Battle on two fronts to offer equal opportunities in medical education

“I was once asked to explain my research when I applied for a programme for talented researchers. When I finished speaking about my work, I was asked: ‘Can you really conduct research on that topic?’” During the entire interview, Karen Stegers-Jager speaks passionately and without interruption about her research. But she seems startled by her own anecdote and falls silent for a few seconds. “Doctors had no idea that you could conduct research in this area. I was flabbergasted at the time.”

At first glance, Stegers-Jager seems to be a bit of an outsider in the academic hospital. In a setting where thousands of people have the primary task of ‘healing people’, she hasn’t spent a single moment in her past ten years at Erasmus MC on patient health – at least not in a hands-on way. But indirectly, she has the same goal as all the employees in the hospital’s teaching department: turning out the best doctors possible.

In 2012 Stegers-Jager obtained her doctorate on the role of ethnicity and cultural background on academic success among medical students. “I wanted to discover which students ran the risk of dropping out or of a study delay and what we could do to remedy that.” She discovered that in the bachelor’s phase (in the Medicine programme this phase also places emphasis on passing exams), there were few disparities. But once the clinical component of the programme started (clinical placements), the results stated to diverge.

“People with a different background, no matter what that might involve, communicate differently than expected in hospital,” explains Stegers-Jager. “The assessment of clinical placements has much more to do with interpretation than marking exams. It’s mostly about communication. But a different way of communicating doesn’t mean that particular approach is wrong.” However, this doesn’t get expressed during the assessment: a logical, but undesirable outcome, according to the educationalist. “Subconsciously we place our trust in people that most resemble us. While there’s nothing strange about that – it’s a primeval instinct – it’s important that we are aware of this.”

In her next study she wants to raise awareness of this issue at Erasmus MC. Stegers-Jager received a Veni grant last year to conduct research over the next four years into the first impression students make at an assessment. “In the clinical phase, students are assessed based on subjective grounds. I want to research whether we treat students unfairly when we do this. A fair assessment for every student in our multicultural society is essential if we are to continue producing good doctors in the future.”

She offers an example to clarify her point. “Students with a non-Western background might communicate in a different manner than students with a typical Dutch background, but this doesn’t mean one is better than the other. In the Netherlands we always try to keep patients fully informed about their care, even if it involves bad news. In other cultures such news is communicated through friends or family. That’s not better or worse; it’s just a different culture. It’s something you have to take into consideration.”

A recurring theme in Stegers-Jager’s studies is combating inequities in the field of medicine. The seeds of her involvement in social issues were sown in her youth. In spite of the milieu in which she was raised, her parents taught her that her privileged position was not a given. “My father was mayor, so I was part of ‘high society’. But I attended what could certainly – at that time – be referred to as a ‘black school’, where the majority of students had a non-Dutch background. It was a conscious decision on the part of my parents. They felt I should come into contact with all facets of the population and I learned then that someone’s background doesn’t make that person better or worse. That’s why I’ve always had this socially motivated drive, even during my studies. My graduation research was on distance education for children all over the world, so I’ve always been interested in this theme.”

Her initial career steps gave her the definitive push in the direction of research in medical school education. “I realised that I had always been fortunate. That I had always held an advantage… well, aside from being a woman,” she says, laughing. “But I knew right away that I was looking for societal impact in my work.”

When she arrived at Erasmus MC ten years ago, Stegers-Jager hoped she would be able to immediately contribute added value in terms of making an impact on society. Over the years she discovered she had to struggle to find her place. “In this organisation education isn’t really the top priority. It’s mainly seen as something you do on the side, so committing yourself solely to education was difficult for some people to fathom. That made it difficult at times.”

In practice it meant that within her own research group she was able to do her work unimpeded, but she found it difficult to gain a foothold outside of this setting. “We weren’t really a part of the organisation. Gaining respect was difficult in such a large organisation, especially when the emphasis is on healthcare and medical scientific research.” When asked if that was a frustrating time for her, she first ponders the question before answering. “In a sense, yes, but I tried not to waste my energy on the negative aspects. There’s not much point in doing that.”

By this time, thanks to the impact of her doctoral research, Stegers-Jager and her colleagues are no longer ignored. One tangible result was the establishment of the iMERR (institute of Medical Education Research Rotterdam) in 2014. “Since then our research has become more important within the faculty,” she says with a big smile. “Yes, I do believe that I was one of the catalysts in bringing this about. We demonstrated that research into medical education is truly relevant.”

She has done much more than just raising awareness at the rest of Erasmus MC regarding research in medical education. The research carried out by Stegers-Jager has resulted in a variety of changes in the curriculum and in various initiatives over the years. For example, the decentralised selection policy has been amended and the process for assessing medical interns has been changed. “This used to be a single assessment, but now students are assessed multiple times by different assessors.” Her research has also led to a much stronger position for the themes of diversity and inclusion. This can be seen in the special student-lecturer days organised around these themes and in the establishment of an Inclusiveness in education working group.

With or without these changes, in the hierarchical world of medicine, obtaining a Veni grant is something that compels admiration. A slightly embarrassed Stegers-Jager discloses that the grant has raised her status. “Of course all the recognition is nice. But is it my crowning achievement in my work? Certainly not. There’s still so much to do and that’s the first thing we need to work on.”

Her view that there is much that needs to be changed is confirmed daily in practice. “I recently spoke to a doctor who told me that a colleague had told her he prefers to treat each patient in the same way he would like to be treated. She replied that it should actually be the other way around, and I agree with her completely. Doctors need to treat patients the way the patient would want to be treated. The difference may appear simple, but it is a fundamental difference.”

It’s in these moments that a pioneer like Stegers-Jager draws strength from her idea that there is still much to be done, and she will certainly be active in the coming time. “We have to ensure that the doctors we produce are more than just carbon copies of the doctors we already have. They have to be able to respond appropriately to society’s needs. In the future doctors need to assess someone based on what that person does, not on that person’s identity. We need to train these doctors by providing equal opportunities for all our students and I want to continue contributing to this in the future.”