Blind spots in medical education - International perspectives.

BACKGROUND: All individuals and groups have blind spots that can create problems if unaddressed. The goal of this study was to examine blind spots in medical education from international perspectives. METHODS: From December 2022 to March 2023, we distributed an electronic survey through international networks of medical students, postgraduate trainees, and medical educators. Respondents named blind spots affecting their medical education system and then rated nine blind spot domains from a study of U.S. medical education along five-point Likert-type scales (1 = much less attention needed; 5 = much more attention needed). We tested for differences between blind spot ratings by respondent groups. We also analyzed the blind spots that respondents identified to determine those not previously described and performed content analysis on open-ended responses about blind spot domains. RESULTS: There were 356 respondents from 88 countries, including 127 (44%) educators, 80 (28%) medical students, and 33 (11%) postgraduate trainees. At least 80% of respondents rated each blind spot domain as needing 'more' or 'much more' attention; the highest was 88% for 'Patient perspectives and voices that are not heard, valued, or understood.' In analyses by gender, role in medical education, World Bank country income level, and region, a mean difference of 0.5 was seen in only five of the possible 279 statistical comparisons. Of 885 blind spots documented, new blind spot areas related to issues that crossed national boundaries (e.g. international standards) and the sufficiency of resources to support medical education. Comments about the nine blind spot domains illustrated that cultural, health system, and governmental elements influenced how blind spots are manifested across different settings. DISCUSSION: There may be general agreement throughout the world about blind spots in medical education that deserve more attention. This could establish a basis for coordinated international effort to allocate resources and tailor interventions that advance medical education.

Group concept mapping for health professions education scholarship.

While explicit conceptual models help to inform research, they are left out of much of the health professions education (HPE) literature. One reason may be the limited understanding about how to develop conceptual models with intention and rigor. Group concept mapping (GCM) is a mixed methods conceptualization approach that has been used to develop frameworks for planning and evaluation, but GCM has not been common in HPE. The purpose of this article is to describe GCM in order to make it more accessible for HPE scholars. We recount the origins and evolution of GCM and summarize its core features: GCM can combine multiple stakeholder perspectives in a systematic and inclusive manner to generate explicit conceptual models. Based on the literature and prior experience using GCM, we detail seven steps in GCM: (1) brainstorming ideas to a specific "focus prompt," (2) preparing ideas by removing duplicates and editing for consistency, (3) sorting ideas according to conceptual similarity, (4) generating the point map through quantitative analysis, (5) interpreting cluster map options, (6) summarizing the final concept map, and (7) reporting and using the map. We provide illustrative examples from HPE studies and compare GCM to other conceptualization methods. GCM has great potential to add to the myriad of methodologies open to HPE researchers. Its alignment with principles of diversity and inclusivity, as well as the need to be systematic in applying theoretical and conceptual frameworks to practice, make it a method well suited for the complexities of contemporary HPE scholarship.

Examining the WFME Recognition Programme at 10 years.

BACKGROUND: In 2012, the World Federation for Medical Education (WFME) evaluated and formally recognized the first agency in its Recognition Programme (RP). The RP was developed to review accrediting authorities in response to a 2010 policy by the Educational Commission for Foreign Medical Graduates (ECFMG) to require international medical graduates (IMGs) seeking to practice in the U.S. to graduate from an appropriately accredited medical school. By the end of 2022, WFME had recognized 33 accrediting bodies and received applications from another 16, which accounted for over three-quarters of the world's medical schools. In 2023, WFME leadership changed hands, and the ECFMG will take its first steps toward implementing its Recognized Accreditation Policy. APPROACH: In this article, we look back at the genesis of the RP and describe its first decade as informed by the limited existing peer-reviewed literature and the emerging activities of accrediting agencies that could have significant implications for the quality of medical education internationally. CONCLUSIONS: The rapidly growing influence of WFME on medical education worldwide has largely occurred without significant awareness or scrutiny, and there is a need for the WFME to demonstrate greater transparency, proactively engage its stakeholders, and support research and evaluation.

Blind spots in medical education: how can we envision new possibilities?

As human beings, we all have blind spots. Most obvious are our visual blind spots, such as where the optic nerve meets the retina and our inability to see behind us. It can be more difficult to acknowledge our other types of blind spots, like unexamined beliefs, assumptions, or biases. While each individual has blind spots, groups can share blind spots that limit change and innovation or even systematically disadvantage certain other groups. In this article, we provide a definition of blind spots in medical education, and offer examples, including unfamiliarity with the evidence and theory informing medical education, lack of evidence supporting well-accepted and influential practices, significant absences in our scholarly literature, and the failure to engage patients in curriculum development and reform. We argue that actively helping each other see blind spots may allow us to avoid pitfalls and take advantage of new opportunities for advancing medical education scholarship and practice. When we expand our collective field of vision, we can also envision more "adjacent possibilities," future states near enough to be considered but not so distant as to be unimaginable. For medical education to attend to its blind spots, there needs to be increased participation among all stakeholders and a commitment to acknowledging blind spots even when that may cause discomfort. Ultimately, the better we can see blind spots and imagine new possibilities, the more we will be able to adapt, innovate, and reform medical education to prepare and sustain a physician workforce that serves society's needs.

Breaking Borders: How Barriers to Global Mobility Hinder International Partnerships in Academic Medicine.

This article describes the authors' personal experiences of collaborating across international borders in academic research. International collaboration in academic medicine is one of the most important ways by which research and innovation develop globally. However, the intersections among colonialism, academic medicine, and global health research have created a neocolonial narrative that perpetuates inequalities in global health partnerships. The authors critically examine the visa process as an example of a racist practice to show how the challenges of blocked mobility increase inequality and thwart research endeavors. Visas are used to limit mobility across certain borders, and this limitation hinders international collaborations in academic medicine. The authors discuss the concept of social closure and how limits to global mobility for scholars from low- and middle-income countries perpetuate a cycle of dependence on scholars who have virtually barrier-free global mobility-these scholars being mainly from high-income countries. Given the current sociopolitical milieu of increasing border controls and fears of illegal immigration, the authors' experiences expose what is at stake for academic medicine when the political sphere, focused on tightening border security, and the medical realm, striving to build international research collaborations, intersect. Creating more equitable global partnerships in research requires a shift from the current paradigm that dominates most international partnerships and causes injury to African scholars.

Paradox of Patient-Centered Care and the Implications for Patient Involvement in Continuing Professional Development.

INTRODUCTION: Patient-centered care (PCC) is widely considered as essential in chronic disease management. As the underlying rationale for engaging patients in continuing professional development (CPD) is commonly described as fostering care that is more patient-centered, we hoped to understand the discursive conditions for how educators and health professionals can (or cannot) learn with, from, and about patients. METHODS: Using diabetes as a case, we conducted a Foucauldian discourse analysis of an archive of relevant policy documents, professional and educational texts, to explore different conceptualizations of practice and the implications for PCC. We also conducted in-depth interviews with a purposive sample of physicians to understand their experiences in providing and teaching PCC. We sought to understand: How has PCC been discursively constructed? Whose interests does advocating PCC serve? What are the implications for patient involvement in CPD? RESULTS: We describe three discursive constructions of PCC, each extending the reach of biomedical power. PCC as a disease intervention emphasizes knowing and relating to patients to normalize laboratory test results. PCC as a form of confession promotes patients to come to their own realizations to become responsible for their own health, but through the lens and evaluation of physicians. PCC as a disciplinary technique makes visible the possibility of using a checklist to judge physician competency in providing PCC. DISCUSSION: PCC may be constructed in ways that paradoxically reinforce rather than challenge conventional, provider-centric paradigms. Our results challenge educators to acknowledge the existence and effects of discourses when involving patients in the planning and delivery of CPD.

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.

Competent to provide compassionate care? A critical discourse analysis of accreditation standards.

BACKGROUND: Medical school accreditation is recognised internationally as an important quality control process for programmes that lead to the Medical Doctor (MD) degree. Accreditation standards govern the accreditation process which in turn drives educational objectives. Given the power of these standards to shape what becomes valued in the curricula, it is therefore imperative to ensure that core values and ideals of the profession are meaningfully incorporated. As the provision of compassionate care has long been a central medical value, this value should be clearly articulated in MD programme accreditation standards. METHODS: We conducted a Critical Discourse Analysis of compassionate care within Undergraduate Medical Education (UME) Accreditation Standards governing North American medical schools since 1957. We explored how and to what extent the written language of the accreditation standards incorporated compassionate care. RESULTS: References to compassionate care in the UME Accreditation Standards were few and far between. Historically, a statement of 'The Objectives of Undergraduate Medical Education' published by the Association of American Medical Colleges (AAMC) was referenced for the first and only time in the 1957 standards, describing the development of attributes such as the provision of compassionate care as a basic objective of UME. Thereafter, there was infrequent mention of this value. Terms that could potentially incorporate aspects of compassionate care were identified, yet these were explicated in ways that limited connection to compassion. Instead, the term 'care' has increasingly been used instrumentally (ie acute care, chronic care). CONCLUSION: The relative absence of language pertaining to compassionate care in accreditation standards is troubling as compassion is integral to good medical care. This absence is particularly important to attend to in the current era of competency-based training where we must be explicit about all important curricular objectives lest essential values and practices be unintentionally lost.

Tackling the void: the importance of addressing absences in the field of health professions education research.

Many processes and practices in the field of health professions education have been based more on tradition and assumption than on evidence and theory. As the field matures, researchers are increasingly seeking evidence to support various teaching and assessment methods. However, there is a tendency to focus on a limited set of topics, leaving other areas under-examined and limiting our understanding of the field. By explicitly examining areas that are undescribed, i.e. absences in the literature, researchers and scholars have the potential to enrich our practice and our field's understanding of what counts as legitimate research. Using the theoretical framework of Bourdieu's concept of field, we conducted an instrumental case study of three published research projects that each had a finding of absence. We examined each case individually, and then analyzed across cases. Our dataset included published papers, peer-review feedback, and reflective notes. Each of the cases interrogated a different form of absence: absence of content, absence of research, and absence of evidence. While the typology suggests that each absence was different, there were similarities across cases in terms of challenges in 'proving' the reality of the absence and some disbelief or discomfort with accepting the findings as rigorous and/or legitimate. Absence research has potential to add to our theoretical and methodological approaches to the field. This type of research is potentially an exciting and productive new way for scholars to shed light on aspects of health professions education that have received limited attention to date.

Dismantling the master's house: new ways of knowing for equity and social justice in health professions education.

Health professions education (HPE) is built on a structural foundation of modernity based on Eurocentric epistemologies. This foundation privileges certain forms of evidence and ways of knowing and is implicated in how dominant models of HPE curricula and healthcare practice position concepts of knowledge, equity, and social justice. This invited perspectives paper frames this contemporary HPE as the "Master's House", utilizing a term referenced from the writings of Audre Lorde. It examines the theoretical underpinnings of the "Master's House" through the frame of Quijano's concept of the Colonial Matrix of Power (employing examples of coloniality, race, and sex/gender). It concludes by exploring possibilities for how these Eurocentric structures may be dismantled, with reflection and discussion on the implications and opportunities of this work in praxis.

Critical Theory: Broadening Our Thinking to Explore the Structural Factors at Play in Health Professions Education.

As part of the Philosophy of Science series of Invited Commentaries, this article on critical theory describes the origins of this research paradigm and its key concepts and orientations (ontology, epistemology, axiology, methodology, and rigor). The authors frame critical theory as an umbrella term for different theories, including feminism, antiracism, and anticolonialism. They emphasize the structural analysis that critical scholars conduct to uncover and sometimes address the role that social, political, cultural, economic, ethnic, and gender factors play in health professions education. They note the importance of acknowledging one's social location when doing critical research and highlight the core values of democracy and egalitarianism that underpin critical research. Methodologically, the authors stress how critical scholars reject singular truths in favor of more nuanced portraits of concepts and events, mobilize inductive approaches over deductive ones, and use critical theory to develop their projects and analyze their data. Following upon this elucidation of critical theory, the authors apply this paradigm to analyze the sample case of Lee, a medical resident who was involved in a medication error. The authors conclude that research conducted in the critical tradition has the potential to transcend individualistic accounts by revealing underlying structural forces that constrain or support individual agency.

A Dialogic Approach to Teaching Person-Centered Care in Graduate Medical Education.

BACKGROUND: Training future physicians to provide compassionate, equitable, person-centered care remains a challenge for medical educators. Dialogues offer an opportunity to extend person-centered education into clinical care. In contrast to discussions, dialogues encourage the sharing of authority, expertise, and perspectives to promote new ways of understanding oneself and the world. The best methods for implementing dialogic teaching in graduate medical education have not been identified. OBJECTIVE: We developed and implemented a co-constructed faculty development program to promote dialogic teaching and learning in graduate medical education. METHODS: Beginning in April 2017, we co-constructed, with a pilot working group (PWG) of physician teachers, ways to prepare for and implement dialogic teaching in clinical settings. We kept detailed implementation notes and interviewed PWG members. Data were iteratively co-analyzed using a qualitative description approach within a constructivist paradigm. Ongoing analysis informed iterative changes to the faculty development program and dialogic education model. Patient and learner advisers provided practical guidance. RESULTS: The concepts and practice of dialogic teaching resonated with PWG members. However, they indicated that dialogic teaching was easier to learn about than to implement, citing insufficient time, lack of space, and other structural issues as barriers. Patient and learner advisers provided insights that deepened design, implementation, and eventual evaluation of the education model by sharing experiences related to person-centered care. CONCLUSIONS: While PWG members found that the faculty development program supported the implementation of dialogic teaching, successfully enabling this approach requires expertise, willingness, and support to teach knowledge and skills not traditionally included in medical curricula.

Exploring the approaches of non-Indigenous researchers to Indigenous research: a qualitative study.

BACKGROUND: Given the history of unethical research in Indigenous communities, there is often apprehension among Indigenous communities toward research carried out by non-Indigenous researchers. We examined the approaches, experiences and motivations among non-Indigenous researchers at a research-intensive Canadian university conducting research with Indigenous communities to understand approaches to ethical research with Indigenous peoples. METHODS: We performed a critical constructivist qualitative study incorporating decolonizing methodologies. We conducted semistructured interviews with 8 non-Indigenous University of Toronto researchers with a research focus/interest related to Indigenous health between August and October 2017. The interviews were transcribed and thematically analyzed through an iterative process. Shared experiences among the researchers were arranged into primary themes. RESULTS: We identified 4 primary themes related to the conduct of Indigenous research by non-Indigenous researchers: 1) relationships with communities are foundational to the research process, 2) non-Indigenous researchers experience a personal self-reflective journey grounded in reconciliation, allyship and privilege, 3) accepted knowledge frameworks in Indigenous research are familiar to most but are inconsistently applied and 4) institutions act as barriers to and facilitators of ethical conduct of Indigenous research. Four core principles - relationships, trust, humility and accountability - unified the primary themes. INTERPRETATION: We identified strengths and areas for improvement of current policies and practices in Indigenous research by non-Indigenous researchers. Although non-Indigenous researchers value relationships, and their research is informed by Indigenous knowledge, institutional barriers to implementing recommended elements exist, and certain policy statements such as the Tri-Council Policy Statement 2 lack applicability to secondary data analysis for some non-Indigenous researchers.

Family physicians and health advocacy: Is it really a difficult fit?

OBJECTIVE: To examine whether family medicine residents and faculty members appreciate the full spectrum of health advocacy as described in articles published in Canadian Family Physician in 2016 and to identify the perceived challenges and enablers of advocating across the entire spectrum. DESIGN: Analysis of a subset of data from a qualitative study using semistructured interviews and focus groups. SETTING: University of Toronto in Ontario. PARTICIPANTS: A total of 9 family medicine faculty members and 6 family medicine residents. METHODS: A subset of transcripts from a 2015 qualitative study that explored family medicine and psychiatry residents' and faculty members' understanding of the CanMEDS-Family Medicine health advocate role were reviewed, guided by interpretive descriptive methodology. MAIN FINDINGS: Results indicated that family medicine physicians and residents were able to identify the full spectrum of advocacy described in the Canadian Family Physician articles and that they valued the role. Further, there was widespread agreement that being a health advocate was linked with their identities as health professionals. The time it takes to be a health advocate was seen as a barrier to being effective in the role, and the work was seen as extremely challenging owing to system constraints. Participants also described a gap in training relating to advocacy at the system level as a challenge. CONCLUSION: Team-based care was seen as one of the most important enablers for becoming involved in the full spectrum of advocacy, as was time for personal reflection.

Strategic Planning in Health Professions Education: Scholarship or Management?

Strategic planning, in its various forms, is an evaluation practice that is ubiquitous in academic medicine. However, published reports of strategic planning at academic health centers usually ignore theory. In a 2017 strategic planning exercise at the Wilson Centre, a scholarly model evolved using a theoretical framework and a research approach rather than a conventional management model, which typically identifies outcomes and how to achieve them. After completing this exercise, the authors considered the larger questions of the assumptions underpinning different models of strategic planning and strategic planning's value to academic medicine. To elaborate on these questions, the authors examine relevant literature and set out the Wilson Centre's emergent scholarly model. They describe the main features of the scholarly model, including ways it differs from a management approach and from the typical approach to strategic planning in the authors' experience and in the field of health professions education research. The authors also share lessons learned as a means to encourage consideration by other academic organizations.