The need for critical and intersectional approaches to equity efforts in postgraduate medical education: A critical narrative review.

BACKGROUND: Racialised trainees in Canada and the USA continue to disproportionately experience discrimination and harassment in learning environments despite equity, diversity, and inclusion (EDI) reform efforts. Using critical approaches to understand what problems have been conceptualised and operationalised as EDI issues within postgraduate medical education (PGME) is important to inform ongoing learning environment reform in resident training. METHODS: We conducted a critical narrative review of EDI literature from 2009-2022 using critical race theory (CRT) and the concept of intersectionality to analyse how issues of discrimination in PGME have been studied. Our search yielded 2244 articles that were narrowed down to 349 articles for relevance to Canadian and American PGME contexts. We attended to reflexivity and our positionality in analysing the database and identifying themes related to EDI reform. RESULTS: Interest convergence was noted in how EDI reform was rationalised primarily by increased productivity. Problems of learner representation, gender inequities and curricular problems were conceptualised as EDI issues. The role that racism played in EDI-related problems was largely invisible, as were explicit conceptualisations of race and gender as social constructs. Overall, there was a lack of critical or intersectional approaches in the literature reviewed. Misalignment was noted where studies would frame a problem through a critical lens, but then study the problem without attention to power. DISCUSSION: Interest convergence and epistemic injustice can account for the absence of critical approaches due to the alignment of existing EDI work with institutional interests and priorities. Interest convergence conceptually limits existing EDI reform efforts in PGME. CRT and intersectionality connect racialised learner experiences to systemic phenomena like racism and other forms of discrimination to challenge dominant assumptions. Because they attend to power, critical approaches are key to understanding why inequities have persisted to advance equity in learning environments for racialised and intersectionally marginalised learners.

Detour or New Direction: The Impact of the COVID-19 Pandemic on the Professional Identity Formation of Postgraduate Residents.

PURPOSE: The COVID-19 pandemic has resulted in numerous disruptions to health professions education training programs. Much attention has been given to the impact of these disruptions on formal learning opportunities in training; however, little attention has been given to the impact on professional socialization and professional identity formation. This study explored the impact of the pandemic and resultant curricular changes on the professional identity of family medicine residents. METHOD: 23 family medicine residents at the University of Toronto were interviewed between September 2020 and September 2022. Using symbolic interactionism as a theoretical framework, thematic analysis explored the meanings residents attributed to both experiences that were disrupted due to the pandemic, and new experiences that resulted from these disruptions. RESULTS: Participant responses reflected that disruptions in training did not always align with their expectations for family medicine and plans for future practice; however, these new experiences also reinforced their understanding of what it means to be a family physician. While participants felt the pandemic represented a loss of agency and negatively impacted relationships in their training program, it also provided a sense of belonging and membership in their profession. Finally, these new experiences continually blurred the line between professional and personal identities through the impact of the pandemic on participants' sense of well-being and safety. CONCLUSIONS: The impact of the pandemic on training experiences extends beyond the loss of formal learning opportunities. Participant responses reflect the collective influence of the formal, informal, and hidden curriculum on the professional socialization and professional identity formation of residents-and how these different curricular influences were disrupted due to the pandemic. These training experiences have important implications for the future practice of residents who completed their training during the pandemic and highlight the role of training programs in supporting the professional identity formation of residents.

Constructing "Burnout": A Critical Discourse Analysis of Burnout in Postgraduate Medical Education.

PURPOSE: In 1974, Dr. Herbert Freudenberger coined the term burnout. With the creation of the Maslach Burnout Inventory in 1984, burnout went from a pop psychology term to a highly studied phenomenon in medicine. Exponential growth in studies of burnout culminated in its adoption into the International Classification of Diseases-11 in 2022. Yet, despite increased awareness and efforts aimed at addressing burnout in medicine, many surveys report burnout rates have increased among trainees. The authors aimed to identify different discourses that legitimate or function to mobilize burnout in postgraduate medical education (PGME), to answer the question: Why does burnout persist in PGME despite efforts to ameliorate it? METHOD: Using a Foucauldian discourse analysis, this study examined the socializing period of PGME as an entry point into burnout's persistence. The archive from which the discourses were constructed included over 500 academic articles, numerous policy documents, autobiographies, videos, documentaries, social media, materials from conferences, and threads in forums including Reddit. RESULTS: This study identified 3 discourses of burnout from 1974-2019: burnout as illness, burnout as occupational stress, and burnout as existentialism. Each discourse was associated with statements of truth, signs and signifiers, roles that individuals play within the discourse, and different institutions that gained visibility as a result of differing discourses. CONCLUSIONS: Burnout persists despite effort to ameliorate it because it is a productive construct for organizations. In its current form, it depoliticizes issues of health in favor of wellness and gives voice to the challenge of making meaning from the experience of being a clinician.

Conceptualizations of "good death" and their relationship to technology: A scoping review and discourse analysis.

Background and Aims: By the 1960s, medicine experienced technological revolutions that enabled it to control and medicalize death in many circumstances. The modern conceptualization of "good death" emerged in the late 1960s with the beginning of the hospice movement, and palliative care became an official medical specialty in 1987. This project aims to elucidate how the idea of "good death" has been discussed and perceived since then, as well as the impact of medical technologies on death. Methods: The terms "good death," "technology," and "palliative care" were searched. One hundred ninety English sources that discussed "good death" explicitly or implicitly, published between 1987 and 2020, were included in the final analysis. Texts were analyzed for discursive themes related to "good death" and technology and demographic data related to authors, geographies, types of text, and date of publication. Results: The discourse of a "good death" with the patient being in control dominated the archive. Other discourses include a good death being peaceful and comfortable, one where the patient is not alone, and one that is not prolonged. Medical technology discourses are largely negative in the setting of death. Conclusion: Findings indicate a strong critique of the medicalization of death in the literature. This also complements the dominance of discourses on patient autonomy. Medical discourses of "good death" and technology permeate discussion outside of the healthcare context, and there is an absence of spirituality and neutrality in "good death" discourses. The results of this study are relevant for ethics and communication in geriatric and palliative care.

On the advantages and disadvantages of virtual continuing medical education: a scoping review.

Introduction: With the COVID-19 pandemic, most continuing medical education activities became virtual (VCME). The authors conducted a scoping review to synthesize the advantages and disadvantages of VCME to establish the impact of this approach on inequities that physicians face along the intersections of gender, race, and location of practice. Methods: Guided by the methodological framework of Arksey and O'Malley, the search included six databases and was limited to studies published between January 1991 to April 2021. Eligible studies included those related to accredited/non-accredited post-certification medical education, conferences, or meetings in a virtual setting focused on physicians. Numeric and inductive thematic analyses were performed. Results: 282 studies were included in the review. Salient advantages identified were convenience, favourable learning formats, collaboration opportunities, effectiveness at improving knowledge and clinical practices, and cost-effectiveness. Prominent disadvantages included technological barriers, poor design, cost, lack of sufficient technological skill, and time. Analysis of the studies showed that VCME was most common in the general/family practice specialty, in suburban settings, and held by countries in the Global North. A minority of studies reported on gender (35%) and race (4%). Discussion: Most studies report advantages of VCME, but disadvantages and barriers exist that are contextual to the location of practice and medical subspecialty. VCME events are largely organized by Global North countries with suboptimized accessibility for Global South attendees. A lack of reported data on gender and race reveals a limited understanding of how VCME affects vulnerable populations, prompting potential future considerations as it evolves.

Introduction: Par suite de la pandémie de la COVID-19, la plupart des activités de formation médicale continue ont été offertes en ligne. Les auteurs ont effectué une revue exploratoire de la littérature visant à faire la synthèse des avantages et des inconvénients de la formation médicale continue en mode virtuel (FMCV) et à évaluer les effets de cette approche sur les inégalités qui affectent les médecins en fonction du sexe, de la race et du lieu d'exercice. Méthodes: Suivant le cadre méthodologique d'Arksey et O'Malley, nous avons effectué une recherche dans six banques de données, que nous avons limitée aux études publiées entre janvier 1991 et avril 2021. Les études incluses étaient celles relatives à la formation médicale post-certification, accréditée ou non, aux conférences et aux réunions destinées aux médecins qui se sont déroulées dans un cadre virtuel. Une analyse numérique et une analyse thématique inductive ont été réalisées. Résultats: Au total, 282 articles ont été inclus dans l'étude. Les principaux avantages identifiés sont la commodité, les formats favorables à l'apprentissage, les possibilités de collaboration, l'efficacité pour l'amélioration des connaissances et des pratiques cliniques et le rapport coût-efficacité. Les principaux inconvénients sont les obstacles technologiques, les défauts de conception, le coût, les compétences technologiques insuffisantes et le manque de temps. L'analyse des études a montré que la FMCV était plus courante dans la spécialité de la médecine générale/familiale, dans les banlieues et dans les pays du Nord. Quelques études prennent en compte sexe (35 %) et race (4 %). Discussion: La plupart des études évoquent les avantages de la FMCV, mais il existe des inconvénients et des obstacles liés au lieu de pratique et à la surspécialité médicale. La plupart des activités de FMCV sont organisées dans les pays du Nord et leur accessibilité n'est pas optimale pour les participants provenant des pays du Sud. Le manque de données sur e sexe et la race des participants limite à notre compréhension de la façon dont la FMCV affecte les populations vulnérables. Ces facteurs seraient à prendre en considération dans les recherches futures sur le sujet au fur et à mesure que la FMCV évolue.

What makes a 'good doctor'? A critical discourse analysis of perspectives from medical students with lived experience as patients.

What constitutes a 'good doctor' varies widely across groups and contexts. While patients prioritise communication and empathy, physicians emphasise medical expertise, and medical students describe a combination of the two as professional ideals. We explored the conceptions of the 'good doctor' held by medical learners with chronic illnesses or disabilities who self-identify as patients to understand how their learning as both patients and future physicians aligns with existing medical school curricula. We conducted 10 semistructured interviews with medical students with self-reported chronic illness or disability and who self-identified as patients. We used critical discourse analysis to code for dimensions of the 'good doctor'. In turn, using concepts of Bakhtinian intersubjectivity and the hidden curriculum we explored how these discourses related to student experiences with formal and informal curricular content.According to participants, dimensions of the 'good doctor' included empathy, communication, attention to illness impact and boundary-setting to separate self from patients. Students reported that formal teaching on empathy and illness impact were present in the formal curriculum, however ultimately devalued through day-to-day interactions with faculty and peers. Importantly, teaching on boundary-setting was absent from the formal curriculum, however participants independently developed reflective practices to cultivate these skills. Moreover, we identified two operating discourses of the 'good doctor': an institutionalised discourse of the 'able doctor' and a counterdiscourse of the 'doctor with lived experience' which created a space for reframing experiences with illness and disability as a source of expertise rather than a source of stigma. Perspectives on the 'good doctor' carry important implications for how we define professional roles, and hold profound consequences for medical school admissions, curricular teaching and licensure. Medical students with lived experiences of illness and disability offer critical insights about curricular messages of the 'good doctor' based on their experiences as patients, providing important considerations for curriculum and faculty development.

Ideological dilemmas of healthcare professionals who do not speak up at interprofessional team meetings.

In healthcare settings, speaking up is considered essential for patient safety. Indeed, voice opportunities are widely available mandatory mechanisms for speaking up at the routine interprofessional team meetings of our study site. Yet, healthcare professionals in team meetings often do not go beyond straightforward reporting of test results and biomedical-functional parameters, suggesting that members with psycho-social information related to the patient are not participating fully in team meetings. Post-meeting interviews with some of the team members revealed the moments of silence and the ideological contradictions underlying team discussions. We explored silences and contradictions as argumentative meanings inherent in naturally occurring speech. The identification of opposing meanings tells of ideological dilemmas that may explain why healthcare practitioners do not speak up vigorously. We identified three such dilemmas: the ideology of working in teams versus the ideology of working solo; the ideology of autonomy versus the ideology of paternalism; and the ideology of collectivism versus the ideology of individuality. The dilemmas made visible the dimensions of silence as well as silencing as an imposition of silence from above. We suggest focussing on mapping disciplinary and interpretive differences and their effects amongst team members may motivate voice. Further studies should explore the affective dimensions of silence in interprofessional team meetings.

Factors Influencing Professional Identity Construction in Fourth-Year Pharmacy Students.

Objectives. To explore the key factors that influence professional identity construction in fourth-year pharmacy students enrolled in a Doctor of Pharmacy program.Methods. A single-site instrumental case study of current fourth-year pharmacy students from the Leslie Dan Faculty of Pharmacy, University of Toronto, was used. Thirteen students participated in semistructured interviews. Poststructural social identity theories were used to analyze the data and identify themes that influence identity construction in pharmacy students.Results. Data analysis identified five overarching themes that influence pharmacy student professional identity construction: path to pharmacy, curriculum, environment, preceptors, and patient interactions. The Leslie Dan Faculty of Pharmacy curriculum prioritized the health care provider identity, which influenced the students desire to "become" clinicians. Based on their internalized health care provider identity, they rejected preceptors and practice environments that negatively impacted their ability to embody this identity.Conclusion. The findings of this study suggest that pharmacy students align themselves strongly with health care provider identities at the cost of other potentially relevant identities. Pharmacy education programs may benefit from curricular reforms that incorporate and legitimize multiple pharmacist identities to ensure a strong pharmacy workforce for the future.

Protection, freedom, stigma: a critical discourse analysis of face masks in the first wave of the COVID-19 pandemic and implications for medical education.

Background: The COVID-19 pandemic has spotlighted the face mask as an intricate object constructed through the uptake of varied and sometimes competing discourses. We investigated how the concept of face mask was discursively deployed during the first phase of the COVID-19 pandemic. By examining the different discourses surrounding the use of face masks in public domain texts, we comment on important educational opportunities for medical education. Method: We applied critical discourse methodology to look for key phrases related to face masks that can be linked to specific socio-economic and educational practices. We created an archive of 171 English and Mandarin texts spanning the period of February to July 2020 to explore how discourses in Canada related to discourses of mask use in China, where the pandemic was first observed. We analyzed how the uptake of discourses related to masks was rationalized during the first phase of the pandemic and identified practices/processes that were made possible. Results: While the face mask was initially constructed as personal protective equipment, it quickly became a discursive object for rights and freedoms, an icon for personal expression of political views and social identities, and a symbol of stigma that reinforced illness, deviance, anonymity, or fear. Conclusion: Discourses related to face masks have been observed in public and institutional responses to the pandemic in the first wave. Finding from this research reinforce the need for medical schools to incorporate a broader socio-political appreciation of the role of masks in healthcare when training for pandemic responses.

Contexte: La pandémie de la COVID-19 a mis en lumière le masque facial comme sujet complexe, construit par des discours variés et parfois contradictoires. Nous avons étudié la manière dont le concept du masque a été déployé discursivement pendant la première phase de la pandémie, notamment en examinant les différents discours entourant son utilisation dans des textes du domaine public, tout en relevant d'importantes perspectives pédagogiques qui en découlent pour l'éducation médicale. Méthode: Adoptant l'approche de l'analyse critique du discours, nous avons dégagé des énoncés clés qui peuvent être liés à des pratiques socio-économiques et éducatives précises. Nous avons créé une archive de 171 textes en anglais et en mandarin couvrant la période de février à juillet 2020 afin de comparer les discours sur le port du masque au Canada et en Chine, où la pandémie a été observée pour la première fois. Nous avons analysé la rationalisation du port du masque par le discours, ainsi que les pratiques et procédures qu'elle a permis de mettre en place lors de la première vague de la pandémie. Résultats: Alors qu'au départ, le masque était destiné à servir d'équipement de protection individuelle, il est rapidement devenu un objet discursif lié aux droits et libertés, un étendard du droit de la personne d'exprimer ses opinions politiques et son identité sociale, et un symbole de la stigmatisation qui renforçait la maladie, la déviance, l'anonymat ou la peur. Conclusion: L'analyse des discours relatifs au port du masque observés dans les réponses publiques et institutionnelles à la première vague de la COVID-19 confirme la nécessité pour les facultés de médecine d'intégrer dans l'enseignement de la gestion pandémique une appréciation sociopolitique plus large du rôle du masque en santé.

Evolving discourses of COVID-19 and implications for medical education: a critical discourse analysis.

Background: The othering of individuals has been identified as a concern during the COVID-19 pandemic. The purpose of this study was to examine public commentary during early stages of the pandemic for: 1) emerging discourses that highlighted population-level inequities, and 2) the implications these discourses may have for medical education. Methods: Using a critical discourse analysis (CDA) approach, an archive of texts available in the public domain discussing COVID-19 was iteratively created, reviewed, and coded. We used an intersectional framework to analyze how COVID-19 highlighted structural and institutional inequity at the population level. Results: We found 86 representative texts published from March to June 2020. We focused our analysis on implications within Ontario. The two major discourses that emerged were "COVID-19 as Equalizer" and "COVID-19 as Discriminator." The former emerged in the early stages of the pandemic to mobilize public health recommendations and describe near-universal impacts on the public. The latter followed to highlight new and pre-existing forms of marginalization exacerbated by the pandemic. Conclusions: This study provides a unique perspective on how structural and systemic responses to COVID-19 were shaped through analysis of public discourse, and therefore, has implications for how the COVID-19 pandemic and future pandemics are framed for future medical learners.

Contexte: L'altérisation a été soulevée comme effet préoccupant de la pandémie de la COVID-19. L'objectif de cette étude était d'examiner les réactions du public au cours des premiers stades de la pandémie afin de dégager : 1) les discours émergents témoignant d'inégalités au sein de la population, et 2) les incidences potentielles de ces discours sur l'éducation médicale. Méthodes: L'approche adoptée est celle de l'analyse critique du discours (ACD). Nous avons constitué une archive de textes du domaine public contenant des commentaires relatifs à la COVID-19, que nous avons examinés, codés de manière itérative et analysés transversalement pour déceler dans quelle mesure la pandémie a mis en évidence les inégalités structurelles et institutionnelles au sein de la population. Résultats: Nous avons trouvé 86 textes représentatifs publiés entre mars et juin 2020. Nous avons concentré notre analyse sur les incidences en Ontario. Les deux principaux discours qui ont émergé sont «la COVID-19 comme facteur égalisateur¼ et «la COVID-19 comme facteur discriminant¼. Le premier est apparu au début de la pandémie pour inciter au respect des recommandations de santé publique et pour décrire les effets quasi universels sur la population. Il a été suivi par un second discours, mettant en lumière les formes nouvelles et préexistantes de marginalisation exacerbées par la pandémie. Conclusions: Cette étude offre une perspective unique de la pandémie telle qu'elle est perçue par le biais d'une analyse du domaine public. Elle peut donc éclairer la manière de présenter la gestion des pandémies aux futurs apprenants en médecine.

Transformative learning in the setting of religious healers: A case study of consultative mental health workshops with religious healers, Ethiopia.

Objective: Psychiatric interventions that consider the socio-cultural and spiritual traditions of patients are needed to address stigma and improve access to mental health services. Productive collaboration between traditional healers and biomedical practitioners hold promise in such efforts, and applying tenets of transformative learning hold potential for mitigating an overemphasis on biomedical models in such collaboration. We present a framework for how to engage in health system reform to enhance mental health services in communities that are distrustful of, or unfamiliar with biomedical approaches. Our research question was how to bridge two seemingly opposing paradigms of mental health care, and we sought to understand how the theory of transformational learning (TLT) can be applied to learning among Religious healers and biomedical practitioners in culturally appropriate ways to improve collaboration. Methods: TLT informed the development, implementation, and evaluation of an educational intervention in Addis Ababa, Ethiopia that aimed to improve delivery of mental health services at two Holy water sites. The initiative involved both psychiatrists and religious healers with extensive experience providing care to mentally ill patients. Using a focused ethnographic approach that incorporates document analysis methodology, this qualitative study examined recordings and minutes of stakeholder meetings, workshops and informal interviews with participants, analyzed for evidence of Mezirow's 11 stages of transformative learning. A participatory action approach was used to encourage practice change. Results: All participants exhibited a high degree of engagement with the of the collaborative project and described experiencing "disorienting dilemmas" by Mezirow's classic description. Opportunities to reflect separately and in large groups encouraged a re-examination of attitudes previously contributing to siloed approaches to care and led to instrumental changes in mental health care delivery and a higher degree of coordination and collaboration between psychiatrists and traditional healers. Conclusion: Our study demonstrates the utility of TLT in both the design and evaluation of initiatives aiming to bridge cross-cultural and cross-professional divides. The learning process was further enhanced by a collaborative participatory action model adjusted to accommodate Ethiopian socio-political and cultural relations.

Re-thinking "I"dentity in medical education: genealogy and the possibilities of being and becoming.

Professional identity formation has emerged as a key topic for medical education research, with contributions from perspectives of psychological development and socialization opening up needed conversations in the field. Yet mainstream training practices may have the unintended effects of educating for a physician typology that may be too narrow to account for the complexity of learners' personal identities. Alternative approaches, such as Foucauldian genealogy, offer ways to empirically investigate how the legitimate contours of being and becoming have come to be as they are, how they shape professional identities, and to which degree their borders may be made more inclusive. Drawing upon an example of the contemporary practice of competency-based medical education in the Canadian context, this paper considers how genealogy's methodological tools of critical distancing, the dispositif, and problematization may help reveal how educational practices shape the identities of physicians-in-training in ways both intended and unintended. From this perspective it becomes apparent that any attempt to explore professional identity is incomplete without also considering that a trainee's evolving sense of self is inexorably bound up with forces of knowledge, power, and ethics that shape them into becoming certain kinds of physician subjects rather than others. In mapping this terrain, a genealogical approach determines how we reached the now in which we find ourselves and how we might transform it, such that we may shift the possibilities afforded to health professionals to establish professional identities aligned with their personal identities in ways that maximize inclusivity and minimize marginalization.

(Re)producing "Whiteness" in Health Care: A Spatial Analysis of the Critical Literature on the Integration of Internationally Educated Health Care Professionals in the Canadian Workforce.

PURPOSE: There is a gap in the literature to understand how professionalizing systems intersect with socioeconomic and political realities such as globalization to (re)produce social inequities between those trained locally and those trained abroad. In this critical review, the question of how systemic racism is reproduced in health care is addressed. METHOD: Electronic databases and nontraditional avenues for searching literature such as reference chaining and discussions with experts were employed to build an archive of texts related to integration of internationally educated health care professionals (IEHPs) into the workforce. Data related to workplace racialization were sought out, particularly those that used antiracist and postcolonial approaches. Rather than an exhaustive summary of the data, a critical review contributes to theory building and a spatial analysis was overlayed on the critical literature of IEHP integration to conceptualize the material effects of the convergence of globalization and professional systems. RESULTS: The critical review suggests that professions maintain their value and social status through discourses of "Canadianness" that maintain the homogeneity of professional spaces through social closure mechanisms of credential nonrecognition and resocialization. Power relations are maintained through mechanisms of workplace racialization/spatialization and surveillance which operate through discourses of "foreign-trainedness." CONCLUSIONS: Movement of professionals supports a professional system that on the surface values diversity while maintaining its social status and power through the (re)production of the discourse of "Whiteness." The analysis shows how in the process domestic graduates are emplaced as the "rightful" citizens of professional paces while IEHPs are marginalized in the workforce.

Participation of women in the health workforce in the fragile and conflict-affected countries: a scoping review.

INTRODUCTION AND BACKGROUND: The full participation of women as healthcare providers is recognized globally as critical to favorable outcomes at all levels, including the healthcare system, to achieving universal health coverage and sustainable development goals (SDGs) by 2030. However, systemic challenges, gender biases, and inequities exist for women in the global healthcare workforce. Fragile and conflict-affected states/countries (FCASs) experience additional pressures that require specific attention to overcome challenges and disparities for sustainable development. FCASs account for 42% of global deaths due to communicable, maternal, perinatal, and nutritional conditions, requiring an appropriate health workforce. Consequently, there is a need to understand the impact of gender on workforce participation, particularly women in FCASs. METHODS: This scoping review examined the extent and nature of existing literature, as well as identified factors affecting women's participation in the health workforce in FCASs. Following Arksey and O'Malley's scoping review methodology framework, a systematic search was conducted of published literature in five health sciences databases and grey literature. Two reviewers independently screened the title and abstract, followed by a full-text review for shortlisted sources against set criteria. RESULTS: Of 4284, 34 sources were reviewed for full text, including 18 primary studies, five review papers, and 11 grey literature sources. In most FCASs, women predominate in the health workforce, concentrated in nursing and midwifery professions; medicine, and the decision-making and leadership positions, however, are occupied by men. The review identified several constraints for women, related to professional hierarchies, gendered socio-cultural norms, and security conditions. Several sources highlight the post-conflict period as a window of opportunity to break down gender biases and stereotypes, while others highlight drawbacks, including influences by consultants, donors, and non-governmental organizations. Consultants and donors focus narrowly on programs and interventions solely serving women's reproductive health rather than taking a comprehensive approach to gender mainstreaming in planning human resources during the healthcare system's restructuring. CONCLUSION: The review identified multiple challenges and constraints facing efforts to create gender equity in the health workforce of FCASs. However, without equal participation of women in the health workforce, it will be difficult for FCASs to make progress towards achieving the SDG on gender equality.

How pharmacists perceive their professional identity: a scoping review and discursive analysis.

OBJECTIVES: The objectives of this scoping review were to (a) explore how pharmacists perceive their professional roles and identities and (b) describe factors impacting which professional roles or identities pharmacists embody in different pharmacy practice settings. METHODS: A scoping review using a deductive approach was undertaken for this study. Systematic searches were conducted in five databases: Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, EBSCO Cumulative Index to Nursing and Allied Health and Scopus (Elsevier). Key words searched included pharmacist, identity, professional role and one variations of these. Results were double-blind screened for relevance by two authors. Data extraction was facilitated by the web-based software platform COVIDENCE. Foucauldian critical discourse analysis was used to deconstruct how pharmacists perceive their professional roles and identities. KEY FINDINGS: In total, 21 701 articles were retrieved in the search. Following de-duplication and screening, 23 studies from 11 different countries were included. Five major identity themes were identified: Clinician, Dispenser, Business Person, Patient Counsellor and Physician Supporter. The dispenser identity was the most widespread, but it was viewed by many pharmacists as undesirable. The clinician identity also had a strong presence but was viewed as an identity that pharmacists aspire to embody. CONCLUSIONS: This scoping review illustrates that pharmacists do not uniformly perceive themselves to be clinicians. A significant gap exists between the profession's desired identity and that embodied by practicing pharmacists. The resulting dissonance may be a contributing factor to the lack of wide-scale practice change that the profession has been seeking for decades.