Aquifer is committed to serving as a leader in addressing biases and inequities encountered in clinical practice, and in life, through our transparent approach to developing, delivering, and optimizing online health professions education and continuous learning.
The virtual cases in our curriculum have been created to represent a diverse population made up of individual patients with their own identities: this means that each virtual patient has been given certain characteristics, which are represented here through narratives and photos. We strive to use person-centered language (e.g., a “person with diabetes” rather than “a diabetic”) to recognize the shared humanity of our characters, who serve as representations of real people who exist beyond their disease states. We have also made every effort (through thoughtful creation; faculty and student review; ongoing education on race, gender and culture; changes in response to user feedback; reflection and rewriting) to avoid perpetuating stereotypes or bias through the pairing of individual patient characteristics with health or disease. Still, we are unable to avoid such pairing in portraying our virtual patients, and we recognize that any creative process, despite our best efforts, inherently may include some bias.
We recognize that there are variations in how individuals self-identify, that individuals within groups may have different preferences, and that those preferences may change over time. Since inclusive language honors the rights of individuals to define their own identities, we include a dashboard (similar to that found in a typical Electronic Health Record) at the beginning of each case which reflects each patient’s self-identified name, age, gender identity, pronouns, language chosen for medical communication, as well as sex assigned at birth. These particular descriptors are included upfront due to their importance in fostering appropriate communication (e.g., using the correct name and pronouns) between the healthcare team and patient and in understanding a patient’s underlying biology (e.g., the presence of reproductive organs).
For those virtual patients whose stories and characters are fully developed within a particular case, we also include self-identified race/ethnicity as part of the social history. We include this here, rather than in the dashboard, to acknowledge that while race/ethnicity is not a biological or genetic construct that is relevant to medical decision-making, it may impact a particular patient’s experience in the world and in the healthcare system. When race and ethnicity correlate with clinical outcomes (e.g., differing rates of disease), we strive to make explicit that these disparate outcomes are not due to biological phenomena and may be due to systemic and structural factors that should be addressed as part of the patient’s care.
Where we have been perceived to be unsuccessful, we invite thoughtful students and educators to leave us constructive feedback and alternative suggestions. We also recognize that individual story-based scenarios can be a source of triggering for individual learners; we acknowledge this unintended impact with sympathy and, similarly, invite feedback on our approach to this issue. We value learning from, and improving with, our educational community, and we strive to practice cultural humility in all that we do.
In the end, we offer you what we strive to make a thoughtful, inclusive, and productive learning experience.
References/Inspiration:
- https://jamanetwork.com/journals/jama/fullarticle/2783090
- https://jamanetwork.com/journals/jama/pages/instructions-for-authors
- https://www.aap.org/en/about-the-aap/american-academy-of-pediatrics-equity-and-inclusion-efforts/words-matter-aap-guidance-on-inclusive-anti-biased-language/
- https://www.mdcalc.com/race
- https://www.cdc.gov/healthcommunication/Resources.html
- https://www.nejm.org/doi/full/10.1056/NEJMp2112312?query=race_and_medicine
- https://www.nejm.org/doi/full/10.1056/NEJMp2201950?query=race_and_medicine
- https://www.commonwealthfund.org/publications/2018/sep/focus-reducing-racial-disparities-health-care-confronting-racism
- https://www.aafp.org/pubs/afp/content/diversity.html
