Whiteness theory and the (in)visible hierarchy in medical education.

CONTEXT: The theory of whiteness in medical education has largely been ignored, yet its power continues to influence learners within our medical curricula and our patients and trainees within our health systems. Its influence is even more powerful given the fact that society maintains a 'possessive investment' in its presence. In combination, these (in)visible forces create environments that favour White individuals at the exclusion of all others, and as health professions educators and researchers, we have the responsibility to uncover how and why these influences continue to pervade medical education. PROPOSAL: To better understand how whiteness and the possessive investment in its presence create (in)visible hierarchies, we define and explore the origin of whiteness by examining whiteness studies and how we have come to have a possessive investment in its presence. Next, we provide ways in which whiteness can be studied in medical education so that it can be disruptive. CONCLUSION: We encourage health profession educators and researchers to collectively 'make strange' our current hierarchical system by not just recognising the privileges afforded to those who are White but also recognising how these privileges are invested in and maintained. As a community, we must develop and resist established power structures to transform the current hierarchy into a more equitable system that supports everyone, not just those who are White.

Asian Conscientization: Reflections on the Experiences of Asian Faculty in Academic Medicine.

ISSUE: Asians have experienced a rise in racialized hate crimes due to the anti-Asian rhetoric that has accompanied the COVID-19 pandemic. However, there has been little acknowledgement of anti-Asian discrimination within the medical education community. While anti-Asian hate is not new or unfamiliar to us, four authors of Asian descent, it has given us an opportunity to reflect on how we have been complicit in and resistant to the larger racial narratives that circulate in our communities. EVIDENCE: In this article, we provide a brief history of Asians in the Americas with a focus on anti-Asian hate. Next, while presenting stories from the perspective of Asian medical education researchers who were born/have settled in the U.S. and Canada, we take the opportunity to reflect on how our personal experiences have shaped our perceptions of ourselves, and the representations of Asians in the field of medicine. IMPLICATIONS: We hope to create awareness about how stereotypes of success tied to Asians can be used as a tool of oppression creating strife between Black communities, Asian communities, and other people of color. There is a need to develop critical consciousness to address the issues of equity in academia and in clinical practice.

COVID As a Catalyst: A Qualitative Study Of Professional Identity Formation among U.S. Medical Students During COVID-19.

PHENOMENON: Students become physicians not only by mastering medical knowledge, but also through a process of Professional Identity Formation (PIF). In this study, we used the conceptual framework of Jarvis-Selinger et al. to explore the impact of COVID, as a major public health crisis, on the PIF of preclinical medical students in our country. APPROACH: At two U.S. medical schools, we interviewed 28 medical students twice as they moved from first to second year during the 2020-2021 COVID pandemic and explored the impact of COVID-19 on PIF. We coded the transcribed interviews and identified themes using constructivist thematic analysis. FINDINGS: We identified three themes: 1) mental health and wellness impacts; 2) inhabiting identity as a health professional during COVID; and 3) questioning the role of physicians in society. Routines and support systems were disrupted, undermining wellness and confidence in professional choices. Students noted the need to be public health role models, and COVID prompted feelings of pride, while also causing them to question expectations of self-sacrifice amid a new politicization of medicine. Students felt that physicians must be increasingly engaged in public health and political communication. INSIGHTS: Our findings inform medical educators seeking to build a scaffolding to support PIF during a public health crisis, and highlight the importance of current events and politics on PIF. Our recommendations include the need for student support, longitudinal mentorship, curricular space to discuss the impact of sociopolitical factors on PIF, and revisiting foundational concepts such as professionalism to take into account the social and political context. Our findings add to understanding of PIF during the COVID pandemic, but are also relevant to teaching and learning during future public health crises.

Bricolage: A tool for race-related, historically situated complex research.

BACKGROUND: As medical education grapples with larger issues of race and racism, researchers will need new tools to capture society's complex issues. One promising approach is bricolage, a methodological and theoretical approach that allows researchers to bend analytical tools to meet their needs. Bricolage is both a metaphor and an activity to describe the cognitively creative process researchers engage in while conducting interdisciplinary and multidimensional research. PROCESS: At the heart of bricolage is the researchers' engagement in critical hermeneutics, which at its basic level recognises that all objects under study are subject to larger social, political, and historical forces that constrain individuals. Researching with bricolage treats objects of inquiry as part of a historically situated complex system. As such, data are interpreted in ways that build conceptual bridges between individuals' concrete experiences and concepts acknowledging larger social, historical, economic, and political forces. PEARLS: To engage in bricolage, researchers should begin by reading and comparing ideas across disciplines to expose disciplinary-specific assumptions, as well as learn about new theories, approaches and methods that might be utilised for a bricolage project. Researchers should also ask themselves philosophical questions to identify new readings or their data. And finally, researchers should experiment with analytical metaphors because they help to frame new relationships between seemingly unrelated theories, methods and concepts. As researchers engage in bricolage, they need to sidestep their training and over-reliance on research protocols and checklists and engage in a creative tinkering to interpret the world in new ways. In doing so, scholars will be able to push traditional research boundaries and generate critical dialogue to move the field forward.

Intersectionality: a means for centering power and oppression in research.

Intersectionality theory examines how matrices of power and interlocking structures of oppression shape and influence people's multiple identities. It reminds us that people's lives cannot be explained by taking into account single categories, such as gender, race, sexuality, or socio-economic status. Rather, human lives are multi-dimensional and complex, and people's lived realities are shaped by different factors and social dynamics operating together. Therefore, when someone occupies multiple marginalized intersections, their individual-level experiences reflect social and structural systems of power, privilege, and inequality. And yet, knowing that people occupy different social locations that afford them unique experiences is not the same as knowing how to analyze data in an intersectional way. Intersectional analyses are rigorous, and require the use of theory at multiple levels to see theoretical connections that are often only implicit.In this paper, we ask "How does one actually do intersectional research and what role does theory play in this process?" In an effort to make intersectionality theory more accessible to health professions education research, this article describes the simpler version of intersectional analyses followed by the more complex version representing how it was originally intended to be used; a means to fight for social justice. Using pilot data collected on first-generation medical students' professional identity experiences, we demonstrate the thinking and engagement with theory that would be needed to do an intersectional analysis. Along the way, we describe some of the challenges researchers may find in using intersectionality in their own work. By re-situating the theory within its original roots of Black feminist thought, we hope other health professions education (HPE) researchers consider using intersectionality in their own analyses.

Exploring how physician educators approach politically charged topics with learners.

CONTEXT: Medical educators hold and encounter different beliefs and values on politically charged health-related topics such as reproductive rights and immigration. Their views on these topics have implications for how they approach them with learners, yet little work has explored medical educators' views and pedagogical approaches. In this study, we used Hess's approaches to controversial topics (avoidance, denial, privilege, balance) as a guiding conceptual framework to explore physician educators' views on and approaches to politically charged topics. We used this understanding to provide guidance on how best to address politically charged issues within medical education. METHOD: We used a constructivist qualitative approach to explore medical educators' approaches to politically charged topics. We interviewed 37 physician educators from two medical schools in different regions of the United States. In these semi-structured interviews, we presented participants with vignettes depicting politically charged topics arising in an educational setting. Participants described and explained their response to each vignette. Interviews were recorded, transcribed and analysed using constructivist-oriented thematic analysis. RESULTS: Participants were thoughtful about preparing learners for participation in a professional community that holds certain responsibilities to a politically and culturally diverse society. Although some adopted clear approaches on politically charged topics and declared their stance on the topic to learners, others took a balanced approach, focused only on the medical aspects and withheld their views. The context and location of practice played a role in the approaches participants adopted. Additionally, they had varied views on which topics had a place in medical education. CONCLUSION: Our findings provide insights that can help guide medical educators and training programmes in decisions about their role in facilitating conversations about politically charged, health-related topics and helping learners form their own perspectives and approaches to such topics.

'Whispers and shadows': A critical review of the professional identity literature with respect to minority physicians.

OBJECTIVES: Professional identity formation (PIF) is a growing area of research in medical education. However, it is unclear whether the present research base is suitable for understanding PIF in physicians considered to be under-represented in medicine (URM). This meta-ethnography examined the qualitative PIF literature from 2012 to 2019 to assess its capacity to shine light on the experiences of minoritised physicians. METHODS: Data were gathered using a search of six well-known medical education journals for the term 'professional identit*' in titles, keywords, abstracts and subheadings, delineated with the date range of 2012-2019. All non-relevant abstracts were removed and papers were then further reduced to those that focused only on learners' experiences. This left 67 articles in the final dataset, which were analysed using a collaborative approach among a team of researchers. The team members used their professional expertise as qualitative researchers and personal experiences as minoritised individuals to synthesise and interpret the PIF literature. RESULTS: Four conceptual categories were identified as impacting PIF: Individual versus Sociocultural Influences; the Formal versus the Hidden Curriculum; Institutional versus Societal Values; and Negotiation of Identity versus Dissonance in Identity. However, a major gap was identified; only one study explored experiences of PIF in URM physicians and there was an almost complete absence of critical stances used to study PIF. Combined, these findings suggest that PIF research is building on existing theories without questioning their validity with reference to minoritised physicians. CONCLUSIONS: From a post-colonial perspective, the fact that race and ethnicity have been largely absent, invisible or considered irrelevant within PIF research is problematic. A new line of inquiry is needed, one that uses alternative frameworks, such as critical theory, to account for the ways in which power and domination influence PIF for URM physicians in order to foreground how larger sociohistorical issues influence and shape the identities of minoritised physicians.

Contending with Our Racial Past in Medical Education: A Foucauldian Perspective.

ISSUE: Practices of systemic and structural racism that advantage some groups over others are embedded in American society. Institutions of higher learning are increasingly being pressured to develop strategies that effectively address these inequities. This article examines medical education's diversity reforms and inclusion practices, arguing that many reify preexisting social hierarchies that privilege white individuals over those who are minoritized because of their race/ethnicity. Evidence: Drawing on the work of French theorist Michel Foucault, we argue that medical education's curricular and institutional practices reinforce asymmetrical power differences and authority in ways that disadvantage minoritized individuals. Practices, such as medical education's reliance on biomedical approaches, cultural competency, and standardized testing reinforce a racist system in ways congruent with the Foucauldian concept of "normalization." Through medical education's creation of subjects and its ability to normalize dominant forms of knowledge, trainees are shaped and socialized into ways of thinking, being, and acting that continue to support racial violence against minoritized groups. The systems, structures, and practices of medical education need to change to combat the pervasive forces that continue to shape racist institutional patterns. Individual medical educators will also need to employ critical approaches to their work and develop strategies that counteract institutional systems of racial violence. Implications: A Foucauldian approach that exposes the structural racism inherent in medical education enables both thoughtful criticism of status-quo diversity practices and practical, theory-driven solutions to address racial inequities. Using Foucault's work to interrogate questions of power, knowledge, and subjectivity can expand the horizon of racial justice reforms in medicine by attending to the specific, pervasive ways racial violence is performed, both intra- and extra-institutionally. Such an intervention promises to take seriously the importance of anti-racist methodology in medicine.

Patients and Guns: Florida Physicians Are Not Asking.

OBJECTIVES: The number of deaths from gun violence continues to increase in the United States. Despite multiple studies demonstrating that counseling patients leads to safer gun storage, it is not routinely practiced by physicians. There are multiple barriers to discussing firearms with patients. A barrier in Florida, until recently, was a law preventing physicians from asking patients about firearms. The law was overturned in 2017; however, it is unclear whether physicians are aware of this decision. We undertook a survey to study University of Florida faculty physicians' knowledge, attitudes, and practices related to discussing firearms safety. METHODS: The survey consisted of 15 questions related to firearms and counseling. Invitations to participate were e-mailed in 2018 to faculty in general internal medicine, emergency medicine, and surgery within our institution. RESULTS: The response rate was 50% (n = 71/142). The majority of faculty surveyed did not own a gun (56%). Ninety-one percent of faculty surveyed agreed that "gun violence is a public health issue" and 93% agreed that gun safety discussion with patients at risk for suicidal or violent behavior is important. More than half of the respondents (62%) believed they could effectively discuss firearms safety with patients; 73% strongly agreed or agreed that they would discuss gun safety with at-risk patients, whereas 27% were either neutral or disagreed. Fewer still (55%) feel comfortable initiating conversations, and only 5% of participants always talk to at-risk patients about gun safety. Twenty-four percent discussed gun safety most of the time, 30% discussed it sometimes, 32% rarely discussed it, and 9% never discussed it; 76% were aware of the 2017 court decision overturning the physician gag law in Florida. The most-often cited barriers to discussions included lack of time (36%), worry about negative reaction from patient (30%), worry about lack of support from administration (13%), and lack of knowledge (20%). Gun owners and nonowners differed significantly on only two survey items: having taken a firearms safety course (gun owners more likely, relative risk 1.63, 95% confidence interval 1.16-2.29, P = 0.001) and agreeing with gun violence being a public health issue (gun owners being less likely, relative risk 1.24, 95% confidence interval 1.03-1.49, P = 0.006). CONCLUSIONS: Faculty miss opportunities to prevent gun violence despite acknowledging that it is important to do so. More than 40% of the physicians who were surveyed do not counsel at-risk patients about gun safety, citing a lack of knowledge, a persisting belief that asking patients about guns in Florida is illegal, worry about negative patient reactions, and time limitations. Inaction persists despite increased awareness and activism by physicians regarding gun violence. A wider availability of continuing medical education opportunities to learn about firearms counseling should be considered.

Team-Based Learning Activities for First-Year Medical Students: Perception of the Learners.

OBJECTIVES: Team-based learning (TBL) is an active learning strategy that is used increasingly in medical education to promote critical thinking, knowledge application, teamwork, and collaboration. The aim of this study was to assess the students' perspective on the utility of TBL compared with traditional lectures. METHODS: We used a validated TBL student assessment instrument comprising three subscales studying accountability, preference for lecture or TBL, and student satisfaction. First-year medical students enrolled at the University of Florida College of Medicine in spring semester 2016 were asked to complete the questionnaire. RESULTS: The response rate was 50% (70/138). Although 81% of students reported that they had to prepare before TBL and believed they had to contribute to the learning of their team, only 52% believed that they were accountable for team learning. The majority believed that TBL activities are an effective approach to learning (74%), with 78% agreeing that TBL activities helped them recall information. Fewer than half (45%), however, believed that TBL helped improve their grades. CONCLUSIONS: Students reported a preference and satisfaction with TBL over traditional lectures, but a mixed response was noted on the questions pertaining to accountability for team learning.

Gender, religion, and sociopolitical issues in cross-cultural online education.

Cross-cultural education is thought to develop critical consciousness of how unequal distributions of power and privilege affect people's health. Learners in different sociopolitical settings can join together in developing critical consciousness-awareness of power and privilege dynamics in society-by means of communication technology. The aim of this research was to define strengths and limitations of existing cross-cultural discussions in generating critical consciousness. The setting was the FAIMER international fellowship program for mid-career interdisciplinary health faculty, whose goal is to foster global advancement of health professions education. Fellows take part in participant-led, online, written, task-focused discussions on topics like professionalism, community health, and leadership. We reflexively identified text that brought sociopolitical topics into the online environment during the years 2011 and 2012 and used a discourse analysis toolset to make our content analysis relevant to critical consciousness. While references to participants' cultures and backgrounds were infrequent, narratives of political-, gender-, religion-, and other culture-related topics did emerge. When participants gave accounts of their experiences and exchanged cross-cultural stories, they were more likely to develop ad hoc networks to support one another in facing those issues than explore issues relating to the development of critical consciousness. We suggest that cross-cultural discussions need to be facilitated actively to transform learners' frames of reference, create critical consciousness, and develop cultural competence. Further research is needed into how to provide a safe environment for such learning and provide faculty development for the skills needed to facilitate these exchanges.

Status of portfolios in undergraduate medical education in the LCME accredited US medical school.

AIM: We sought to investigate the number of US medical schools utilizing portfolios, the format of portfolios, information technology (IT) innovations, purpose of portfolios and their ability to engage faculty and students. METHODS: A 21-question survey regarding portfolios was sent to the 141 LCME-accredited, US medical schools. The response rate was 50% (71/141); 47% of respondents (33/71) reported that their medical school used portfolios in some form. Of those, 7% reported the use of paper-based portfolios and 76% use electronic portfolios. Forty-five percent reported portfolio use for formative evaluation only; 48% for both formative and summative evaluation, and 3% for summative evaluation alone. RESULTS: Seventy-two percent developed a longitudinal, competency-based portfolio. The most common feature of portfolios was reflective writing (79%). Seventy-three percent allow access to the portfolio off-campus, 58% allow usage of tablets and mobile devices, and 9% involve social media within the portfolio. Eighty percent and 69% agreed that the portfolio engaged students and faculty, respectively. Ninety-seven percent reported that the portfolios used at their institution have room for improvement. CONCLUSION: While there is significant variation in the purpose and structure of portfolios in the medical schools surveyed, most schools using portfolios reported a high level of engagement with students and faculty.

Decolonial framework for applying reflexivity and positionality in global health research.

Contemporary research practices link to colonial and imperialist knowledge creation and production and may promote harmful perspectives on marginalized and oppressed groups. We present a framework for a decolonial approach to research in global health and health promotion applicable across research settings. This framework is aimed at anticipating and alleviating potentially harmful practices inherent in dominant research methods. The framework focuses from a macro- and micro-level perspective on three critical dyads: 'context' and 'accountability'; 'researcher identity' and 'positionality'; and 'procedural ethics' and 'ethics in practice' considerations. We present guidance for how to consider reflexivity and positionality as they apply in this framework in global health and health promotion research practice.

Why Competency Frameworks Are Insufficiently Nuanced for Health Equity Teaching and Assessment.

This article suggests how competency-based medical education should robustly integrate health equity by focusing on physicians' responsibilities to (1) know why and how underlying structural mechanisms contribute to health equity and then (2) take action to achieve health equity in their practice. This article first canvasses currently available frameworks for helping trainees cultivate these 2 specific skills of discernment and action. This article then offers strategies for teaching and assessing these skills in specific learning activities.

Editors as Gatekeepers: One Medical Education Journal's Efforts to Resist Racism in Scholarly Publishing.

PURPOSE: Journals have begun to expand the racial diversity of editors as a first step to countering institutional racism. Given the power editors hold as gatekeepers, a diverse team helps ensure that minoritized scholars have equal opportunity to contribute. In 2021, Teaching and Learning in Medicine ( TLM ) created an editorial internship for racially minoritized individuals. This study examines the first 6 months of this program to better understand its creation and initial successes. METHOD: The authors employed critical collaborative autoethnography, a qualitative methodology, focusing on the underlying assumptions around power and hierarchy that are implicit in the design and implementation of the TLM internship. Participants included 13 TLM editorial board members (10 internship selection committee members, 3 mentors, 2 independent researchers), 3 external selection committee members, and 3 interns, with some holding multiple roles. Ten participants served as authors of this report. Data included archival emails, planning documents, and focus groups. The initial analysis explored what happened and how and was followed by a thematic analysis in which participants reflected on their responsibility for implementing an antiracist program. RESULTS: While the program developed interns' editorial skills, which they greatly valued, and diversified the TLM editorial board, it did not achieve the goal of fostering antiracism. Mentors focused on conducting joint peer reviews with interns, assuming that racial experiences can and should be separate from the editorial process, thus working within, rather than trying to change, the existing racist system. CONCLUSIONS: Given these findings, greater structural change is needed to disrupt the existing racist system. These experiences underscore the importance of recognizing the harmful impact a race-neutral lens can have on antiracist efforts. Moving forward, TLM will implement lessons learned ahead of offering the internship again with the goal of creating the transformative change intended with the creation of the program.

Change in action: using positive deviance to improve student clinical performance.

At our medical college many students have lower ratings in their clinical performance once they start their clinical years (third year). This is contrary to their results in other written exams. Some students demonstrate better clinical performance. We used the six-step Positive Deviance (PD) Conceptual Framework to identify and disseminate the strategies employed by the successful students to improve group clinical performance. Fifty 3rd year students (of a 5-year MBBS program) rotating through internal medicine were assessed mid-rotation with mini-CEX and 360° evaluations. Twenty students (40%) who performed well were invited for in depth interviews in order to identify positive deviant behavior in their clinical skills learning practices. The seven students (14%) who reported novel behaviors were asked to develop strategies for dissemination of their learning behavior in their peers. They decided to work in small groups with their peers, using the identified PD behaviors to encourage learning of history taking and examining skills in their peers. Group performance was assessed at the end of rotation, using mini-CEX and 360° evaluation in comparison to a subsequent group of students in the same year that did not work in PD peer learning groups. For the 360° evaluation the EP(2) (generalizability coefficient) was 0.92 and for the mini-CEX the EP(2) was 0.95, taking into account the variances between participants, groups, time and the interactions effects; thus indicating good reliability of both the assessment methods. A statistically significant difference (p < 0.05) was seen for improvement in medical interviewing skills and clinical judgment on the mini-CEX exam and 360 evaluation (p < 0.0001) in the PD group. Positive Deviance approach can help highlight behaviors among medical students, which contribute to success but may go unnoticed. Learning strategies based on the PD framework can improve student's group performance.

Can I Ask a Question About URiM Awards That I Don't Know the Answer to? Designing an Award for Underrepresented Medical Education Researchers.

Meaningful Equity, Diversity, and Inclusion (EDI) efforts may be stymied by concerns about whether proposed initiatives are performative or tokenistic. The purpose of this project was to analyze discussions by the Research in Medical Education (RIME) Program Planning committee about how best to recognize and support underrepresented in medicine (URiM) researchers in medical education to generate lessons learned that might inform local, national, and international actions to implement meaningful EDI initiatives. Ten RIME Program Planning Committee members and administrative staff participated in a focus group held virtually in August 2021. Focus group questions elicited opinions about "if and how" to establish a URiM research award. The focus group was recorded, transcribed, and thematically analyzed. Recognition of privilege, including who has it and who doesn't, underpinned the focus group discussion, which revolved around 2 themes: (1) tensions between optics and semantics, and (2) potential unintended consequences of trying to level the medical education playing field. The overarching storyline threaded throughout the focus group discussion was intentionality. Focus group participants sought to avoid performativity by creating an award that would be meaningful to recipients and to career gatekeepers such as department chairs and promotion and tenure committees. Ultimately, participants decided to create an award that focused on exemplary Equity, Diversity, and Inclusion (EDI) scholarship, which was eventually named the "RIME URiM Research Award." Difficult but productive conversations about EDI initiatives are necessary to advance underrepresented in medicine (URiM) scholarship. This transparent commentary may trigger further critical conversations.

Professionalism revisited during the pandemics of our time: COVID-19 and racism.

In this article the authors review the current-day definition of professionalism through the lens of the two ongoing pandemics: COVID-19 and racism. The pandemics have led to contemporary practice-related questions, such as: does professionalism entail that health care providers (HCP) be compelled to treat patients without PPE or if patients refuse to wear masks? And what role do HCP play in society when confronted with glaring health disparities and police brutality? The authors propose using care ethics as a theory to view professionalism, as it takes into account broadly encompassing relationships between HCP and society, history and context. Professionalism viewed through a care ethics lens would require professionalism definitions to be expanded to allow for interventions, i.e., not just refrain from doing harm but actively interfere or take action if wrong is being witnessed. Principles related to the primacy of patient welfare need to be re-addressed to prevent systematic self-sacrifice which results in harm to HCP and burnout. Mature care should be a characteristic of professionalism ensuring that HCP care for the sick but be practically wise, highlighting the importance of balancing too little and too much care for self and others. Professionalism needs to be viewed as a bi-directional relational exchange, with society demonstrating solidarity with those providing care. Additionally, given the scale of health disparities, simply stating that HCP need to work towards social justice oversimplifies the problem. Professionalism needs to encompass incorporating critical action and critical pedagogy into health care training and the health care profession to demonstrate solidarity with those impacted by racism.

RIME 60 Years: Celebration and Future Horizons.

This year marks the 60th anniversary (1961-2021) of Research in Medical Education (RIME). Over the past 6 decades, RIME has selected medical education research to be presented each year at the Association of American Medical Colleges Annual Meeting: Learn Serve Lead and published in a supplement of Academic Medicine. In this article, the authors surveyed RIME chairs from the past 20 years to identify ways that RIME has advanced medical education research and to generate ideas for future directions. RIME chairs described advancements in the rigor and impact of RIME research and the timeliness of the topics, often serving as a driver for cutting-edge research. They highlighted RIME's role in promoting qualitative research, introducing new epistemologies, and encouraging networking as a means of career advancement. Going forward, RIME chairs suggested (1) strengthening collaborations with formal advanced MEd and PhD degree programs, (2) creating formal mentorship channels for junior and minority faculty, and (3) promoting research related to knowledge translation.