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.

Feedback, learning and becoming: Narratives of feedback in complex performance challenges.

INTRODUCTION: Becoming a general practitioner (or family medicine specialist) is challenging, as trainees learn to manage complex and ambiguous situations. Feedback is a key component of this learning. Although research has tended to focus on feedback's momentary processes and impacts, there is value in seeking to understand the work it does over time and how trainees position themselves across multiple feedback encounters. We ask: how do newly qualified GPs narrate themselves and their experiences with complex performance challenges? Within these narratives, what is the role of feedback? METHODS: The research adopts a holistic and sequential narrative analysis approach, with in-depth narrative interviews of 16 general practice trainees who had just completed their training requirements. The analysis involved restorying the participant narratives chronologically. Each narrative formed a unit of analysis where narrative commonalities across plots, characters, emotions and the role of feedback were interpreted. RESULTS: Four plotlines within GP trainees' stories of complex performance challenges were identified: Journeyperson, Hero's Quest, Solo Journeyer and Endless Struggle. Trainees, supervisors and feedback are positioned differently within these plotlines. Narratives were saturated with emotions. DISCUSSION: The plotlines bring together an alternative way of understanding how feedback, learning and becoming are woven together. They illustrate how multiple interactions with patients, supervisors, peers and systems thread together into an overall trajectory. How a trainee positions themselves as protagonists and who they characterise as their antagonists can help direct the focus of supervisors' feedback conversations.

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.

Evaluative judgement in practice education: How does the ability to judge the quality of work impact placement performance?

INTRODUCTION: Occupational therapy students need to be ready to work autonomously in a range of environments as soon as they complete their degree. Practice education experiences are considered key to students developing the competencies that autonomous work requires. To function autonomously in practice environments, it is argued that practitioners need to be able to judge the quality of their own work and the work of others. This is referred to as evaluative judgement. However, there is limited empirical literature relating to evaluative judgement and even less exploring the concept within occupational therapy. METHODS: This study used qualitative methods, seeking to understand the evaluative judgements of clinical practice made by third- and fourth-year occupational therapy students during practice education. RESULTS: Twenty-one interviews were conducted with third- (n = 10) and fourth-year occupational therapy students (n = 1), university support staff supporting practice education (n = 4), and practice education supervisors (n = 5) at one Australian university. Practice education grades and documentation were also used as data. Data were analysed thematically, and two themes, each with three sub-themes, were identified: students coming to understand expected standards, with the following sub-themes: students attuning to cues, cues that inform supervisors about students' meeting the standards, and barriers and frustrations to understanding standards; and practising and developing evaluative judgement, with the following sub-themes: making comparisons, acting on feedback, and reflective practice. CONCLUSIONS: Practice education experiences provide many context-specific opportunities for students to develop their evaluative judgement. Students may be supported to come to know what quality work looks like by offering scaffolded opportunities to develop evaluative judgement in university and practice education settings.

Informal peer support for rural doctors.

INTRODUCTION: Practising medicine exposes physicians to emotionally difficult situations, which can be devastating, and for which they might be unprepared. Informal peer support has been recognised as helpful, although this phenomenon is understudied. Hence, it is important to develop a better understanding of the features of helpful informal peer support from the experiences of physicians who have successfully moved through such difficult events. This could lead to new and potentially more effective ways to support struggling physicians. METHODS: Rural Canadian generalist physicians were interviewed. Using a hermeneutic phenomenological approach, data analysis was oriented towards understanding features of helpful informal peer support and the meanings that participants derived from the experience. RESULTS: Eleven rural generalist physicians took part. Peer support prompted the processing of difficult emotional experiences, which initially seemed insurmountable and career-ending. Participants overcame feelings of emotional distress after even brief encounters of informal peer support. Most participants described the support they received as vitally important. After the peer support encounter, practitioners no longer thought of leaving medical practice and felt more able to handle such difficulties moving forward. CONCLUSIONS: Informal peer support enabled recipients to move through an emotionally difficult experience. Empathy, shared vulnerability and connection were the part of the peer support encounter. In addition, the support offered benefits which are known to help physicians not only process emotionally difficult events but also to acquire 'post-traumatic growth'. Practitioners, healthcare leaders and medical educators all have roles to play in enabling the conditions for informal peer support to flourish. INTRODUCTION: La pratique de la médecine expose les médecins à des situations émotionnellement difficiles, qui peuvent être dévastatrices, et auxquelles ils ne sont pas préparés. Le soutien informel par les pairs a été reconnu comme utile, même si ce phénomène est peu étudié. Il est donc important de mieux comprendre les caractéristiques du soutien informel par les pairs à partir des expériences de médecins qui ont réussi à traverser des événements aussi difficiles. Cela pourrait conduire à de nouvelles façons, potentiellement plus efficaces, de soutenir les médecins en difficulté. MTHODES: Onze médecins généralistes canadiens ruraux ont été interrogés. En utilisant une approche phénoménologique herméneutique, l'analyse des données a été orientée vers la compréhension des caractéristiques du soutien informel utile par les pairs et des significations que les participants ont tirées de l'expérience. RSULTATS: Le soutien des pairs a incité à vivre des expériences émotionnelles difficiles, qui semblaient au départ insurmontables et mettant fin à une carrière. Les participants ont surmonté leurs sentiments de détresse émotionnelle après même de brèves rencontres de soutien informel par leurs pairs. La plupart des participants ont décrit le soutien qu'ils ont reçu comme étant d'une importance vitale. Après la rencontre de soutien par les pairs, les praticiens ne pensaient plus à quitter la pratique médicale et SE sentaient plus capables de faire face à de telles difficultés à l'avenir. CONCLUSION: Le soutien informel par les pairs a permis aux bénéficiaires de traverser une expérience émotionnellement difficile. L'empathie, la vulnérabilité partagée et la connexion faisaient partie de la rencontre de soutien par les pairs. En outre, le soutien a offert des avantages connus pour aider les médecins non-seulement à gérer des événements émotionnellement difficiles, mais également à acquérir une 'croissance post-traumatique'. Les praticiens, les dirigeants des soins de santé et les enseignants en médecine ont tous un rôle à jouer pour permettre aux conditions propices au soutien informel par les pairs de s'épanouir.