Professionalism Policies and Practices as Experienced by First-Generation Medical Students, Residents, and Physicians.

Phenomenon: While professionalism is largely understood to be complex and dynamic, it is oftentimes implemented as if it were static and concrete. As a result, policies and practices reflect dominant historical norms of the medical profession, which can cause tension for trainees from marginalized groups. One such group comprises those who identify as first-generation physicians - those whose parents have not earned an associate's degree or higher. This group is highly diverse in terms of gender, race, ethnicity, and socioeconomic status; however, their experiences with institutional professionalism policies and practices has not yet been fully explored. In this study, our aims were to understand the ways in which these participants experience professionalism, and to inform how professionalism can be more inclusively conceptualized. Approach: In November 2022-March 2023, we conducted semi-structured interviews with 11 first-generation medical students, residents, and physicians and analyzed select national and institutional professionalism policies in relation to key themes identified in the interviews. The interviews were designed to elicit participants' experiences with professionalism and where they experienced tension and challenges because of their first-gen identity. Data were analyzed using thematic analysis through a critical perspective, focused on identifying tensions because of systemic and historical factors. Findings: Participants described the ways in which they experienced tension between what was written, enacted, desirable, and possible around the following elements of professionalism: physical appearance; attendance and leaves of absence; and patient care. They described a deep connection to patient care but that this joy is often overshadowed by other elements of professionalism as well as healthcare system barriers. They also shared the ways in which they wish to contribute to changing how their institutions conceptualize professionalism. Insights: Given their unique paths to and through medicine and their marginalized status in medicine, first-generation interviewees provided a necessary lens for viewing the concept of professionalism that has been largely absent in medicine. These findings contribute to our understanding of professionalism conceptually, but also practically. As professionalism evolves, it is important for institutions to translate professionalism's complexity into educational practice as well as to involve diverse voices in refining professionalism definitions and policies.

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.

'The program director's word it's stronger than the word of God': Epistemic injustice revealed through narratives of remediated graduate medical education residents.

BACKGROUND: Though graduate medical education (GME) residency training provides positive experiences for many trainees, it may also result in major stressors and negative experiences, particularly for those requiring remediation. Residents requiring remediation may experience feelings of dismay, shame and guilt that can negatively affect their training, self-efficacy and their medical careers. Power differentials between educators and residents may set the stage for epistemic injustice, which is injustice resulting from the silencing or dismissing a speaker based on identity prejudice. This can lead to decreased willingness of trainees to engage with learning. There is a paucity of literature that explores GME experiences of remediation from the resident perspective. OBJECTIVE: To synthesise the narratives of physician experiences of remediation during residency through the lens of epistemic injustice. METHODS: Between January and July 2022, we interviewed US physicians who self-identified as having experienced remediation during residency. They shared events that led to remediation, personal perspectives and emotions about the process and resulting outcomes. Interviews were analysed using narrative analysis with attention to instances of epistemic injustice. RESULTS: We interviewed 10 participants from diverse backgrounds, specialties and institutions. All participants described contextual factors that likely contributed to their remediation: (1) previous academic difficulty/nontraditional path into medicine, (2) medical disability or (3) minoritised race, gender or sexual identity. Participants felt that these backgrounds made them more vulnerable in their programmes despite attempts to express their needs. Participants reported instances of deflated credibility and epistemic injustices with important effects. CONCLUSIONS: Participant narratives highlighted that deep power and epistemic imbalances between learners and educators can imperil GME trainees' psychological safety, resulting in instances of professional and personal harm. Our study suggests applying an existing framework to help programme directors (PDs) approach remediation with epistemic humility.

"A Look Under the Hood": Reflections on the Inaugural RIME Mentorship Program.

In 2021, Research in Medical Education (RIME) celebrated 60 years of advancing scholarship in health professions education (HPE). At that time, the nation's educational institutions faced a public reckoning on the long-standing pandemic of racism that sweltered in their practices and policies, laid bare by COVID-19 and the Black Lives Matters movement. RIME responded with a mentorship program for minoritized early career HPE faculty, which aims to amplify their voices in settings where their experiences and contributions are frequently dampened. The program fosters professional development through structured activities, participation as RIME committee interns, and formal mentorship channels to support career growth and offer experiences with scholarly publishing. This commentary was written by the first cohort of RIME mentees who are HPE scholars from various professions and diverse backgrounds with struggles traversing professional landscapes as immigrants and as individuals with minoritized identities and hopes for belonging in medical and educational institutions. In this commentary, the mentees describe the merits of the RIME mentorship program and what it meant to them and their unique marginalities. They also examine opportunities for improvements within the program to further reduce barriers faced by minoritized early career HPE faculty who often face limited support with scholarly activities.

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.

Enculturating a Community of Action: Health Professions Educators' Perspectives on Teaching With Wikipedia.

PURPOSE: Health professions educators are increasingly called on to engage learners in more meaningful instruction. Many have used Wikipedia to offer an applied approach to engage learners, particularly learning related to evidence-based medicine (EBM). However, little is known about the benefits and challenges of using Wikipedia as a pedagogic tool from the collective experience of educators who have sought to improve their instructional practice with it. This study aims to synthesize the perspectives of health professions education (HPE) instructors on the incorporation of Wikipedia editing into their HPE courses. METHOD: Applying a constructivist approach, the authors conducted semistructured interviews from July to December 2020, with 17 participating HPE instructors who had substantively integrated Wikipedia into their curriculum at 13 institutions. Participants were interviewed about their experiences of integrating Wikipedia editing into their courses. Thematic analysis was conducted on resulting transcripts. RESULTS: The authors observed 2 broad themes among participants' expressed benefits of teaching with Wikipedia. First, Wikipedia provides a meaningful instructional alternative that also helps society and develops learners' information literacy and EBM skills. Second, Wikipedia supports learners' careers and professional identity formation. Identified challenges included high effort and time, restrictive Wikipedia sourcing guidelines, and difficult interactions with stakeholders. CONCLUSIONS: Findings build on known benefits, such as providing a real-world collaborative project that contextualizes students' learning experiences. They also echo known challenges, such as the resource-intensive nature of teaching with Wikipedia. The findings of this study reveal the potential of Wikipedia to enculturate HPE students within a situated learning context. They also present implications for HPE programs that are considering implementing Wikipedia and faculty development needed to help instructors harness crowd-sourced information tools' pedagogic opportunities as well as anticipate their challenges.

Integrating Wikipedia editing into health professions education: a curricular inventory and review of the literature.

INTRODUCTION: Wikipedia is an online encyclopedia read by millions seeking medical information. To provide health professions students with skills to critically assess, edit, and improve Wikipedia's medical content, a skillset aligned with evidence-based medicine (EBM), Wikipedia courses have been integrated into health professions schools' curriculum. This literature review and curricular inventory of Wikipedia educational initiatives provides an overview of current approaches and identifies directions for future initiatives and research. METHODS: Five databases were searched for articles describing educational interventions to train health professional students to edit Wikipedia. Course dashboards, maintained by Wiki Education (Wiki Edu), were searched for curricular materials. From these sources, key details were extracted and synthesized, including student and instructor type, course content, educational methods, and student outcomes. RESULTS: Six articles and 27 dashboards reported courses offered between 2015 and 2019. Courses were predominantly offered to medical and nursing students. Instructors delivered content via videos, live lectures, and online interactive modules. Course content included logistics of Wikipedia editing, EBM skills, and health literacy. All courses included assignments requiring students to edit Wikipedia independently or in groups. Limited details on assessment of student learning were available. DISCUSSION: A small but growing number of schools are training health professions education students to improve Wikipedia's medical content. Course details are available on Wiki Edu dashboards and, to a lesser extent, in peer-reviewed publications. While more needs to be done in conducting and sharing assessment of student learning, integrating Wikipedia into health professions education has potential to facilitate learning of EBM and communication skills, improve Wikipedia's online content, and engage students with an autonomous environment while learning. Future considerations should include a thorough assessment of student learning and practices, a final review of student edits to ensure they follow Wikipedia's guidelines and are written in clear language, and improved sharing of teaching resources by instructors.