Cultivating the Soil for Culturally Responsive Health Care

While recently receiving physical therapy for a herniated disk, Dr. Rich Salas, Chief Diversity Officer at Des Moines University (DMU), ran into a fourth-year medical student on rotation in the clinic. The student, a White woman from a rural community, pulled Salas aside to thank him for bringing awareness to diversity, equity, and inclusion issues over a decade at DMU as she now felt more prepared to practice medicine.

Joelle Bruckert-Frisk, a third year DMU medical student from Oregon, agrees. As she’s entered rotations in pediatrics, family medicine, and OB/GYN, she’s seeing different family dynamics than she’s personally used to. Her education has prepared her to be aware of the assumptions she might make about her patients and to consider additional resources a family may need to support their well-being.

These insights are the result of DMU’s commitment to not just teach the science of medicine, but also to help students apply that science in a culturally and socially responsive way. After more than a decade of intentional work on diversity, equity, and inclusion (DEI), President and CEO Dr. Angela Franklin says DMU is moving “beyond the adolescent phase," with shifts happening throughout campus that are transforming the way health sciences education is delivered. This work is having ripple effects across the community and in national conversations.

“A lot of institutions make the mistake of trying to change things overnight when some people are not ready,” said Franklin. “It’s not planting seeds; it’s the soil. You have to get the environment ready for this. People need to understand why the work is so important.”

To help DMU along its journey, Mid-Iowa Health Foundation provided a grant that supported faculty in updating its first-year DEI course for osteopathic students and hosting community learning opportunities, with some events bringing in national presenters. Funding from outside the university is valuable, staff say, allowing them to be innovative and strategic in building engagement in DEI efforts.

“We cannot improve the health of all community members without improving the ways in which health care is delivered,” said Dr. Nalo Johnson, President & CEO of Mid-Iowa Health Foundation.  “It is imperative that we not only have health professionals who look like the community members they are serving, but also that all health providers are given the training and held accountable to engage with their patients in a culturally and socially responsible manner.  We are grateful for DMU’s leadership in preparing their students in this way.”

Cultivating the soil

Dr. Franklin began her tenure at DMU like many leaders entering a new institution. She assessed the organization’s strengths, weaknesses, opportunities, and threats. As she spoke with stakeholders about the current environment, she heard a common theme: DMU does not have a diverse student body and that diverse students wouldn’t want to come to the institution. She reflected on those comments with her own experience as a Black woman recruited and welcomed by the DMU community as an example of what was possible for the university.

Twelve years ago, the school had no DEI plan and only one staff member in the admissions office dedicated to recruiting students of color. When that person left, Franklin reworked the position into a Director of Multicultural Affairs, seeking someone who would not just recruit diverse students, but also foster the type of community where everyone felt included and engaged once they arrived.

Dr. Rich Salas came to the role with experience leading the multicultural office at the larger Colorado State University institution. Like Franklin, he recognized DMU’s vision and potential, and that it would be a long-term commitment to build the department and infuse DEI throughout the campus.

Instead of diving into actions right away, Salas began by asking faculty members to have coffee to get to know one another. By the third meeting, he offered to help as faculty members thought about questions they would receive related to DEI during their program accreditation processes.

Salas also hosted lunch and learns on DEI topics, inviting students, faculty, and staff to join. At first, he received questions from faculty about why these meetings were necessary or comments that implied these were “nice to think about” topics, but not essential to medical training.

Franklin and Salas spent time talking with faculty and staff about why the work was important – building the environment to advance greater efforts. They pointed to DMU’s mission – “to improve lives in our global community by educating diverse groups of highly competent and compassionate health professionals.” Achieving this mission required DEI work, driven by a guiding principle of inclusiveness, or in other words, embracing a culture of diversity that accepts and respects the unique characteristics of each individual.

Many students expressed eagerness for this learning.

“Students are saying this work is vital to our success,” said Franklin. “We want to understand and give good quality care to any patient that crosses our threshold.”

Engaging students in the “why”

When Dr. Salas gives an introductory lecture to students, he starts with data from the U.S. Census Bureau that points to how society is rapidly growing in diversity. He then highlights the health disparities that exist, especially for Black and Brown individuals. While the U.S. is one of the wealthiest countries, “there are structural/systemic pieces that prevent us from better health outcomes,” he says.

“Health equity means that every individual, regardless of their components of identity, will receive optimal care, the best care, the care that they need," Salas says.

One of the goals in engaging students is to help them advance along a continuum of “unaware of DEI concepts” to “highly skilled at engaging with others within a multi-cultural environment.” DMU aims to foster conversations that do not shame or blame, but rather, provide space to learn and grow together. Salas uses his own story of receiving care from his grandmother, a folk healer, to illustrate how health care providers “have to be aware that there are many ways of viewing how health and wellness unfold from cultural lenses,” he said. “Culture plays a part in how we heal, how we view medicine.”

With so many cultures in the world, DMU also has shifted from trying to educate on how to serve different groups of people to how to help providers be aware of their own biases and engage with others in ways that build trust and compassion. The Mid-Iowa Health Foundation grant supported DMU in redeveloping its first-year course focused on DEI concepts to creating space for self-reflection as students consider the intersectionality of diverse identities and the role of a provider’s own assumptions and biases.

While most courses have about 40 hours of lecture time, this course has five hours, with the rest of the time spent in small group conversation and listening to panel presentations from community members sharing their experiences with the health care system. Listening to community members has the greatest impact, said Dr. Lisa Streyffeler, Chair of Behavioral Medicine, Medical Humanities & Bioethics, who co-leads the course. “That is when we can connect our students with people in the community to hear, ‘This is what I would want you to know.’”

With her degree in psychology, Streyffeler also encourages medical students to recognize the self-care work that’s needed. “The idea that you’re not allowed to be a vulnerable, complex fallible human being as a physician, I’m hoping that’s shifting,” she said.

One challenge is recognizing that some students have been leading social justice work, while others are unaware or uncomfortable with these kinds of conversations. In redeveloping the first-year course, the faculty found a range of resources that then allow students to map out their learning journey.  

As some topics have become more politicized, faculty also have become more intentional about establishing why these conversations are necessary. “I think the critical piece is to connect with students’ basic desire to help people be healthier,” said Streyffeler, and this means acknowledging data that shows there are disparities in health outcomes.

Salas also works with diverse students who may become frustrated by the assumptions or judgments others are making, using strategies like the BAR method – take a deep breath, acknowledge what you’re hearing, and respond. “Some folks may not understand our experiences, but it doesn’t allow them to dismiss that this is certainly a challenge some people have.”

Bruckert-Frisk said that hearing from others’ experiences had the greatest impact.

“As medical students or anyone in an academic field, you get so stuck in the book stuff and learning about this diagnosis and that diagnoses, you lose connection that these are real patients you’re talking about,” she said. “It’s so important to bring that human side to medicine and remind us that these are real people and real experiences and not just numbers and documentation and that illness or that illness.”

Another lesson that’s stayed with her is recognizing the barriers people have to care. In one session, students had to work through different scenarios that their patients may be experiencing, such as a single mother whose car is in the shop and is trying to get her kids to a medical appointment. “We should always make the assumption that people are doing their best,” said Bruckert-Frisk.

Integrating across campus

Streyffeler says one impact of teaching the first-year course is that “it makes me even more acutely aware of the human beings who are physicians, and the enormous diversity of experiences people are bringing to the table."

It confirms that she cannot have a one-size-fits-all approach to teaching.

Faculty and broader campus engagement has been a critical focus of Salas’ work. He has used a film series that involves setting a theoretical framework for intercultural awareness before diving into nine discussions around different topics of diversity. Each session involves watching a half-hour film sharing real life stories from veterans, LGBTQ+ individuals, individuals from different races and ethnicities, and other identities. The film is followed by a discussion that helps participants consider what preconceived notions they have of a particular group and how might that impact the care they provide.

At first, 10 faculty members participated in the series, set up as lunch and learns, going through it twice to become co-facilitators and receiving a certificate of completion. Over a decade, more than 200 faculty members have become trained. And training has led to a slow infusion of the videos and topics into their courses. The podiatry program was the first to embed the entire video series into its curriculum.

The Multicultural Department also organizes a book club and cultural events. In the wake of George Floyd’s murder, DMU issued the 846 Challenge, representing the 8 minutes and 46 seconds of police brutality Floyd experienced. The challenge involved committing to meeting with EIGHT people on campus you hadn’t met before, identifying FOUR personal things you could work on, and coming up with SIX potential solutions.

The solutions part is especially critical, said Salas, going beyond just self-reflection and direct care. It gets at “structural competency” or looking further upstream to how policies, systems, and structures have been created that are causing the health issues health care providers are seeing.  

“If we don't understand the root cause of that,” he said, “We're missing a big portion of what the solution could potentially be in a collective form.”

Another critical component is engaging leadership, especially DMU’s Board of Trustees. Franklin said that while she has felt the Board’s support, she also has dedicated time to helping build their understanding and to involve them in the DEI work happening on campus. This work led to flattening the leadership hierarchy, including bringing Salas’ role up to an executive leadership level. Grant funding also supported the University in bringing to campus Dr. Howard Ross, a White male physician who focuses on identifying and addressing unconscious bias, who led a Board workshop on why DEI work matters.

Influencing the broader community

Franklin views DMU’s role as not just educating its community on campus, but also how to influence the health care system, especially as DMU students move into the hospital setting to continue their training. All CEOs from the major central Iowa hospital systems have a board seat on DMU’s Board of Trustees – an intentional step to build shared understanding and alignment.

The Mid-Iowa Health Foundation grant supported the institution in hosting learning events for the campus and community around topics including implicit bias, serving the Muslim community, and creating safe zones for LGBTQ+ patients.

The University’s Glanton event, which raises money to provide scholarships to students who would otherwise not be able to attend medical school, has also shifted from a sole focus on hearing students’ stories to also building understanding of issues around health equity and the work DMU is doing to transform health sciences education. At this fall’s event, DMU alumni Dr. Omar Lateef, now CEO of the Rush University System for Health (RUSH), shared the challenges health systems are experiencing coming out of the pandemic and what it takes to transform a health system to improve care for all members.  

“People come to the event to understand and have a greater appreciation for the work and the impact it makes—to reimagine what it means when we talk about DEI,” said Franklin.  

Seeing the ripple effects

Students occasionally stop by Salas’ office to thank him for creating the space to talk about topics related to DEI. White students especially tell him that they’re not as fearful to engage in these conversations. They understand how to frame questions. They can see how structural racism is playing out in the health care system.

While the number of applicants for DMU’s programs has consistently remained high, more of those accepted are choosing DMU, said Franklin. One of her favorite tasks is to have a Zoom meeting with each of the Glanton scholarship recipients and their families. She often watches family members’ surprise when they see a Black woman is the president of the university.

“There’s a lot of extra efforts to make sure students choose us and feel supported in the decision,” she said.

Students are also taking what they are learning into their residencies. One Glanton scholarship recipient shared a story of a recent emergency room experience in which the health care team assumed that an African American male who couldn’t speak must be using drugs until he could finally write on a piece of paper to the medical student: “sickle cell stroke.”

“It happens over and over and over again in our health systems,” said Franklin, but students are becoming more aware of these assumptions and how they are influencing the quick decisions they’re making. They’re identifying where changes could be made to processes like intake forms.

DMU also is asked to share its work with other institutions and groups across the nation. Streyffeler and Salas have joined colleagues in presenting at conferences and collaborating with other learning institutions.

Because of these requests, Salas is branching out to create DMU's own Health Equity: Providing Culturally Responsive Care teaching and learning video series. The DMU video series will include best practices on current cultural competencies, cultural humility, and a segment on structural competency needed for health care professionals today. The new video series, created as funding is available, will be integrated into the campus curriculum as well as shared with other institutions seeking teaching and learning tools that engage students, faculty, and staff in conversations.

When asked how DMU has integrated its DEI work across campus, Salas and Franklin also emphasize that it must start with leadership prioritizing and investing in the work, and that the journey should be slow and intentional to be sustainable.

“I tell people to be very careful about how you move forward and make sure you bring people along,” said Franklin. “Talk to people and find your way to get validated from the highest levels of leadership. Get integrated into the culture. We can now say it’s in our DNA, because we chose to.”

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