Patient representation in New Zealand general practice and rural health case-based teaching: a quality improvement exercise

Introduction

Healthcare providers contribute to health inequity through their biases,¹ resulting in reduced access to health care, reduced health promotion, lower health expectations and worse health outcomes.² Ethnicity, weight, socioeconomic status and sexual orientation are the most prevalent biases in health care.^3–5 New Zealand medical practitioners have an obligation to uphold Te Tiriti o Waitangi, but Māori continue to experience health inequity and worse health outcomes compared to non-Māori.⁶ Health inequity is also experienced by Pasifika, Asian, MELAA (Middle Eastern, Latin American and African peoples), former refugees, LGBTQI+ and disability communities.⁷

Biases can be conveyed through attitudes, words or actions. Explicit biases are conscious attitudes, whereas implicit biases are unconscious cognitive associations.⁸ Medical school culture can teach and reinforce biases,^9,10 influencing how students respond to their patients.¹¹ A biased health workforce is one driver of inequity.¹² Conversely, cultural safety promotes a respectful and non-discriminatory health environment and is an essential element of quality care.^13–15 A medical school curriculum that provides opportunities for self-reflection and has a continuous focus on cultural safety can address biases.^13,16,17

Case studies are widely used in medical education and ideally represent the wider population demographics.¹⁷ Students at the University of Otago Dunedin School of Medicine currently spend 15 weeks in general practice and rural health (GPRH) modules. Students are taught in clinical placements, tutorials, simulated safe and effective outcome (SECO) clinics and are assessed via objective structured clinical examinations (OSCEs).^18,19 SECO and OSCE cases typically involve a simulated patient played by an actor. OSCE and SECO cases are developed to simulate holistic patients, therefore, contain more information than tutorial vignettes developed to illustrate a point.

Cases describing Māori patients had been archived because they portrayed negative cultural stereotypes. GPRH teaching staff are now concerned about the limited diversity of the remaining cases, and how that may contribute towards patient stereotyping and bias. Therefore, this project aims to determine how well teaching cases used in GPRH represent the New Zealand population.

Method

Document analysis is an effective method of evaluating the diversity of teaching material, and has been used in a similar exercise undertaken in the University of Otago School of Pharmacy.²⁰

All documentation that included case-based teaching conducted in GPRH across the year 4 and 5 curriculum was reviewed. These included tutorial handouts featuring clinical vignettes, SECO clinic cases and OSCE cases. Cases were included in the study if they contained at least one piece of demographic or social data. Cases were excluded if there was no demographic information provided (ie the case only described a medical condition and/or medication). Data was extracted and recorded by JG.

Case data were categorised according to the following characteristics: demographic (age, sex, gender, ethnicity, employment status, employment type, living situation, relationship status, sexual orientation and religion), clinical (medical conditions, number of medications, allergy status, height, weight, body mass index (BMI) and immunisation status) and social (smoking status, alcohol use, recreational drug use, exercise and diet). The categories used are based on the New Zealand Census criteria and the Ariā classification management system.²¹ Ariā provides definitions, classifications, concordances and standards used for data and statistical activities across the New Zealand government.²²

Details were recorded if present; if absent, a characteristic was marked as undefined. Non-specific characteristics were also recorded as undefined. For example, patient name was not considered to provide sufficient information to define sex, gender or ethnicity. Names may be unisex, used unconventionally or change (eg because of adoption or marriage). However, pronouns (he/him, she/her and they/them) were assumed to be indicators of gender and sex, unless the case explicitly noted the patient was transgender.

Categorisation was discussed between the authors and discrepancies resolved. Cases that fitted more than one category (eg multiple medical conditions or comorbidities) were included in each relevant category, resulting in higher totals in some categories than the overall number of cases.

Categorised data were summarised using simple descriptive statistics (number and percentage of cases). Data were stratified by teaching mode.

The documents analysed were printed teaching materials containing fictional clinical cases. No people, medical records or human tissues were involved in this document analysis, therefore, no formal ethical review was undertaken.

Results

One hundred and thirty five clinical teaching cases met the inclusion criteria for the document analysis. There were 39 SECO, 45 OSCE and 51 tutorial cases.

Demographic characteristics are described in Table 1. Age of cases was well defined (129/135, 95.6%). Age of cases ranged from 18 months to 91 years of age. The most common age category for cases was the 21–40 year age group. Ethnicity was infrequently defined. Only 31/135 (23.0%) of cases had ethnicity defined; these were always under the category of NZ European (defined ethnicities included NZ European, NZ Pakeha, NZ Portuguese, Caucasian and English). No cases explicitly represented other important ethnic groups in New Zealand, including Māori, Pacific, Asian or MELAA peoples. Employment status was comparatively well defined, particularly in OSCE and SECO cases (90/135, 66.7%). Most cases were employed, typically in professional occupations (21/68, 30.9%). Living situation (55/135, 40.7%), relationship status (57/135, 42.2%) and sexual orientation (52/135, 40.0%) were mostly undefined.

Clinical characteristics are described in Table 2. Every scenario described at least one medical condition. Skin infections (12/138, 8.7%), respiratory infections (10/138, 7.2%), hepatobiliary disease (9/138, 6.5%), injuries (9/138, 6.5%) and reproductive health (8/138, 5.8%) were the most common. Most cases had no comorbidities (89/142, 62.7%). Of cases with comorbidities, hypertension (14/142, 9.9%), type 2 diabetes (6/142, 4.2%) and arthritis (5/142, 3.5%) were the most common. Clinical presentations were evenly distributed between sex categories. Some cases were adaptable to permit both a female and male version. However, there were some exceptions. Females were overrepresented in cases describing sexually transmitted infections (3/3, 100.0%) and depression (3/4, 75.0%). Males were overrepresented in cases describing arthritis (5/7, 71.4%) and COPD (3/4, 75.0%; undefined 1/4, 25.0%). In some adaptable cases, minor alterations in the narrative could be interpreted as stereotyping, eg an otherwise identical case varied only by female comorbid depression and male comorbid hypertension. Medications were mostly defined, with the highest category being 1–4 medications (49/135, 36.3%). Medications were generally well defined in OSCEs (30/45, 66.7%) and SECOs (31/39, 79.5%), but not in tutorial cases (9/51, 17.7%).

Social characteristics were included in most OSCEs and SECOs, although were usually absent from tutorial cases (Table 3). Overall, smoking status (61/135, 45.2%), alcohol status (58/135, 43.0%), recreational drug use (20/135, 14.8%), exercise (36/135, 26.7%) and diet (12/135, 8.9%) were undefined. All seven cases including recreational drugs use were students. Exercise and dietary information were rarely included and were usually only present if relevant to the presenting condition, eg veganism and vitamin B12 deficiency.

Discussion

This study audited the clinical cases presented to year 4 and 5 medical students during their GPRH rotations. Basic demographic details were usually well defined, however, important markers of diversity including ethnicity, gender, sexual orientation, living situation and religion were not. If stated, demographic details described the majority groups of the New Zealand population – ie most cases were NZ European, heterosexual and living with at least one other person.

Medical conditions and medications were well defined. Cases with sexually transmitted diseases, major depressive disorders and urinary tract infections were mainly female, while those with COPD, arthritis or hypertension were more often male.

Social characteristics were rarely defined, particularly in the tutorial vignettes. This may be justified as the teaching purpose of these vignettes differs to that of the OSCE and SECO cases which are developed to simulate a holistic patient rather than focus solely on their medical condition. Recreational drug use was poorly defined, despite 49.0% of the adult population (aged 16–64 years) having used recreational drugs at least once.²³ Furthermore, all drug users in these cases were between the ages of 17 and 22 years, which may exacerbate the stereotype of younger individuals and drug use.

Similar research conducted by the University of Otago School of Pharmacy found that the curriculum was lacking in diversity and had potential to contribute to systemic racism, prejudice and implicit bias within the education system.²⁰ A University of Auckland Medical School study confirmed the presence of ethnic bias among medical students, although this was not associated with altered clinical decision making.¹¹ Other studies consider education to hold an important role for the development or mitigation of implicit bias.^6,24,25 Clinical cases used in teaching medical students could be revised to ensure the demographic characteristics of these cases represent a mirror on society, reflecting the University of Otago’s Mirror on Society selection policy, to ensure minority groups are not neglected and negative stereotypes are not reinforced.²⁶

There were also some factors that are important to acknowledge. While female and male cases were evenly distributed, clinical presentations in females favoured sexual health, with some potentially sexist anomalies (eg all sexually transmitted infections occurred in women). Although it is possible that this is consistent with presentation rates in general practice,²⁷ medical school teaching should provide adequate context for presentation rates, eg acknowledging the burden of reproductive health on women, the historical context of limited research in female health, as well as the impact of social constructs on inaccurate stereotyping of disorders, eg ‘male’ heart disease and ‘female’ depression.²⁸

All defined cases were cis-gender and heterosexual, assumed from pronoun use and partner sex. No transgender cases were identified. This lack of diversity may serve to exacerbate the invisible status of LGBTQI+ representation and undermine formal teaching about the health issues and inequities among this population. Transgender patients have unique healthcare considerations and typically have poorer physical and mental health.²⁹ A lack of access to culturally safe providers is a major barrier to care for transgender individuals, with calls made to improve medical student and physician education in transgender health care.²⁹

While primary medical condition was well defined, few cases had comorbidities. This is despite 7.9% of the population having multimorbidity (the co-presence of two or more long term medical conditions) according to past hospital discharge data, and 27.9% using past pharmaceutical dispensing data.³⁰ Multimorbidity is common in the New Zealand population, and is increasingly common with greater age, socioeconomic deprivation and in Māori and Pacific ethnic groups. Patients with multimorbidity are at increased risk of polypharmacy and adverse outcomes. General practitioners are considered vital to the management of multimorbidity. With calls made to improve medical training and education to address this challenge, further focus on the implications of including or excluding multimorbidity in cases should be considered.³¹

Clinical cases used in teaching medical students could be revised to ensure the demographic characteristics of these cases represent a mirror on society, to ensure minority groups are not neglected and negative stereotypes are not reinforced. A lack of diversity in clinical teaching cases may cause invisibility of these groups, resulting in an inequitable loss of the health benefits they could have received if these social influences on health were considered and addressed.²⁰

Strengths of this study include access to and collection of all cases meeting inclusion criteria, contributing a large body of data for analysis. Inclusion of material from different teaching modalities across the department, including unprecedented access to review OSCE cases, allowed for a complete picture of the Department’s case-based undergraduate teaching curriculum.

There were, however, limitations in this study. While efforts were made to define variables accurately, some variables may have been over- or underestimated. For example, ethnicity was classified as undefined unless explicitly stated in the case stem. Surname was considered an unreliable marker of ethnicity due to marital name changes or modifications and adoption.³² This method meant ethnicity was recorded as ‘not defined’ in cases that may have been written with the intention of adding diversity using ethnically stereotypical surnames, eg ‘Wang’ or ‘Law’. Secondly, the analysed curriculum was composed of different forms of teaching, of which SECO and OSCE cases were intended to be more developed (looking at the patient as a whole) than tutorial vignettes which focus on specific conditions. A practical reason for the lack of definition of certain variables in SECO and OSCE cases were that they use simulated patients. Subsequently, variables based on appearance (eg height, weight, BMI and ethnicity) cannot be too specific to ensure use of available actors. It is possible intended diversity was ‘diluted’ because of the inclusion of the different teaching materials. Finally, this study does not represent student exposure elsewhere in the medical school curriculum to teaching centred around diversity, equity and inclusion.

Limited diversity in teaching materials may cause students to assume patients represent the majority group and may contribute to minority group stereotyping.¹⁷ Assumptions may also be reinforced by the name of the case, or appearance of the selected actor. Limited diversity in medical education, including teaching materials, staff and students, may adversely impact cultural safety in medical school and healthcare settings.³³ If medical education is culturally homogenous, students from diverse backgrounds may feel alienated and forced to conform to a Western-orientated standard of professionalism rather than encouraging use of the cultural strengths they have.³⁴ Conversely, embracing diversity in medical school education helps develop culturally safe future clinicians.³³ Patients treated in culturally safe settings are more likely to receive appropriate health information, adhere to treatment and be satisfied with their care.³⁵ With improvements in cultural safety, the workforce can move closer to achieving health equity.¹³

Therefore, the findings of this study demonstrate an urgent need to review the teaching cases used through the lens of equity, inclusion and diversity (see Box 1).²⁰ Future health professionals need sustained and consistent opportunities to engage with the diversity and needs of the community they will serve.²⁴

A major concern that had discouraged case development was that increasing case diversity would require appropriate SECO and OSCE actors, and recruitment might prove too challenging. However, discussion with the actor coordinator was illuminating. They had already been providing more culturally diverse actors on their own initiative and did not feel increasing this further would be too difficult. A meeting of the GPRH teaching staff was held to discuss these findings. Staff had already recognised the issue and were keen to update cases. Staff have requested support from the University of Otago Kōhatu Centre for Hauora Māori, a centre for teaching and research excellence in Hauora Māori, to collaboratively develop culturally appropriate cases. Support to develop other new cases will be sought (eg from Va’a o Tautai, the University of Otago Centre for Pacific Health), to ensure new cases strengthen cultural safety across the curriculum. The cases are now under active review and iterative updates are planned. Future research is proposed to assess the impact of more diverse cases on medical student biases.

Conclusion

This study found teaching cases for medical students lacked diversity, particularly in terms of ethnicity, gender and sexual orientation. This may encourage biases in medical students and contribute to inequity in the healthcare system. This current work has provided impetus to update teaching cases.

Data availability

Data may be available from the corresponding author on request.

Conflicts of interest

The authors declare no competing interests.

Declaration of funding

This research was funded by a University of Otago Health Sciences summer research scholarship awarded to Jessica Gu.