'Yourself in all your forms': A grounded theory exploration of identity safety in medical students.

INTRODUCTION: Identity threats, such as stereotype threat and microaggressions, impair learning and erode well-being. In contrast to identity threat, less is known about how learners experience feelings of safety regarding their identity. This exploratory study aims to develop a theory of identity safety in the clinical learning environment. METHODS: This multi-institutional, qualitative interview study was informed by constructivist grounded theory and critical pedagogy. Participants were clinical students at three public medical schools in the United States in 2022. Investigators purposively sampled participants for interviews based on their responses to an 11-item survey with an open-ended question soliciting students' personal identities and responses to both the racial/ethnic and gender Stereotype Vulnerability Scales. The investigators interviewed, coded, constantly compared and continued sampling until the codes could be developed into categories, then concepts and finally into a theory. The team engaged in critical reflexivity throughout the analytic process to enrich data interpretations. RESULTS: Sixteen diverse students were interviewed. We organised their identity-salient experiences into identity threat, threat mitigation and identity safety. Participants experienced identity threat through unwelcoming learning environments, feeling compelled to change their behaviour in inauthentic ways or sociopolitical threat. Threat mitigation occurred when a participant or supervisor intervened against an identity threat, dampening but not eliminating the threat impact. Participants characterised identity safety as the ability to exist as their authentic selves without feeling the need to monitor how others perceive their identities. Identity safety manifested when participants demonstrated agency to leverage their identities for patient care, when others upheld their personhood and saw them as unique individuals and when they felt they belonged in the learning environment. DISCUSSION: Attending to identity safety may lead to educational practices that sustain and leverage team members' diverse identities. Identity safety and threat mitigation may work together to combat identity threats in the learning environment.

Structural stigma within inpatient care for people who inject drugs: implications for harm reduction.

BACKGROUND:  Individuals suffering with addiction have historically experienced disproportionally high levels of stigma. The process of inpatient care for those with substance abuse disorder (SUD) is multifaceted, shaped by the interplay of human interactions within the healthcare team and overarching structural factors like policy. While existing literature predominantly addresses personal and interpersonal stigma, the influence of structural stigma on care delivery practices remains understudied. Our research aims to investigate the impact of structural stigma on care processes for individuals with SUD admitted to acute medicine units. METHODS:  We conducted a secondary analysis of observation notes and interview transcripts utilizing an analytic framework related to structural stigma adapted from previous research. Data was collected from June 2019 to January 2020 in 2 hospitals. 81 participants consented to observation and 25 to interviews. Interviews were conducted with patients (n = 8), healthcare staff (n = 16), and caregivers (n = 1). RESULTS:  Each aspect of care for people with SUD is adversely influenced by structural forms of stigma. There was evidence of a gap in accessing care and time pressures which deteriorated care processes. Structural stigma also manifested in the physical spaces designed for care and the lack of adequate resources available for mental health and addictions care. We found that structural stigma perpetuated other forms of implicit and explicit stigma. CONCLUSIONS:  Structural stigma and other forms of stigma are interconnected. Improving care for people with SUD in hospital settings may require addressing structural forms of stigma such as how physical spaces are designed and how mental healthcare is integrated with physical healthcare within inpatient settings.

Anti-oppressive pedagogy in medical education: A qualitative study of trainees and faculty.

PURPOSE: Despite the proliferation of interest in health equity and justice in medical education, there is limited research into the practical implementation of pedagogical approaches that align with anti-oppressive practices. This study sought to explore how to integrate anti-oppressive pedagogy into medical education. METHODS: Using constructivist grounded theory, the authors conducted 19 semi-structured interviews with a continuum of medical education stakeholders including learners and faculty in a Canadian context between June and August 2021. Transcripts were iteratively analysed using constant comparative analysis. RESULTS: Findings suggest that existing approaches to anti-oppressive pedagogy in medical education are misaligned with the perceived values, priorities, pace, biomedical focus and hierarchical nature of medical education, and medical practice. Although some learners are motivated to advance anti-oppressive teaching, their motivations are often related to their personal experiences of oppression. Participants suggested that transformative and structural changes are required to effectively integrate anti-oppressive pedagogy into medical education. Suggestions included a shift to community-based learning while ensuring adequate compensation for educators and addressing resistance at individual and institutional levels. CONCLUSION: Anti-oppressive pedagogy does not presently align with existing medical education practices. Effectively integrating anti-oppressive approaches will require individual and institutional reflection on the values and assumptions that underpin the field before progress can be made in a meaningful and sustainable way.

Normalising disclosure or reinforcing heroism? An exploratory critical discourse analysis of mental health stigma in medical education.

INTRODUCTION: There has been a proliferation of initiatives targeted towards improving psychological wellbeing among medical learners. Yet many learners do not seek assistance due to stigma against help seeking. Understanding the prevailing discourses on the effects of mental health stigma in the context of medical education will improve insight on how to address stigma and improve wellbeing. In this study, the authors sought to explore discourses on stigma in medical education through a Foucauldian Critical Discourse Analysis. METHODS: The authors assembled several sets of texts related to stigma in medical education. The initial archive consisted of social media discourse and was expanded to include digital news media. Next, the authors conducted semi-structured qualitative interviews with medical students, residents and faculty. Using principles of Critical Discourse Analysis informed by the writings of Michel Foucault, the authors analysed the archive to identify truth statements, representative statements and discursive effects. RESULTS: Analysis revealed an emancipatory discourse of disclosure that normalised help-seeking, which conflicted with a discourse of performance. Results suggested that public disclosure remains challenging in private contexts due to a medical culture that rewards perfectionism and lauds heroism. Discourses on performance positioned disclosure as disruptive to the system's need to maintain its own hegemony. Overall, stigma was perceived as rooted within the structural power of the medical education system and society at large. CONCLUSION: Discourses on stigma in medical education hold implications for the teaching, learning and overall wellbeing of medical learners. The tensions between discourses on disclosure and performance have the potential to perpetuate further distress for learners and worsen asymmetries in power. Interventions to address stigma would benefit from understanding and addressing the role of power and hierarchy in maintaining and dismantling stigma.

Freedom from discrimination or freedom to discriminate? Discursive tensions within discrimination policies in medical education.

The importance of advancing equity, diversity, and inclusion for all members of the academic medical community has gained recent attention. Academic medical organizations have attempted to increase broader representation while seeking structural reforms consistent with the goal of enhancing equity and reducing disproportionality. However, efforts remain constrained while minority groups continue to experience discrimination. In this study, the authors sought to identify and understand the discursive effects of discrimination policies within medical education. The authors assembled an archive of 22 texts consisting of publicly available discrimination and harassment policy documents in 13 Canadian medical schools that were active as of November 2019. Each text was analysed to identify themes, rhetorical strategies, problematization, and power relations. Policies described truth statements that appear to idealize equity, yet there were discourses related to professionalism and neutrality that were in tension with these ideals. There was also tension between organizations' framing of a shared responsibility for addressing discrimination and individual responsibility on complainants. Lastly, there were also competing discourses on promoting freedom from discrimination and the concept of academic freedom. Overall, findings reveal several areas of tension that shape how discrimination is addressed in policy versus practice. Existing discourses regarding self-protection and academic freedom suggest equity cannot be advanced through policy discourse alone and more substantive structural transformation may be necessary. Existing approaches may be inadequate to address discrimination unless academic medical organizations interrogate the source of these discursive tensions and consider asymmetries of power.

From distress to detachment: exploring how providing care for stigmatized patients influences the moral development of medical trainees.

In acute hospital settings, medical trainees are often confronted with moral challenges and negative emotions when caring for complex and structurally vulnerable patients. These challenges may influence the long term moral development of medical trainees and have significant implications for future clinical practice. Despite the importance of moral development to medical education, the topic is still relatively under-explored. To gain a deeper understanding of moral development in trainees, we conducted a qualitative exploration of how caring for a stigmatized population influences their moral development. Data were collected from 48 medical trainees, including observational field notes, supplemental interviews, and medical documentation from inpatient units of two urban teaching hospitals in a Canadian context. Utilizing a practice-based approach which draws on constructivist grounded theory, we conducted constant comparative coding and analysis. We found that caring for stigmatized populations appeared to trigger frustration in medical trainees, which often perpetuated feelings of futility as well as avoidance behaviours. Additionally, hospital policies, the physical learning environment, variability in supervisory practices, and perceptions of judgment and mistrust all negatively influenced moral development and contributed to apathy and moral detachment which has implications for the future. Recognizing the dynamic and uncertain nature of care for stigmatized patients, and addressing the influence of structural and material factors provide an opportunity to support moral experiences within clinical training, and to improve inequities.

Exploring implicit influences on interprofessional collaboration: a scoping review.

Interprofessional collaboration (IPC) is fraught with multiple tensions. This is partly due to implicit biases within teams, which can reflect larger social, physical, organizational, and historical contexts. Such biases may influence communication, trust, and how collaboration is enacted within larger contexts. Despite the impact it has on teams, the influence of bias on IPC is relatively under-explored. Therefore, the authors conducted a scoping review on the influence of implicit biases within interprofessional teams. Using scoping review methodology, the authors searched several online databases. From 2792 articles, two reviewers independently conducted title/abstract screening, selecting 159 articles for full-text eligibility. From these, reviewers extracted, coded, and iteratively analyzed key data using a framework derived from socio-material theories. Authors found that many studies demonstrated how biases regarding dominance and expertise were internalized by team members, influencing collaboration in predominantly negative ways. Articles also described how team members dynamically adapted to such biases. Overall, there was a paucity of research that described material influences, often focusing on a single material element instead of the dynamic ways that humans and materials are known to interact and influence each other. In conclusion, implicit biases are relatively under-explored within IPC. The lack of research on material influences and the relationship among racial, age-related, and gender biases are critical gaps in the literature. Future research should consider the longitudinal and reciprocal nature of both positive and negative influences of bias on collaboration in diverse settings.

Qualitative analysis of medical student reflections on the implicit association test.

INTRODUCTION: Health professions educators use the Implicit Association Test (IAT) to raise awareness of implicit bias in learners, often engendering strong emotional reactions. Once an emotional reaction ensues, the gap between learner reaction and strategy identification remains relatively underexplored. To better understand how learners may identify bias mitigation strategies, the authors explored perspectives of medical students during the clinical portion of their training to the experience of taking the IAT, and the resulting feedback. METHODS: Medical students in Bronx, NY, USA, participated in one 90-minute session on implicit bias. The focus of analysis for this study is the post-session narrative assignment inviting them to take the race-based IAT and describe both their reaction to and the implications of their IAT results on their future work as physicians. The authors analysed 180 randomly selected de-identified essays completed from 2013 to 2019 using an approach informed by constructivist grounded theory methodology. RESULTS: Medical students with clinical experience respond to the IAT through a continuum that includes their reactions to the IAT, acceptance of bias along with a struggle for strategy identification, and identification of a range of strategies to mitigate the impact of bias on clinical care. Results from the IAT invoked deep emotional reactions in students, and facilitated a questioning of previous assumptions, leading to paradigm shifts. An unexpected contrast to these deep and meaningful reflections was that students rarely chose to identify a strategy, and those that did provided strategies that were less nuanced. CONCLUSION: Despite accepting implicit bias in themselves and desiring to provide unbiased care, students struggled to identify bias mitigation strategies, a crucial prerequisite to skill development. Educators should endeavour to expand instruction to bridge the chasm between students' acceptance of bias and skill development in management of bias to improve the outcomes of their clinical encounters.

Twelve tips for teaching implicit bias recognition and management.

Implicit biases describe mental associations that affect our actions in an unconscious manner. We can hold certain implicit biases regarding members of certain social groups. Such biases can perpetuate health disparities by widening inequity and decreasing trust in both healthcare and medical education. Despite the widespread discourse about bias in medical education, teaching and learning about the topic should be informed by empirical research and best practice. In this paper, the authors provide a series of twelve tips for teaching implicit bias recognition and management in medical education. Each tip provides a specific and practical strategy that is theoretically and empirically developed through research and evaluation. Ultimately, these twelve tips can assist educators to incorporate implicit bias instruction across the continuum of medical education to improve inequity and advance justice.

Lost together: Experiences of family physicians with emerging adult mental health.

OBJECTIVE: To explore the perceptions and experiences of FPs with emerging adult (EA) mental health to inform opportunities for improvement in EA mental health care. DESIGN: Constructivist grounded theory methodology, including theoretical sampling and constant comparative analysis of data to synthesize results. SETTING: Southwestern Ontario. PARTICIPANTS: Twenty practising FPs. METHODS: In-depth, semistructured, in-person interviews, which were audiorecorded and transcribed verbatim. MAIN FINDINGS: Family physicians recognized the unique situation of EAs being between adolescence and adulthood, having heavy psychosocial needs, and lacking a connection to the health care system. Experience and confidence are needed to treat the EA population, but provision of mental health care to EAs is influenced by resources, knowledge, and communication. Family physicians noted that they are the default physician while EAs wait for specialized care, and are often the physicians that the patient is referred back to after specialized care. Often, the FP knows and treats the EA's entire family, which participants described as enabling them to understand the EA's unique context. CONCLUSION: Family physicians and EAs are "lost together" in a fragmented health care system. Family physicians have the unique potential to assist EAs with their mental health needs, but that is not being actualized. Family physicians can support mental health outcomes for EAs through an improvement in knowledge and skills, and through forming family practice teams.

Implicit Stigma Recognition and Management for Health Professionals.

OBJECTIVE: Stigma against individuals with mental illness has disastrous consequences for patient outcomes. Better approaches to reducing stigma in health care professionals are required. Implicit stigma education is an emerging area of research that may inform the design and implementation of stigma reduction programs. In this "in brief report," the authors describe the evaluation of a novel implicit stigma reduction workshop for health professionals. METHODS: The authors conducted a realist evaluation using a longitudinal multiple case study approach. Once a conceptual model was established, three case studies were conducted on physicians and nurses (n = 69) at an academic health sciences center. Within each case, pre- and post-attitudinal scales and qualitative data from semi-structured interviews were used. Consistent with realist evaluation principles, context-mechanism-outcome configuration patterns were analyzed. RESULTS: An implicit stigma recognition and management workshop produced statistically significant changes in participant attitudes in two out of three contexts. The qualitative evaluation described the perceptions of sustainable changes in perspective and practice. The degree to which individual participants learned with and worked among inter-professional teams influenced outcomes. CONCLUSIONS: Implicit stigma recognition and management is a useful educational strategy for reducing stigma among health professionals. Once stigma is recognized, curricular interventions may promote behavioral change by encouraging explicit alternative behaviors that are sustained through social reinforcement within inter-professional teams.

Adaptive reinventing: implicit bias and the co-construction of social change.

Emerging research on implicit bias recognition and management within health professions describes individually focused educational interventions without considering workplace influences. Workplace learning theories highlight how individual agency and workplace structures dynamically interact to produce change within individuals and learning environments. Promoting awareness of individual biases shaped by clinical learning environments may therefore represent a unique type of workplace learning. We sought to explore how individuals and the workplace learning environment interact once awareness of implicit biases are triggered within learners. In accordance with longitudinal case study methodology and informed by constructivist grounded theory, we conducted multiple longitudinal interviews with physician and nurse participants over 12 months. Our results suggest that implicit bias recognition provokes dissonance among participants leading to frustration, and critical questioning of workplace constraints. Once awareness is triggered, participants began reflecting on their biases and engaging in explicit behavioural changes that influenced the perception of structural changes within the learning environment itself. Collaboration, communication and role modeling within teams appeared to facilitate the process as individual and workplace affordances were gradually transformed. Our findings suggest a potential model for understanding how individual learners adaptively reinvent their role in response to disruptions in their learning environment.

Precision Education and Equity: A Participatory Framework to Advance Equitable Assessment.

ABSTRACT: Precision education (PE) may hold promise for the future of the field. Leveraging data and learning analytics to foster continuous improvement of individuals, programs, and organizations seems like a potential mechanism to advance both medical education and health care delivery systems toward a more equitable future. However, PE initiatives may also have unintended consequences and perpetuate inequities instead of ameliorating them. Although there have been some principles, ideas, and suggestions on how PE implementation may promote equity-particularly for the field of assessment-there is a lack of practical and evidence-informed guidance to support a more equitable and participatory approach to PE implementation. This paper provides actionable recommendations on how PE may advance equitable assessment. First, PE implementation must include democratizing access and ownership while enhancing literacy and transparency. Open and transparent access to both data and PE technology has the potential to enhance PE by fostering greater participation, rigor, and potential innovation. Transparency may also safeguard the use of assessment data for equitable purposes. Second, PE implementation must be cocreated with diverse learners. PE has the potential to empower learners if they are given an opportunity to participate in the development, application, and implementation of PE. Overall, a participatory approach to PE implementation has the potential to improve equitable assessment.

A Mixed Methods Study of Perceptions of Mental Illness and Self-Disclosure of Mental Illness Among Medical Learners.

Introduction: Mental illness stigma remains rooted within medical education and healthcare. We sought to measure perceptions toward mental illness and explore perceptions of self-disclosure of mental illness in medical learners. Method: In a mixed-methods, sequential design, authors recruited medical learners from across Canada. Quantitative data included the Opening Minds Scale for Healthcare providers (OMS-HC), the Self Stigma of Mental Illness Scale (SSMIS), and a wellbeing measure. Qualitative data included semi-structured interviews, which were collected and analyzed using a phenomenological approach. Results: N = 125 medical learners (n = 67 medical students, n = 58 resident physicians) responded to our survey, and N = 13 participants who identified as having a mental illness participated in interviews (n = 10 medical students, n = 3 resident physicians). OMS-HC scores showed resident physicians had more negative attitudes towards mental illness and disclosure (47.7 vs. 44.3, P = 0.02). Self-disclosure was modulated by the degree of intersectional vulnerability of the learner's identity. When looking at self-disclosure, people who identified as men had more negative attitudes than people who identified as women (17.8 vs 16.1, P = 0.01) on the OMS-HC. Racially minoritized learners scored higher on self-stigma on the SSMIS (Geometric mean: 11.0 vs 8.8, P = 0.03). Interview data suggested that disclosure was fraught with tensions but perceived as having a positive outcome. Discussion: Mental illness stigma and the individual process of disclosure are complex issues in medical education. Disclosure appeared to become more challenging over time due to the internalization of negative attitudes about mental illness.

Shifting paradigms: A collective and structural strategy for addressing healthcare inequity.

Healthcare inequity is a persistent systemic problem, yet many solutions have historically focused on "debiasing" individuals. Individualistic strategies fit within a competency-based medical education and assessment paradigm, whereby professional values of social accountability, patient safety, and healthcare equity are linked to an individual clinician's competence. Unfortunately, efforts to realise the conceptual linkages between medical education curricula and goals to improve healthcare equity fail to address the institutional values, policies, and practices that enable structural racism. In this article, we explore alternative approaches that target collective and structural causes of health inequity. We first describe the structural basis of healthcare inequity by identifying the ways in which institutional culture, power and privilege erode patient-centred care and contribute to epistemic injustice. We then outline some reasons that stereotypes, which are a culturally supported foundation for discrimination, bias and racism in healthcare, cannot be modified effectively through individualistic strategies or education curricula. Finally, we propose a model that centres shared values for leadership by individuals and institutions with consistency in goal setting, knowledge translation, and talent development. Figure 1 summarises the key recommendations. We have provided cases to supplement this work and facilitate discussion about the model's application to practice.

Disorienting or Transforming? Using the Arts and Humanities to Foster Social Advocacy.

Introduction: The arts and humanities (AH) have transformative potential in medical education. Research suggests that AH-based pedagogies may facilitate both personal and professional transformation in medical learners, which may then further enhance the teaching and learning of social advocacy skills. However, the potential for such curricula to advance social advocacy training remains under-explored. Therefore, we sought to identify how AH may facilitate transformative learning of social advocacy in medical education. Methods: Building upon previous research, we conducted a critical narrative review seeking examples from the literature on how AH may promote transformative learning of social advocacy in North American medical education. Through a search of seven databases and MedEdPORTAL, we identified 11 articles and conducted both descriptive and interpretative analyses of their relation to key tenets of transformative learning, including: disorientation/dissonance, critical reflection, and discourse/dialogue. Results: We found that AH are used in varied ways to foster transformative learning in social advocacy. However, most approaches emphasize their use to elicit disorientation and dissonance; there is less evidence in the literature regarding how they may be of potential utility when applied to disorienting dilemma, critical reflection, and discourse/dialogue. Discussion: The tremendous potential of AH to foster transformative learning in social advocacy is constrained due to minimal attention to critical reflection and dialogue. Future research must consider how novel approaches that draw from AH may be used for more robust engagement with transformative learning tenets in medical education.