Playing well with others: lessons from theatre for the health professions about collaboration, creativity and community.

Despite collaboration among different professions being recognized as fundamentally important to contemporary and future healthcare practice, the concept is woefully undertheorized. This has implications for how health professions educators might best introduce students to interprofessional collaboration and support their transition into interprofessional, collaborative workplaces. To address this, we engage in a conceptual analysis of published collaborative, interprofessional practices and conceptual understandings in theatre, as a highly collaborative art form and industry, to advance thinking in the health professions, specifically to inform interprofessional education. Our analysis advances a conceptualization of collaboration that takes place within a work culture of creativity and community, that includes four modes of collaboration, or the ways theatre practitioners collaborate, by: (1) paying attention to and traversing roles and hierarchies; (2) engaging in reciprocal listening and challenging of others; (3) developing trust and communication, and; (4) navigating uncertainty, risk and failure. We conclude by inviting those working in the health professions to consider what might be gleaned from our conceptualization, where the embodied and human-centred aspects of working together are attended to alongside structural and organizational aspects.

Power/knowledge: A sociomaterial perspective on a new accreditation process during COVID-19.

INTRODUCTION: The COVID-19 pandemic had significant impacts on many aspects of health care and education, including the accreditation of medical education programmes. As a community of international educators, it is important that we study changes that resulted from the pandemic to help us understand educational processes more broadly. As COVID-19 unfolded in Canada, a revised format of undergraduate medical accreditation was implemented, including a shift to virtual site visits, a two-stage visit schedule, a focused approach to reviewing standards and the addition of a field secretary to the visit team. Our case study research aimed to evaluate the sociomaterial implications of these changes in format on the process of accreditation at two schools. METHODS: We interviewed key informants to understand the impacts, strengths and limitations of changes made to the accreditation format. We used an abductive approach to analyse transcripts and applied a sociomaterial lens in looking for interconnections between the material and social changes that were experienced within the accreditation system. RESULTS: Stakeholders within the accreditation system did not anticipate that changes to the accreditation format would have significant impacts on how accreditation functioned or on its overall outcomes. However, key informants described how the revised format of accreditation reconstructed how power was distributed and how knowledge was produced. The revised format contributed to changes in who held power within each of the programmes, within each of the visiting teams and between site members and visiting team members. As power shifted across stakeholders in response to material changes to the accreditation format, key informants described changes in how knowledge was produced. CONCLUSIONS: Our findings suggest that the most powerful knowledge about any given programme might best be obtained through individualised tools, technologies and voices that are most meaningful to the unique context of each programme. Deliberate attention to how knowledge and power are influenced by the interactions between material and social processes within accreditation may help educators and leaders see the effects of change.

Articulating the ideal: 50 years of interprofessional collaboration in Medical Education.

CONTEXT: Health care delivery and the education of clinicians have changed immensely since the creation of the journal Medical Education. In this project, we seek to answer the following three questions: How has the concept of collaboration changed over the past 50 years in Medical Education? Have the participants involved in collaboration shifted over time? Has the idea of collaboration itself been transformed over the past 50 years? METHODS: Starting from a constructionist view of scientific discourse, we used directed content analysis to sample, code and analyse 144 collaboration-related articles over the 50-year life span of Medical Education. We developed an analytical framework to identify the key components of varying articulations of 'collaboration', with a focus on shifts in language and terminology over time. Our sample was drawn from an archive of 1221 articles developed to celebrate the 50th anniversary of Medical Education. RESULTS: Interprofessional collaboration is conceptualised in three primary ways throughout our sample: as a psychometric property; as tasks or activities, and, more recently, as 'togetherness'. The first conceptualisation articulates collaboration as involving knowledge or skills that are teachable to individuals, the second as involving the education of teams to engage in structured meetings or task distribution, and the third as the building of networks of individuals who learn to form team identities. The 'leader' of collaboration is typically conceptualised as the doctor, who is consistently articulated by authors as the active agent of collaborative care. Other clinicians and students of other professions are, as the wording in this sentence suggests, usually positioned as 'others', and thus as more passive participants in, or even observers of, 'collaboration'. CONCLUSIONS: In order to meet goals of meaningful collaboration leading to higher-quality care, it behoves us as a community of educators and researchers to heed the ways in which we teach, think and write about interprofessional collaboration, interrogating our own language and assumptions that may be betraying and reproducing harmful care hierarchies.

In search of educational efficiency: 30 years of Medical Education's top-cited articles.

CONTEXT: Academic journals represent shared spaces wherein the significance of thematic areas, methodologies and paradigms are debated and shaped through collective engagement. By studying journals in their historical and cultural contexts, the academic community can gain insight into the ways in which authors and audiences propose, develop, harness, revise and discard research subjects, methodologies and practices. METHODS: Thirty top-cited articles published in Medical Education between 1986 and 2014 were analysed in a two-step process. First, a descriptive classification of articles allowed us to quantify the frequency of content areas over the time span studied. Secondly, a discourse analysis was conducted to identify the continuities, disruptions and tensions within the three most prominent content areas. RESULTS: The top-cited articles in Medical Education focused on three major areas of interest: problem-based learning, simulation and assessment. In each of these areas of interest, we noted a tension between the desire to produce and apply standardised tools, and the recognition that the contexts of medical education are highly variable and influenced by political and financial considerations. The general preoccupation with achieving efficiency may paradoxically jeopardise the ability of medical schools to address the contextual needs of students, teachers and patients. CONCLUSIONS: Understanding the topics of interest for a journal's scholarly audience and how these topics are discursively positioned, provides important information for researchers in deciding how they wish to engage with the field, as well as for educators as they assess the relevance of educational products for their local contexts.

Misalignments of purpose and power in an early Canadian interprofessional education initiative.

Interprofessional education (IPE) has been widely incorporated into health professional curricula and accreditation standards despite an arguably thin base of evidence regarding its clinical effects, theoretical underpinnings, and social implications. To better understand how and why IPE first took root, but failed to grow, this study examines one of the earliest documented IPE initiatives, which took place at the University of British Columbia between 1960 and 1975. We examined a subset of 110 texts (academic literature, grey literature, and unpublished records) from a larger study that uses Critical Discourse Analysis to trace the emergence of IPE in Canada. We asked how IPE was promoted and received, by whom, for what purposes, and to what effects. Our analysis demonstrates that IPE was promoted as a response to local challenges for the Faculty of Medicine as well as national challenges for Canada's emerging public healthcare system. These dual exigencies enabled the IPE initiative, but they shaped it in somewhat divergent ways: the former gave rise to its core component (a health sciences centre) and the latter its ultimate purpose (increasing the role of non-medical professions in primary care). Reception of the initiative was complicated by a further tension: nurses and allied health professionals were sometimes represented as independent experts with unique knowledge and skills, and sometimes as assistants or substitutes for medical doctors. We relate the successes and frustrations of this early initiative to particular (mis)alignments of purpose and relationships of power, some of which continue to enable and constrain IPE today.

Setting the standard: Medical Education's first 50 years.

CONTEXT: By understanding its history, the medical education community gains insight into why it thinks and acts as it does. This piece provides a Foucauldian archaeological critical discourse analysis (CDA) of the journal Medical Education on the publication of its 50th Volume. This analysis draws upon critical social science perspectives to allow the examination of unstated assumptions that underpin and shape educational tools and practices. METHODS: A Foucauldian form of CDA was utilised to examine the journal over its first half-century. This approach emphasises the importance of language, and the ways in which words used affect and are affected by educational practices and priorities. An iterative methodology was used to organise the very large dataset (12,000 articles). A distilled dataset, within which particular focus was placed on the editorial pieces in the journal, was analysed. RESULTS: A major finding was the diversity of the journal as a site that has permitted multiple - and sometimes contradictory - discursive trends to emerge. One particularly dominant discursive tension across the time span of the journal is that between a persistent drive for standardisation and a continued questioning of the desirability of standardisation. This tension was traced across three prominent areas of focus in the journal: objectivity and the nature of medical education knowledge; universality and local contexts, and the place of medical education between academia and the community. CONCLUSIONS: The journal has provided the medical education community with a place in which to both discuss practical pedagogical concerns and ponder conceptual and social issues affecting the medical education community. This dual nature of the journal brings together educators and researchers; it also gives particular focus to a major and rarely cited tension in medical education between the quest for objective standards and the limitations of standard measures.

Shapeshifters: Global South scholars and their tensions in border-crossing to Global North journals.

INTRODUCTION: Global South researchers struggle to publish in Global North journals, including journals dedicated to research on health professions education (HPE). As a consequence, Western perspectives and values dominate the international academic landscape of HPE. This study sought to understand Global South researchers' motivations and experiences of publishing in Global North journals. METHODS: This study used a hermeneutic phenomenological perspective. Unstructured interviews were conducted with 11 authors from 6 Global South countries. Interview transcripts were analysed through a process of familiarisation, identifying significant statements, formulating meanings, clustering themes, developing exhaustive descriptions, producing a fundamental structure and seeking verification. RESULTS: Participants described being motivated by local institutional expectations, to improve reputation, to meet Global North perceptions of quality and to draw attention to their Global South context. Participants described experiences where their work was deemed irrelevant to Global North audiences, they were unable to interpret rejections and had learnt to play the publishing game by attending to both local and global imperatives. These motivations and experiences revealed several practical, academic and transformational tensions that Global South authors faced. CONCLUSION: The tensions and negotiations encountered by Global South authors who publish in HPE journals reflect a 'border consciousness' whereby authors must shift consciousness, or become 'shapeshifters', inhabiting two or more worlds as they cross borders between the Global South and Global North conventions. There is an added burden and risk in performing this shapeshifting, as Global South authors stand astride the borders of two worlds without belonging fully to either.

Reimagining global mental health in Africa.

In 2001, the WHO launched The World Health Report most specifically addressing low-income and middle-income countries (LAMICs). It highlighted the importance of mental health (MH), identifying the severe public health impacts of mental ill health and made 10 recommendations. In 2022, the WHO launched another world MH report and reaffirmed the 10 recommendations, while concluding that 'business as usual for MH will simply not do' without higher infusions of money. This paper suggests the reason for so little change over the last 20 years is due to the importation and imposition of Western MH models and frameworks of training, service development and research on the assumption they are relevant and acceptable to Africans in LAMICs. This ignores the fact that most mental and physical primary care occurs within local non-Western traditions of healthcare that are dismissed and assumed irrelevant by Western frameworks. These trusted local institutions of healthcare that operate in homes and spiritual spaces are in tune with the lives and culture of local people. We propose that Western foundations of MH knowledge are not universal nor are their assumptions of society globally applicable. Real change in the MH of LAMICs requires reimagining. Local idioms of distress and healing, and explanatory models of suffering within particular populations, are needed to guide the development of training curricula, research and services. An integration of Western frameworks into these more successful approaches are more likely to contribute to the betterment of MH for peoples in LAMICs.

Faster, higher, stronger - together? A bibliometric analysis of author distribution in top medical education journals.

INTRODUCTION: Medical education and medical education research are growing industries that have become increasingly globalised. Recognition of the colonial foundations of medical education has led to a growing focus on issues of equity, absence and marginalisation. One area of absence that has been underexplored is that of published voices from low-income and middle-income countries. We undertook a bibliometric analysis of five top medical education journals to determine which countries were absent and which countries were represented in prestigious first and last authorship positions. METHODS: Web of Science was searched for all articles and reviews published between 2012 and 2021 within Academic Medicine, Medical Education, Advances in Health Sciences Education, Medical Teacher, and BMC Medical Education. Country of origin was identified for first and last author of each publication, and the number of publications originating from each country was counted. RESULTS: Our analysis revealed a dominance of first and last authors from five countries: USA, Canada, UK, Netherlands and Australia. Authors from these five countries had first or last authored 70% of publications. Of the 195 countries in the world, 43% (approximately 83) were not represented by a single publication. There was an increase in the percentage of publications from outside of these five countries from 23% in 2012 to 40% in 2021. CONCLUSION: The dominance of wealthy nations within spaces that claim to be international is a finding that requires attention. We draw on analogies from modern Olympic sport and our own collaborative research process to show how academic publishing continues to be a colonised space that advantages those from wealthy and English-speaking countries.

Teaching poverty and health: importing transformative learning into the structures and paradigms of medical education.

Background: As a paradigm of education that emphasizes equity and social justice, transformative education aims to improve societal structures by inspiring learners to become agents of social change. In an attempt to contribute to transformative education, the University of Toronto MD program implemented a workshop on poverty and health that included tutors with lived experience of poverty. This research aimed to examine how tutors, as members of a group that faces structural oppression, understood their participation in the workshop. Methods: This research drew on qualitative case study methodology and interview data, using the concept of transformative education to direct data analysis and interpretation. Results: Our findings centred around two broad themes: misalignments between transformative learning and the structures of medical education; and unintended consequences of transformative education within the dominant paradigms of medical education. These misalignments and unintended consequences provided insight into how courses operating within the structures, hierarchies and paradigms of medical education may be limited in their potential to contribute to transformative education. Conclusions: To be truly transformative, medical education must be willing to try to modify structures that reinforce oppression rather than integrating marginalized persons into educational processes that maintain social inequity.

Contexte: En tant que paradigme favorisant l'équité et la justice sociale, l'éducation axée sur la transformation vise à améliorer les structures sociétales en inspirant les apprenants à devenir des agents du changement social. Dans une visée d'éducation transformatrice, le programme de doctorat en médecine de l'Université de Toronto a mis en place un atelier sur le thème de la santé et la pauvreté auquel participaient des tuteurs ayant une expérience vécue de la pauvreté. Notre recherche visait à examiner comment les tuteurs, en tant que membres d'un groupe confronté à l'oppression structurelle, ont compris leur participation à l'atelier. Méthodes: Cette recherche qualitative s'est appuyée sur une méthodologie d'étude de cas et sur des données d'entrevue, en utilisant le concept d'éducation transformatrice comme prisme pour l'analyse et l'interprétation des données. Résultats: Nos résultats s'articulent autour de deux grands thèmes : les décalages entre l'apprentissage transformateur et les structures de l'éducation médicale, et les conséquences inattendues de l'éducation transformatrice au sein des paradigmes dominants de l'éducation médicale. Ces divergences et ces conséquences non voulues ont permis de constater que les cours qui sont ancrés dans les structures, les hiérarchies et les paradigmes contribueront peu à l'éducation transformatrice. Conclusions: Pour que l'éducation médicale soit véritablement transformatrice, il faut qu'il y ait une volonté de modifier les structures qui renforcent l'oppression plutôt que de faire entrer les personnes marginalisées dans des processus éducatifs qui perpétuent l'inégalité sociale.

Transdisciplinary teamwork: the experience of clinicians at a functional restoration program.

INTRODUCTION: This research explored the experience of clinicians during the transition from working as an interdisciplinary team to providing a transdisciplinary model of care in a functional restoration program (FRP) for clients with chronic disabling musculoskeletal pain. METHODS: This qualitative study used a grounded theory approach to data collection and analysis. In depth interviews were conducted to gather data and analysis was performed by the coding of emergent themes. RESULTS: Three major themes were identified that contributed towards building a successful transdisciplinary team: the client population; opportunities for communication with colleagues; and an organizational structure that supports transdisciplinary teamwork. CONCLUSIONS: Transdisciplinary teams with multiple health care providers are suitable for treating patients with complex needs and with injuries that are chronic in nature. However, transdisciplinary teamwork requires input from an organizational level and from a communication level to effectively contribute to both clinician satisfaction and to improved coordination in patient care.

"Can you go back to work?": Family physicians' experiences with assessing patients' functional ability to return to work.

Objective To explore the challenges academic FPs face when assessing patients' functional ability to return to work; to produce a detailed account of FPs' experiences and views on workplace disability management; to describe which parts of the disability assessment and management process FPs would like to modify or relinquish; and to provide solutions to streamline the overall process of assessing disability. Design Qualitative phenomenologic study using in-depth interviews. Setting A family health team located in a large urban teaching hospital in Toronto, Ont. Participants Purposive sample of 6 FPs. Methods Participants were invited to participate in 1-hour, in-depth interviews. Themes were derived from qualitative analysis of the data using a phenomenologic approach. Main findings Four themes emerged from the interviews: the FP's role in filing a compensation claim; the complexity of the patient; the FP's lack of training in occupational health; and possible solutions to improve the process of assessing the functional ability of an injured worker. Conclusion As in other areas of medicine, the role of the FP is to restore health; optimize social, psychological, and functional capabilities; and minimize the negative effects of injury. Assessing functional abilities for return to work can be challenging, as FPs are trained to focus on assessing and treating symptoms rather than on determining occupational functioning. Functional assessment forms do not provide enough information for physicians and serve as a poor communication tool among the stakeholders involved with returning an injured worker to work.

Timing of surgical antibiotic prophylaxis administration: complexities of analysis.

BACKGROUND: The timing of prophylactic antibiotic administration is a patient safety outcome that is recurrently tracked and reported. The interpretation of these data has important implications for patient safety practices. However, diverse data collection methods and approaches to analysis impede knowledge building in this field. This paper makes explicit several challenges to quantifying the timing of prophylactic antibiotics that we encountered during a recent study and offers a suggested protocol for resolving these challenges. CHALLENGES: Two clear challenges manifested during the data extraction process: the actual classification of antibiotic timing, and the additional complication of multiple antibiotic regimens with different timing classifications in a single case. A formalized protocol was developed for dealing with incomplete, ambiguous and unclear documentation. A hierarchical coding system was implemented for managing cases with multiple antibiotic regimens. INTERPRETATION: Researchers who are tracking prophylactic antibiotic timing as an outcome measure should be aware that documentation of antibiotic timing in the patient chart is frequently incomplete and unclear, and these inconsistencies should be accounted for in analyses. We have developed a systematic method for dealing with specific problematic patterns encountered in the data. We propose that the general adoption of a systematic approach to analysis of this type of data will allow for cross-study comparisons and ensure that interpretation of results is on the basis of timing practices rather than documentation practices.

The role of spending money and drinking alcohol in adolescent smoking.

AIMS: Previous studies have shown inconsistent findings with regard to the association between amount of spending money and adolescent smoking. Drinking alcohol may be a mediator of the association between spending money and adolescent smoking. However, no studies have examined this potential role. The objective of this study was to investigate the association between amount of spending money and adolescent smoking and the potential mediation role of alcohol use in this association. DESIGN: The 2003 Ontario Student Drug Use Survey of students in grades 7-12. MEASUREMENTS: Multivariable logistic, probit and linear regression models were used to investigate the association between amount of spending money and smoking, and the contribution of drinking alcoholic beverages to this relationship. FINDINGS: Spending money was associated positively with experimental smoking, current smoking and daily consumption of cigarettes (P < 0.01). The analysis adjusted for confounders showed that students with spending money > or =$20/week were significantly more likely to be experimental smokers, students with > or =$30/week were significantly more likely to be current smokers and students with > or =$60/week smoked significantly more cigarettes/day (P < or = 0.05), compared to students with <$10/week. Alcohol use was an important mediator, responsible for 81% of the association of spending money with experimental smoking, 38% with current smoking and 37% with daily consumption of cigarettes. CONCLUSIONS: Amount of spending money was associated significantly and positively with smoking among adolescents, and alcohol use mediated this association. Integrated tobacco prevention programs may be more effective, and increasing taxes on cigarettes and alcohol would increase price sensitivity among youth and protect against adolescent smoking.

Humanism, the Hidden Curriculum, and Educational Reform: A Scoping Review and Thematic Analysis.

BACKGROUND: Medical educators have used the hidden curriculum concept for over three decades to make visible the effects of tacit learning, including how culture, structures, and institutions influence professional identity formation. In response to calls to see more humanistic-oriented training in medicine, the authors examined how the hidden curriculum construct has been applied in the English language medical education literature with a particular (and centering) look at its use within literature pertaining to humanism. They also explored the ends to which the hidden curriculum construct has been used in educational reform efforts (at the individual, organizational, and/or systems levels) related to nurturing and/or increasing humanism in health care. METHOD: The authors conducted a scoping review and thematic analysis that draws from the tradition of critical discourse analysis. They identified 1,887 texts in the literature search, of which 200 met inclusion criteria. RESULTS: The analysis documents a strong preoccupation with negative effects of the hidden curriculum, particularly the moral erosion of physicians and the perceived undermining of humanistic values in health care. A conflation between professionalism and humanism was noted. Proposals for reform largely target medical students and medical school faculty, with very little consideration for how organizations, institutions, and sociopolitical relations more broadly contribute to problematic behaviors. CONCLUSIONS: The authors argue that there is a need to transcend conceptualizations of the hidden curriculum as antithetical to humanism and offer suggestions for future research that explores the necessity and value of humanism and the hidden curriculum in medical education and training.