Interview by Ben Shachar (2T1), a medical student at the University of Toronto
I recently had the pleasure of meeting and chatting with Dr. Ayelet Kuper (MD, DPhil). Dr. Kuper is a Staff Physician and Scientist at the Sunnybrook Health Sciences Centre and the Wilson Centre. She is also an Associate Professor and the Co-Lead for Person-Centered Care Education in the Department of Medicine at the University of Toronto. I reached out to Dr. Kuper after attending several of her lectures on such topics as cultural safety, equity, and qualitative research. I was captivated by her commitment to social justice, her research in medical education, and her background in the humanities.
BS: What first drew you to the humanities?
AK: I’ve always been someone who is interested in both art and science. My mother will tell you that she did her very best to get me to not be a doctor and to do something related to writing or editing. She thought that that would be a much more interesting and fulfilling career. She’s very glad that I now write and do things related to the humanities as a physician.
The opportunity arose in university to take several humanities classes and then later to do a PhD. I was always going to medical school, but I thought that it would be much more interesting to first do something personal and also something that involved a lot of reading.
BS: What was the transition to medical school like after finishing your PhD at Oxford?
AK: It was a bit strange – I was used to sitting quietly and thinking deeply about one thing for a very long time. Instead I landed in a curriculum that was a million hours a day of lectures, dissections, exams, and memorizing things quickly – it was just a different way of learning. But it was a way of learning that I was used to from my undergraduate studies. It was a shock to come back from this time of contemplation and reflection into the whirlwind that is first year medical school.
It wasn’t bad – it was just weird. I got used to it again and I also came out the other end back into a place where I can spend time thinking – whether that’s about the individual patient, something in my research, or something that I’m reading. I have a little bit of that time again.
BS: Was this “shock” what inspired your passion for medical education?
AK: I don’t know if that’s what it was early on, but even in first year I was involved in medical education.
I think the thing that really got me involved and engaged was the pass/fail/honours debate. This is a piece of ancient history where the MD Program decided to go from an ABC grading system to a numbers system where everyone got their exact percentage grade. Many students really didn’t want that.
Myself and four or five other students, with the help of a couple of faculty members, led the campaign to get it changed to pass/fail/honours – this was when I was in second-year. We ran surveys, we held votes, and we took it all the way to Faculty Council. That is when I thought wow – you really can make a difference.
At the same time I was very interested in the research behind how we teach our medical students, so I got more involved on the research side.
BS: How do you incorporate the humanities into your career today?
AK: In a few different ways. As a researcher, most of the research that I do is based in theory that I learned from reading cultural and literary theory as a humanities PhD student. It is based on the methodologies and research methods that I learned from studying the humanities.
As a teacher, I use the humanities both as a teaching tool and as a way to help me think about my teaching.
As a clinician, I use the skills that I have learned from the humanities in my interactions with my patients. They help me have more person-centered interactions with my patients and to articulate for myself how to treat them with compassion.
BS: In addition to helping develop compassion, do you think that there are other benefits for medical students to engage in the humanities?
AK: I think so – I think that there are lots of different ways that you can use them in teaching and learning. For example, we are using the humanities now to inform faculty development in the Department of Medicine related to developing a critical consciousness and an orientation towards social justice that relates to our patients.
There are lots of ideas from the humanities that can inform patient care, the ways we think about our patients, and the ways that we construct our hospital systems, our educational systems, and our institutions.
BS: You’re teaching medical students concepts that weren’t in the discourse 15 or 20 years ago – things like reflexivity and social justice. Have you encountered any resistance?
AK: For sure. Mostly from faculty members who didn’t learn this material when they were training. I’m sure that there are students in the MD Program who don’t yet know why it is relevant either.
When I interact with clerks on the ward they never seem to think that this stuff isn’t relevant. They might say “I never learned about this” or “I find it hard to think about this,” but they see the relevance of it the minute that they walk onto the ward. When I teach the most senior residents, many of them say “wow, why haven’t I been taught this before,” because they never got this as students.
I get more pushback from students for teaching research methods (which many find boring) than I get for teaching social justice.
BS: What inspires you to teach medical students about things like equity, diversity, and cultural safety?
AK: My patients. My patients who get bad care because they are from a structurally marginalized group or because they are racialized or because they are poor. Patients who don’t get the same care that I would get if I walked into a hospital. This means that we need our doctors to be different, we need our doctors to be aware. If you are not aware, you can’t disrupt the system and you can’t make it better. It’s all about making it better for our patients.
Equity is one of the 6 pillars of quality for a reason. If you don’t have equitable care, quality is only for a few – and then it’s not quality.
BS: How should medical students deal with implicit biases?
AK: We all hold implicit biases; it’s impossible not to. We may even hold implicit biases that are harmful to ourselves. I am sure that if I took the gender implicit association test today, I would probably have an implicit bias against women in leadership roles for example. That’s just the way you grow up – you grow up seeing men as Prime Ministers and Presidents – and it’s just ingrained in you. That’s not to say that if I think consciously about it that that’s what I’m going to believe. That’s the pattern that almost every person who is brought up in a Canadian context has who does implicit bias testing.
I think that implicit bias testing is useful in a very specific way. I think it’s useful to force you to reflect about your own biases and to be aware that you have them. It’s really humbling to acknowledge your own biases. When you have moments where you’re hit by your own privilege, which I have on a regular basis, it’s really humbling. Privilege is just like breathing because you don’t even notice it.
BS: How can medical schools advance diversity through their curriculum?
AK: It’s not just through curriculum – some of it is through who gets into medical school and who is supported while they’re in medical school. It’s all very well and good to make sure you have structurally marginalized students admitted into medical school, but you actually have to support them going through medical school – including encountering things like racism, discrimination, and colonialism while they’re here.
It’s also the faculty members that you hire, so that people see diverse faces and understand that that’s medicine too.
It’s putting systems into place in our schools and hospitals that don’t structurally discriminate against one group or another.
And it’s about not teaching our students “people like this do that” – the old cultural competency that I was taught – but teaching students to be humble about their privilege. Teaching people to be reflexive, aware of their privilege, aware of their values, aware of the values of the profession, and aware of how their choices impact on the real lives of our patients.
BS: What’s the biggest change that you’ve seen in your career in healthcare?
AK: One of the biggest changes I’ve seen is more of an interest in these concepts that come from the humanities and the social sciences – more of an acceptance of their potential relevance.
When I applied for a job at U of T as a faculty member, I was initially told that my PhD in literature wasn’t at all relevant to my work so it couldn’t be considered a graduate degree relevant to my appointment as a physician. Now I know quite a few people who are planning or doing graduate degrees related to the humanities who see themselves as on a track to being faculty members in a medical school. I work in a department where we have someone who is a philosopher, and other people who are literary scholars; our Vice-Chair Education is a Levinas scholar. Humanities have become a more accepted part of the work of the physician.
BS: How has medical education evolved over your career?
AK: The acceptance of different ways to think about knowledge more generally. A decade or so ago, medical education research was entirely objectivist and was almost entirely focused on problems of assessment. One of the reasons it was objectivist was actually because it was largely focused on assessment, so there was all this emphasis on defensibility and reproducibility. But it was also mostly focused on assessment because those were the kinds of questions that you could ask if you were looking for true/objective answers. It was a bit circular.
About 15 years ago, the field had this amazing, flowering explosion and all of a sudden it became this place where you could do almost anything methodologically so long as it was rigorous.
Today, one person could be talking from the most absolute objectivist, positivist lens and someone else could be talking about a critical post-structuralist approach to power and they are both in the same room, in the same field, and actually learning from each other. It’s kind of neat and that is the biggest change in medical education research – and I can see that trickling down to how we do medical education and what we actually teach.
We now realize that many of the things that we thought were settled in the research literature about medical education totally aren’t. It’s been really incredible and really fun.
BS: What are some current inadequacies in Canadian medical education?
AK: I am unconvinced that competency-based education holds promise. I think that it’s going to be a lot of extra work for little or no gain. There is little or no evidence that all that extra work will make anything better. Yet we’re spending all of our money and all our faculty resources and time changing everything to fit into this framework because we were told that we have to. It would be as if we changed all the drugs we prescribe at the hospital, but not have any trials of those drugs first.
BS: Do you have any advice for first or second year medical students?
AK: Find what you’re passionate aboutand do it. Don’t worry if it’s a bit non-traditional. If you do it and you’re good at it then it’s OK and it will work out.
BS: Do you have any book or journal recommendations?
AK: A thousand and therefore none! But I’ll give you two.
On the social justice front, there is a great book called Anti-Racist Healthcare Practice by Elizabeth Anne McGibbon and Josephine B. Etowa. It’s written for clinicians on the front lines.
I’ll give you another one that’s on the top of my pile right now: Ursula Franklin’s The Real World of Technology. She was a U of T emeritus professor of Engineering who won the Pearson Peace Prize and led the lawsuit that achieved pay equity for women faculty members at UofT. The Real World of Technology is a compilation of her CBC Massey Lectures. It’s an amazing book, a lot of which relates to different approaches to learning and to education – it’s a really interesting and inspiring read.