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      The growth mindset in medical education: A call for faculty development

      a , b , c

      EClinicalMedicine

      Elsevier

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          Abstract

          Despite a national call for increased under-represented in Medicine (URiMs) in the United States’ (US) medical schools, data from 2018 to 19 indicate that the number of Latino/Hispanic (6%) African American (7%), and American Indian/Alaska Natives (0.2%) has plateaued [1]. Attention to creating a culture that is supportive of URiM trainees is critical to providing our increasingly diverse patients a similarly representative healthcare workforce. Increasing URiM physicians will not only help to meet a predicted 139,000 physician shortfall by 2033 but it will also help to ensure greater access to quality care for all patients including racial and ethnic minorities [1]. A lack of mentorship, stereotype threat, and racial bias from instructors resulting in isolation in medical training are factors responsible for a disproportionate number of URiMs [2,3]. A necessary starting point for reversing this trend is promoting an understanding of the racism endemic in medical centers, departments, and individuals in conjunction with institution-wide educational programs focused on creating an antiracist culture. Exploration of education research, the historical perspective of medicine and the current racial climate in the US has provided us an opportunity to consider novel approaches for medical education. Our current medical education system was designed to be exclusionary and that groundwork was effectively laid out by the Flexner report in 1910 [4]. Achieving an antiracist culture in education will require attention to what is often referred to as the ‘hidden curriculum’: unspoken values, beliefs, and norms perpetuated by educators who serve as behavioral models in medicine [5]. However, physician educators are not explicitly trained in educational theory for developing pragmatic approaches for learning. While the goals of medical education are clear we are lacking pedagogical standards to create a coherent and uniform training for residents (the current pedagogy is based on individual preference). Additionally, segregated spaces promote reliance on potentially harmful stereotypes of URiMs which limit White faculty's understanding of URiM trainees, precluding meaningful relationship building [2,3]. Unlearning years of systemic oppression in medicine will require an educational curriculum which affords awareness and engagement to support self-reflection, morality-inspired consciousness, and daily effort to evoke change. Psychologist Dr. Carol Dweck has compiled multiple studies on the growth vs. fixed mindset in education. Mindset theory holds that our implicit assumption about the origin of our abilities, intelligence and talent have a profound impact on how we view our mistakes or failures. According to Dweck, the growth mindset approach to education promotes the idea that ability is acquired through effort with failure as an opportunity for improvement while the more prevalent fixed mindset promotes the idea that intelligence or ability cannot be changed [6]. Building upon Dr. Carol Dweck's research, the fixed mindset characterizes our current medical education climate which may be undermining the development of our learners [6]. Consideration of her work for expanding diversity and inclusion programming to incorporate the growth mindset will undoubtedly promote a more suitable educational culture necessary for deconstructing systemic racism in academic health centers and fostering a culture of inclusion and belonging. Systemic racism is an injurious example of the fixed mindset inaugurated with the enslavement of Black people as a free workforce in the US which ended “officially” in 1865 when the 13th Amendment was passed. Historically, medical providers were complicit in the indispensable fixed characterizations of Black people as “less than” White people evidenced by a lengthy history of harmful surgeries and the denial of treatment to Black people for the purpose of experimentation. This occurred in American history from the moment Black people were enslaved until the early 1970′s [7]. These fixed racist mindsets historically overlooked knowledge gaps, omissions in care, and abusive practices which are pivotal to understanding Black people's mistrust of the US medical system. Historically, the highly competitive field of medicine was populated by White men over Black people—stereotyped as intellectually inferior [4,8]. According to Dr. Dweck, educators who regard members of under-represented groups as fixed or less than decide early on who is “smart” and who is weak. Such educators unilaterally determine which students to give up on before training begins. In medicine, these adverse learning environments weaken academic performance and increase stress for trainees leading to increased numbers of URiMs to drop out of medical training or leave academic medicine entirely [2,9]. It is this same fixed mindset that has led to the characterization of Black men as “guilty” or “dangerous” resulting in a self-defense justification for the police killing of George Floyd and countless other Black Americans. The antiracist sentiments being proclaimed by a majority of medical training institutions today requires dismantling of this apparent fixed mindset. Within education, results from a university sample of 150 STEM Professors and >15,000 students revealed that racial achievement gaps in courses taught by fixed mindset faculty were twice as large as the gaps in courses taught by more growth mindset-oriented faculty. Student evaluations in classes taught by fixed mindset faculty indicated a negative educational climate [10]. In contrast, the growth mindset may offer an opportunity for a more positive learning environment in medical education (Table 1). The success of the growth mindset for learning requires full engagement from educators [6]. Table 1 Racism to Anti-racism: Example Dialogue and Actions Moving from Fixed to Growth Mindset in Medical Education with a Racialized Lens. Table 1 Image, table 1 In summary, the growth mindset requires an understanding of the varied levels and experiences of our trainees. Learning about the history of racism in health care and education is the starting point for faculty to undo assumptions about the URiM learner and focus on community building by appreciating differences as strengths. The growth mindset educator is relational, actively listens, recognizes growth and hard work, and collaborates with learners to create an environment and plan for academic success. The power of the growth mindset in improving the educational climate for URiM is one aspect of a multi-factorial approach for change including: education to promote awareness of systemic racism; policy instituted by educationally equipped leaders to support equity and inclusion; and institution-wide educational programs which incorporates the growth mindset for teaching. By framing the growth mindset to include a race equity lens White faculty will necessarily focus on effort for growth and proficiency; relationship building; valuing different races, cultures, and perspectives and will create clear actionable goals for educating a diverse healthcare workforce. Author contribution All authors contributed equally to this article. Dr. Harrison specifically contributed to all aspects of this work, theory, design, literature searches, writing, and editing, design and development of Table 1. Declaration of Competing Interest The authors declare no competing interests.

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          The social and learning environments experienced by underrepresented minority medical students: a narrative review.

          To review the literature on the social and learning environments experienced by underrepresented minority (URM) medical students to determine what type of interventions are needed to eliminate potential barriers to enrolling and retaining URM students.
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            Is Open Access

            STEM faculty who believe ability is fixed have larger racial achievement gaps and inspire less student motivation in their classes

            Racial achievement gaps are twice as large, and all students are less motivated, when STEM faculty believe ability is fixed.
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              Progress for Whose Future? The Impact of the Flexner Report on Medical Education for Racial and Ethnic Minority Physicians in the United States

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                Author and article information

                Contributors
                Journal
                EClinicalMedicine
                EClinicalMedicine
                EClinicalMedicine
                Elsevier
                2589-5370
                20 November 2020
                December 2020
                20 November 2020
                : 29-30
                Affiliations
                [a ]Resident Physician, PGY-3, Dept. of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR 97239, United States
                [b ]Neuroanesthesia Medical Director, Assistant Professor of Anesthesiology and Perioperative Medicine, School of Medicine, Oregon Health & Science University, Portland, OR 97239, United States
                [c ]Professor of Medicine, Department of General Internal Medicine & Geriatrics, Division of Hospital Medicine, Oregon Health & Science University, Portland, OR 97239, United States
                Article
                S2589-5370(20)30392-8 100648
                10.1016/j.eclinm.2020.100648
                7691162
                © 2020 The Authors

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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