The Tensegrity Curriculum: A Comprehensive Curricular Structure Supporting Cultural Humility in Undergraduate Medical Education

Introduction

Crafting medical school curricula that produce patient-centered, self-aware, and culturally humble and responsive physician leaders is a challenge fraught with tension. This urgency for change is fueled by the copious research that demonstrates disparities in access and outcomes for patients from systemic oppression, exposing inherent power and privilege in exam rooms and healthcare systems alike. For instance, a recent study revealed that from 1999 to 2020, 1.63 million Black Americans lost their lives in excess compared to white Americans, with COVID expanding that gap in 2020.¹ Health inequities within healthcare systems are complex. It is imperative that medical schools train students to take ownership in closing the gap in health disparities because not doing so has grave consequences for marginalized communities. Adapting a medical school curriculum requires motivation of administrative leaders and faculty to shift to new models, develop new pedagogies and content, and dedicate to a shared vision to change.

Within any complex system, inherent tension can provide stability and adaptability. Originally, an architectural term, tensegrity is an amalgamation of the words tension and integrity, used to describe a system of compressed components within a network of chords.² The field of chemistry and biology also uses this concept to refer to the interwoven cellular structure of organisms. In 2013, the osteopathic medical community adopted this concept to enhance the illustration of total-body unity, from the intricacies of spinal mechanics to the shared principles of whole-person care and health.² In 2019, Rowan-Virtua School of Osteopathic Medicine (Rowan-Virtua SOM) applied the concept of tensegrity to inspire change among faculty and leadership. The concept illustrated how to provide a tangible balance needed across all disciplines and competencies to train holistic physicians. As part of the mission to train culturally competent physicians, the goal was to train students to identify and interrupt implicit bias as well as understand systemic inequities that contribute to health disparities.

Leading evidence from the early 2000s heralded cultural competence as a leading success factor in physician education.^3–5 In its landmark call to action in 2005, the Association of American Medical Colleges (AAMC) defined cultural competence in health care “as a set of congruent behaviors, knowledge, attitudes and policies that combine the tenets of patient/family-centered care with an understanding of the social and cultural influences that affect the quality of medical services and treatment.”⁶ As a result, accreditation agencies – the American Association of Colleges of Osteopathic Medicine (AACOM) and AAMC – introduced standards for cultural competence and the awareness of its importance grew, albeit slowly, among clinicians in practice, trainees, and educators.^6,7 Over the next decade, medical education curricula taught necessary skills for physicians when interacting with people of diverse cultures and differing belief systems, including preparation for recognizing and addressing cultural biases presenting during individual patient care.⁶

While attention to cultural competence was an important first step, it has been recognized that a more comprehensive approach is needed to create truly humanistic physicians. Doctors need to have the skills to work effectively with patients with different lived experiences, and also need to be able to identify and dismantle systems of oppression to impact the health of communities.⁸ To produce these outcomes, it is insufficient to only teach students specific clinical tools they must add to their skillset, one that is already strongly influenced and developed at the beginning of medical education by individual implicit bias. Instead, it is crucial to invite students to develop self-awareness, to recognize and normalize the unconscious biases that are inherent in everyone. We must also inspire healthcare trainees and professionals to dedicate time and energy to challenge personal unconscious biases due to the deleterious effects they have on the most marginalized patients.

The process of commitment to ongoing self-critique, termed cultural humility, encourages the healthcare community to “redress the power imbalances in the physician-patient dynamic, and to develop mutually beneficial and non-paternalistic partnerships with communities”.^8,9

Equally important to acknowledge is that naming truths about racism, sexism, heterosexism (among other ‘isms) and intersectionalities of oppression that contribute to healthcare disparities requires faculty to embody self-awareness, cultural humility, and responsiveness themselves. Faculty also need to model having these difficult conversations which requires creating a learning environment that balances emotional safety and honest truth-telling.¹⁰ Due to the power imbalance between students and faculty, students can feel uncomfortable and fearful of saying something wrong. To co-create a psychologically safe space between faculty and students, faculty need to verbalize that it is a safe space and show it with action (eg, modeling and being clear about expectations for students show up with kindness, empathy, self-compassion for self and others, and intellectual curiosity).¹⁰ In addition to faculty commitment, institutional support is vital for the success of any curricula renewal that centers cultural humility and responsiveness in all competency domains so that it is executed successfully and sustainable.

Building this curriculum cannot be done by simply adding one lecture, changing one course, or implementing a new set of educational standards in isolation of the faculty who deliver the content. For an innovative curriculum to generate self-awareness, knowledge and skills in addition to the commitment it takes for the learner, a frameshift is required in the way the entire curriculum is conceptualized, organized and delivered. It requires a shared understanding of systemic oppression and the direct links to disparities in healthcare, a personal commitment to model and teach ongoing self-critique and learning, a cohesive and actualized mission, and recognition that the healthcare landscape is ever-changing and that medical schools must prepare trainees to adapt and function within it. Rowan-Virtua SOM is one of the largest medical schools in New Jersey, a public osteopathic medical school which consistently produces graduates who enter primary care specialties and practice in underserved communities. This call to higher action was heard and answered with vigor and dedication by the institution with support for the Tensegrity Curriculum and its short- and long-term objectives (Figure 1).

Figure 1 Rowan-Virtua School of Osteopathic Medicine Vision, Mission, and Goals of the Tensegrity Curriculum.

Method

To address these complex healthcare inequities in the United States, and to strengthen its educational profile, Rowan-Virtua SOM implemented the Tensegrity Curriculum in July 2019. The process of renewing the curriculum took three years involved multiple faculty, administrators, committees, and students coming together to research best practices across allopathic and osteopathic United States medical schools for the global aim of training physicians to function adaptively in a dynamic and changing modern healthcare environment. The main objective of this renewal process was to redistribute emphasis of all competency domains, giving additional attention to the integration and application of humanism, cultural humility, patient-centeredness, self-awareness, cultural and social responsiveness. The long-term goal is that health inequities will be mitigated by training physicians to be attentive to their own implicit bias and learning skills to dismantle systems of oppression that contribute to health disparities.

The Tensegrity Curriculum was designed with a multi-disciplinary committee which conducted a systematic review of current United States curricula. The committee at Rowan-Virtua SOM, working from a shared commitment to the school’s mission and vision,¹¹ examined each course and block within the curriculum and proposed a redesign.

Results

The Tensegrity Curriculum has several key components devoted to training students in understanding the social determinants of health, enhancing emotional intelligence, identifying and interrupting implicit bias, and advocating for colleagues, patients, and communities (Table 1).

Table 1 Key Curricular Components Integrated Through the Tensegrity Curriculum Which Train Students in Humanism, Cultural Humility, Patient-Centeredness, Self-Awareness, Cultural and Social Responsiveness. Goals and Objectives are Adapted from Syllabi and Course Manuals for Each Curricular Component

Pre-Clerkship & Clerkship Format

Rowan-Virtua SOM has two tracks for pre-clerkship curriculum: Synergistic-Guided Learning (SGL) and Problem-Based Learning (PBL). The two tracks share common courses and intersessions with separate system blocks and clinical skills courses.

The SGL track is largely lecture based, with a system-based format combining basic and clinical sciences in a one-pass system. The PBL track consists of small groups of students working with a facilitator to learn curricular content by working through medical cases, with a focus on basic science in first year and clinical sciences in second year, using a two-pass system, in which content is reviewed twice during the pre-clerkship years.¹² Students begin core clerkships at the end of second year when SGL and PBL tracks merge.

Community Service Learning and Leadership (CSLL)

CSLL is a three-year longitudinal curricular thread based on the foundation of a 40-year collaboration with the New Jersey Area Health Education Centers (AHEC).¹³ CSLL moves students from evaluation and reflection of the student’s personal and professional self (CSLL I), to understanding groups, team dynamics, and health systems (CSLL II), culminating in a two-week core clerkship in Year 3 (CSLL III), in which students identify needs of an assigned underserved area and provide recommendations for meeting community needs (Figure 2).

Figure 2 The curricular arc of the Community Service Learning and Leadership curriculum at Rowan-Virtua SOM. Year I focuses on self-awareness and reflection. Year II includes logic models, methodologies, and standardized patient encounters. Year III culminates in a 2-week rotation in a medically underserved community. Abbreviations: AHEC, Area Health Education Center; QI, quality improvement.

The primary focus of CSLL I is to assist students in increasing self-awareness. To close the gap in health disparities, it is critical for students to reflect on their own implicit biases and have strategies to address them.¹⁴ Emotional intelligence and implicit bias are covered in lecture and small group format with guided discussion by a trained facilitator. A panel discussion presents shared experiences of being recipients and perpetrators of implicit bias in healthcare with success strategies for navigating them. Later in the year, students take the Implicit Association Test (IAT) and critically analyze the process of taking the test in small groups.¹⁴ CSLL I hosts an interprofessional education event, where students work with multiple health professionals on cases in small groups. Assessments in CSLL I include quizzes, reflective writing exercises, participation in small group activities, and a case presentation applying the concepts learned throughout the year.

CSLL II uses Standardized Patient (SP) encounters for students to gauge their comfort and confidence in having difficult conversations in simulated situations. Students then choose an underserved population in which to volunteer, provide service, and research. Quality improvement (QI) methodologies are taught using lecture, and students prepare group presentations on their population, its social determinants of health, a QI system analysis, and recommendations for improvement. Students then complete a critical analysis reflecting on the experience and how it relates to their future as a physician.

CSLL III concludes the longitudinal curriculum, in a 2-week required clerkship located in urban and rural communities with a wide distribution of health inequities in New Jersey. Students are assigned to a community-based organization within one of Rowan-Virtua SOM’s clinical hub sites or within a one of three local AHEC Centers (ie, River, Garden, or Shore AHEC) to facilitate placement in various community-based agencies in the counties served by the NJ AHEC program. Students may be placed at any of AHEC’s collaborating service-learning site/host organizations (ie, Healthcare for Homeless Shelters, wound care programs, Federally Qualified Health Centers (FQHC), or mobile food pantries). Within a hub site, students may be placed at a hospital system’s free or charity care clinic, a community-based primary care practice, or at a public health department. The crux of service-learning experience is the reciprocal nature of the relationship between students and the community. CSLL benefits students by providing learning experiences, while the host site benefits from students who bring healthcare innovation and new ideas to the community. It is Rowan-Virtua SOM and AHEC’s shared goal that students will witness and contribute to extra-medical disciplines and how the wider community impacts overall health and healthcare. Students also dig deeper into their own perceptions, attitudes, and values through reflective activities, like journaling and narrative medicine, and present to their site preceptor at the conclusion of the rotation. The host site providers serve as community preceptors for students and provide official components of the student’s grade.

The longitudinal nature of CSLL allows faculty to assist trainees with the hard work of breaking down biases as a method of cultivating cultural humility before placement into underserved communities. There are several important considerations for this curricular design. First, it allows students to develop emotional intelligence, understand and challenge implicit biases to decrease the likelihood of perpetrating microaggressions onto colleagues and patients. Second, it specifically invites students to question stereotypes, learn about systems of oppression, and develop skills to manage difficult conversations within the safety of the pre-clerkship curriculum. Learning first in low-stakes environments (eg, small groups, Simulation Center activities), prepares students to interact with community partners doing real-time service work in their third year. This progression mirrors the sequencing of clinical activities and procedures within clinical medicine courses.

System Blocks: Health Equity Modules & Case-Based Learning

Pre-clerkship System Blocks cover foundational basic and clinical sciences, and two components within them address social determinants of health, healthcare disparities and cultural inclusiveness: (1) Health Equity Modules and (2) Case-Based Learning (CBL), which, within the Tensegrity Curriculum, includes required psychosocial components.

Health equity is defined as “an approach to health that strives to give everyone the best chance at the healthiest possible life”.¹⁵ Health inequity is defined as the difference in health outcomes irrespective of individual choices or behaviors.^15,16 Whether it is social, environmental, or economic pressures lead to differences in health outcomes. Health disparities can occur as part of an inequity, but they may occur as a result of the choices we make as well.¹⁶ Health disparities and inequities require a deep understanding of social determinants of health. The awareness that these disparities disproportionately affect communities of color, and implementing skills to aggressively challenge the status quo to stabilize health inequities, will increase health outcomes in these affected communities. Within each System Block for both pre-clerkship tracks, students are assigned materials on health equity topics that relate to the content of that block (Table 2).

Table 2 System Block Health Equity Modules and Assignments, with a Synopsis of Each Required Element, Adapted from Syllabi and Course Content

CBL sessions are part of the SGL track and are held in small groups facilitated by physicians. Students work through clinical cases, evaluating differential diagnoses to hone clinical reasoning skills. In the Tensegrity Curriculum, cases explicitly address healthcare disparities, implicit bias and patient advocacy. Faculty who compose cases are assigned one psycho-social component and are expected to include discussion questions aligned with case objectives (Figure 3).

Figure 3 Psycho-social and system-level components included in Case-Based Learning which emphasize humanism, cultural humility, patient-centeredness, self-awareness, cultural and social responsiveness.

Intersessions: Human Sexuality & Health System Sciences

Intersessions are week-long courses focused on crucial concepts impacting patient care. Human Sexuality and Health Systems Sciences are two of the intersessions in the Tensegrity Curriculum which include specific content on cultural awareness and humility.

Human Sexuality occurs in Year I, providing concentrated attention to sensitive aspects of human sexuality and sexual health. The content expands on sessions from the Endocrinology and Reproduction Blocks, and builds on lessons from CSLL, addressing misinformation, controversy, and prejudice, encouraging students to identify and interrupt personal biases related to gender identity and sexual orientation.

Health System Sciences (HSS) I and II are each week-long intersessions occurring during Years I and II, respectively. Crafted using the American Medical Association’s Education Consortium foundational text, the first week of this content provides fundamental understanding of healthcare delivery systems, value-based health care, patient safety, and QI.¹⁷ This intersession sets the stage for CSLL Year II, which then delves again into QI methodologies, and CSLL Year III, and requires student groups to utilize QI methodologies while on the CSLL clerkship. The second week covers action-oriented steps to healthcare transformation, leadership, health information technology, and continual QI. By this time in the curriculum, students are primed to begin third-year clerkships; with the concepts of emotional intelligence, implicit bias, cultural humility, health equity, and social awareness now weaved into the curriculum, the expectation is that they can begin to integrate these concepts as they step up to real-time clinical care.

Areas of Distinction: Cultural Competency & Humanism

Areas of Distinction (AoD) are elective curricular components that are recognized and included in Medical Student Performance Evaluation (MSPE) letters for residency applications, with requirements for didactic education, community service, and scholarly work. Rowan-Virtua SOM has twelve AoDs, two of which are Cultural Competency, and Humanism (see Table 3). These elective opportunities provide focused attention, advising and development into the intricacies of cultural competence and humility, and encourage an even deeper dive into interrupting implicit bias within the learner, and proposing system-level changes that result in new and generalizable knowledge in these areas.

Table 3 Requirements for Areas of Distinction in Cultural Competency and Humanism at Rowan-Virtua SOM

Conclusions

In the spirit of the osteopathic tenet, “Structure and function are reciprocally interrelated”,¹⁸ the concept of tensegrity invites faculty to encourage critical discourse, respecting that the inherent tension between these perspectives is what creates stability. Together, faculty are also energized toward the shared mission of training physicians who are humanistic, culturally competent, and humble, and who will approach future work with patient-centeredness, self-awareness, cultural humility and social responsiveness.

Among the leadership at Rowan-Virtua SOM, the Tensegrity Curriculum now provides a roadmap for innovative curriculum development, actualizing change-efforts in diversity, equity, and inclusion (DEI). As a community, students, faculty, and leadership see each other working toward the weaving-in of principles of DEI within all of our work. This increases legitimacy for the content and bolsters character and pride.

Despite increased focus on cultural humility in evolving medical education standards, studies show that empathy decreases among medical trainees as education progresses.¹⁹ Next steps for institutions undergoing vast curricular changes include researching their effectiveness both in meeting the stated goals and objectives, but also in investigating whether retention or even improvement in empathy is possible. Breaking down biases, developing self-awareness, and fully preparing oneself to enter and care for marginalized communities requires a cognitive shift in the learner and a paradigm shift in educational systems. The tension will be felt. Yet the integrity it inspires could sustain empathy, lessen gaps in healthcare disparities and improve health equity in our curriculum and communities.