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Science, Curriculum, and Public Controversies
Scientists, medical practitioners, and other “specialists” certainly must be prepared to cope with public controversies related to their work: from scientists who serve on the Intergovernmental Panel on Climate Change to medical researchers and health professionals who explain the dangers of opting out of required vaccinations for personal, not medical, reasons. In many cases, scientists and medical practitioners play an active role in public deliberation on crucial issues. Yet to what degree does higher education in science, medicine, and other technical areas prepare students for these challenges as well as foster deeper knowledge and respect for the communities affected? We write this essay to suggest ideas based on our combined experiences about how the curriculum provides this preparation.
Tribal Internships at the Intersection of Science and Deliberation
Since the US Indian Self-Determination and Educational Assistance Act of 1975, the 566 federally recognized tribes have put in place their own educational, health, environmental, and other governmental agencies and departments that rely on scientists to perform research and regulatory functions that support tribal self-determination and cooperation with state, federal, nonprofit organizations, and private entities. For tribes, this ideally involves hiring scientists who are themselves tribal members or members of other tribes, or scientists of other heritages who have the cultural and social competency to work in tribal contexts. One of the authors (Whyte) has worked on connecting tribes to science, technology, engineering, and mathematics tools, especially those of climate science, for tribal planning purposes.
A number of case studies point out that scientists in tribes are often responsible for convening public deliberation and dialogue about controversial issues. In the changing world in which we live, this involves issues of what species should be restored with limited funds or whether jobs should be traded off for environmental quality. For example, in the Little Band of Ottawa Indians, who live in what is now known to most as the Manistee, Michigan, area, tribal biologists helped to organize a cultural context group made up of a range of tribal members, from staff to elders to ordinary tribal citizens. This group holds cross-cutting deliberations about how to build programs that engage with non-tribal members on key issues affecting the environment. These deliberative efforts have led to the creation of a unique restoration program—the Lake Sturgeon Stewardship program—which has brought together tribal members and others around a vision of taking responsibility for the environmental quality of the watershed (Holtgren 2013).
Many people working in Indian country today understand the importance of tribal scientists convening deliberative processes and the mentoring of future tribal scientists. Tribal colleges and universities are taking the lead in educating students to take on these roles in addition to their “lab” scientific training. The Sustainable Development Institute at College of Menominee Nation (CMN) has an active internship program that is highly integrated within research, education, and outreach projects and can include sometimes up to fifteen college students enrolled in different disciplines at CMN and other institutions of higher education.
In the internship program, the students not only learn about sustainability science, how to do research, and how to carry themselves professionally—they are also expected to take part in and organize the deliberative events organized by the institute. In one case in 2014, the interns supported the organization of a 150-attendee deliberative summit connecting tribal scientists with federal climate scientists. In another case in 2015, the Sustainable Development Institute organized an Indigenous Planning Summer Institute, which was geared toward providing interns with lessons and materials on how to engage in the deliberations needed for tribal planning.
At Haskell Indian Nations University, students enrolled in the environmental science program and the Indigenous and American Indian studies program founded the Indigenous Peoples Climate Change Working Group. The working group, now in its tenth year, meets twice a year, usually at a tribal college, to utilize aspects of physical and social sciences to contemplate climate change and variability holistically. In these meetings, the working group has engaged tribes and native and non-native scientists in a dialogue about the significance of climate change and how to determine policies that are beneficial to various tribes, given differences in location, values, worldviews, economic status, and other concerns. One Haskell graduate, Paulette Blanchard (Absentee Shawnee), used the skill sets she developed as a working group member to organize the largest intertribal deliberative gatherings of both native and non-native scientists and leaders on climate change issues affecting Oklahoma tribes (Riley et al. 2012).
For both Menominee and Haskell, a significant component of this work has been helping students see the possibility of returning to their own tribal nations to work and establish meaningful careers. The programs set up enduring peer and mentorship relationships that students can rely on in years to come as they engage in career planning. This suggests that college preparation for work not only involves learning skills that one now needs to practice as an effective environmental scientist but also imagining where that practice can occur.
Physician Heal Thyself: the Community as Medical Trainer
For decades, the United States has struggled to overcome dramatic health disparities between black and white citizens, and today whites still have a longer healthy life expectancy than blacks. For instance, according to Morbidity and Mortality Weekly Report, non-Hispanic black adults are at least 50 percent more likely to die of heart disease or stroke prematurely (before age 75) than their non-Hispanic white counterparts (Frieden 2013).
There has long been a belief in medical education circles that one way to address these disparities is to train physicians who are more culturally competent at working with residents in the urban core of cities, where African American populations tend to be concentrated. One strategy calls for dramatically increasing the number of African American practicing physicians, with the expectation that they will be more competent and more willing to practice in urban areas.
However, very little progress has been made toward this goal. Marc Nivet, chief diversity officer of the Association of American Medical Colleges (AAMC), made headlines in many medical publications in 2013 when he noted that there were 100 fewer black males enrolled in medical school that year than there were in 1984. Data obtained from the AAMC website shows that there was a modest gain of 3 percent in the number of male African American medical school graduates from 2002 to 2011, but the proportion of new doctors who were black men remained about the same: 2.6 percent in 2002 and 2.4 percent in 2011. Overall, African Americans account for 13 percent of the US population, but only 6 percent of 2011 matriculants into medical school were black, as are just 4 percent of practicing doctors.
Cleveland State University (CSU) has confronted this challenge head on with its Urban Primary Care Initiative. In this program, the Northeast Ohio Medical University (NEOMED) and CSU work together to identify and train health care professionals to meet the challenges of creating a more diverse health care workforce that cares for medically underserved populations. Each year up to thirty-five CSU students enter the joint program. CSU students in the program can be promoted to a guaranteed seat at NEOMED in two years if they successfully meet the grade point average (GPA) and Medical College Admission Test (MCAT) requirements.. Both universities aggressively pursue scholarships for students while they are at CSU and NEOMED, some in exchange for their promise to work in underserved Cleveland neighborhoods after receiving their medical degrees.
The Urban Primary Care Initiative has three ambitious goals. The first is to train medical professionals who are distinctively qualified to practice in urban communities—specifically, in the city of Cleveland. This is accomplished through a community-based curriculum developed by CSU and NEOMED known as the Cleveland Neighborhood Model in which students become immersed in one of eight targeted Cleveland neighborhoods, all of which exhibit low health indicators. During their two years at CSU, students spend considerable time learning about all the neighborhoods before focusing on one of them to fully engage with that community’s family and health care networks. This engagement includes shadowing health care professionals and working with community partners to address the social determinants of health in the neighborhood. One component of the Cleveland Neighborhood Model sends interdisciplinary teams of health professions students to local communities to promote the health of small groups of residents and their families. When the urban primary care students matriculate to NEOMED, they maintain their focus and relationships in those neighborhoods.
The second goal is to recruit a critical mass of students from the very neighborhoods where the curriculum is implemented. This addresses the need for diversity in the medical profession, since most of the target neighborhoods are predominantly African American and Latino. However, it is also the case that these students are prime candidates for the program because they enter with valuable insights into the culture and practices within an urban community.
The third goal is to deploy these students back to the target neighborhoods as primary care physicians—pediatricians, family doctors, gynecologists, and internists—after they complete their medical education and residencies. While there are ongoing efforts to provide student scholarships that require this professional commitment, it is understood that the most compelling reason for students to practice in these neighborhoods will be a sense of obligation that is driven by some allegiance to their communities and their residents.
The primary strategy for achieving these goals is to give local residents significant influence in the program’s design and execution, particularly as it engages its students. This deep level of participation is pursued in multiple ways.
A fifteen-member Community Advisory Board is involved in every aspect of the program, from curriculum development to creation of retention strategies. The board’s diverse membership includes not only representatives from the major health systems in the region but also ministers and community activists. Its prominence is bolstered by two revered local leaders who co-chair the board: former Congressman Louis Stokes and retired physician and health care advocate Edgar Jackson.
In addition, a lead organization from each of the eight targeted neighborhoods plays an active role designing the community experiences for students and helping them to navigate the neighborhoods. The lead organizations vary greatly, from community development corporations to settlement houses. All, however, were selected because they are highly respected in their communities and operate under a model of inclusive participation by community residents.
Finally, a corps of Community Champions has been recruited from those neighborhoods and assigned to each student in the program. The Champions—from retirees to leaders of grassroots organization to a firefighter—not only provide emotional support to students but also involve the students in community activities that expose them to the practices of neighborhood leadership.
The expectation is that by embracing the community in such fundamental ways and giving it authority, community stakeholders will play an active role recruiting their best and brightest for the program, encouraging them to persist through completion and, ultimately, to return to the urban communities where they learned to practice as professionals. Centering knowledge of a community and one’s professional responsibility to its people as part of curricular preparation for a medical career is a radical notion—and one that promises to reduce disturbing racial health disparities.
Undergraduate Preparation for Medical School—Science Is Only Part of the Story
Almost 50,000 undergraduate students applied for 20,300 places in allopathic medical schools in the United States last year, and another 18,000 applied for the approximately 6,700 places in osteopathic medical schools (Beck 2015). How should these students have been advised in college to prepare to be accepted to a medical school and then to be a physician?
AAMC developed the MCAT, which most schools use, along with students’ GPAs, to screen applicants to consider for interviews. Admission to medical school is attained by only about one in four applicants who are interviewed. The MCAT has undergone a major change this year. What was previously a four-hour test with three sections, mostly related to science knowledge and critical thinking, is now a seven-hour test with four sections. The new section covers psychology, sociology, and the biological foundations of behavior. MCAT questions are designed to test not just what the student knows but how well the student can apply what she or he knows to new problems. Although these changes to the MCAT were announced three years ago, those who took the test in April 2015 were the first cohort to experience the new format. For more information about the new MCAT, see the fall 2012 issue of Peer Review, www.aacu.org/peerreview/2012/fall.
The standards for subject prerequisites for medical school admission were established by the Council on Medical Education of the American Medical Association (AMA) in 1904. In 1910, Abraham Flexner, an educational reformist and author of Medical Education in the United States and Canada, revised these requirements somewhat but only included math and science subjects. By 1929, some schools and students were already publicly suggesting other opinions regarding appropriate preparation for medical school.
For Flexner, who exposed the poor state of academic rigor present in the medical schools in the United States in 1910, an emphasis on preparation in the sciences for those entering medical school was understandable. He and the leaders of the best medical schools at the time sought to enroll students who were prepared to advance the knowledge of the scientific causes of diseases so that better diagnostic tests and treatments could be found for acute and chronic diseases.
There is still a need for scientific discovery in medicine today. However, many patients need physicians who are prepared to form therapeutic alliances with them to treat chronic illness such as obesity, diabetes, and high blood pressure with lifestyle modifications such as diet and exercise, which are equally, if not more, effective in managing these conditions as prescribing medications.
Some medical schools believe their mission is to prepare elite research physicians for careers in an academic setting, while other medical schools are more interested in preparing students for the practice of medicine. One of the schools that embraces the latter mission has been using a different strategy for choosing some of its students for quite a while.
Mt. Sinai’s Icahn School of Medicine began its “early assurance” program in 1987. This program, originally known as the Humanities and Medical Program, is as now called the FlexMed program in honor of Abraham Flexner. Students apply to FlexMed during their sophomore year of college. Applicants must have completed either one year of chemistry, biology, or physics. Once accepted, students are free to pursue any areas of undergraduate study, without having to meet traditional science requirements or taking the MCAT. However, FlexMed students are required to take some undergraduate science and math courses—maintain to make at least a B in each one and to maintain an overall GPA of 3.5. They may major in whatever interests them but students admitted to the program are required to take courses on statistics, ethics, and, public or global health or health policy. FlexMed students who do not have a sufficient background in clinically relevant sciences are asked to participate in a six-week course before matriculation to medical school that emphasizes basic concepts in biochemistry, molecular biology, and anatomy.
About five years ago, the Boston University School of Medicine began reviewing all of the applications they received to evaluate for information on life experiences, socioeconomic status, and cultural and ethnic background. The students selected to be interviewed when these criteria were included had college grades and MCAT scores equal to those chosen for interview by traditional screening methods, but they produced a class that was more collegial, supportive of one another, and open to new ideas.
These examples reinforce the notion behind the changes made to the MCAT, which suggests that choosing students with a broader educational background does not harm the performance of medical students and may provide advantages that may enhance the physician workforce of the future. These shifts suggest a growing acknowledgment that successful physicians need to know about more than diseases and diagnoses; they need to know their patients too. By gaining more comprehensive knowledge of the patients—their contexts, communities, and behaviors—physicians can more effectively practice their job of healing.
As the examples in this article show, the way colleges prepare students for careers in scientific fields, such as medicine and environmental management, has begun to change. These changes have been driven largely by what many health care practitioners and environmental scientists have discovered is actually part of their jobs. Both deeper knowledge of specific communities and an ability to publicly engage and share power with those communities are now understood by some as indispensable components of practicing these professions effectively. This has profound implications for what preparation for work might actually mean in colleges. Thinking about one’s public responsibility—and to whom—as part of preparation for work is no longer just a personal preference, but is coming to be a workplace necessity.
Association of American Medical Colleges. 2015. “Section II: Current Status of the U.S. Physician Workforce.” Accessed July 9, 2015. http://bit.ly/1BdjPnW.
Beck, Melinda. 2015. “Medical-College Entrance Exam Gets an Overhaul.” Wall Street Journal, April 15. http://www.wsj.com/articles/medical-college-entrance-exam-gets-an-overhaul-1429092002.
Frieden, Thomas R. 2013. “Foreword.” Morbidity and Mortality Weekly Report. November 22. http://1.usa.gov/1HvOvbA.
Holtgren, M. 2013. “Bringing Us Back to the River.” In The Great Lake Sturgeon, edited by Nancy Auer and Dave Dempsey, 133–147. East Lansing, MI: Michigan State University Press.
Riley, Rachel, Paulette Blanchard, Randy Peppler, Bull Bennett, and Daniel Wildcat. 2012. “Oklahoma Inter-Tribal Meeting on Climate Variability and Change—December 12.” 2011 Meeting Summary Report. Norman, OK: National Weather Center.
Kyle Powys Whyte is associate professor of philosophy and Timnick Chair in the Humanities at Michigan State University; 2009 K. Patricia Cross Scholar; Byron P. White is vice president for university engagement and chief diversity officer at Cleveland State University; and Darlyne Menscer is a physician for Carolinas Health Care System