Josiah Macy Jr. Foundation Conference on COVID-19 and the Impact on Medical and Nursing Education: Conference Recommendations Report

The World Health Organization declared COVID-19 a global pandemic in March 2020, and by the time this report reaches readers in late 2021, it will have been raging around the globe for nearly 2 years with no clear end in sight. Despite the existence of effective vaccines, the goal of defeating the pandemic has morphed into managing it, with people the world over trying to resume some semblance of their prepandemic lives—ideally, not just to survive but to thrive.

Now that the initial crisis point has passed, society has an obligation to examine and learn from its early pandemic experiences. We have an opportunity to use the lessons learned not just in preparation for the next global health crisis but to reconsider the status quo more broadly. This exercise is necessary in every sector of American society, and most certainly in the health professions education (HPE) system, which trains tomorrow’s doctors, nurses, and other health care professionals—those who will be delivering increasingly excellent care, improving the health of the public, and guiding the nation through the next global health crisis.

Within HPE, the obligation to learn and opportunity to improve are more like imperatives. Many of the pandemic’s most difficult challenges existed long before COVID-19, but inertia inhibited progress, requiring many lessons to be learned again and more forcefully. Yes, certain process and policy disruptions arose early on that were new and specific to the pandemic, such as the fact that, due to quarantine restrictions, undergraduate medical and nursing students suddenly found themselves isolated and learning online. Much can be learned from these practical and logistical challenges encountered during the pandemic and from the innovative solutions that were tested in response. But the pandemic also highlighted the need to make transformative changes in HPE that address persistent issues already known to have a negative impact on health care quality and patient outcomes. These include racism and discrimination in health care and a health care culture that does not support the well-being of providers, particularly learners. They also include lingering barriers that have impeded transitions to better models for educating health professionals, namely competency-based education (CBE) and interprofessional education (IPE).

To help improve HPE learning environments, the Josiah Macy Jr. Foundation hosted a virtual conference in July 2021 on COVID-19 and the Impact on Medical and Nursing Education. The conference brought together a group of faculty, learners, leaders, and other experts in HPE to consider their own pandemic experiences as well as those of their peers and colleagues and to identify ways that learning environments can and should be made better, regardless of the next major health crisis.

“Having taught and trained during the worst global pandemic in more than a century, our health professions faculty, students, and trainees are emerging from a life-altering, career-defining experience,” said Macy Foundation President Holly Humphrey, MD, during her opening remarks at the conference:

The COVID-19 pandemic opened our eyes not just to the many ways that we were—and still are—unprepared for a major health crisis, but it also exposed the inequities and disparities that are rife within our health care system. We knew before the pandemic that there are significant gaps in the quality of care we are delivering, gaps that will exacerbate any crisis, and now we know we can no longer delay addressing the situation.

Conference Background and Overview

There was no question that the Macy 2021 conference would focus on the pandemic. The goal of the annual conference is to examine and make recommendations to address a pressing challenge to HPE. COVID-19 was the most urgent challenge confronting health care delivery and HPE beginning in 2020—and it remains dominant as of the writing of this report in the second half of 2021. To assemble and lead a conference planning committee in designing a virtual meeting (the Foundation’s first) that would ultimately produce credible, meaningful, and actionable recommendations, the Macy Foundation recruited Lepaine Sharp-McHenry, DNP, MS, RN, FACDONA, dean of the College of Natural, Behavioral, and Health Sciences at Simmons University, and Alison Whelan, MD, chief academic officer of the Association of American Medical Colleges.

Together with Foundation staff, Drs. Sharp-McHenry and Whelan assembled a conference planning committee composed of a representative group of those who would be invited to the conference: health professions leaders, educators, and learners with front-line knowledge on how the pandemic was playing out in health professions learning environments (a list of committee members and conferees appears at the end of this article). In the past, HPE learners have been invited, and contributed significantly, to Macy Foundation conferences, but this year marked the first time that learners—specifically, a candidate for a bachelor’s degree in nursing and a medicine fellow—served on the conference planning committee.

The committee made 2 decisions early in the process that shaped the conference in terms of focus, agenda, invitation list, and commissioned papers. They determined that the conference should limit its focus to academic medicine and nursing because these have been the predominant health professions working on the front lines of the pandemic. They also determined that the voices of health professions learners—defined as undergraduate medical and nursing school students, graduate-level nursing students, and medical residents and fellows—should be front and center during the conference. And because the conference was scheduled for July—which can be an unpredictable month of transitions for HPE students, residents, and fellows—the planning committee decided to host a preconference meeting focused on learners’ perspectives and issues.

Preconference meeting centers learners’ voices

On April 23, 2021, the Macy Foundation hosted a 1-day, preconference, virtual meeting to ensure that the voices of health professions students and trainees would be heard firsthand. The meeting was organized around 4 papers ^1-4 that students and trainees were commissioned to write, reporting on their own experiences and those of their peers as health professions learners during the COVID-19 pandemic. In addition to the 11 learners who coauthored the papers, participants at the April meeting included the 11 members of the conference planning committee and 6 Macy Foundation staff members.

At the meeting, the authors presented their papers for discussion. Each paper featured the perspectives and experiences of a different category of learner describing the impact of COVID-19 on their education; one was written by undergraduate medical students, another by undergraduate nursing students, another by a medical resident who is now a fellow and an assistant professor, and another by graduate nursing students. Each learner-authored paper was made available to meeting participants for their review before April 23, as was a short video overview of each paper.

Then, in preparation for the July conference, participants were asked to read the 4 student papers as well as 7 more commissioned papers ^5-11 and 5 case studies. ^12-16 These were produced by medicine and nursing faculty members, also reflecting on the pandemic’s impacts on nursing and medical education. The 16 commissioned papers and case studies ^1-16 will be published in the March 2022 supplement to Academic Medicine and are now available in preview online.

These papers and case studies formed the basis for small-group and plenary discussions at the July conference. The “Themes From the Conference Discussion” section of this report integrates and outlines the primary themes that emerged from both the April meeting and the July conference. A glossary of terms used throughout this report appears in Box 1.

Box 1

Glossary

• Antiracism goes beyond the passive concept of “not being racist” and calls for people to actively oppose racism and promote racial justice.
• Cocreation/coproduction of learning occurs when learners participate actively with faculty in designing and delivering curricula and other educational activities.
• Competency-based education is an outcomes-based education and assessment model focused on ensuring that all learners acquire certain observable abilities (competencies).
• Equity is achieved when all people are valued and respected, and ongoing efforts are made to avoid and/or resolve inequities, injustices, and disparities.
• Heroism, or going above and beyond the call of duty, is a term that has been applied frequently to health care workers during the pandemic. Heroism may be necessary in a short-term crisis, but it is not sustainable, and providers may experience guilt, shame, anxiety, etc., when they feel unworthy of the label.
• Holistic review is an HPE admissions process that looks at a variety of factors when assessing an individual applicant, including unique life experiences and personal attributes as well as academic achievements. It is designed to help schools better understand how well prepared an applicant is to matriculate as well as how they might contribute value as a student and as a future health care professional.
• Professional identity formation is the process by which HPE learners come to think, act, and feel like members of their chosen professions; it is the transition from medical student to professional physician and from nursing student to professional nurse.
• Social determinants of education are factors—such as socioeconomic stress; racism, bias, and oppression; food and housing insecurity; poor access to health care; and unsafe, underresourced neighborhoods—that create educational disparities among HPE learners. Learners whose backgrounds have been shaped by these factors are at a disadvantage in HPE compared with their peers with more affluent backgrounds.

Abbreviation: HPE, health professions education.

Consensus vision statement sets the stage

After a year of planning and preparation, a preconference meeting, and a significant amount of preconference reading, 50 conferees came together via Zoom from July 12 to 15, 2021. One of the conferees’ first activities was to discuss, revise, finalize, and approve a consensus vision statement that had been drafted by the conference planning committee and Macy staff. Producing such a statement at the start of a meeting has become a regular activity at annual Macy conferences for 2 reasons. First, it prompts conferees to begin interacting immediately in ways that are conducive to reaching consensus around conference recommendations—a much bigger goal of the conference. Second, encouraging conferees to produce a shared vision for the conference provides a way to get everyone pulling in the same direction toward the same purpose and goals. For this Macy conference, the conferees reached consensus around the statement in Box 2.

Box 2

Consensus Vision Statement

• To improve the health of people and communities, we—the people who work and learn in health professions learning environments—will build on the lessons learned from and the momentum created by the COVID-19 pandemic. We commit to transforming health professions education so that it continuously adapts, achieves equity for all, and enriches the human experience of giving and receiving care.

Themes From the Conference Discussion

Following the consensus vision statement exercise, conferees began discussing, in small groups and plenary sessions, their experiences and observations from the initial wave of the pandemic—and how the most relevant of these could be turned into recommendations. The following themes appeared repeatedly in the conference discussions; most were introduced at the 1-day, preconference meeting in April and were expanded upon during the 3-and-a-half-day event in July.

Theme 1: The onset of the COVID-19 pandemic coincided with increases in racist activities and hate crimes and brought with it more awareness of the tremendous inequities and resulting disparities within the U.S. health care delivery and HPE systems. These factors—born of a societal tradition of racism and oppression—have implications for HPE.

In 2020, racist behaviors and language—and their deleterious effects on people—were so commonplace and overt across American society that COVID-19 and racism were sometimes referred to together as the “twin pandemics.” Manifestations of these 2 pandemics included:

• High levels of COVID-19–related health inequities and disparities experienced by marginalized populations in the United States, particularly Black, Latinx, and Indigenous people, who, according to one of the commissioned papers, ³ “died of COVID-19 at roughly twice the rate of White people;”
• Increased awareness of racist incidents in which Black men, women, and children, often without provocation, were brutalized and killed by police in the United States, sparking global protests during the summer and fall of 2020; and
• Increased incidence of hate crimes and discriminatory behaviors directed toward Asian Americans, immigrants, and visitors.

These and other hard realities meant that health professions learners who are Black, Indigenous, or people of color (BIPOC) and their allies not only saw entire communities ravaged by COVID-19 and structural racism but also were more likely to experience discrimination themselves or see it directed toward their families, friends, peers, colleagues, patients, and communities. In response to these issues and experiences, many BIPOC health professions learners and their allies—according to many of the commissioned papers and much of the conference discussion—were activated as social justice leaders, protesters, and advocates within their academic communities, in the communities that surround their institutions, and even nationally via traditional and social media. They called for institutional commitments to antiracism and antioppression efforts in their learning environments, including removing harmful bias from curricula, recognizing racism—rather than race—as a social determinant of health, and providing more institutional support for BIPOC students and students from other traditionally marginalized communities.

One of the commissioned papers ⁸ centered on the concept of “social determinants of education” (SDOEs) as requiring immediate attention within HPE. Some SDOEs act as barriers that deter students from considering or completing an HPE program, including socioeconomic stress; racism, bias, and oppression; food and housing insecurity; poor access to health care; and unsafe, underresourced neighborhoods. These barriers are most likely to be encountered by students who often are the focus of diversity and inclusion efforts, such as BIPOC students, those from lower-income backgrounds, or members of other marginalized communities. HPE institutions already recognize the need to recruit, support, and graduate learners who reflect the nation’s very diverse population, but doing so requires them to address SDOEs as part of those efforts.

The bottom line reached during the conference discussion was that HPE leaders, faculty, and learners need to work together—with patients and families—to dismantle structural racism and eliminate discrimination and harmful bias in all aspects of HPE and health care delivery.

Theme 2: The pandemic took (and continues to take) a tremendous toll on the mental health and well-being of everyone working and learning on the front lines of health care, and exposed the need to develop mental health supports and resources for HPE workers and learners to prevent burnout, depression, anxiety, etc.

According to the commissioned papers and conference discussion, those working and learning on the front lines of COVID-19 experience daily assaults on their mental health and well-being, including:

• witnessing severe illness, death, grief, and loss on a massive scale;
• grieving traumatic illnesses and losses among their own family, friends, and colleagues;
• worrying about their own health and safety and that of the people they care about;
• dealing with frequent ethical dilemmas, such as witnessing or being the target of racism and discrimination, managing limited resources and reconciling the effects of shortages on peers and patients, and experiencing fear of retribution for speaking up about an ethical issue; and
• managing overwhelming feelings, such as hopelessness, sadness, anger, guilt, and more.

The pandemic, while exacerbating physical, psychological, and moral burdens on providers and learners, also exposed the extent to which wellness and mental health needs are not a priority for HPE programs and are even stigmatized within the HPE culture. While the papers suggest that these and many other pandemic-related challenges helped HPE learners develop empathy and resilience and become more flexible and creative in their approaches to problems, these developments were experienced as double-edged swords given the demands under which they were forged. Take heroism, for example; one of the papers ⁷ noted that, initially, health care workers and learners found the “health care providers are heroes” narrative somewhat supportive, but it quickly became an additional burden for many as they confronted their own human limits during the unrelenting waves of illness.

Further, while HPE institutions made—and are making—attempts to support the well-being of workers and learners, well-meaning efforts presented as supporting “self-care” and building “resilience” may inadvertently communicate that faculty and learners are responsible for their own well-being, despite the fact that their institutions are creating and controlling the detrimental circumstances, exposures, and experiences.

During the discussion, conferees strongly favored systematic efforts to both assess and address the mental health impacts of the past year on HPE faculty and learners. Several conferees suggested that the use of a trauma-informed care lens—which asks, “what happened to you?” instead of “what’s wrong with you?”—will be important to the success of such efforts. In addition to making mental health resources readily available and easily accessible, HPE institutions need to make a cultural shift toward viewing the accessing of mental health care services as a sign of personal strength rather than weakness or deficiency. Related to these efforts is the need to provide both faculty and learners with tools to address ethical conflicts, such as by developing safe spaces in which to raise and address such conflicts and by training faculty in mentoring learners on managing ethical issues.

Theme 3: The pandemic further exposed the shortcomings of traditional HPE models and reinforced the need to fully transition to CBE and IPE models.

HPE values pedagogical traditions. Compared with what has been shown to be more effective, most medical and nursing schools continue to follow a rigid, time-based educational model that focuses too much on normative assessment and creates professional silos. IPE teaches learners from different health professions how to work together in teams and reflects how health care is delivered in clinical settings, and CBE focuses on teaching every learner to master specific observable abilities as opposed to moving everyone through the same time-bound series of exposures and experiences. In recent decades, both have been the focus of efforts to improve HPE.

Several of the commissioned papers and the conference discussion explored the fact that, from March to June 2020, due to the pandemic, HPE learners lost clinical time in which they normally would have practiced providing in-person care to patients. Many also graduated early and moved into provider roles despite having taken a very different path to completing their degree requirements. Further, some graduate-level learners were redeployed to new roles that did not necessarily align with their experience or area of expertise. Accelerating the transition to CBE would provide an immediate and more realistic understanding of where every learner stands in terms of mastery of skills and knowledge at any given point in their educational experience. As one conferee said, given the telescoping of educational time that occurred, we needed to be able to quickly gauge a student’s actual skill level, regardless of how long they had been in their current program.

Pandemic-related disruptions and restrictions also highlighted the importance of IPE. During the pandemic, clinicians leaned heavily on the other members of their care teams—for support, for problem-solving, for efficiency, and more. Undergraduate-level learners, however, sometimes found themselves losing the few team-based learning opportunities they had, while graduate-level learners found themselves suddenly practicing on health care teams for which they did not feel well prepared. During the conference discussion, an undergraduate medical student commented: “We had much less exposure to teamwork during the pandemic, which was a shame because each discipline should have a stake in the others’ educations because one day they will be working together as teammates.”

Conferees also discussed the need to transition to programmatic assessment strategies in HPE, both at the institutional level and across institutions nationally. The traditional, normative approach to assessment used by almost all HPE schools relies on grading and ranking systems to compare learners. Such systems foster competition rather than collaboration among learners and encourage them to narrowly focus their learning on achieving top grades and high scores. It also creates inequities because learners with more resources have an advantage, such as in preparing for high-stakes exams. Adopting a programmatic approach to assessment both within and across HPE institutions would align with the ongoing transition to CBE because it encourages a growth mindset and focuses on assessing the consistency and stability of a learner’s achievement level.

Theme 4: The pandemic forced HPE learning environments to quickly adopt technology-based solutions to several practical challenges, and those solutions should be evaluated and advanced or set aside.

Early in the pandemic, traditional in-person learning in classrooms and clinical environments was severely curtailed due to social distancing and quarantine requirements. In response, HPE leaders and faculty quickly pivoted to technology-based solutions that would allow learning to continue with, hopefully, little disruption. These solutions included moving classes online, with both live lectures and recordings that could be accessed asynchronously; increasing use of simulation exercises that were also moved online; and enabling learners to participate in patient care via virtual rounds and telehealth visits. Also introduced during the pandemic was the virtual medical residency interview process, which was well received by many learners and programs alike because it saved them time and money. All of these technology-based solutions injected an unprecedented level of flexibility into traditionally rigid HPE learning environments.

According to the papers and discussion, the question now becomes how best to integrate these virtual educational experiences with traditional in-person experiences. The goal is to use technology to enhance and optimize the education of health professionals. This means research is needed to evaluate potential best practices, identifying when in-person learning is necessary and when online instruction works just as well. For example, virtual encounters should not completely replace in-person practitioner–patient interactions, and virtual learning may create challenges around professional identity formation. As one conferee put it, “To be effective professionals, we need—at some level—those personal connections with our patients and with our peers.” But it may make sense, for example, to expand the use of virtual residency program applications to include undergraduate HPE school applications. In the papers and during the conference discussion, participants agreed on the need for faculty development in the use of technology for teaching and mentoring.

Theme 5: The pandemic revealed the ways that traditional HPE hierarchies inhibit the contributions and autonomy of learners—and learners demonstrated that they have much to share.

Traditional HPE is hierarchical, and learners—who are at the bottom of the hierarchy—are negatively affected by power imbalances. This became more visible during the pandemic, when learners sometimes felt ignored or acted upon by faculty and administrators rather than being invited to participate or consult on problems or decisions to be made. According to the papers and discussion, students sometimes felt (and still feel) that the system does not recognize them as adult learners with agency, autonomy, and the ability to contribute to their learning. Further, students sometimes felt (and still feel) as if their needs are the last to be considered by faculty and administrators.

HPE students bring valuable skills, expertise, and knowledge to HPE learning environments and their efforts should be acknowledged and possibly even compensated (financially or otherwise, such as through academic credit). For example, HPE students, both before and during the pandemic, have played valuable leadership and advocacy roles around diversity, equity, and inclusion at their institutions, and they should be recognized for those contributions. In addition, early in the pandemic, when their roles were shifting and their educational programming was changing, learners found ways to both advance their learning and contribute value to their institutions by working in COVID-19 testing (and eventually vaccination) clinics, conducting contact tracing, and staffing COVID-19 information lines. These examples also demonstrate how learners help academic health centers honor their commitment to community service, which is part of their 4-pronged mission: education, research, patient care, and community service.

The papers and the conference discussion suggested that the concepts of learner-centeredness and the cocreation/coproduction of learning should replace the HPE hierarchy. As one of the papers ⁹ put it:

Engaging students as partners can enhance [health professions] education by creating opportunities for student innovation in curricular design, public health initiatives, and health care delivery.... [V]iewing students as co-creators and part-owners of their education empowers them to gain agency and encourages their creativity, initiative, resilience, and problem solving skills—all of which are needed to address current and future challenges to the health care community.

Additional themes that arose from the commissioned papers and conference discussion—and are reflected in the recommendations—include the following:

• The pandemic revealed the extent to which HPE learning environments are lacking in much-needed flexibility. The need for increased flexibility in HPE is apparent in, and a component of, every opportunity for HPE improvement mentioned above. The papers and discussion repeatedly reiterated the benefits during the pandemic of increased flexibility in HPE, which was experienced in myriad ways that are worth preserving.
• The pandemic exposed the need for more effective, efficient, safe, and transparent communication in HPE learning environments, particularly between traditional decision makers (i.e., institutional leadership, management, faculty) and learners. Information is power, especially during a crisis, and imbalances result when communication is not efficient or effective. During the pandemic, communication was a challenge on and across many levels. The most effective communication processes—whether the purpose is to quickly communicate a change of plan to a group of learners or to create safe spaces for difficult conversations—are cocreated by faculty and students.
• The pandemic reinforced the need for HPE senior executives to lead academic health care and HPE through transformative, systemic change—and hold themselves accountable for doing so. An overarching theme to which the conference discussion kept returning was the need for systemic, structural transformation in HPE—change that has been elusive to date and must be fully embraced by those at the top who can make it happen. Conferees noted that commitment to meaningful improvements such as those identified at the conference must be baked into the missions of HPE institutions and organizations, and leadership must be accountable for the results.

At one point during the conference discussions, a conferee summed up the prevailing sense among participants that, as difficult as the pandemic experience was and continues to be, there is forward momentum toward improvements in HPE: “In the whole list of things that we’re talking about [at this conference]—CBE, equity and diversity, mental health and well-being, technology, all of it—all of these things have been talked about for years and years, but the pandemic has pushed us to make some progress. We can’t squander that; we must keep it moving forward.”

In the spirit of moving forward, the conferees reached consensus around the following recommendations for HPE.

Conference Recommendations

Recommendation 1: Leaders and educators in academic health systems and HPE institutions must collaborate with their learners to enhance HPE by redesigning learning environments to prioritize antiracism, diversity, equity, inclusion, and cultural humility; working with learners to cocreate HPE learning experiences; and defining meaningful roles for learners in the local community.

The pandemic revealed that traditional institutional hierarchies have not always appreciated or fully recognized the abilities of HPE learners to contribute to their own education and to the environments in which they learn and work. During the pandemic, however, HPE learners demonstrated the value of their underused capabilities and made significant contributions in clinical and community-based environments. They showed that, with support, they can adapt their own learning processes and goals. They initiated and directed innovative efforts to address urgent challenges, including leveraging technology to optimize teaching and learning, mitigating shortages of personal protective equipment, and staffing community contact-tracing efforts. They helped ignite within their institutions the antiracism and health justice movements that coincided with the pandemic, showing that they have much to teach leadership and faculty on this issue. Health system and HPE leaders and educators must recognize and build on these demonstrated capacities, valuing learners’ voices and their contributions to their own learning and engaging them in continually advancing HPE.

Action Step 1.1. Health system and HPE leaders and educators must create and nurture an environment of mutual trust, transparency, and accountability with learners and trainees, including initiating and sustaining safe systems for frequent, bidirectional communications.

Action Step 1.2. Health system and HPE leaders and educators must commit to learner-centeredness, providing learners with more choice and greater flexibility in learning modalities by capitalizing on the technological innovations in teaching and learning that arose during the pandemic.

Action Step 1.3. Health system and HPE leaders and educators must recognize the added value of learners’ contributions to communities, to HPE programs and institutions, and to health system performance and patient outcomes. Public or formal recognition and acknowledgment could take many forms, such as academic credit, tuition relief, or direct compensation.

Action Step 1.4. Health system and HPE leaders and educators must collaborate with learners on educational program direction, working in partnership to evaluate existing policies for bias; implement equitable recruitment policies and practices; foster retention of a diverse student body; develop unbiased and flexible advancement policies; design and evaluate bias-free curricula and assessment; and develop community engagement initiatives.

Action Step 1.5. Health system and HPE leaders and educators must support HPE learners in taking on roles as educators, change agents, and content experts within their HPE institutions—much as learners sometimes did out of necessity during the first waves of the pandemic. This may include participation on committees, focus groups, dialogue circles, and student-run groups.

Action Step 1.6. Leaders of health systems and directors of clinical education programs must prepare for future crises that may necessitate redeployments. This must include anticipating appropriate roles for learners as well as putting plans in place to ensure that inexperienced health providers are afforded adequate supervision when redeployed in crisis situations. Such planning efforts might include orientations, pairing more and less experienced clinicians on teams and creating and making readily available protocols/clinical algorithms, as well as supervision response teams, when needed.

Recommendation 2: Health system and HPE leaders and educators must facilitate adoption of competency-based and IPE across the HPE continuum from matriculation to licensure to career-long continuing education.

During the pandemic, the value of CBE as an evidence-based approach to improving HPE became clear, as did the fact that it requires further development. HPE educators recognize why CBE models are optimal for learner advancement and also see that appropriate curricula, assessment, and faculty development programs are required before such models can be effectively implemented. Transitioning to competency-based HPE requires relevant stakeholders to work together to dismantle barriers and collaborate on developing and/or improving systems of selection, training, assessment, and advancement of learners. Facilitating enhanced and expanded IPE, training, and collaborative practice also requires breaking down barriers and traditional silos.

Action Step 2.1. All HPE institutions and academic health systems must convert to competency-based curricula and learner assessment.

Action Step 2.2. HPE leaders and educators must be held accountable for promoting interprofessional HPE and collaborative practice.

Action Step 2.3. Accreditors, licensing bodies, and certifiers must engage with HPE leaders, educators, and learners to develop a valid, reliable, and equitable programmatic assessment strategy for competency-based HPE that addresses advancement and certification.

Action Step 2.4. HPE educators, clinical supervisors, and program directors must, with learners, develop and provide equal access to systems that collect, analyze, and display comprehensive data on learner competency and performance that is used to nurture learner growth.

Action Step 2.5. Accrediting, licensing, and certifying bodies must require health systems to develop and adopt a policy that ensures that learner advancement through competency-based HPE training experiences is not hindered by reliance on learners to fulfill workforce staffing needs.

Action Step 2.6. Health system and HPE leaders and educators must ensure that learner progress is prioritized, even in times of crisis, and that all undergraduate and graduate HPE trainees have access to clinical experiences that are arranged and supported by the school, rather than being expected to arrange such experiences themselves.

Action Step 2.7. Congress should identify a national funding resource to support research for the development, implementation, and assessment of the most effective, efficient, and equitable approaches to educating future health care professionals.

Recommendation 3: HPE leaders, educators, and learners—together—must examine and eliminate the detrimental effects of the SDOEs on HPE learners and build equitable learning environments for everyone.

The pandemic revealed the negative impact of inequities on the educational experiences and professional opportunities of HPE learners. In the same way that everyone working and learning in the health professions must understand how the social determinants of health create health disparities among patients, they must also understand that SDOEs create educational disparities among learners. People whose lives have been shaped by factors such as socioeconomic stress; racism, bias, and oppression; food and housing insecurity; poor access to health care; and unsafe, underresourced neighborhoods are at a significant disadvantage compared with their peers in terms of access to HPE and the health professions. Because society needs these learners as future health professionals, a fundamental goal of HPE leaders and educators must be to ensure that all HPE learners have opportunities to advance, thrive, and achieve their potential.

Action Step 3.1. HPE leaders and educators—together with learners—must identify and eliminate specific inequities within their institutions that impede learner success and progression. This may mean, for example, creating a fund that provides financial support when unexpected life events, such as the death of a family member, upend a learner’s academic year. Other examples might include making tutors and exam preparation resources available to all learners and reducing the burden on those who are disproportionately asked to contribute to diversity, equity, and inclusion efforts. Such efforts must not cause beneficiaries to experience stigma, shame, or additional burden.

Action Step 3.2. Leaders of HPE schools must reconfigure their financial aid strategies, policies, and practices to prioritize need over merit and ensure that all accepted students have their financial needs met.

Action Step 3.3. Leaders of HPE schools and programs must ensure that the full cost of attendance is clearly communicated and accounted for in financial support packages provided to learners.

Recommendation 4: HPE leaders, educators, and learners must work together to build learning environments that nurture professional identity formation and foster personal integrity, mutual respect, compassion, personal well-being, and belonging among those who work and learn within them.

HPE learning environments must support learners in resolving ethical challenges and prioritizing their own well-being, while also developing the professional identity and other attributes expected of health care professionals. The fundamental need for this sort of foundational support became more evident during the pandemic and accompanying national civic unrest, both of which severely tested the capacities of HPE learning environments and providers, particularly BIPOC providers. During the first waves of the pandemic, health care clinicians and HPE faculty and learners across the country experienced death, dying, and grief among patients and their families on a scale not often seen. Providing and learning to provide high-quality patient care in facilities that were overwhelmed by acutely ill patients created significant personal and professional challenges for faculty and learners alike. They faced ethical conflicts over issues such as the allocation of patient beds and other limited resources, inequitable access to personal protective equipment, and how to balance the health of their patients against the need to keep themselves and their families safe. In some cases, learners found it difficult to speak up or find support in addressing these sorts of challenges for fear of appearing difficult or weak during a crisis.

Action Step 4.1. HPE and health system leaders and educators, together with learners, must develop compassionate policies and practices that support the well-being of students, staff, and faculty. Examples include flexible time off for rest, recovery, and life events, including the ability to work and learn from home when necessary, and protected time for students and compensated time for employees to access mental health and well-being services.

Action Step 4.2. Health system and HPE leaders and educators must actively work to end the stigmas that may prevent HPE learners from requesting flexibility or resources to support their own well-being. For example, program directors and clinical leaders responsible for organizing patient care assignments should take into account learners’ unanticipated needs for time off, and institutions should make emotional support resources available to HPE learners on an opt-out rather than opt-in basis.

Action Step 4.3. HPE educators must develop required programming on death and dying so that learners are prepared to understand and manage their own grief as they guide and support patients and families through loss. In health care environments with numerous patient deaths, there must be programs in place to help learners, faculty, and clinicians.

Action Step 4.4. Health system and HPE leaders must promote mental health and well-being for workers and learners in their organizations by identifying and eliminating norms and practices that foster a dangerous focus on perfectionism, self-sacrifice, and heroism—all of which can result in personal depletion and contribute to burnout.

Action Step 4.5. HPE leaders and educators must guarantee the physical and psychological safety of learning environments for everyone learning and working within them. This requires mitigating potential threats to safety and preventing all forms of mistreatment, discrimination, and retribution—and promptly managing any negative events that occur.

Action Step 4.6. Leaders of health systems and HPE institutions and programs must, with their organizational mission in mind, develop and use an ethical framework to guide and evaluate difficult decisions made during a crisis, such as a pandemic. They should develop, implement, and evaluate their practices and policies aligned with this framework to monitor organizational performance.

Recommendation 5: Leaders of national and state agencies that influence HPE as well as leaders of academic health systems and HPE schools must identify and eliminate racism, oppression, harmful biases, and inequities in all HPE policies, procedures, and practices. The objective should be to adopt and continually refine antiracist, antidiscriminatory curricula and practices, including in patient care and in all academic health systems and health professions institutions.

All HPE stakeholders—including accreditors, licensing bodies, payers, and regulators—must work together to dismantle the structures and systems that have perpetuated racism and oppression within and across the health professions. These include admissions, assessment, and promotion policies that discriminate against BIPOC HPE learners and others; persistent, inaccurate use of racialized examples in HPE curricula; and institutional tolerance of discriminatory language and behaviors directed toward providers by colleagues, patients, and patients’ families. Identifying and addressing the myriad examples of racism and other forms of oppression in HPE require intense self-examination within institutions as well as a comprehensive, coordinated, national approach across all academic health centers and HPE schools.

During the early months of the pandemic, HPE institutions and health care systems showed that meaningful change is possible when they responded collaboratively, flexibly, and swiftly to various challenges by modifying or eliminating long-established policies and practices that created inequities. This same action-oriented approach is required to rid health care and HPE of structural racism, oppression, and harmful bias. More evidence-informed practices are needed to identify, evaluate, and validate the tools, interventions, and assessment methods being used to achieve diversity, equity, and inclusion in HPE and in patient care.

Action Step 5.1. National and state bodies with responsibility for and oversight of HPE must hold institutions accountable for prioritizing and implementing antiracism and equity initiatives. This effort must include the development, validation, and dissemination of measures that can be used to assess outcomes related to equity and antiracism, and must mandate measurement as a requirement for accreditation.

Action Step 5.2. Leaders of HPE institutions and academic health systems must advocate for substantial funding from public and private sources to critically examine best practices in, and support broad expansion of, educational pathway programs that have been shown to increase the numbers of HPE learners from historically excluded groups. These programs must begin at the earliest possible stages of education.

Action Step 5.3. The National Institutes of Health and other federal funding agencies must dedicate a substantial amount of funding to research that identifies best practices in eliminating racism and harmful biases from research, HPE, and clinical care.

Action Step 5.4. HPE leaders and educators must reject normative assessment and ranking of prospective learners and trainees and prioritize institutional adoption of holistic review—which takes into consideration learners’ lived experiences, attributes, academic achievements, and more—as part of all admissions processes across the continuum of HPE and graduate-level training programs.

Action Step 5.5. Health system and HPE leaders and educators must not participate in, promote, or advertise the results of efforts that impose normative, national rankings on HPE schools, such as those done by U.S. News and World Report and Doximity.

Action Step 5.6. National and state agencies responsible for administering health professions licensing examinations must use pass–fail performance reporting to help eliminate inequities.

Action Step 5.7. The U.S. government should develop and fund a sustainable program that will allow all interested HPE learners to pursue service programs postgraduation in exchange for tuition debt relief.

Action Step 5.8. Health system and HPE leaders and educators must establish equity in compensation and review their assessment and advancement policies to eliminate bias and inequities in retention, promotion, and tenure for faculty.

Conclusion

During the July discussions, a conferee asked: “If we all agree that there has been forward momentum, that we’re seeing some progress [on many of the challenges being discussed], the crux of the issue then becomes identifying why. What changed during the pandemic that enabled us to start seeing these challenges differently and acting on them?” The response from several conferees: The pandemic added urgency and clarity and required decisive action.

It is that sense of urgency, clarity, and need for decisive action that the conferees are seeking to bolster with these recommendations. The challenges identified and the solutions discussed are not new to HPE. What is new is the opportunity to make real progress while the traditional commitment to maintaining the status quo is undermined by a historic, catastrophic pandemic. “Previous Macy Foundation conferences have covered many of the topics raised at this meeting,” said Dr. Humphrey. “There are recommendations around eliminating harmful bias and discrimination, ¹⁷ around implementing competency-based ¹⁸ and interprofessional education, ¹⁹ around the use of technology ²⁰ from Macy and from many other organizations focused on HPE. We have the road maps and guidebooks on how to improve, but progress has been slow. The pandemic has shown us that we can act—that we must act—now.”

Conference Participants:

Emma Bickford, BSN, University of Oklahoma Health Sciences Center; Mina Boazak, MD, MMCi (planning committee member), Animo Sano Psychiatry; Robert A. Cain, DO, American Association of Colleges of Osteopathic Medicine; Logan Camp-Spivey, PhD, MSN, RN, University of South Carolina Upstate Mary Black School of Nursing; Holly Caretta-Weyer, MD, MHPE, Stanford University School of Medicine; Marissa Carruth, Oregon Health and Science University; Keme Carter, MD, The University of Chicago Pritzker School of Medicine; Subani Chandra, MD, Columbia University Medical Center; Lily Chang, MD, Virginia Mason Medical Center; Angela K. Clark, PhD, MSN, RN, CNE, University of Cincinnati College of Nursing; Tamara Cook, DNP, APRN, FNP-BC, CPN, University of South Carolina Upstate Mary Black School of Nursing; Jennifer Dias, Icahn School of Medicine at Mount Sinai; Liam Directo, OHSU Student Nurses Association of Portland; Malika Fair, MD, MPH, Association of American Medical Colleges, The George Washington University; Colleen Farrell, MD, Weill Cornell Medicine; Cynthia Foronda, PhD, RN, CNE, CHSE, University of Miami School of Nursing and Health Studies; Lorraine Frazier, PhD, RN, Columbia University School of Nursing; Katherine Gielissen, MD, MHS, Yale University School of Medicine; Marianne Green, MD, Northwestern University Feinberg School of Medicine; Morgan Head, BSN, Oklahoma Children’s Hospital; Robbie Henson, PhD (planning committee member), Oklahoma Baptist University College of Nursing; Mark Hughes, MD, MA, Johns Hopkins School of Medicine; Holly J. Humphrey, MD (planning committee member), Josiah Macy Jr. Foundation; Alicia Hurtado, MD, MA, Icahn School of Medicine at Mount Sinai; Pamela R. Jeffries, PhD, RN, Vanderbilt University School of Nursing; Benjamin Kinnear, MD, MEd, University of Cincinnati Medical Center, Cincinnati Children’s Hospital Medical Center; Lynne M. Kirk, MD (planning committee member), Accreditation Council for Graduate Medical Education, University of Texas Southwestern Medical Center; Cynthia A. Leaver, PhD, APRN, FNP-BC, American Association of Colleges of Nursing; Shirleatha Lee, PhD, RN, CNE, University of South Carolina Upstate Mary Black School of Nursing; Dana Levinson, MPH (planning committee member), Josiah Macy Jr. Foundation; Catherine R. Lucey, MD, University of California, San Francisco School of Medicine; Monica L. Lypson, MD, Columbia University Vagelos College of Physicians and Surgeons; Leon McDougle, MD, MPH, OSU Wexner Medical Center, The Ohio State University College of Medicine, National Medical Association; David Muller, MD (planning committee member), Icahn School of Medicine at Mount Sinai; Tracey L. Murray, DNP, CRNP, FNP-BC, RN, Coppin State University, College of Health Professions; Dimitri Papanagnou, MD, MPH, Thomas Jefferson University Sidney Kimmel Medical College; Ashley K. Parks, MS, BSN, FNP-BC, Simmons University; Patricia Poitevien, MD, MSc, Brown University Warren Alpert School of Medicine, Association of Pediatric Program Directors; Baillie Power (planning committee member), Simmons University; Cynda Hylton Rushton, PhD, RN, Johns Hopkins Berman Institute of Bioethics and the School of Nursing, Johns Hopkins Hospital’s Ethics Committee and Consultation Service; Michael Ryan, MD, MEHP (planning committee member), Virginia Commonwealth University School of Medicine, Children’s Hospital of Richmond; Stephen C. Schoenbaum, MD, MPH (planning committee member), Josiah Macy Jr. Foundation; Lepaine Sharp-McHenry, DNP, MS, RN (planning committee member), Simmons University College of Natural, Behavioral, and Health Sciences; Joan M. Stanley, PhD, DS (Hon), NP, American Association of Colleges of Nursing; Helen Taggart, PhD, RN, Georgia Southern University, Boise State University; Charlotte Thrall, DNP, FNP-C, CNE, Arizona State University; David Turner, MD, American Board of Pediatrics, Duke Children’s Hospital; Tener Goodwin Veenema, PhD, MPH, MS, RN, Johns Hopkins Center for Health Security, Johns Hopkins Bloomberg School of Public Health; Alison J. Whelan, MD (planning committee member), Association of American Medical Colleges; Marianne Williams, MS, BSN, RN, Simmons University; Andrew C. Yacht, MD, MSc, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell; Ellen W. Yau-Wang, MSN, RN, APRN, FNP-BC, Chamberlain University Chicago; and John Young, MD, MPP, PhD, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Zucker Hillside Hospital. Staff: Peter Goodwin, MBA, Josiah Macy Jr. Foundation; Karen Kourt, Josiah Macy Jr. Foundation; Teri Larson, Teri Larson Consulting; Yasmine Legendre, MPA, Josiah Macy Jr. Foundation; Lexi Barber Mostek, EMC Meetings and Events; and Heather Snijdewind, Josiah Macy Jr. Foundation.

Acknowledgments:

The conference recommendations were compiled, edited, and organized by Teri Larson.