only means by which you can understand health disparities is by talking to your patients, and then you only have their view of what their health disparities are like, it's certainly a challenge to come up with a curriculum that addresses all the things it should address. - Dermatology Faculty Time Lack of Time to Teach There was a common sentiment among faculty that they felt pressure to find time (during clinical care or in didactic curriculum) to introduce a formal curriculum on health equity. Due to busy resident and faculty schedules, the focus on teaching clinical skills to residents and providing care for patients left little time to teach about health equity. Curricular Prioritization Challenges Several faculty members commented similarly that when deciding whether to incorporate health equity into the curriculum, a consideration had to be made for what would need to be removed or “bumped” to create space. Faculty expressed concern over the amount of material to be covered in a health equity curriculum and being unclear on how to distill it to the “most important that all residents need to learn.” Considering the volume of content residents are required to learn, one faculty wanted to “know what [residents would be] getting out of it,” i.e., determining the benefit before adding something new to the curriculum. Faculty Knowledge and Expertise Lack of Formal Training in Health Equity Topics Faculty cited inadequate knowledge, limited prior training, or insufficient expertise in health equity topics as barriers to incorporating health equity into the residency curriculum. Several noted that conversations around health equity and social determinants of health “only picked up...a few years ago.” Curricular implementation had been limited to their experiential learning and/or leaning on the faculty interested in the topics. Lack of Skills to Address Healthcare Disparities Moreover, there were concerns about faculty translating theoretical learning skills into practical or modeling skills in addressing healthcare disparities. One faculty noted that residents may have theoretical knowledge but limited practical ability when the attendings they are working with “[don’t] know what you’re talking about or [haven’t] really thought about it...” Lack of Knowledge of How to Implement Health Equity Curriculum Several participants noted an additional challenge surrounding the “how” of implementing health equity curricula. One faculty discussed being unclear of the competency aims for the health equity curriculum. At the same time, another commented that they did not have formal means for assessing resident competency in health equity topics. A third faculty member described not knowing if they should be “pointing out” inequities in their teaching or questioned if they should teach only if they can instruct confidently on how to “solve the inequity”. Faculty Discomfort Discomfort in Faculty Leading Conversations Interviewed faculty identified several scenarios in which a curriculum on health equity themes brought discomfort, resulting in further efforts being avoided or deferred to others. A faculty member, who self-identified as White, described being nervous facilitating conversations around health inequities in Black maternal health without having a co-facilitator. Discomfort in Creating Uncomfortable Experiences for Residents One faculty member expressed difficulty creating educational opportunities around health equity themes without negatively impacting residents of certain racial backgrounds. Discomfort with “Teaching up” and “Doing it Wrong” Notably, several faculty commented on their residents having more knowledge of health equity topics than they. Faculty expressed difficulty with teaching about health equity to their residents, “who are better at this than we are.” and not wanting to “do it wrong.” This same faculty member felt that the time has passed and/or it would be a heavy lift for many faculty to gain the skills to become health inequity experts at this point, so residents “will always be ahead of faculty until [they] all retire.” Institutional Barriers Resource Allocation Several faculty members interviewed highlighted inadequate institutional resources to support incorporating health equity into the curriculum despite their desire to do so, whether through funding of experiences or support of faculty time to develop it. One commented that health equity teaching is often volunteer-based, and despite having a faculty member with an interest in teaching about health equity, due to their clinical role and mechanism of compensation, their effort would not be compensated to do this. Another faculty believed the institution did not supply the resources due to a lack of perceived value in the health equity curriculum. Lack of Buy-In Faculty also identified a lack of buy-in as a barrier to curricular implementation. One faculty interviewed expressed having members of their faculty "... who actively feel attacked a little bit by some of the things that are talked about in these spaces. So just buy-in is a problem. ” Another mentioned that their faculty were not interested in participating or leading sessions in a Journal Club on Health Equity to address their residency’s curricular gap. One faculty commented on gaps in training and support for residents providing hands-on care to socially vulnerable patients – in particular, noting that formalized support to provide care for populations that did not have the highest financial return, was not a high institutional priority. Faculty Diversity Several faculty commented on the benefit of having diversity within their residency cohort and the impact on discussions involving health equity. Still, a few faculty also commented on the impact of limited faculty diversity on their ability to implement the curriculum. One faculty member expressed that when most of the faculty share similar views and perspectives on health disparities, creating a comprehensive curriculum can be challenging due to their narrow perspective on understanding the diverse patient population. Another program director shared feelings that recruiting a more diverse faculty would be an additional resource to promoting topics related to health equity in the curriculum. Discussion Our project identified barriers to health equity curricular implementation as perceived by core residency faculty at our large academic institution. The study’s findings support existing literature and further explored challenges faculty face around protected time to incorporate health equity within a curriculum. [6,8,11] Faculty's numerous responsibilities and activities leave inadequate time to curate this content intentionally; it is often relegated to unprotected time. Further, the clinical demands on residents and the need to cover extensive content within limited didactic time make it challenging for faculty to prioritize dedicated health equity education in the curriculum. One of the most expressed barriers to curricular implementation identified in this study was limited faculty knowledge and expertise around health equity. Faculty mentioned gaps in their knowledge, lack of skills to address healthcare disparities, or how to implement health equity curriculum. The second most expressed barrier in the study was faculty discomfort. Faculty development and continuing education workshops can enhance faculty competency and develop skills for resident assessment. Moreover, creating a shared learning space where faculty and residents can co-learn may avoid the challenges to the educational hierarchy (e.g., residents “who are better at this than we are”) and create room for bi-directional learning. A series of faculty workshops can include facilitator training in leading difficult discussions, developing departmental health equity champions, enhancing confidence in creating educational experiences, and sharing best practices for implementing and assessing outcomes of health equity curricula. At the institutional level, incorporating health equity education within institutional values statements across all levels and specialties can establish it as an organizational priority and induce a cultural shift. [12] This can be through strategic planning process to address structural racism, expansion of health equity courses, increased hiring of faculty with health equity focuses. Further, support through the allocation of protected time, intentional recruitment and retention of diverse faculty, funding for designated personnel, and centralized resources to offload the burden of one or few faculty can reinforce these values, create spaces for health equity conversations, and enhance the care delivered. Sustained institutional investment supporting faculty time to develop and deliver educational materials, and educational time for these topics within resident schedules could address the expressed time barriers. [13] Faculty can avoid reinventing the wheel by implementing audits to enhance current education and leverage existing resources, such as the American Medical Association (AMA) Health Equity Education Center and ACGME Equity Matters Toolkit, across departments. [14–15] Further, faculty can co-lead centralized learning opportunities (e.g., joint-conferences and service learning) and prioritize and integrate high-yield health equity content within existing lectures rather than displacing required topics. [14–16] While this study enhances our understanding of health equity curricula at our institution, there are some limitations. First, there were challenges with outreach and recruitment of study participants. Though recruitment emails were sent to all residency program directors and coordinators, with an additional request to have them forward the invite to their respective core residency leadership, the unidirectional nature of this study limited the ability to discern how many educators received the invitation to participate. Additionally, participation in this voluntary study was low and lacked representation from several specialties. Despite the robust qualitative findings, the perspectives included may not reflect the entire community of GME leaders at the institution. Further, given the potential for participant identification, selected participant demographics (including race/ethnicity, gender identity, and age) were not collected. Thus, we are unable to discern representativeness or whether further thematic associations exist. Additional research is needed to investigate the prevalence of these perspectives across GME at large and to explore whether other personnel or institutional characteristics are correlated with the identified themes. By analyzing the current state of health equity curricular implementation, we aim to design an intentional GME curricular framework for use across the institution. This manuscript highlights findings from individual interviews and focus groups regarding perceived faculty and institutional barriers to health equity curricular implementation. Next steps for this work include assessing resident and community member perspectives on barriers, facilitators and key characteristics desired for future health equity curricular enhancements and collaborating with institutional leadership to develop a framework addressing identified barriers for future curricular implementation. Conclusions Through this investigation, we were able to qualitatively explore residency faculty perspectives on health equity curriculum experiences and identified key areas academic institutions might address to overcome challenges faculty face in implementing health equity curriculum. A multi-pronged approach can leverage resources from the institution to achieve common goals across specialties, address ACGME requirements, and provide residents with training to reduce healthcare disparities in their clinical practice. Abbreviations ACGME - Accreditation Council for Graduate Medical Education AMA - American Medical Association GME - Graduate Medical Education IRB - Institutional Review Board Declarations Ethics Approval : The study received ethics approval from the Thomas Jefferson Institutional Review Board (IRB #22E.762). Consent for Publication : Informed consent was obtained from all individual participants included in the study. Participants signed informed consent regarding publishing their data. All participant personal information has been deidentified from the data. Availability of Data and Materials : The data that support the findings of this study are not openly available due to reasons of sensitivity. Demographic data cannot be shared openly to protect the study participants privacy. Competing Interests : The authors report there are no competing interests to declare. Funding : This work was funded in part through an internal institutional award, The Carl Mansfield, MD, Equity Scholar Award for Career Development, Thomas Jefferson University, Jefferson Collaborative for Health Equity. Authors’ Contributions : K.F. conceptualized the work. K.F. and D.S. designed the work, conducted the interviews/focus groups, acquired the data, developed the tables and wrote the main manuscript text. K.F., D.S., and Q.P. developed the codebook and analyzed the data. K.F., D.S. Q.P. and R.S. reviewed and revised the manuscript prior to submitting. All authors have approved the submitted version and agree to be personally accountable for the contributions and ensure the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. Acknowledgements : We would like to thank all our participants for sharing their experiences with us and for their dedication to this important work. We would like to thank Ibriana Garvey, MPH for helping with literature review and scheduling the interviews for this project. We thank the Jefferson Collaborative for Health Equity for their assistance in this project's efforts. References Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, D.C.: National Academies Press; 2003. doi:10.17226/12875 Advancing Racial Equity in U.S. Health Care: State Disparities | Commonwealth Fund. https://www.commonwealthfund.org/publications/fund-reports/2024/apr/advancing-racial-equity-us-health-care. 2023 National Healthcare Quality and Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); December 2023. AHRQ Pub. No. 23(24)-0091-EF. Maldonado ME, Fried ED, DuBose TD, Nelson C, Breida M. The role that graduate medical education must play in ensuring health equity and eliminating health care disparities. Ann Am Thorac Soc. 2014;11(4):603–607. doi:10.1513/AnnalsATS.201402-068PS Common program requirements (residency). https://www.acgme.org/globalassets/PFAssets/ProgramRequirements/CPRResidency_2022v2.pdf. ACGME Common Program Requirements (VIA1b1a). Hernandez RG, Thompson DA, Cowden JD. Responding to a call to action for health equity curriculum development in pediatric graduate medical education: Design, implementation and early results of Leaders in Health Equity (LHE). Front Pediatr . 2022;10:951353. doi:10.3389/fped.2022.951353 Atkinson RB, Khubchandani JA, Chun MBJ, et al. Cultural competency curricula in US graduate medical education: A scoping review. J Grad Med Educ . 2022;14(1):37–52. doi:10.4300/JGME-D-21-00414.1 Fatahi G, Racic M, Roche-Miranda MI, et al. The current state of antiracism curricula in undergraduate and graduate medical education: A qualitative study of US academic health centers. Ann Fam Med. 2023;21(Suppl 2):S14-S21. doi:10.1370/afm.2919 Dupras DM, Wieland ML, Halvorsen AJ, Maldonado M, Willett LL, Harris L. Assessment of training in health disparities in US internal medicine residency programs. JAMA Netw Open . 2020;3(8):e2012757. doi:10.1001/jamanetworkopen.2020.12757 King, Nigel. Doing template analysis. In Qualitative Organizational Research: Symon G, Cassell C. Qualitative Organizational Research: Core Methods and Current Challenges. 1 Oliver’s Yard, 55 City Road London EC1Y 1SP : SAGE Publications, Inc.; 2012. doi:10.4135/9781526435620 Weiss KB, Co JPT, Bagian JP, CLER Evaluation Committee. Challenges and opportunities in the 6 focus areas: CLER national report of findings 2018. J Grad Med Educ. 2018;10(4 Suppl):25–48. doi:10.4300/1949-8349.10.4s.25 Higginbotham EJ, Hertz K, Fahl C, Duckett DB, Mahoney K, Jameson JL. Addressing Structural Racism Using a Whole-Scale Planning Process in a Single Academic Center. Health Equity . 2023;7(1):487–496. doi:10.1089/heq.2023.0093 Butts GC, Abner P, Hess L, et al. Designing a road map for action to address bias and racism within a large academic medical center. Acad Med . June 2023. doi:10.1097/ACM.0000000000005289 Health Equity Education Center | AMA Ed Hub. https://edhub.ama-assn.org/health-equity-ed-center Accreditation Council for Graduate Medical Education. https://dl.acgme.org/pages/equity-matters Treacy-Abarca S, Aguilar M, Vassar SD, Hernandez E, El-Farra NS, Brown AF. Enhancing existing medical school curricula with an innovative healthcare disparities curriculum. BMC Med Educ . 2021;21(1):613. doi:10.1186/s12909-021-03034-7 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Nov, 2024 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 16 Aug, 2024 Editor assigned by journal 13 Aug, 2024 Submission checks completed at journal 13 Aug, 2024 First submitted to journal 30 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4830646","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":341140739,"identity":"dee9ac71-2c19-4f5d-b726-6148ed58ba40","order_by":0,"name":"Krys Foster","email":"data:image/png;base64,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","orcid":"","institution":"Thomas Jefferson University","correspondingAuthor":true,"prefix":"","firstName":"Krys","middleName":"","lastName":"Foster","suffix":""},{"id":341140740,"identity":"1effeb26-5720-47b1-9353-28fead01ce1b","order_by":1,"name":"Dhruvi Shah","email":"","orcid":"","institution":"Thomas Jefferson University","correspondingAuthor":false,"prefix":"","firstName":"Dhruvi","middleName":"","lastName":"Shah","suffix":""},{"id":341140741,"identity":"03dcbdb0-a06e-4663-8d8d-ce00099cf4d0","order_by":2,"name":"Quinn Plunkett","email":"","orcid":"","institution":"Thomas Jefferson University","correspondingAuthor":false,"prefix":"","firstName":"Quinn","middleName":"","lastName":"Plunkett","suffix":""},{"id":341140742,"identity":"58ae19f2-89bf-4cd4-a046-39a5aaa66dd0","order_by":3,"name":"Randa Sifri","email":"","orcid":"","institution":"Thomas Jefferson University","correspondingAuthor":false,"prefix":"","firstName":"Randa","middleName":"","lastName":"Sifri","suffix":""}],"badges":[],"createdAt":"2024-07-30 18:10:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4830646/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4830646/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-024-06276-3","type":"published","date":"2024-11-11T15:57:59+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69284918,"identity":"405d4f32-cd4d-442f-8cff-6c1c2eb20097","added_by":"auto","created_at":"2024-11-18 19:23:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":742624,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4830646/v1/e3772dc8-5d6d-4ea4-90b4-b154a34d7bf1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Understanding Faculty Perspectives on Health Equity Curriculum Implementation in Graduate Medical Education: A Qualitative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHealth inequities and the impact of implicit bias on healthcare disparities remain prominent issues despite numerous national calls to address these matters, reports on their impact on patient health and mortality, and increased awareness of social determinants of health. \u003csup\u003e[1\u0026ndash; 3]\u003c/sup\u003e To address this public health need, clinicians must have the knowledge and skills to detect and reduce health care disparities in their patient populations.\u003c/p\u003e \u003cp\u003eIn 2017, the Accreditation Council for Graduate Medical Education (ACGME) introduced a mandate requiring all United States medical residency programs to include healthcare disparities and social determinants of health in their curriculum.\u003csup\u003e[4]\u003c/sup\u003e Creating an environment where trainees develop skills and expertise to provide equitable care through specifically designed curricula is one way to support appropriate education.\u003csup\u003e[5]\u003c/sup\u003e Several graduate medical education (GME) programs include defined health equity education in their training, however, no standardization exists across programs. \u003csup\u003e[6\u0026ndash;9]\u003c/sup\u003e For example, a scoping literature review performed by Atkinson et al exploring cultural competency curricula in GME identified a diversity of curricular designs and competency assessment tools, highlighting the variable and individualized approaches programs take to address the mandate. \u003csup\u003e[7]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMoreover, the lack of consensus on how to teach health equity makes implementing curriculum difficult.\u003csup\u003e[7]\u003c/sup\u003e Faculty are often tasked with creating educational material for topics and behaviors they were not taught, making it difficult to teach, evaluate programming and assess learner\u0026rsquo;s competency. \u003csup\u003e[9]\u003c/sup\u003e Therefore, we sought to better understand the current implementation of residency health equity curricula across a large academic medical institution. Specifically, this study explored faculty and resident perspectives on current health equity related curricular experiences through qualitative inquiry.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting and Participants\u003c/h2\u003e \u003cp\u003eThis study was conducted between November 2022 and April 2023 at a single, large, urban academic institution in the Northeast comprised of 21 residency specialties. Faculty participants were recruited using an internal email directory of program directors. Program directors were encouraged to share the initial email with their core residency faculty. In this email, interested faculty were asked to complete a voluntary Qualtrics form detailing their name, email address, and specialty, which was then utilized for outreach. Using stratified sampling, we aimed for at least two-thirds of program representation to ensure diverse perspectives on health equity curricular implementation. Twelve total interviews and focus groups were conducted with faculty participants.\u003c/p\u003e \u003cp\u003e Participating faculty received an emailed copy of the consent form before the formal meeting. Verbal consent was requested from participants before starting an interview or focus group. Interviews and focus groups were semi-structured, 45\u0026ndash;60-minute virtual sessions conducted by a professional facilitator (KF) and a research coordinator with prior experience with focus groups. Sessions were audio recorded and professionally transcribed using an external transcription agency, REV\u0026copy;. Notes were taken during each focus group and interview to augment the transcript. Participants were given \u003cspan\u003e$\u003c/span\u003e50 gift cards as an incentive for their interviews. The study received ethics approval from the Thomas Jefferson Institutional Review Board (IRB #22E.762).\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eInterview \u0026amp; Focus Group Moderator Guide\u003c/h2\u003e \u003cp\u003eThe moderator guides were developed by KF in consultation with experienced qualitative researchers in the department and an expert from the institution who have conducted similar interviews. The guides were iterative, informed by a needs assessment, and questions were tailored to the participants. The guides were supported by a priori themes and studies that sought input from faculty regarding GME curricula. The guides included questions on curricular experiences related to health equity, interest, barriers, and facilitators to curricular implementation, and the feasibility of implementing a formalized residency curriculum addressing health equities across the institution.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eCode Book and Data Analysis\u003c/h2\u003e \u003cp\u003eResearchers performed template analysis to identify significant patterns, or themes, within the data, for exploration and interpretation of the specific research questions. \u003csup\u003e[10]\u003c/sup\u003e Interview and focus group transcripts were used for the coding process. An a priori codebook was developed to utilize NVivo\u0026copy; software for thematic analysis. Three researchers (KF, DS, QP) independently coded all transcripts using the same codebook with NVivo\u0026copy; software. Codes were organized into a coding template; the codebook evolved as the analysis progressed, new codes were added as themes emerged, and existing ones were refined as needed. The process was iterative, with continuous review of revising, combining, or splitting codes. After consensus was reached for codes pertaining to the main topics, the codes relegated to \u0026ldquo;quotes of interest\u0026rdquo; were discussed to decide how they should be coded.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eEleven interviews and one focus group were conducted with 13 unique faculty participants with one faculty who participated in both. These included ten program directors and three assistant program directors from 11 specialties (Table\u0026nbsp;1). Participant names and personal information were de-identified and stored appropriately to preserve participant anonymity with only internal researchers having access to this data. Other demographic information (i.e. race) was not collected.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;1: Participant Faculty Roles and Specialties (N\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eN (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFaculty Role\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProgram Director\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociate Program Director\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepartment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDermatology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnostic Radiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (15.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstetrics and Gynecology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (15.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePediatrics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical Medicine and Rehabilitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiation Oncology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThroughout the analysis, themes and subthemes collapsed and expanded as they evolved. The themes emerging from the qualitative interviews related to faculty perceived barriers to implementing health equity curricula fall under the themes of faculty time, faculty knowledge and expertise, faculty discomfort, and institutional barriers. These themes, subthemes, and illustrative quotes are further described below and in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuotes Illustrating Main Themes and Subthemes Regarding Faculty Barriers for Health Equity Curriculum Implementation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFaculty Illustrative Quote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eFaculty Time (N\u0026thinsp;=\u0026thinsp;17)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eLack of time to teach (N\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI think for formal curriculum, honestly, it's a time thing. They have so much to learn...and there's only so much time we have to deliver it.\u003c/p\u003e \u003cp\u003e- \u003cem\u003eDiagnostic Radiology\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e...I think often we're very focused on, okay, they've got to keep doing the surgeries and they've got to keep seeing patients and treating the pneumonias because that's what they're here to learn. And the other stuff happens when it happens.\u003c/p\u003e \u003cp\u003e- \u003cem\u003ePhysical Medicine and Rehabilitation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI think it's somewhat variable...I think some people, they compensate for the residents or they don't take the time to really delve into it, and I think some of that is also because it frustrates the residents when I sidetrack them for five minutes because they just want to get to their next patient resident clinic...\u003c/p\u003e \u003cp\u003e- \u003cem\u003eDermatology\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eCurriculum prioritization (N\u0026thinsp;=\u0026thinsp;5)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThere's a group of pathology educators...and they're coming up with a DI curriculum. That's supposed to be modular, that could theoretically slot into any pathology curriculum in the US, which we'll use once we get there...I don't know what I'm going to bump in order to fit that in.\u003c/p\u003e \u003cp\u003e- \u003cem\u003ePathology\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnd the challenge is, that is a huge amount of material. So what is the stuff that's most important that all residents need to learn? Because I can't teach my residents all of what they need to know about the medicine.\u003c/p\u003e \u003cp\u003e- \u003cem\u003eEmergency Medicine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI feel like our residents have so much that they need to know. If I'm going to add something real to the curriculum, I want to know what they're getting out of it.\u003c/p\u003e \u003cp\u003e- \u003cem\u003ePathology and Genomic Medicine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eFaculty knowledge and expertise (N\u0026thinsp;=\u0026thinsp;28)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eLack of formal training in health equity topics (N\u0026thinsp;=\u0026thinsp;8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThere has been no formal education for many of the faculty. We know this is a thing, we know it impacts, but we don't have the skills taught and we don't know how to get right to the core of the issue with a skillset that isn't there.\u003c/p\u003e \u003cp\u003e- \u003cem\u003eInternal Medicine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e...all our lectures are delivered by attendings, but they might not feel they have expertise in that area or they don't have time to really research it and delve into it to change their lecture.\u003c/p\u003e \u003cp\u003e- \u003cem\u003eDiagnostic Radiology\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOur biggest barrier is lack of internal expertise in this manner, which I don't think surprises anybody...We've done our best to lean on certain faculty who have interest in this issue, which you wish it was everyone. And everyone has an interest, and everyone feels that it's a problem, but having the expertise to teach is the barrier.\u003c/p\u003e \u003cp\u003e- \u003cem\u003ePhysical Medicine and Rehabilitation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLack of skills to address healthcare disparities (N\u0026thinsp;=\u0026thinsp;5)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e...you've heard this lecture, you found this information and you want to put it into practice in clinic, but the attending that you're working with doesn't know what you're talking about or hasn't really thought about it or hasn't done anything. And so it's great to teach residents, but we also need the education for the attendings...\u003c/p\u003e \u003cp\u003e- \u003cem\u003ePediatrics\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eLack of knowledge of how to implement health equity curriculum (N\u0026thinsp;=\u0026thinsp;15)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhat should we be doing? Saying, \"Well, there's inequity happening,\" and pointing it out, but then we keep going about our day because we have to [...] Or, should we be teaching how to solve the inequity, which that's really daunting. I don't know how to do that. So then I get afraid to do, I don't know, to do anything.\u003c/p\u003e \u003cp\u003e- \u003cem\u003ePhysical Medicine and Rehabilitation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI mean, other than evaluating each resident on their evaluations, where we have sections regarding, of course, patient interactions, interactions with family, professionalism, we don't have, say, an examination assessing cultural competency and knowledge of disparities and all these things.\u003c/p\u003e \u003cp\u003e- \u003cem\u003eDiagnostic Radiology\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eFaculty discomfort (N\u0026thinsp;=\u0026thinsp;24)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDiscomfort in faculty leading conversations (N\u0026thinsp;=\u0026thinsp;10)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI also was going to have a movie screening for that movie Aftershock that came out, and I just couldn't find the right time and space to do it. Then again, I got nervous about being the person to facilitate the conversation, and needed a co-facilitator and couldn't schedule that.\u003c/p\u003e \u003cp\u003e- \u003cem\u003eObstetrics and Gynecology\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDiscomfort in creating uncomfortable experiences for residents (N\u0026thinsp;=\u0026thinsp;4)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSometimes I struggle with creating educational opportunities that are going to be really important for my White residents, without alienating, or relying too much on my Black residents, to give their perspective, or their experience, or also traumatize them from things that may be affecting their friends and family, and potentially themselves at some point.\u003c/p\u003e \u003cp\u003e- \u003cem\u003eObstetrics and Gynecology\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDiscomfort with \"teaching up\" and \"doing it wrong\" (N\u0026thinsp;=\u0026thinsp;10)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIt's so hard to teach something to our young people, who are better at this than we are.\u003c/p\u003e \u003cp\u003e- \u003cem\u003ePhysical Medicine and Rehabilitation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eDiscomfort with \"teaching up\" and \"doing it wrong\" (N\u0026thinsp;=\u0026thinsp;10)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe train to teach me, and those that are clinicians and doing fine, to be health inequity experts seems like such a darn lift. And so I'm fearful that the learners are always going to be ahead of faculty until we all retire.\u003c/p\u003e \u003cp\u003e- \u003cem\u003ePhysical Medicine and Rehabilitation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSo I think challenges are [...] we don't want to do it wrong, we want to do it in a real way that is appropriately sensitive.\u003c/p\u003e \u003cp\u003e- \u003cem\u003ePathology and Genomic Medicine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInstitutional barriers (N\u0026thinsp;=\u0026thinsp;17)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eResource allocation (N\u0026thinsp;=\u0026thinsp;6)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhen everybody's already so busy or have the different hats that they wear and you don't have the financial support of it, I think there's desire there, but the reimbursement is not.\u003c/p\u003e \u003cp\u003e- \u003cem\u003eInternal Medicine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003eInstitutional barriers (N\u0026thinsp;=\u0026thinsp;17)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eResource allocation (N\u0026thinsp;=\u0026thinsp;6)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFunding again, would be an obstacle just for those other opportunities we had mentioned earlier, just getting them outside the borders of Philadelphia specifically and looking at other places and what being underserved or what inequities are there that are maybe different than the types that we see in Philadelphia.\u003c/p\u003e \u003cp\u003e- \u003cem\u003eInternal Medicine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI think one of our biggest challenges is, or I have someone who's willing and able, and wants to teach, and is well respected by residents, patients, nationally, but doesn't have time. Time, because her job is clinical, and the way that she's compensated, and her time is structured, there's no opportunity other than her volunteering. And at some point, she gets... You have to say no, right? You can't do everything, or you won't, or you'll burn out.\u003c/p\u003e \u003cp\u003e- \u003cem\u003eObstetrics and Gynecology\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e...I don't think that enough time is given because I think it is perceived as a bit of an energy time and resource sink.\u003c/p\u003e \u003cp\u003e- \u003cem\u003eInternal Medicine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eLack of buy-in (N\u0026thinsp;=\u0026thinsp;7)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI think we run the gamut from people who are interested but don't have knowledge, to people who actively feel attacked a little bit by some of the things that are talked about in these spaces. So just buy-in is a problem.\u003c/p\u003e \u003cp\u003e- \u003cem\u003ePathology\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI think it is not the highest priority because it does not come with the dollars that I think the institution desires...Things that make money, the procedures, the healthy patients with support cycle through in and out, that makes things happen.\u003c/p\u003e \u003cp\u003e- \u003cem\u003eInternal Medicine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eFaculty diversity (N\u0026thinsp;=\u0026thinsp;4)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf we are successful as a department in recruiting more diverse faculty, I think again, that would bring in new perspective, new life and new mentorship in terms of promoting these topics.\u003c/p\u003e \u003cp\u003e- \u003cem\u003eInternal Medicine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI think also having a less than diverse faculty...I think when your faculty all has a somewhat similar point of view of the world and the only means by which you can understand health disparities is by talking to your patients, and then you only have their view of what their health disparities are like, it's certainly a challenge to come up with a curriculum that addresses all the things it should address.\u003c/p\u003e \u003cp\u003e- \u003cem\u003eDermatology\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eFaculty Time\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eLack of Time to Teach\u003c/h2\u003e \u003cp\u003eThere was a common sentiment among faculty that they felt pressure to find time (during clinical care or in didactic curriculum) to introduce a formal curriculum on health equity. Due to busy resident and faculty schedules, the focus on teaching clinical skills to residents and providing care for patients left little time to teach about health equity.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCurricular Prioritization Challenges\u003c/h2\u003e \u003cp\u003eSeveral faculty members commented similarly that when deciding whether to incorporate health equity into the curriculum, a consideration had to be made for what would need to be removed or \u0026ldquo;bumped\u0026rdquo; to create space. Faculty expressed concern over the amount of material to be covered in a health equity curriculum and being unclear on how to distill it to the \u0026ldquo;most important that all residents need to learn.\u0026rdquo; Considering the volume of content residents are required to learn, one faculty wanted to \u0026ldquo;know what [residents would be] getting out of it,\u0026rdquo; i.e., determining the benefit before adding something new to the curriculum.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eFaculty Knowledge and Expertise\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section4\"\u003e \u003ch2\u003eLack of Formal Training in Health Equity Topics\u003c/h2\u003e \u003cp\u003eFaculty cited inadequate knowledge, limited prior training, or insufficient expertise in health equity topics as barriers to incorporating health equity into the residency curriculum. Several noted that conversations around health equity and social determinants of health \u0026ldquo;only picked up...a few years ago.\u0026rdquo; Curricular implementation had been limited to their experiential learning and/or leaning on the faculty interested in the topics.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLack of Skills to Address Healthcare Disparities\u003c/h2\u003e \u003cp\u003eMoreover, there were concerns about faculty translating theoretical learning skills into practical or modeling skills in addressing healthcare disparities. One faculty noted that residents may have theoretical knowledge but limited practical ability when the attendings they are working with \u0026ldquo;[don\u0026rsquo;t] know what you\u0026rsquo;re talking about or [haven\u0026rsquo;t] really thought about it...\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLack of Knowledge of How to Implement Health Equity Curriculum\u003c/h2\u003e \u003cp\u003eSeveral participants noted an additional challenge surrounding the \u0026ldquo;how\u0026rdquo; of implementing health equity curricula. One faculty discussed being unclear of the competency aims for the health equity curriculum. At the same time, another commented that they did not have formal means for assessing resident competency in health equity topics. A third faculty member described not knowing if they should be \u0026ldquo;pointing out\u0026rdquo; inequities in their teaching or questioned if they should teach only if they can instruct confidently on how to \u0026ldquo;solve the inequity\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFaculty Discomfort\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eDiscomfort in Faculty Leading Conversations\u003c/h2\u003e \u003cp\u003eInterviewed faculty identified several scenarios in which a curriculum on health equity themes brought discomfort, resulting in further efforts being avoided or deferred to others. A faculty member, who self-identified as White, described being nervous facilitating conversations around health inequities in Black maternal health without having a co-facilitator.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eDiscomfort in Creating Uncomfortable Experiences for Residents\u003c/h2\u003e \u003cp\u003eOne faculty member expressed difficulty creating educational opportunities around health equity themes without negatively impacting residents of certain racial backgrounds.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eDiscomfort with \u0026ldquo;Teaching up\u0026rdquo; and \u0026ldquo;Doing it Wrong\u0026rdquo;\u003c/h2\u003e \u003cp\u003eNotably, several faculty commented on their residents having more knowledge of health equity topics than they. Faculty expressed difficulty with teaching about health equity to their residents, \u0026ldquo;who are better at this than we are.\u0026rdquo; and not wanting to \u0026ldquo;do it wrong.\u0026rdquo; This same faculty member felt that the time has passed and/or it would be a heavy lift for many faculty to gain the skills to become health inequity experts at this point, so residents \u0026ldquo;will always be ahead of faculty until [they] all retire.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eInstitutional Barriers\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003eResource Allocation\u003c/h2\u003e \u003cp\u003eSeveral faculty members interviewed highlighted inadequate institutional resources to support incorporating health equity into the curriculum despite their desire to do so, whether through funding of experiences or support of faculty time to develop it. One commented that health equity teaching is often volunteer-based, and despite having a faculty member with an interest in teaching about health equity, due to their clinical role and mechanism of compensation, their effort would not be compensated to do this. Another faculty believed the institution did not supply the resources due to a lack of perceived value in the health equity curriculum.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLack of Buy-In\u003c/h2\u003e \u003cp\u003eFaculty also identified a lack of buy-in as a barrier to curricular implementation. One faculty interviewed expressed having members of their faculty \"...\u003cem\u003ewho actively feel attacked a little bit by some of the things that are talked about in these spaces. So just buy-in is a problem.\u003c/em\u003e\u0026rdquo; Another mentioned that their faculty were not interested in participating or leading sessions in a Journal Club on Health Equity to address their residency\u0026rsquo;s curricular gap.\u003c/p\u003e \u003cp\u003eOne faculty commented on gaps in training and support for residents providing hands-on care to socially vulnerable patients \u0026ndash; in particular, noting that formalized support to provide care for populations that did not have the highest financial return, was not a high institutional priority.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eFaculty Diversity\u003c/h2\u003e \u003cp\u003eSeveral faculty commented on the benefit of having diversity within their residency cohort and the impact on discussions involving health equity. Still, a few faculty also commented on the impact of limited faculty diversity on their ability to implement the curriculum. One faculty member expressed that when most of the faculty share similar views and perspectives on health disparities, creating a comprehensive curriculum can be challenging due to their narrow perspective on understanding the diverse patient population. Another program director shared feelings that recruiting a more diverse faculty would be an additional resource to promoting topics related to health equity in the curriculum.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur project identified barriers to health equity curricular implementation as perceived by core residency faculty at our large academic institution. The study\u0026rsquo;s findings support existing literature and further explored challenges faculty face around protected time to incorporate health equity within a curriculum. \u003csup\u003e[6,8,11]\u003c/sup\u003e Faculty's numerous responsibilities and activities leave inadequate time to curate this content intentionally; it is often relegated to unprotected time. Further, the clinical demands on residents and the need to cover extensive content within limited didactic time make it challenging for faculty to prioritize dedicated health equity education in the curriculum.\u003c/p\u003e \u003cp\u003eOne of the most expressed barriers to curricular implementation identified in this study was limited faculty knowledge and expertise around health equity. Faculty mentioned gaps in their knowledge, lack of skills to address healthcare disparities, or how to implement health equity curriculum. The second most expressed barrier in the study was faculty discomfort. Faculty development and continuing education workshops can enhance faculty competency and develop skills for resident assessment. Moreover, creating a shared learning space where faculty and residents can co-learn may avoid the challenges to the educational hierarchy (e.g., residents \u0026ldquo;who are better at this than we are\u0026rdquo;) and create room for bi-directional learning. A series of faculty workshops can include facilitator training in leading difficult discussions, developing departmental health equity champions, enhancing confidence in creating educational experiences, and sharing best practices for implementing and assessing outcomes of health equity curricula.\u003c/p\u003e \u003cp\u003eAt the institutional level, incorporating health equity education within institutional values statements across all levels and specialties can establish it as an organizational priority and induce a cultural shift.\u003csup\u003e[12]\u003c/sup\u003e This can be through strategic planning process to address structural racism, expansion of health equity courses, increased hiring of faculty with health equity focuses. Further, support through the allocation of protected time, intentional recruitment and retention of diverse faculty, funding for designated personnel, and centralized resources to offload the burden of one or few faculty can reinforce these values, create spaces for health equity conversations, and enhance the care delivered.\u003c/p\u003e \u003cp\u003eSustained institutional investment supporting faculty time to develop and deliver educational materials, and educational time for these topics within resident schedules could address the expressed time barriers.\u003csup\u003e[13]\u003c/sup\u003e Faculty can avoid reinventing the wheel by implementing audits to enhance current education and leverage existing resources, such as the American Medical Association (AMA) Health Equity Education Center and ACGME Equity Matters Toolkit, across departments.\u003csup\u003e[14\u0026ndash;15]\u003c/sup\u003e Further, faculty can co-lead centralized learning opportunities (e.g., joint-conferences and service learning) and prioritize and integrate high-yield health equity content within existing lectures rather than displacing required topics. \u003csup\u003e[14\u0026ndash;16]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhile this study enhances our understanding of health equity curricula at our institution, there are some limitations. First, there were challenges with outreach and recruitment of study participants. Though recruitment emails were sent to all residency program directors and coordinators, with an additional request to have them forward the invite to their respective core residency leadership, the unidirectional nature of this study limited the ability to discern how many educators received the invitation to participate. Additionally, participation in this voluntary study was low and lacked representation from several specialties. Despite the robust qualitative findings, the perspectives included may not reflect the entire community of GME leaders at the institution. Further, given the potential for participant identification, selected participant demographics (including race/ethnicity, gender identity, and age) were not collected. Thus, we are unable to discern representativeness or whether further thematic associations exist. Additional research is needed to investigate the prevalence of these perspectives across GME at large and to explore whether other personnel or institutional characteristics are correlated with the identified themes.\u003c/p\u003e \u003cp\u003eBy analyzing the current state of health equity curricular implementation, we aim to design an intentional GME curricular framework for use across the institution. This manuscript highlights findings from individual interviews and focus groups regarding perceived faculty and institutional barriers to health equity curricular implementation. Next steps for this work include assessing resident and community member perspectives on barriers, facilitators and key characteristics desired for future health equity curricular enhancements and collaborating with institutional leadership to develop a framework addressing identified barriers for future curricular implementation.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThrough this investigation, we were able to qualitatively explore residency faculty perspectives on health equity curriculum experiences and identified key areas academic institutions might address to overcome challenges faculty face in implementing health equity curriculum. A multi-pronged approach can leverage resources from the institution to achieve common goals across specialties, address ACGME requirements, and provide residents with training to reduce healthcare disparities in their clinical practice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003col\u003e\n \u003cli\u003eACGME - Accreditation Council for Graduate Medical Education\u003c/li\u003e\n \u003cli\u003eAMA - American Medical Association\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGME - Graduate Medical Education\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIRB - Institutional Review Board\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e: The study received\u0026nbsp;ethics\u0026nbsp;approval from the Thomas Jefferson Institutional Review Board (IRB #22E.762).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e: Informed consent was obtained from all individual participants included in the study. Participants signed informed consent regarding publishing their data. All participant personal information has been deidentified from the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e: The data that support the findings of this study are not openly available due to reasons of sensitivity. Demographic data cannot be shared openly to protect the study participants privacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e: The authors report there are no competing interests to declare. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This work was funded in part through an internal institutional award, The Carl Mansfield, MD, Equity Scholar Award for Career Development, Thomas Jefferson University, Jefferson Collaborative for Health Equity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eK.F. conceptualized the work.\u003c/li\u003e\n \u003cli\u003eK.F. and D.S. designed the work, conducted the interviews/focus groups, acquired the data, developed the tables and wrote the main manuscript text.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eK.F., D.S., and Q.P. developed the codebook and analyzed the data.\u003c/li\u003e\n \u003cli\u003eK.F., D.S. Q.P. and R.S. reviewed and revised the manuscript prior to submitting.\u003c/li\u003e\n \u003cli\u003eAll authors have approved the submitted version and agree to be personally accountable for the contributions and ensure the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: We would like to thank all our participants for sharing their experiences with us and for their dedication to this important work. We would like to thank Ibriana Garvey, MPH for helping with literature review and scheduling the interviews for this project. We thank the Jefferson Collaborative for Health Equity for their assistance in this project\u0026apos;s efforts. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eSmedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, D.C.: National Academies Press; 2003. doi:10.17226/12875\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAdvancing Racial Equity in U.S. Health Care: State Disparities | Commonwealth Fund. https://www.commonwealthfund.org/publications/fund-reports/2024/apr/advancing-racial-equity-us-health-care.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003e2023 National Healthcare Quality and Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); December 2023. AHRQ Pub. No. 23(24)-0091-EF.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMaldonado ME, Fried ED, DuBose TD, Nelson C, Breida M. The role that graduate medical education must play in ensuring health equity and eliminating health care disparities. Ann Am Thorac Soc. 2014;11(4):603\u0026ndash;607. doi:10.1513/AnnalsATS.201402-068PS\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCommon program requirements (residency). https://www.acgme.org/globalassets/PFAssets/ProgramRequirements/CPRResidency_2022v2.pdf. ACGME Common Program Requirements (VIA1b1a).\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHernandez RG, Thompson DA, Cowden JD. Responding to a call to action for health equity curriculum development in pediatric graduate medical education: Design, implementation and early results of Leaders in Health Equity (LHE). \u003cem\u003eFront Pediatr\u003c/em\u003e. 2022;10:951353. doi:10.3389/fped.2022.951353\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAtkinson RB, Khubchandani JA, Chun MBJ, et al. Cultural competency curricula in US graduate medical education: A scoping review. \u003cem\u003eJ Grad Med Educ\u003c/em\u003e. 2022;14(1):37\u0026ndash;52. doi:10.4300/JGME-D-21-00414.1\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFatahi G, Racic M, Roche-Miranda MI, et al. The current state of antiracism curricula in undergraduate and graduate medical education: A qualitative study of US academic health centers. Ann Fam Med. 2023;21(Suppl 2):S14-S21. doi:10.1370/afm.2919\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDupras DM, Wieland ML, Halvorsen AJ, Maldonado M, Willett LL, Harris L. Assessment of training in health disparities in US internal medicine residency programs. \u003cem\u003eJAMA Netw Open\u003c/em\u003e. 2020;3(8):e2012757. doi:10.1001/jamanetworkopen.2020.12757\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKing, Nigel. Doing template analysis. In Qualitative Organizational Research: Symon G, Cassell C. Qualitative Organizational Research: Core Methods and Current Challenges. 1 Oliver\u0026rsquo;s Yard, 55 City Road London EC1Y 1SP : SAGE Publications, Inc.; 2012. doi:10.4135/9781526435620\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWeiss KB, Co JPT, Bagian JP, CLER Evaluation Committee. Challenges and opportunities in the 6 focus areas: CLER national report of findings 2018. J Grad Med Educ. 2018;10(4 Suppl):25\u0026ndash;48. doi:10.4300/1949-8349.10.4s.25\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHigginbotham EJ, Hertz K, Fahl C, Duckett DB, Mahoney K, Jameson JL. Addressing Structural Racism Using a Whole-Scale Planning Process in a Single Academic Center. \u003cem\u003eHealth Equity\u003c/em\u003e. 2023;7(1):487\u0026ndash;496. doi:10.1089/heq.2023.0093\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eButts GC, Abner P, Hess L, et al. Designing a road map for action to address bias and racism within a large academic medical center. \u003cem\u003eAcad Med\u003c/em\u003e. June 2023. doi:10.1097/ACM.0000000000005289\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHealth Equity Education Center | AMA Ed Hub. https://edhub.ama-assn.org/health-equity-ed-center\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAccreditation Council for Graduate Medical Education. https://dl.acgme.org/pages/equity-matters\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTreacy-Abarca S, Aguilar M, Vassar SD, Hernandez E, El-Farra NS, Brown AF. Enhancing existing medical school curricula with an innovative healthcare disparities curriculum. \u003cem\u003eBMC Med Educ\u003c/em\u003e. 2021;21(1):613. doi:10.1186/s12909-021-03034-7\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Graduate Medical Education; Health Care Disparities, Health Equity, Faculty Curricular Barriers, Residency Faculty Perspectives","lastPublishedDoi":"10.21203/rs.3.rs-4830646/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4830646/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite increased awareness of persistent healthcare disparities, integrating health equity education into medical residency curricula needs urgent expansion. The Accreditation Council for Graduate Medical Education (ACGME) mandates addressing healthcare disparities and social determinants of health, but implementation remains insufficient due to pervasive barriers.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo explore residency faculty perspectives at one institution surrounding implementing a health equity curriculum within their programs.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eBetween November 2022 and April 2023, qualitative interviews and focus groups were conducted with residency faculty participants (n\u0026thinsp;=\u0026thinsp;13) from a large academic medical institution. Participants were recruited via an internal email list directory of program directors. Semi-structured sessions explored faculty perspectives on health equity curriculum implementation. Data analysis utilized template analysis and thematic coding.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFaculty perceived barriers included limited time for teaching health equity, challenges in prioritizing health equity content within the curriculum, lack of formal training and expertise, discomfort in leading discussions, and institutional barriers such as resource allocation and lack of buy-in.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eFindings underscored the need for institutionally supported faculty development and protected learning time for health equity education. Despite participant recruitment and representation limitations, the study provides valuable insights for addressing curricular challenges. This study highlights critical areas for improving health equity curriculum implementation in graduate medical education. Addressing these faculty barriers can enhance resident competency in identifying and addressing healthcare disparities.\u003c/p\u003e\u003ch2\u003eTrial Registration:\u003c/h2\u003e \u003cp\u003e The study received ethics approval from the Thomas Jefferson Institutional Review Board (IRB #22E.762).\u003c/p\u003e","manuscriptTitle":"Understanding Faculty Perspectives on Health Equity Curriculum Implementation in Graduate Medical Education: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-10 11:19:13","doi":"10.21203/rs.3.rs-4830646/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-16T13:18:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-13T10:46:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-13T10:44:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-07-30T18:08:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a8cfcaa4-8a10-4534-9db2-30e0181505fc","owner":[],"postedDate":"September 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-18T19:16:28+00:00","versionOfRecord":{"articleIdentity":"rs-4830646","link":"https://doi.org/10.1186/s12909-024-06276-3","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2024-11-11 15:57:59","publishedOnDateReadable":"November 11th, 2024"},"versionCreatedAt":"2024-09-10 11:19:13","video":"","vorDoi":"10.1186/s12909-024-06276-3","vorDoiUrl":"https://doi.org/10.1186/s12909-024-06276-3","workflowStages":[]},"version":"v1","identity":"rs-4830646","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4830646","identity":"rs-4830646","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}