Implementation of a "Health equity rounds" curriculum in a military internal medicine residency program: A pilot study

Introduction: Health disparities in the Military Health System (MHS) have been consistently documented despite the system ensuring equal access to care for its beneficiaries. Research has shown that social, economic, and political factors (i.e., Social Determinants of Health) and health care-specific factors like provider bias and systemic discrimination are key drivers of health disparities in the general population. Medical education focused on introducing these concepts using case-based learning has led to effective learning of health equity terminology. However, a significant gap exists in identifying optimal teaching approaches to develop skills to recognize these factors in actual clinical cases. This begs the million-dollar question: can case-based learning help trainees acquire the skills needed to identify the main factors contributing to health disparities in the MHS?

Materials and methods: A longitudinal case-based curriculum was developed in which clinical cases from the Internal Medicine Wards, Medical Intensive Care Unit, or General Internal Medicine Clinic at the National Capital Consortium were solicited from trainees and analyzed for evidence of health care provider bias and systemic forms of discrimination using small groups. The National Capital Consortium Internal Medicine Residency Program implemented this pilot study in November 2021. A retrospective pretest-posttest survey assessing trainee reactions to the curriculum and changes in self-reported confidence in skills was used for curriculum assessment. Survey data were analyzed using a paired samples t-test.

Results: The survey was administered during the last session of the 2022-2023 academic year, with 14 of the 23 available trainees completing it: a 60.8% response rate. Overall, 93% reported that the cases selected that academic year were engaging; the skills they were taught were practice-changing, and the educational value of the curriculum was good, very good, or excellent. Confidence ratings, assessed via a 5-point Likert Scale, demonstrated a statistically significant increase in self-reported confidence in the following skill domains with large effect sizes: identification of bias and systemic discrimination in clinical cases-change in mean: 1.07 (Pre: 3.29, Post: 4.36), P < .001, g = 1.38; recognizing and mitigating personal biases-change in mean: 0.71 (Pre: 3.50, Post: 4.21), P <.001, g = 1.10; participating in a discussion about health care provider bias and systemic discrimination-change in mean: 0.79 (Pre: 3.57, Post: 4.36), P = .001, g = 1.06; and leading a discussion about bias and systemic discrimination-change in mean: 1.00 (Pre: 2.93, Post: 3.93), P = .002, g = 0.98.

Conclusions: As the need to address health disparities in the United States becomes more pressing, so does the need for military physicians to recognize the drivers of these disparities within the MHS. Results from this pilot study of Health Equity Rounds suggest that case-based learning may be an optimal teaching approach to improve the skills of military Internal Medicine trainees in identifying and recognizing the impact of health care provider bias and systemic discrimination on clinical cases from the MHS.