Unravelling epistemic injustice in medical education: The case of the underperforming learner.

CONTEXT: Epistemic injustice refers to a wrong done to someone in their capacity as a knower. While philosophers have detailed the pervasiveness of this issue within healthcare, it is only beginning to be discussed by medical educators. The purpose of this article is to expand the field's understanding of this concept and to demonstrate how it can be used to reframe complex problems in medical education. METHODS: After outlining the basic features of epistemic injustice, we clarify its intended (and unintended) meaning and detail what is required for a perceived harm to be named an epistemic injustice. Using an example from our own work on introversion in undergraduate medical education, we illustrate what epistemic injustice might look like from the perspectives of both educators and students and show how the concept can reorient our perspective on academic underperformance. RESULTS: Epistemic injustice results from two things: (1) social power dynamics that give some individuals control over others, and (2) identity prejudice that is associated with discriminatory stereotypes. This can lead to one, or both, forms of epistemic injustice: testimonial and hermeneutical. Our worked example demonstrates how medical educators can be unaware of when and how epistemic injustice is happening, yet the effects on students' well-being and sense of selves can be profound. Thinking about academic underperformance with epistemic injustice in mind can reveal an emphasis within current educational practices on diagnosing learning deficiencies, to the detriment of holistically representing its socially constructed and structural nature. CONCLUSIONS: This article builds upon recent calls to recognise epistemic injustice in medical education by clarifying its terminology and intended use and providing in-depth application and analysis to a particular case: underperformance and the introverted medical student. Equipped with a more sophisticated understanding of the term, medical educators may be able to re-conceptualise long-standing issues including, but also beyond, underperformance.

Researching lived experience in health professional education.

INTRODUCTION: Qualitative approaches have flourished in medical education research. Many research articles use the term 'lived experience' to describe the purpose of their study, yet we have noticed contradictory uses and misrepresentations of this term. In this conceptual paper, we consider three sources of these contradictions and misrepresentations: (1) the conflation of perspectives with experiences; (2) the conflation of experience with lived experience; and (3) the conflation of researching lived experience with phenomenology. We offer suggestions to facilitate more precise use of terminology. ARGUMENT: Our starting point is to free researchers from unnecessary shackles: Not every problem in medical education should be studied through experience, nor should every study of experience be phenomenological. Data based on participants' perceptions, beliefs, opinions and thoughts, while based on reflections of experiences, are not in and of themselves accounts of experience. Lived experiences are situated, primal and pre-reflective; perspectives are more abstract. Lived experience-as opposed to experiences as such-deeply attune to bodies, relationality, space and time. There is also a difference between experiences as lived, how a person makes sense of these and what the researcher interprets and represents. Phenomenology is a meaningful approach to the study of lived experience, but other approaches, such as narrative inquiry and self-study, can also offer useful avenues for undertaking this type of research. DISCUSSION: We aim to broaden researchers' scope with this paper and equip researchers with the information they need to be clear about the meaning and use of the terms experience and lived experience. We also hope to open new methodological possibilities for researching experiences as lived and, through highlighting tensions, to prompt researchers of lived experience to strive for ontological closeness and resonance.

Two-Dimensional Deaths? A Discourse Analysis of Patient Death in Preclinical Tutorial Cases at a Canadian Medical School.

Introduction: The prospect of death is everywhere, but seldom directly addressed, in undergraduate medical education (UGME). Despite calls for UGME curricula to address the complex social and emotional aspects of death and dying, most curricula focus on biomedical, legal, and logistical aspects, or concentrate these topics within palliative care content and/or in simulations with simulated patients and manikins. We aimed to add to death education scholarship by exploring the complexities of death and dying within two dimensional simulations-i.e., in the text-based cases used in Case-Informed-Learning (CIL). Method: We conducted a critical discourse analysis exploring how death and dying were discursively constructed in the formal, planned curriculum at one medical school. We used two methods: (1) Document Analysis: We developed a template to analyze 127 cases regarding their discursive constructions of death and dying; (2) Longitudinal Interviewing: We conducted semi-structured interviews with a cohort of 12 medical students, twice annually throughout their medical program (total 92 interviews). We collectively analyzed data, attuning to how the format, content, and purpose of each case discursively constructed death and dying. Results: There were 127 tutorial cases included in the undergraduate, pre-clerkship case-informed curriculum. In the five (4%) cases featuring a patient who dies, death and dying were discursively constructed as: (1) predictable; (2) a plot device; (3) a cautionary tale; (4) an epilogue; (5) deliberate and careful; and (6) an absence. Very few cases highlighted death and dying in their titles, learning objectives, or questions, and where it did feature, it was framed a biomedical fact or outcome. Only one case allowed for a nuanced, in-depth and open-ended discussion of patient death and dying, but it was scheduled at a time that prevented meaningful engagement. This glossing over the complexities of death was identified as a missed opportunity by students, who, as their clinical placements loomed, were eager to broach this topic in detail with tutors and other teaching faculty. Discussion: Death was often a conspicuous absence in this CIL curriculum. In the few cases that featured the death of the main patient character, multiple discourses were mobilized that worked together to construct death as something that happens elsewhere, outside the parameters of core curriculum. In other words, death happens-predictably, slowly, as a means to an end and the result of moral failures, in the case or somewhere in the future-but was not the primary concern. To deepen engagement with these subjects in CIL, we encourage medical educators to attend to representations of patient death by considering the format, content, purpose, and timing of these cases. Conclusion: Carefully rendered cases thoughtfully embedded in the curriculum offer tremendous potential. We suggest nuanced cases featuring patient death, with plenty of space and time for discussion, reflection, and storytelling may help address gaps in formal UGME preclinical curricula addressing death and dying.

Negotiating humanity: an ethnography of cadaver-based simulation.

Human body donation (HBD) serves an essential function in many medical schools, particularly in institutions where people engage in cadaver-based simulation (CBS) as a pedagogical approach. The people who facilitate HBD and CBS have a highly specialized skill set, yet their expertise remains largely unacknowledged, and takes place out of sight from the broader medical school community. This manuscript, based on a two-year practice-based ethnography (Structured Observations n = 68 h, Unstructured Observations n = 150 + hours; Interviews n = 24; and Document/Policy Analysis n = 14) illuminates the complex work of HBD. We identify three primary functions of HBD and CBS (1. Cadaver Intake & Administration, 2. Cadaver Preparation, and 3. Cadaver-Based Pedagogy). We describe how medical educators involved in CBS have developed a skillset specific to their role: negotiating humanity.

A phenomenological exploration of the impact of COVID-19 on the medical education community.

INTRODUCTION: The COVID-19 pandemic has caused unprecedented stress to the medical education community, potentially worsening problems like burnout and work-life imbalance that its members have long been grappling with. However, the collective struggle sparked by the pandemic could generate the critical reflection necessary for transforming professional values and practices for the better. In this hermeneutic phenomenological study, we explore how the community is adapting-and even reconceptualising-their personal and professional roles amidst the COVID-19 crisis. METHOD: Between April and October 2020, we conducted 27 (17F, 10M) semi-structured interviews with medical trainees (8), physicians (8), graduate students (3) and PhD scientists (8) working in medical education in Canada, the United States and Switzerland. Data analysis involved a variety of strategies, including coding for van Manen's four lifeworld existentials, reflexive writing and multiple team meetings. RESULTS: Participants experienced grief related to the loss of long-established personal and professional structures and boundaries, relationships and plans for the future. However, experiences of grief were often conflicting. Some participants also experienced moments of relief, perceiving some losses as metaphorical permissions slips to slow down and focus on their well-being. In turn, many reflected on the opportunity they were being offered to re-imagine the nature of their work. DISCUSSION: Participants' experiences with grief, relief and opportunity resonate with Ratcliffe's account of grief as a process of relearning the world after a significant loss. The dismantling of prior life structures and possibilities incited in participants critical reflection on the nature of the medical education community's professional practices. Participants demonstrated their desire for more flexibility and autonomy in the workplace and a re-adjustment of the values and expectations inherent to their profession. On both individual and systems levels, the community must ensure that long-standing calls for wellness and work-life integration are realised-and persist-after the pandemic is over.

Does Personality Matter? Perceptions and Experiences of Introverts and Extraverts as General Surgeons.

PHENOMENON: Medical educators increasingly recognize both the challenges introverts, compared to extraverts, may face in medical training and the unique strengths they bring to practice. However, few researchers have examined in-depth how introverts and extraverts truly experience training and practice, particularly in specialties like surgery that tend to value qualities (e.g., dominance and assertiveness) typically associated with extraverts. This study aimed to explore the perceptions and experiences of individuals with both personalities within the field of general surgery. APPROACH: Using a constructivist grounded theory approach, six general surgeons and 10 general surgery residents who identified as introverted, extraverted, or ambiverted were recruited from two Canadian tertiary care hospitals to participate in semi-structured interviews. Data collection and analysis occurred iteratively, and data were analyzed using open, selective, and thematic coding. Constant comparison allowed us to make sense of the similar and dissimilar views that emerged from each interview. FINDINGS: Irrespective of their personalities, participants voiced two general patterns of responses. Some participants believed that "personality doesn't matter": that both introverted and extraverted practice styles were equally viable and neither introverts nor extraverts would find surgical training more challenging than the other (culture of equality). However, others believed that "personality matters," emphasizing that surgeons should be dominant and aggressive leaders. Only those who believed "personality matters" felt that introverts sometimes needed to act more extraverted in order to succeed in surgical training (culture of hierarchy). Similar numbers of introverts and extraverts adhered to each viewpoint. INSIGHTS: Our qualitative approach allowed us to draw meaning from the complex subjective experiences of our research participants. Our findings suggest that two competing cultures (equality and hierarchy) co-exist within the field of surgery and that trainees, depending on which culture they adhere most to, will or will not "adapt" their personalities to the workplace. These findings deepen our understanding of the nuances of surgical culture and have important implications for how we select candidates based on personality.

The Lifecycle of a Clinical Cadaver: A Practice-Based Ethnography.

PhenomenonCadavers have long played an important and complex role in medical education. While research on cadaver-based simulation has largely focused on exploring student attitudes and reactions or measuring improvements in procedural performance, the ethical, philosophical, and experiential aspects of teaching and learning with cadavers are rarely discussed. In this paper, we shed new light on the fascinating philosophical moves in which people engage each and every time they find themselves face to face with a cadaver. ApproachOver a two-year period (2018/19-2019/20), we applied ethnographic methods (137 hours of observation, 24 interviews, and the analysis of 22 documents) to shadow the educational cadaver through the practical stages involved in cadaver-based simulation: 1. cadaver preparation, 2. cadaver-based skill practice with physicians and residents, and 3. interment and memorial services. We used Deleuze and Guattari's concepts of becoming and acts of creation to trace the ontological "lifecycle" of an educational cadaver as embedded within everyday work practices. FindingsWe delineated six sub-phases of the lifecycle, through which the cadaver transformed ontologically from person to donor, body, cadaver, educational cadaver, teacher, and loved one/legacy. These shifts involved a network of bureaucratic, technical, educational, and humanistic practices that shaped the way the cadaver was perceived and acted upon at different moments in the lifecycle. By highlighting, at each phase, 1) the ontological transitions of the cadaver, itself, and 2) the practices, events, settings, and people involved in each of these transitions, we explored questions of "being" as it related to the ontological ambiguity of the cadaver: its conceptualization as both person and tool, simultaneously representing life and death. InsightsEngaging deeply with the philosophical questions of cadaver-based simulation (CBS) helped us conceptualize the lifecycle as a series of meaningful and purposeful acts of becoming. Following the cadaver from program entry to interment allowed us to contemplate how its ontological ambiguity shapes every aspect of cadaver-based simulation. We found that in discussions of fidelity in medical simulation, beyond both the physical and functional, it is possible to conceive of a third type: ontological. The humanness of the cadaver makes CBS a unique, irreplaceable, and inherently philosophical, practice.

Questions of Well-Being and Inclusion in Online Undergraduate Medical Education During COVID-19: A 2-Phased Focused Scoping Review.

PURPOSE: Undergraduate medical education (UGME) was transformed by the rapid move to online curriculum delivery during the COVID-19 pandemic. Most research on online UGME has focused on measuring its effectiveness. However, medical educators also require evidence regarding its implications with respect to well-being and inclusion. METHOD: To explore online learning transition, particularly the effect on well-being and inclusion, this 2-phased focused scoping review employed a revised Joanna Briggs Institute approach: (1) developing review questions and objectives; (2) determining eligibility criteria; (3) developing the search strategy; (4) extracting, analyzing, and discussing findings; (5) drawing conclusions; and (6) discussing implications for practice and further research. RESULTS: The review ultimately included 217 articles, of which 107 (49%) explored student and staff well-being during online UGME, 64 (30%) focused on inclusion in this context, and 46 (21%) examined both well-being and inclusion. Additionally, 137 of included articles (63%) were research/evaluation, 48 (22%) were descriptive, and 32 (15%) were opinion. Of the 137 research/evaluation studies, 115 (84%) were quantitative, 10 (7%) were qualitative, 8 (6%) were mixed methods, and 4 (3%) were Reviews. Among these research/evaluation studies, the most commonly used data collection method was surveys (n = 120), followed by academic tests (n = 14). Other methods included interviews (n = 6), focus groups (n = 4), written reflections (n = 3), user data (n = 1), and blood tests (n = 1). CONCLUSIONS: Important questions remain regarding the safety and inclusiveness of online learning spaces and approaches, particularly for members of historically excluded groups and learners in low-resource settings. More rigorous, theoretically informed research in online medical education is required to better understand the social implications of online medical education, including more in-depth, qualitative investigations about well-being and inclusion and more strategies for ensuring online spaces are safe, inclusive, and supportive.

Case-Informed Learning in Medical Education: A Call for Ontological Fidelity.

Case-informed learning is an umbrella term we use to classify pedagogical approaches that use text-based cases for learning. Examples include Problem-Based, Case-Based, and Team-Based approaches, amongst others. We contend that the cases at the heart of case-informed learning are philosophical artefacts that reveal traditional positivist orientations of medical education and medicine, more broadly, through their centering scientific knowledge and objective fact. This positivist orientation, however, leads to an absence of the human experience of medicine in most cases. One of the rationales for using cases is that they allow for learning in context, representing aspects of real-life medical practice in controlled environments. Cases are, therefore, a form of simulation. Yet issues of fidelity, widely discussed in the broader simulation literature, have yet to enter discussions of case-informed learning. We propose the concept of ontological fidelity as a way to approach ontological questions (i.e., questions regarding what we assume to be real), so that they might centre narrative and experiential elements of medicine. Ontological fidelity can help medical educators grapple with what information should be included in a case by encouraging an exploration of the philosophical questions: What is real? Which (and whose) reality do we want to simulate through cases? What are the essential elements of a case that make it feel real? What is the clinical story we want to reproduce in case format? In this Eye-Opener, we explore what it would mean to create cases from a position of ontological fidelity and provide suggestions for how to do this in everyday medical education.

From struggle to opportunity: Reimagining medical education in a pandemic era.

The COVID-19 pandemic has disrupted the international medical education community in unprecedented ways. The restrictions imposed to control the spread of the virus have upended our routines and forced us to reimagine our work structures, educational programming and delivery of patient care in ways that will likely continue to change how we live and work for the foreseeable future. Yet, despite these interruptions, the pandemic has additionally sparked a transformative impulse in some to actively engage in critical introspection around the future of their work, compelling us to consider what changes could (and perhaps should) occur after the pandemic is over. Drawing on key concepts associated with scholar Paulo Freire's critical pedagogy, this paper serves as a call to action, illuminating the critical imaginings that have come out of this collective moment of struggle and instability, suggesting that we can perhaps create a more just, compassionate world even in the wake of extraordinary hardship.