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So, but, and um and welcome to the session, uh It's our final session of the co in the clinic and we're thrilled to have um doc Doctor Jenny with us today, um who's an advocate for incorporating ethnicity into the medical curriculum with a focus on pharmacology. Um So she'll be guiding us through the complexities of um ethnic disparities within pharmacokinetics, but as well within the medical curriculum as well. And we also have Shannon who's a third year graduate entry, medical student, Andrew Yang, a final year medical physiology and therapeutic student. And together they'll discuss um that uh student staff cooperation project. Um And hopefully it will be in a lightning discussion for everybody and to expand their knowledge and also their cultural competence as well. So, um I'm very glad to have them and I'm glad that they've um come today. So I will um mute myself and turn off my screen and give it away to them. Just another thing as well. If you're not speaking, if you can mute your mind as well, that's ok. Thanks everybody. Sorry about all the delays. Um I was having difficulty joining, I'm on my phone and I don't have to say XL please when it comes up. So what we're going to talk about today really is um how we, we starting to think about teaching about interethnic differences in pharmacokinetics through to thinking about ethnicity across the whole medical and medical sciences curriculum. Next slide, please. Sorry again, I haven't seen a change yet. I don't know anyone else. Good. OK, so this is the team. Um So I started this work in 2020 with my colleague who was able to be here today. She's from the School of Life Sciences and she teaches into the pharmacy and pharmacology degree programs. Um, so the early work that I'm going to be talking about was with and then the later work was with Shannon and Julianne Shannon. Do you want to just introduce yourself briefly? Yeah. So, hi, everyone. Uh, good. Mhm. Um, Jenny is actually quite difficult. I don't know if everyone else is experiencing the same thing as me. Um, do I need, do I need to speak? Is that better? Um, I think it's, I think it's to do with connection. It's a connection issue. Oh, ok. Ok. I've got three a month. Can everyone hear me? Ok, because I'm also on 4 g as well. Yeah. Um, your audio is really good. Ok, cool. Um, so, yeah, I'm Shannon. Uh, good evening everyone. And I am a third year graduate entry medical student. I worked on this project alongside, um, Lydia Barry who's also a third year graduate entry medical student and also, um, some second years, uh, both Amy Tle and Rufa. But I'll be touching on what myself and Lydia found during this project. Hi, everyone. So, I'm Julianne. Um, so I'm a third year medical physiology and therapeutic student. And today I'll be talking about what, Blue Martha and Rahi and I, um, also went through when we were writing and, um, researching for this product. Ok, thanks both. Um OK, let's go on to the next slide. Can you hear me now? Yes, we can, Jenny, I've just stood up by the window. Ok. So the plan for today is to talk about what is ethnicity and think about why it's important to consider it um in the curriculum. And so I'm gonna start off by talking about what we were thinking about around ethnicity and pharmacology and then move on to ethnicity across the curriculum and the students as partners project to next slide. OK. So let's think about what is ethnicity and it feels a bit crazy to ask for a definition of something that feels so obvious, but you'll see in a minute that it's not actually that obvious. So the dictionary definition is a large group of people with a shared culture, language, history, set of traditions and so on. So that's the Cambridge Dictionary. But most dictionaries will give you a fairly similar definition next slide, please. OK. So, and I, when we were looking at the Pharmacology research literature. We mapped out all of the papers that had ethnicity as a keyword. And what we found was that over three quarters of them just used the words black, white, Asian Caucasian and slightly less than a quarter said. Was it related to countries like China or Japan or Mexico or so on? I thought this was a bit weird because I don't know about you, but there are lots of different ethnicities within sort of all white people or Black people. And I might be white to look at, but I'm not British and I don't feel like I share ethnicity with quite a lot of other white cultures. So this seems really quite strange if we go on to the next slide, this is what we asked our students. So we did a questionnaire a couple of years ago and this was GE and MPT and Pharmacology BSE and one of the M SE programs. And we just asked students, what do you understand by ethnicity? And from the words they use, we found that the most number of responses used words relating to culture. So tradition, upbringing, Mors, history and so on. And then um the next most common was place that is a place of origin, geography, country and so on, nationality. And then quite a lot less than that were words relating to race, like white, black, Asian Caucasian and so on, a few said um words relating to genetics or appearance or ancestry. So we've now got quite a lot of ranges of definitions for ethnicity. And one of the things that we did following this questionnaire was a number of focus groups. And we asked students to elaborate on what they understood by ethnicity. And we got a really wide variation in responses. Some people said it was just their race, black, white, Asian and so on. But quite a lot of people talked a lot about their culture and their upbringing and their background and so on. And they spoke very much at a family level or a regional level. They talk about themselves as being from a particular country, say or from a particular part of a particular country. Um Not many people have ever referred to themselves as being white or black or Asian as their ethnicity. Um OK. Next slide. OK. So the other thing I just wanted to be clear about was when we talk about ethnicity in the curriculum, we're not just talking about the formal documented curriculum. Ie the Learning act comes even the slides, we're also talking about the hidden that have been made. Um And also about the enacted curriculum. So that is the way we use language. The examples that we choose all of those things are all part of a curriculum. So we need to think about it really like almost as though it's the whole experience that you have when you're doing your degree program. OK. Next slide please. So I guess before we actually talk about some of the data, I wanted to talk about why I think this is important and I'd be really interested to hear about what you think as well. Um I mean, I think the most important thing is that how you think about ethnicity affects what you do with it. So it affects how you treat other people and also crucially how you think about yourself. So I'm going to show you some research later that talks about how it affects how people treat other people. But I think it's just really important to think about how your ethnicity impacts upon how you think about yourself. So the parallel I have is that in a previous life, I guess I was very involved with gender equality largely because I'd spent a lot of my career in very male dominated environments and electronics and engineering and maths. And I found it, there were a lot of unspoken things said about how not always unspoken. A lot of it was spoken. So I was told that women can't be any good at maths and women can't do engineering. And to an extent I internalized that and I didn't really think to challenge it and it wasn't until I was quite a lot older that I realized, I guess the impact that it had on me. So I just, I worry that people um maybe back when I was in my early twenties, um, might, maybe have a similar thing where they, they limit themselves as to what they can do based on what they think society is expecting of them anyway. I just, yeah, II think it's important. So let's move on to the next slide. OK. So the point I came to in all of this was back in 2020. So I just joined the University of Nottingham. I had to prepare my first lectures and I was preparing a lot of pharmacology lectures because if you remember everything had gone online. So I had to record all the video and I came across the nice guidelines for hypertension treatment. And previously in the university I've been at before, I haven't, hadn't really talked very much about clinical guidelines. I'd only really done the basic sciences. So I've never really encountered these nice guidelines before and I was really horrified because basically what it says is if you're Black African or African Caribbean family heritage, you get one class of drugs and if you're not, you get another class of drugs. And that was just really weird because it went against everything I knew and everything I understood about basic biology. Um I couldn't get my head around why this would be in pharmacology. We like to understand mechanisms and stuff. But in terms of mechanisms, this made no sense at all. I mean, I did a quick literature review and a lot of people had done some genome wide association studies but they couldn't, they couldn't get any good links. So it clearly wasn't genetic, but none of them really stacked up and none of them actually had any good data for them. So I did what most people have done, I think. And that is sort of just moved swiftly on because I couldn't think what else to do. Um And it wasn't so last year, I actually, I do have something to say about this. So if you go to the next slide that I know, yeah, and crus again, OK. So what I do now is I explain that there isn't an underlying mechanism. We don't know why there isn't any clear reason why this should be. I also point out that guidelines do change over time. Nice guidelines. We might see them as the gold standard, but they do change. They are made by a committee of human beings and those human beings have their own ideas about how things work. The other really interesting point is that the international and European guidelines are different. So the international and European guidelines and guidelines from all countries around the world, apart from the UK and the US really don't make this distinction. Um which is really strange, I guess there are committees in all of these different countries and they're all looking at the same evidence, but they've made a different decision based on that evidence. Uh Next slide. OK. So what I do now is I do a bit more of a critical appraisal and the reference I've given at the bottom there um really goes through a lot of these points so you can follow up that if you want to. Mhm But essentially there have been questions raised about the statistical analysis of some of the clinical trials of defining an ethnic group. So the all the governments and the United Nations and everybody basically says that you decide what your own ethnicity is. So if you're of mixed heritage, then you can decide which part of your mixed heritage you want to be and you have to fit yourself into a box, I guess. And that isn't a very scientific, it's not a scientific variable. It's absolutely, it's absolutely fine. It's what people should be doing is describing their own ethnicity, but it's a very difficult thing to do. Um I don't know if you've seen that program on TVI think it's DNA family secrets, but there was a man who had been told by his family that he was descended from the Egyptian pharaohs. He was Egyptian, but he didn't really know and he went and had his DNA tested and he really didn't look like he was quite dark, dark eyes, dark hair, slightly dark skin, but he couldn't really point where he was from. And as it turned out from the DNA, it suggested he had a father or grandparents who were from Punjab in India and he was completely gobsmacked. So it just shows you that if you've got that man to ask about his ethnicity, he might have put Egyptian. But actually part of his family was from India and part of the part of the family were from different ethnic groups. They also didn't study longer term outcomes. They didn't consider known confound like socioeconomic inequalities which we know are linked to cardiovascular disease. And a lot of the studies involve African Americans and not UK residents of African origin. And besides, you can't really extrapolate from one ethnic group within Africa to the whole of Africans. Anyway, um let's move on to the next slide. Um OK, so we started to look at ethnicity and ph kinetics. And again, as I mentioned, a lot of the papers are all about Asian or white or black African and occasionally about say Chinese or Japanese. Um And again, this was seemed really quite strange um if we go on to the next slide, um what s and I did was to do a scoping review of the literature. So we looked for all of the literature that talked about ethnicity and pharmacokinetics. And we looked to see from 1980 to the present day. And what we found was that if you look back in the first bar, the gray, dark gray bar is papers that showed no ethnic difference and the green is papers that show ethnic difference. And what's interesting is that over time, the proportion of papers showing ethnic differences is falling dramatically and the number that say no ethnic differences is increasing dramatically. And that's really interesting because that suggests some degree of publication bias, I think. But if you take it overall, you can see that only a third of the papers found significant differences between ethnic groups in terms of their pharmacokinetics. So that means obviously two thirds um did not find a difference. So this idea that there are differences between ethnic groups and PCO kinetics is really just there are some papers, but most of them are saying the opposite. OK. Next slide. So what we did then was we looked at all of these papers and we looked to see what the mechanisms were and we found a whole array of different mechanisms. So things like diet, whether people were taking other medicines, their environment. So maybe the presence of pollution or what altitude they were at um lifestyle factors, like whether they smoked or drank alcohol and obviously liver or kidney disease are going to affect it. But the most, the greatest number of papers talked about genetic variants in relation to ethnic differences. So these are single nucleotide polymorphism. So single DNA changes that will make people either a fast metabolizer or a slow metabolizer a month. Um is really interesting because just because there's more papers that say um a genetic mechanism doesn't necessarily mean that a genetic mechanism is more important. Ok. So it might just be that more people have decided to work on genetic mechanisms for all sorts of reasons. Um So, yeah, but anyway, what I found really quite troubling was there a link between genetics and, and I knew that because of some earlier work that right. Yeah. Ok. I'll keep going. If, if you can't hear me, please let me know. Um, next slide, please. Ok. Um So why was I concerned about um genetics and ethnicity? Um So I was aware of this work by a guy called Brian Donovan and he has done a series of studies and his, his work suggests that students who learn about racial differences in the prevalence of disease are more likely to agree with a genetic argument for racial inequality. Um And there are, it's not just Brian Donovan's group. Now there are a number of people who say this. OK. Next slide. So what we decided, so show and I were trying to work out what we should teach. So we decided that we should teach about inter individual variation um rather than inter ethnic differences because of course, people do vary and there are a lot of reasons why people can vary and that's safe. We can teach about that. It's true. Um mm Well, we also teach about infant akinetic that there are more similarities than there are a lot of mechanisms that underpin into individual variation. OK. Next. OK. And then what we also say is from genetics education research that human variation is continuous. Um and ethnicity is not a proxy for genetics. So there's as much genetic diversity within one racial group as there is between them and another racial group. So let me just explain that in a little bit more. So if you would here to say, I don't know, Singapore as you walked, you would gradually see people's appearances change into another way. You went from white people into the next country being Asian people. It just doesn't work like that. It's the same. If you walked from here to South Africa, you would get a very gradual continuous variation in humans. And the same is true of genetics. People do tend to marry and have Children with people who live nearish to them, but people also move and have done for millions of years or sorry, tens of thousands of years. Um So I guess there, this misconception people think that African people are more likely to be genetically alike, maybe Asian people are more likely to be genetically alike. But what we realize is that actually there's a considerable amount of similarity between. So if you picked one African person and one Asian person or one white person, you're as much likely to have a degree of diversity as you are if you picked two people in Africa. And in fact Africa's is the most genetically diverse continent. OK. Moving on. Um Yeah, so there's greater genetic diversity amongst Africans in between any one racial group and another. But also you can't extrapolate from African Americans to all Africans. Um And the same is true, you can't extrapolate from British people to all white British people, to all white people or Northern European Scandinavian white people to all white people that actually you commonly see this in the scientific literature. Um I've been trying to pick up the pharmacological Society for doing this because you see a lot of papers published where their sample might be Northern European Caucasians as they call it. But they then extrapolate to all white people which is just not justified. So I'll put a couple of references there if this is something you'd like to follow up. OK. Next slide. So that's why I think we need to think about, you know, why do we talk about black white Asian caucasian, etcetera? Why don't we talk about it more at a regional level or at a family level or at what level should you talk about? Ethnicity? It's a really hard thing to pin down. OK. Moving next slide. OK. So there have been a lot of changes since 2020 we've tried to um capture this in a wider curriculum now. So in physiology, there's been a reevaluation and removal of terms that used to adjust for race. So in spirometry and lung function measurements and kidney function measurements, um these have now changed to remove the term that used to be there for race. And so we've obviously updated all our lecture content next slide. OK. So, um, I think when we're thinking about the basic biological science, we need to get away from this idea that people think that there are somehow some innate differences between people in different ethnic groups because this is just not true at the scale of racial groups. Ok. Yes, people's appearance looks a bit different but you know, that old, I don't know if it's a cliche anymore. Certainly when I was growing up, that cliche is that were all the same under the skin is absolutely true from a basic biological science viewpoint. Next slide. Um So I think what we need to realize now. So I think the difficulty that we have with this is that there are clearly differences in health and disease between racial groups. Um That's even though we might be all the same biologically under the skin, actually, there are differences in health outcomes, there are differences in risk factors. And I think we're now getting a much increasing understanding of the impact of social determinants of health. So these and I sort of try to draw it in this diagram. So you've got social and structural determinants of health that might be things like availability of healthy food. It could be levels of stress, it could be all sorts of things, those things have biological consequences, um mechanistic, biological consequences. And that then leads to differences in health and disease that we detect in terms of different risk factors. And I think a lot of that is stated a lot of the time in the literature and, but it's not generally made as, as bold and as clear as that if you like. Um anyway, so that's what I have started to be much more clear about saying is that all of these social factors do have an impact on our health and that can then have an impact on disease and that can then have an impact on pharmacology as well. OK. Next slide. OK. So I just wanted to pause there because I realized that, um, said quite a lot of quite complex conceptual things. I just wondered if there are any questions at this point before we move on to the sort of wider curriculum and bring in Julianne and Shannon. Any, um any thoughts I can't see the chat. So you have to repeat anything for me, please. Are we all good? Should I keep going? II think there's, I can see there's a message on the chat, but I can't see what it is. Can somebody read it out to me? I got it. So, um the question is from Eliza, she says, how come people from a Black Asian and minority ethnic communities are more likely to suffer from hypertension, diabetes, things like that. Yeah. So I think it's, oh, I think the short answer to that is that we don't really know. Um The answer involves quite a lot of speculation. Um So yes, people vary genetically around the world, like I said, as in a continuous fashion. So it might be that there are certain ethnic groups that come to the UK come from a particular part of a certain country. So that could have a factor, have a role to play. There's also these social structural determinants of health, maybe these people or there could be epigenetic effects. So if somebody's parents had emigrated from one country to another and had been through some challenges or all sorts of stress or illness or whatever their Children may then be affected by that. And then more like, so there's been a lot of studies done. These studies are really hard to do, but there was one study done in the Netherlands after what they called the Hunger Winter in the Netherlands during World War two. And then they traced all of the Children and grandchildren of those women who were pregnant at the time and there'd been a famine and there's a lot of studies like that that have started to show sort of epigenetic effects. So basically, yeah, the short answer is we don't know, but there's no reason to assume that it's necessarily genetic. Um I guess that would be my challenge as to why do we always just jump to the genetic mechanism first? In fact, one of the focus groups, one of the students said to me. So we asked the students, so why did you go for a genetic mechanism? And one of the questions that we've given them and they said, well, it's always genetic, isn't it? You know, that's always the mechanism. It's always got to be genetic and, and actually, no, it doesn't. So I don't know why we don't look more widely at all the other possible mechanisms that it could be. Yeah. So I sort of, I think I'd throw that back and say, why do you think it's genetic? Ok. Um Does that I know it's not a very satisfactory answer, but it's the best I can do? OK. That's great. Ok. OK. Should I continue on that? Oh, that was really squeaky. Can you say that again? She said thank you for all the questions. Great. OK. I'll move on then. Um if I can have the next slide. OK. OK. So now it's to hand over to Joanne. Hi, everyone, apologies. Um I just had to unmute my mic. Um But thank you, Jenny. So I'll put this back in the present mode. Oh, all right. Let me sit through this, right. Um So as previous, he mentioned, my name is Julian and I was one of the student curriculum change partners and I'm just gonna briefly talk about what we actually did. Um And what I did alongside Rahima and Blue Martha. Um So these are a few of our aims I'll just quickly read through them. So our first aim was to improve our collective understanding of ethnicity and race in the context of medicine and medical sciences. And we also tried to understand how students perceived the impact of ethnicity and race in their own learning and in medicine. Um And we identified ways of incorporating our understanding into the curriculum. And lastly, we documented the changes made and their rationale so we can share with others. Um So how we did this is that we ran focus groups as well and the data that we collected from that we turned it into a transcript and were able to write a report of what we found through our research. So I had previously attended a Schwartz Round um at Royal Derby Hospital and I was really um really touched by it and I really wanted to incorporate some of the things that I learned within the focus group into, within the short round rather into our focus groups. Um And I think they were quite successful. So we had a number of students across our course attend and they were able to speak about what they viewed um ethnicity as and its role in the medical curriculum. Um So here were a few of the points that were raised. Um So the first one being that race is spoken about in a taboo way. Um So I think the conversations that we facilitated were really helpful in kind of combating some ways or the things that we thought were ii don't wanna say necessarily wrong, but just weren't necessarily right and how race was spoken within our course or just within our studies. Um Another thing is that they were uncertain about what information from ethnicity such as tick tick box forms were used for. So, um in terms of going to the GP or when we were asked to tick boxes in terms of our ethnicities, how was that information used? Um And I think a lot of people didn't really understand the role of them, were they to ensure that we had better health care or was it just to discriminate even further? Um And one thing that we notice as well that the tick box E tick box ethnicities don't always fit one sense of their own ethnicity. For example, someone who is of mixed ethnicity, what box would they tick? Um and students didn't want to mess up in the future by not knowing specific signs presented in different ethnic groups as we are all healthcare er, studentss as well. It's so important for us to ensure that we're giving our patients the right care uh regardless of what role we Entel in our future careers. Um So here is a diagram that um covers the meaning of ethnicity in medicine and medical sciences. So as you can see, we've got four main boxes which are the individual biology, individual psychology, population, evidence based medicine and population sociological. Um and there are quite a few from each one that kind of covers eth the meaning of ethnicity in medicine and medical sciences. So, as you can see here, we've got some genetics, genetic ancestry, physiology, risk factors, clinical trials, representation, belonging, identity, attitudes, behaviors, and health beliefs. Um So yes, another thing that we wanted to tackle were a few myths uh regarding particular diseases such as sickle cell. Um as we are all aware, sickle cell is often presented as something that only affects black people. However, I was even surprised to learn, I think in the first year that it wasn't just Africans who were affected by it, but uh communities in South Asia, Eastern Mediterranean and middle gel. So I think that was the thing to learn and I think it's so important um in terms of representation and representing um different ethnicities within different uh medical diseases and conditions. Um So yes, here is a map of the um populations affected and different countries also affected by sickle cell as well as um malaria too. Um So as you can see here, it isn't just African countries that are affected by these diseases. So I'm just gonna pass back to Jenny to kind of speak more about um the content mapping and how we kind of approach that in terms of different aspects of our course. Thanks Joan. Yeah. So what we were trying to do really was to tease apart all the different areas that ethnicity came into if you like. And we sort of felt that it was easier to think about it in terms of if we were trying to tease it apart. So the first area to look at really is this sort of individual, psychological or the self if you like. So if we go to the next slide, what do I mean by this? So this is the area of representation, identity and belonging and put this first really, because really ethnicity is so much a part of somebody's identity. And I think that's what does make it sometimes a bit difficult to talk about. Um But anyway, so we have a greater diversity now of imagery that we use in our teaching. Um I know our clinical skills and anatomy teams have done a lot of work to try and get photos and images and resources where you might have the patient being of different skin tones or the doctor being of different skin tones and having a whole range of different resources. Um So yeah, it's really important to help people feel like they belong, intercourse and see themselves represented, but also help them to feel good about their own identity in terms of their ethnicity. Next slide. Um Another example, this is the clinical skills team as well. John Fra has put together this clinician of the week where there's a different person each week, not just Black African people, but also all sorts of different protected characteristics. I've been trying to build up a bit of a database of people from different walks of life and different backgrounds in medical science as well. Um So that's, that's cool. So moving on to the next slide, this is now looking at the more sociological or the social aspects of, of this. Um So we've just done psycho and now we're doing social if you like of the psychosocial, the next slide. So now what we have got at the moment is an active bystander program. So this is this is societal attitudes and behaviors. So this is things like racial harassment, microaggressions just the way other people treat people based on the somebody's ethnicity. Um We also have an unconscious bias program because people do have unconscious bias, it's a thing. But if you're aware of it and um and you think about it, then sometimes you can't overcome it completely, but you can at least override it. And I think that's really important. What we realized was that we didn't have very much teaching at all on health beliefs and the cultural influences on, on people's ability or tendency to access health care or how their cultural beliefs affected their healthcare. So that is something that we're looking at. It's not something we can necessarily do overnight, but it's something we're aware of and hoping to get in place for next year. Next slide. OK. So now moving on to the sort of the biology or science side of things. But now looking at a population level. So this is primarily in the evidence based medicine program next slide. Um So what we realized was that we often talk about risk factors, we often talk about them actually in the basic biology lectures too. And this was a finding from the students as partners project that really struck me the most because it's something that each individual um teacher, if you like each individual lecturer would say, oh, in this topic, black people are more likely to have this disease than white people. You know, prostate cancer, black men are more likely to have prostate cancer at a younger age. And each of us would say that none of us would actually say why or what the mechanism was. Um And what we realized from this project was that the net effect of all of that was to make students think that there was a biological basis to these, sorry, there was a biological difference between racial groups that accounted for these different risk factors. Um So they started to think that ethnicity and race were biological constructs whereas by definition of race, a social construct. So I think what we need to really do is to make more of a point about these social and structural determinants of having impacts on people's biology and therefore creating these differences in risks is that we didn't have anything in our sociology teaching. About ethnicity at all. And again, that's something that we need to a gap that we need to fill next line. So what we propose is some new teaching possibly fairly early in the graduate medicine program. At least we weren't really sure yet in the MPT program covering different aspects of ethnicity and include health disparities and health beliefs and need to include the research behind or at least some explanation behind any apparent ethnic differences in disease prevalence. So it was a bit like the nice hypertension guidelines for pharmacology. Um you know, really just sort of trying to look into the background behind it and give some explanation, not just present it as a fact and moving on next slide. Um So yeah, so students said they were taught about how certain conditions impacted on certain ethnic groups, but not the reason why. So we were worried that that was going to reinforce any myths and make people think that there were innate biological differences between ethnic groups. So therefore, we didn't want to present statistics about health disparities as just simple facts without any further explanation. We wanted to try and include reference to the evidence and where it came from, whether there are any explanations and if there aren't to say so essentially. Um Yeah. OK. Next one. Um OK, so now I'm going to hand over to Shannon because Shannon is going to talk about the problem based learning. Hi, everyone. Um So based on a project that lid you and I ran earlier this year. Um PBR cases are what we use. It's the foundation of our medicine program, Preclinical. Um So this was quite an interesting, somewhat deep dive um into the cases. Um If you could just press next, please. So this is what some of the students observed about the PBR cases. So we felt that stereotyping was, was quite perverse like they meant, said that people from ethnic minorities um were typically in less prestigious jobs. Um There was an ethnic minority patient presented as a sort of individual as a representative of a group rather than as the individual themselves. So back to what Julianne kind of mentioned um with sickle cell, um sickle cell patients kind of typically were from an Af African descent um rather than, you know, as an individual themselves. Um We also felt that white patients were the default. Um And there was like a lack of repre representation of East Asian communities when we say white patients were the default. Whenever we'd have a case, it wouldn't be, it wouldn't ever state the ethnicity of that patient if they were white. So it wouldn't be a 26 year old Caucasian male. Um However, if there was a 26 year old, a Caribbean male that would always be distinctively um highlighted and noted. Um There was also a little information about health beliefs and this kind of touches on what Jenny mentioned previously. Um And when health beliefs maybe were mentioned or talked about, you don't really dive into why certain communities may have these health beliefs. Um Different skin tones were not typically well represented um well represented in the PBR cases, I think they have, they have improved over the time. Um But I think this is something that definitely could be. Um readdressed ethnicity is important in how you understand where a patient is coming from, but not one coming up with differentials was also another thing that students had noted. Uh next slide, please. So some of the recommendations that students made. Um So first of all, to show more signs of different conditions, different presentations of anemia, jaundice, palor um in different yeah, in patients with different skin tones just so that we can have better clinical exposure to. Yeah, different presentations on different patients have a more representative uh expression of British population with a range of a range of examples. So during Ramadan, how would we change management or how would we order management of the patient? Um if they're going through Ramadan or fasting and also expressing it that's English as a second language, just ways to navigate those situations because we're going to come across patients, millions of well, maybe not millions, but a variety of patients who will have these um instances and it is good to know and be well prepared and how to to navigate this, especially for clinical practice. Um Another thing is that we recommend to not make ethnicity as a primary focus. Um Yeah, and not have the patient as a representative of, of a group as what I mentioned earlier include ethnicity along with other demographic information in all cases. Um And yeah, Britain to avoid presenting patient as a sort of authoring uh just the next slide, please. Yeah. Um students also recommended to not make assumptions. So ask all patients about their belief systems and cultural practices when relevant, avoid assuming exclusively unhealthy behaviors for minorities. Uh a glaring example that can come from the top of my head when we did this project was that um with diabetes, this was typically um like stereotyped towards South Asian um demographic and without any understanding or any explanation behind this, it was just a stereotype of this patient demographic. Um and there was no context behind that consider any implicit messages and photos and also provide evidence for health disparities in a range of different groups. Acknowledge that if there isn't any known mechanism and suggest ways they might be overcome. A primary example would be um well, for me, anyway, module seven was urogenital in the medical curriculum er for jab. And one thing that was missed was in my opinion was um talking about maternal mortality. Um and as a fact we know that black women, especially in Britain are disproportionately more affected um during childbirth and have higher mortality rates. We need to deep dive into understanding the reason why that is and not just be presented it as a fact. Um And this chart is back on to uh Jenny's point in terms of there is no biological difference between ethnicities. Um Health outcomes are associated with biases in medicine and health care um is also associated with myths that was also talked about. So I feel like these things definitely need to be highlighted, especially if you're going to talk about differences um in healthcare outcomes amongst patient demographics. Uh Next slide, please. Um So yeah, let's go back to Jenny now. OK, thanks. So this is sort of just trying to put it all back together again. Um Really saying that we've been, we've dissected it apart and taken each of the different aspects. And now we're just sort of presenting that diagram again just to because I think it is really complicated and I think what I found really was when we were starting to talk about things, we were getting ourselves in knots really. Um because we'd sort of move between these different aspects of ethnicity. Um So it really sort of, I found it helpful to try and to use it apart. And I think actually to come back to that question about the Asians and diabetes, I mean, why do we think it's even one mechanism for everybody? Like maybe for some people, there's a genetic predisposition, maybe for other people. There's that plus there's also their diet, maybe for other people, there's a degree of stress. I don't know. Why should we think that there's just one mechanism underpinning these things. It's like to be very, very much more complex than that. And that might be why we're struggling to work it all out. Um, so, yeah, it's been a really fascinating project. I've certainly really enjoyed it and I've learned a massive amount, um, starting, it's crazy to think four years ago. Um I had a very superficial and um and I guess limited understanding of what ethnicity really meant. Um And now I've been thinking about it a lot more. Um Yeah, so it's really about how do we as a teacher, how do I then explain it to other people? So that's why I really like to get your thoughts and your feedback. Um Because for me, yeah, I could only really do it by taking it apart and looking at a bunch of different examples and then trying to fit it together, all the pieces of the jigsaw back together so that, that we could see it as a whole. So that's what this diagram is really hoping if we can, if we can help to do that anyway. Thank you very much to everybody who took part in a focus group or answered some questionnaires and especially to all the student partners as well for all of their time and enthusiasm and to my colleagues, he wasn't able to be here this evening. And I'm very happy to take any questions. I'll just have a look at the chat. I can actually see it now. Thank you so much um about the actual to today because I know there was a lot of uh different perspectives and points. Interesting. I was gonna say that's an interesting comment about Egypt. So one of these, so I'm getting those and yeah, feedback. One of the difficulties I think with this whole black white thing is where do countries like Egypt fit in? Um So in some of the Pharmacology deba databases, Egypt goes with Africa and so Egyptians are counted with African people, but there's another Pharmacology Database that puts Egypt with Europe, um which is bizarre and it shows you just how arbitrary the whole thing is. Um Yeah, so and actually one of the databases, the one that puts Egypt with Europe also, you see the map and it has a line along the bottom of Egypt and then what is it, Libya and Tunisia and Morocco and the Morocco bit goes right down the coast. And so it's just like this sort of wiggly line. It's bizarre. Anyway, um Any other questions or if anybody has any feedback, very interested here afterwards? Thanks Sarah. Thank you. And again, there, there will be a feedback form as well at the end. So if you've got any questions for Jenny there, maybe you wanted to ask that's another place to put it or any feedback about the session, um, or any thoughts about ethnicity and how it's presented within your own curriculum. So I know people from different universities, some people are, um, within a university, some people are working at the moment. Um, and thinking about how ethnicity presented within their curriculum, um, it would be really great to hear about that as well in your, um, oh, ok. We've got, we've got another question. Um, someone said, what assumptions and biases, um, did you discover you had before the, before this project that were challenged? So, what kind of biases did you have when you were doing the project? Gosh, that's really hard question, actually. Oh, wow. I, yeah, I guess the, the bias I had was that I hadn't really thought about it if that makes any sense. Like, I haven't really thought what impact this could have. Like, I guess the thing I'm struggling to get my head around and, and you might be able to answer this if it's not too hard question. But like, if you're hearing people say all the time that, you know, black people are more likely to have this disease and they might have that disease and they might like to have the other disease. How does that make you feel like, I don't know, because one of the things as well is that it's not always the case that sometimes white people or Asian people are more likely to get a certain disease, but we never seem to mention that. Which is quite weird. What? Yeah, I'll throw that question back at you any questions before we front everyone and I close. I thought about the any bit. Give her one minute. Mhm. Mhm. So I ask, you know, I guess I'm extrapolating from what they said, but in terms of like collaboration. So as a student, what's the best way to get into collaborating within these kinds of research and things like that? So some of the projects you did, so someone's asking if they can get involved. What's the best way to do that? Gosh. Yeah. So there's a massive amount of work still that we need to do. One of the things is quite a lot of universities around the world have made proposals of things that they would like to do in their curriculum. Um If I'm honest, most of them have come from the US and not really from anywhere else. Um So one of the things I'd like to do is to sort of systematically search and find all of that information and pull all of that together. Um But I guess, you know, just organizing and having more discussion groups, I think what was really lovely about the focus groups that the students ran was just how, I mean, I was just really impressed several of the students came up to me afterwards and just said, how lovely it was for them to have the opportunity to discuss these things. Um, so thinking about, you know, is that something that happens in other universities and in other courses? Um, is it something that we should do more of? I don't know. Um, so I think it's really, you know, I'm really keen to hear your thoughts and to amplify your voice or your collective voice if you like. Um, because I think it's really important that we hear how these things impact on you. Um And I think that whole area is completely open for research. Um So yeah, it's just sort of trying to find the right people. I mean, my issue at the moment is I'm a teaching focused academic and what that means is that I have 10% of my time to do research and 90% of my time to do teaching and pastoral support and Adam and, and so I'm very limited in the amount of time I can take to do these things. So I've still got stacks of stuff, I've got to write up from the previous work that we've been doing. So if you guys can help to immobilize support um from different departments, sociology, psychology, different parts of medicine that would be really helpful for me. Um And just keep the conversation going, I think. Um because yeah, it's, it's not really giving you or no, not giving you that you feeling that you have a voice and it's important and it needs to be heard. Um And you finding ways of, of using that voice and influencing. So you can go to teaching and learning committees to EDI committees to module evaluation forms and you can put questions in there and you can get people to get people to talk about these issues and just get people engaged in talking about it. I'm gonna shut up because I keep talking. I think that's a great, great place to, to end on. Um And yeah, like I said, it's, it's about like students using their, using their voices and um you've really seen with what you guys have done um the importance of that and how it can help, but also like on a bigger level. So people take anything as well from this and they think like this is really important. I wanna speak up and um talk about this. So that's something that I think we'd all advocate for um on this end. So again, thank you so much, Jenny and Julian and Shannon for, for coming and speaking for um the final call, the clinic um talk. Um And I know I've learned quite a lot. Um and I'm sure everyone else has as well. Um And our feedback form comes at the end of the session. So once you leave, you'll get a feedback form and that will allow you to give any feedback as well as receive a certificate as well at the end. Um And I think. Yeah, that's it. So enjoy your evening. Um And thank you so much for coming um to kind of call her in the clinic. Bye. Thank you guys and thank you. Bye, see you. Ok. Um Sorry for the, for the technical issues, Jenny. I hope you can. Yeah, I don't know what happened. Oh dear. I think it must be the firewall that the um uni firewall, but it must be. Yeah, I didn't realize it would be. Yeah. But anyway, it's, it's worked on my phone. So yeah, at least we got you on. I was like, oh gosh, no, I hope she can get on. Um I'm glad you went to get on. Yeah, that was. Yeah, thank you. No, if you have any thoughts on, you know, you get any feedback to let me know I will forward it on to you as well once, once we receive it. Um, and ok, it might take a little bit. So you're gonna head back to back now. Ok. Gosh. Yeah, I think I'm gonna, anyway, I'm gonna go home, take care, catch you later. Thanks again. Thank you. Bye.