Abstract
Lauren Olsen's Curricular Injustice: How U.S. Medical Schools Reproduce Inequalities examines the integration—or, more pointedly, lack thereof—of social science and humanities content into undergraduate medical education, that is, medical school. Currently, medical schools across the United States are expected to include humanities and social science content in medical education based on the hope that such training can ameliorate medicine's chronic failure to serve the most marginalized without further entrenching inequalities. However, as Olsen traces in her comprehensive book, implementation has been largely superficial, without substantive engagement with the critical content and opportunities of either the social sciences or the humanities. Olsen argues that this ultimately undermines the profession's ability to achieve its training goals and, moreover, serves to reify existing structures of power and authority.
Olsen’s book is well researched and compelling in its detailed unpacking of how curricular decisions are made, how they fail to meet the promise and goals of their initial conceptualization, and how, in practice, they fail medical students. Olsen utilizes multiple data sources in her analysis, including reports and standards published by professional organizations, curricular materials from medical schools, participant observation at medical education conferences, interviews with medical school faculty and leadership, and interviews with medical students. Starting at the highest levels of curricular decision-making and ending in examination of what happens in the classroom, Curricular Injustice shows the interlocking factors that produce this disappointing outcome. In so doing, the book provides insights into institutions, the medical profession, and the reproduction of inequality.
Curricular Injustice begins with a history of the social sciences and humanities in medical education, illustrating that this is not a uniquely modern concern. Physician training has historically included and, at times, even prioritized humanities expertise, for example. Contemporary engagement with incorporation of the social sciences and humanities, however, has embraced a kind of magical thinking. In what Olsen terms “curricular dreams,” medical educators frame humanities and social science content as a solution for two vexing issues facing the medical field: burnout and its perpetual failure to provide equitable care to marginalized populations. These robust scholarly traditions are, in simple terms, tasked with fixing entrenched professional challenges facing doctors. Importantly, Olsen notes, the “fixes” these fields purportedly offer are applied at the level of the individual trainee; humanities and social science knowledge is not invoked to address structural contributors to burnout or, say, help future physicians be critical of the role medicine plays in creating and perpetuating inequalities.
Shifting from dreams to implementation, Curricular Injustice next examines the curricular design decisions regarding the humanities and social sciences, finding that, broadly, it is shoe-horned into existing curricula. These fields are allotted comparatively little time in medical training, typically during “non-core” slots in the schedule (e.g., intersession, evenings). Olsen argues that these decisions lead to the marginalization of social science and humanities knowledge. Finally, turning to the classroom (often only proverbially, as humanities and social science content is regularly disseminated in the form of informal group gatherings like book clubs), Olsen drills into the content of instruction in social sciences and humanities, revealing how far it often is from what scholars of the disciplines would recognize. Humanities content is about self-care; social science content is reduced to untheorized stereotypes. Both are frequently taught by clinical faculty with no expertise in the topic and do not include student assessments—participation, not understanding, is the measure of completion. Multiple incentives lead to this outcome, including cost, with clinical faculty typically teaching for low or no pay, but Olsen highlights how it is ultimately the logical upshot of vague professional guidance.
In the conclusion, the book discusses a handful of schools that have successfully integrated social science and humanities content into medical school curricula as a sort of counterfactual, further underscoring the failures of the rest of the decision-makers.
Across the book, Olsen outlines three primary effects of these curricular decisions. First, contrary to the aims of the professional associations overseeing medical education, most medical students do not receive comprehensive instruction in the social sciences or humanities. Second, the instruction they do receive in these fields often misapplies the basic lessons of the fields. Olsen shares examples of the misuse of social science—decontextualized statistics, for example, that counter-intentionally reinforce flawed frameworks of race. Indeed, these therapeutic and atheoretical applications of the humanities and social sciences lack the primary frames scholars in these fields themselves use: critical frames. Third, the way social science and humanities content is presented in medical curricula frames both as unserious and ancillary to the true work of the physician. This forecloses further engagement in these fields, including engagement that could meaningfully affect, enhance, and improve medical education.
Building from this third effect, Olsen further argues that these missed opportunities do active work: collectively, these curricular activities protect and reproduce existing power structures in medicine. They serve to reproduce the privileging of a white, male, elite norm and the docile student. They aren't, in other words, simply neutral or disappointing; they are harmful.
Olsen’s book will be of interest to scholars of organizations, the health professions, and medical sociology as well as scholars interested in the reproduction of race, gender, and class supremacy in institutions and professions. As a sociologist in a medical school, I would love to see faculty in charge of medical education read this book. By the later chapters, Olsen's writing is persuasive and might be consequential for how they think about medical education.
However, Olsen's audience is fundamentally a sociological one. On many occasions, she rightly points out that various medical education practices are deeply problematic and even harmful. For a sociological audience, why and how these practices are a problem is known based on our training. Unfortunately, the text does not always connect the dots for the very medical education audience Olsen describes as being mystified by and misusing social science and humanities content. This perhaps gets at a broader question sociology is facing: how do we make the case for the value of sociology (or other social sciences and the humanities)? This question is especially acute in scenarios like medical education where structural incentives work against investment in the discipline. Curricular Injustice is sure to convince readers that medical education has largely failed to integrate the social sciences and humanities. Now we should be asking, what does it take to compel medical educators to think more intentionally about what they are teaching?