Formation of the Student Advocates for Diversity and Inclusion
In Fall 2017, eight second-year students opened the discussion on diversity and inclusivity at UofSC SOM Greenville. We students, leaders of UIM student interest groups, came together with the shared appeal for promoting an inclusive student environment and establishing a comprehensive curriculum that would adequately prepare students to work with diverse populations. Following informal discussions among ourselves as well as productive meetings with leaders in the medical school and physicians at the associated healthcare system, we took action to fill the gaps we observed in the school infrastructure and curriculum.
Faculty and staff were overwhelmingly supportive upon learning of our concerns. We first requested the formation of a formally recognized student committee on diversity and inclusion. The Student Advocates for Diversity and Inclusion (SADI) was thence formed with dual aims of improving diversity within both the curriculum and the school community. SADI commenced quarterly meetings to serve as the liaison between the school administration (including professors, administrators, physicians, and Student Affairs staff) and the involved student interest groups (including Lesbian, Gay, Bisexual and Transgender (LGBT) Health, SNMA, Medical Students for Health Advocacy, and the LMSA). Our short-term goals included curricular changes and extracurricular programs to expose students to the experiences of diverse patients and providers, which would contribute to meeting the committee’s stated mission of:
“…advancing the integration of diversity and inclusion within the medical school’s curriculum; supporting those student organizations with an emphasis on diversity; and fostering an environment for meaningful discussions centered on diversity and inclusion at UofSC SOM Greenville.”
Curricular changes
One key component of the UofSC SOM Greenville curriculum is the Integrated Practice of Medicine (IPM) course, which teaches students throughout the four years of medical school clinical skills, professionalism standards, and patient-centered care. IPM is a team-taught course that contains the majority of the behavioral, social, and population health curriculum, including cultural competence content. Course faculty continually review class sessions for areas of improvement with regards to LCME requirements and opportunities for method and content development. This review process, combined with the advocacy of SADI, yielded new class sessions on topics of diversity and expansion of the cultural competence curriculum (e.g. in the first year, Introduction to LGBTQ Populations and Social Determinants in Population Health During Pregnancy; in second year, Loss of Trust: History of Medicine, Race, and Discrimination, and a Patients with Obesity panel).
One area in which we wanted to add diversity was the clinical scenarios in the pre-clinical years. In the IPM course, faculty present students with a new case each week to evaluate and discuss. We wanted the patients in these cases to reflect the diverse patients and situations we would see in our clinical practice, with the idea that this would encourage students to begin thinking early on in their careers about the ways in which these factors impact health and patient care. In order to be more intentional about this, we created a checklist (Supplement 1) to guide case presentations to better reflect the diversity of our community. The checklists itemize various patient characteristics including race/ethnicity, sexual/gender identity, English language fluency, religion, socioeconomic status, disability, education level, and neighborhood. IPM faculty members were asked to ensure each of their case scenarios incorporated at least two characteristics from the list and to consider these characteristics in guiding student discussions about how health disparities influence the delivery of patient-centered care. The diversity checklists now guide clinical case development and classroom discussion on how diversity and discrimination create health disparities and affect health outcomes. How the cases have specifically changed since the implementation of the checklist has yet to be determined. While the clinical faculty responsible for creating the cases have been enthusiastic and embraced the concept a thorough and complete content analysis of pre- and post-implementation has yet to be conducted. Next steps in the SADI evaluation will include this type of review.
Opportunities to interact with diverse patients in preclinical years
During the preclinical years, students in the IPM course learn history-taking and clinical exam skills through interactions with standardized patients. As with our patient cases, we believe it is important for the standardized patient population to reflect our community. Barring a few exceptions, most of our standardized patients were white and middle- to upper-class. We wanted to have the opportunity to practice caring for and performing physical exams on other groups of patients we knew we would encounter in our clinical years. Student leaders of the LGBT Interest Group and the LMSA joined together through SADI to advocate for the inclusion of diverse patient populations in the standardized patient setting. Hispanic/Latino and LGBT populations face particular health disparities for various reasons, including physician prejudice, discrimination, lack of training, and language barriers (Snowdon, 2010; Morales et al., 2015). Understanding these disparities, we combined efforts with IPM teachers to take steps to include interactions with LGBTQ, Hispanic/Latino, and Limited English Proficiency populations in the standardized patient curriculum to provide students practice in caring for these populations.
Teachers and administrators also introduced new lectures and trainings focused on Hispanic/Latino, non-English speaking, and LGBT patients; these innovations ensure students are exposed to these populations early, often, and throughout all four years of medical school. For example, in a new classroom session entitled ‘Introduction to LGBTQ+ Populations’ students are not only provided with written pre-class materials with definitions and helpful communication tools, but also have the opportunity to hear from a trans-woman patient about her personal story and her patient advocacy work. Her journey through the healthcare system to transition has had quite an impact on the students. In one particularly impactful interaction with her primary care provider, when she was looking for help with beginning her transition, she received a response that was much less than compassionate. Her doctor told her, “Well, I promised to do no harm and you know you wouldn’t make a very pretty woman anyway.” Patient panels such as this provide students with more salient examples of the diverse patients they will encounter in clinical practice.
Extracurricular programs
We recognized another avenue for positive change in our medical school – extracurricular programs to facilitate conversations about diversity and inclusion. Many of has had participated in activities in college or heard from friends at other schools about impactful events they attended, and we wanted a similar platform for discussion and growth at UofSC SOMG,To provide a platform for students to ask difficult questions, we developed an event entitled Between Two Palms, loosely based on the popular celebrity talk show Between Two Ferns; the palms are representative of the state of South Carolina as displayed on the state flag (Figure 1).
Figure 1. South Carolina State Flag

This image of the South Carolina State Flag is available through the Creative Commons CC) 1.0 Universal Public Domain Dedication and can be found at https://commons.wikimedia.org/wiki/File:Flag_of_South_Carolina.svg
We collected anonymous student questions, on topics of adversity, socioeconomic barriers, immigration, religion, race, and gender in medicine. We invited respected physicians, faculty members, and community leaders to serve as guest speakers to answer the students’ questions. Between Two Palms debuted at UofSC SOM Greenville in February 2018 as a 90-minute evening event. Student-generated questions included the following: “What characteristic traits/attributes makes a female successful in a surgical specialty?”, “Do you believe affirmative action will always hold a place in professional education? How should medical schools balance the need for diversity with increasingly demanding application requirements?”, and “Is it possible to go your entire career as a doctor without killing someone? What do you do when your mistake leads to someone’s death?” We have since hosted four additional iterations of the program to facilitate deeper discussions, create protected space for dialogue on differing perspectives, and broaden students’ awareness of issues facing medicine today. Other memorable questions from subsequent events included, “While medicine is shifted away from using terms named after Nazis, such as ‘Wegener’s Granulomatosis’, there remain many tools and procedures named after J. Marion Sims, an early gynecologist who experimented on enslaved women. Why do you think this is and do you think we will shift away from using his name as well?”, “What is your practice doing to address the high rate of maternal mortality among African American women?”, and “Do you think abortion should be a right?”.
Between Two Palms was created to foster dialogue among students and bring visibility to the diversity within the UofSC SOM Greenville community. We obtained feedback from attendees of the event using audience response technology, by which attendees were invited to submit one- to three-word descriptors in response to the program. Feedback from over 80 students at the first event was overwhelmingly positive, as highlighted by the following descriptors: “provoking”, “honesty”, “worthwhile”, “encouraging”. In all iterations of the program, negative feedback has been exceedingly rare and typically reinforces the need for more open, respectful conversations among students with differing perspectives. Faculty members and physicians who participated as panelists for the events have offered their excitement that these important conversations are happening in medical school now; most also lamented the fact they did not have these opportunities during medical school. We now host Between Two Palms bi-annually to continue to provoke thoughtfulness and dialogue about diversity, discrimination, inclusivity, and bias.