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.

Parents' Experiences with Postpartum Support Groups using Videoconferencing: Perceptions of Safety in the Virtual Space.

PURPOSE: To explore new parents' experiences with web-based videoconferencing as a mechanism of offering postpartum virtual support groups. STUDY DESIGN AND METHODS: Virtual support sessions and individual interviews were conducted to explore participants' experiences with virtual postpartum groups. RESULTS: Thirty-seven parents participated in seven virtual support sessions and 19 participated in individual interviews. Participant narratives centered on perceptions of safety when engaging in virtual support groups. Tools within the virtual space (camera; mute) created a relational paradox which provided safeguards but also hindered the building of trust. Participants described negotiating the fear of harm and judgment within virtual spaces alongside feelings of security in connecting from the safety of their homes. CLINICAL IMPLICATIONS: The virtual environment provides a forum for new parents to access information and support and an avenue for engagement with maternal child nurses and care providers. Awareness of how parents perceive safety in the virtual environment is an important part of facilitating and structuring parent groups on videoconferencing platforms. Nurses should be familiar with videoconferencing technology and be able to guide parents. Experience facilitating virtual groups to ensure safety and security while providing needed support is a valuable nursing skill.

The burden of grief: A scoping review of nurses' and physicians' experiences throughout the COVID-19 pandemic.

Coping with loss is an unfortunate reality faced by healthcare professionals, and the COVID-19 pandemic exacerbated this challenge for those who worked on the frontlines. Our scoping review aimed to comprehensively map the existing literature pertaining to the experiences of grief among nurses and physicians in the context of the pandemic. Six bibliographic databases were searched in 2022, and a targeted search of gray literature and citation chasing was also performed. After screening a total of 2920 records, we included 173 evidence sources in this review. Data was both analyzed descriptively (e.g., frequency counts and percentages) and using a qualitative content analysis approach. Our findings illuminate the myriad losses experienced by nurses and physicians throughout the pandemic. While the literature portrays the coping mechanisms healthcare professionals have developed personally, there is a pronounced need for increased institutional support to alleviate the burdens they carry.

Examining How Postpartum Videoconferencing Support Sessions Can Facilitate Connections between Parents: A Poststructural and Sociomaterial Analysis.

Postpartum support for new parents can normalize experiences, increase confidence, and lead to positive health outcomes. While in-person gatherings may be the preferred choice, not all parents can or want to join parenting groups in person. Online asynchronous chat spaces for parents have increased over the past 10 years, especially during the COVID pandemic, when "online" became the norm. However, synchronous postpartum support groups have not been as accessible. The purpose of our study was to examine how parents experienced postpartum videoconferencing support sessions. Seven one-hour videoconferencing sessions were conducted with 4-8 parents in each group (n = 37). Nineteen parents from these groups then participated in semi-structured interviews. Feminist poststructuralism and sociomaterialism were used to guide the research process and analysis. Parents used their agency to actively think about and interact using visual (camera) and audio (microphone) technologies to navigate socially constructed online discourses. Although videoconferencing fostered supportive connections and parents felt less alone and more confident, the participants also expressed a lack of opportunities for individual conversations. Nurses should be aware of the emerging opportunities that connecting online may present. This study was not registered.

A meta-study analysing the discourses of discourse analysis in health professions education.

INTRODUCTION: Discourse analysis has been used as an approach to conducting research in health professions education (HPE) for many years. However, because there is no one 'right' interpretation of or approach to it, quite what discourse analysis is, how it could or should be used, and how it can be appraised are unclear. This ambiguity risks undermining the trustworthiness and coherence of the methodology and any findings it produces. METHOD: A meta-study review was conducted to explore the current state of discourse analysis in HPE, to guide researchers engaging using the methodology and to improving methodological, analytical and reporting rigour. Structured searches were conducted, returns were filtered for inclusion and 124 articles critically analysed. RESULTS: Of 124 included articles, 64 were from medical education, 51 from nursing and 9 were mutli-disciplinary or from other HPE disciplines. Of 119 articles reporting some sort of data, 50 used documents/written text as the sole data source, while 27 were solely based on interview data. Foucault was the most commonly cited theorist (n = 47), particularly in medical education articles. The quality of articles varied: many did not provide a clear articulation what was meant by discourse, definitions and methodological choices were often misaligned, there was a lack of detail regarding data collection and analysis, and positionality statements and critiques were often underdeveloped or absent. DISCUSSION: Seeking to address these many lacunae, the authors present a framework to facilitate rigorous discourse analysis research and transparent, complete and accurate reporting of the same, to help readers assess the trustworthiness of the findings from discourse analysis in HPE. Scholars are encouraged to reflect more deeply on the applications and practices of discourse analysis, with the ultimate aim of ensuring more breadth and depth when using discourse analysis for understanding and constructing meaning in our field.

Disembodied, dehumanised but safe and feasible: The social-spatial flow of a pandemic OSCE.

INTRODUCTION: The Objective Structured Clinical Examination (OSCE) is a key feature of healthcare education assessment. Many aspects of the OSCE are well-investigated, but not so its sociomaterial assemblage. The Covid-19 pandemic provided a unique opportunity to (re)consider taken-for-granted OSCE practices. Drawing on Law's modes of ordering, our aim was to demonstrate the 'mangle of practice' between space and people; the spatialised and spatialising processes of an OSCE. METHODS: We used a case study approach to critically examine a redesigned final year MBChB OSCE held during the pandemic. We used multiple sources of data to attune to human and non-human actors: OSCE documentation, photographs, field notes and semi-structured interviews with OSCE staff/organisers. Law's modes of ordering was used as an analytical lens to critically consider how people and things flowed through the adapted OSCE. FINDINGS: The overarching ordering was the delivery of a 'pandemic safe' OSCE. This necessitated reordering of 'usual' process to deliver a socially distanced, safe flow of human and non-human actors through the assessment space. Each change had material and social 'knock on' effects. We identified three main interrelated orderings: Substituting technologies for bodies: Disembodied and dehumanised but feasible; Flow through space: Architectural affordances and one-way traffic; Barriers to flow: Time and technology. DISCUSSION: Looking at the OSCE through a sociomaterial lens allows us to critically examine the OSCE's essential and complex processes and the restrictions and affordances of the spaces and props within the OSCE. In doing so, we open the possibility of considering alternative ways of doing OSCEs in the future. Moreover, conceptualising the OSCE as a living set of socially (human) and materially (nonhuman) enacted processes changes the social perception of the OSCE and highlights that an OSCE has agency on people, places and things.

Front row seat: The role MMI assessors play in widening access to medical school.

BACKGROUND: While many medical schools utilize the Multiple Mini-Interview (MMI) to help select a diverse student body, we know little about MMI assessors' roles. Do MMI assessors carry unique insights on widening access (WA) to medical school? Herein we discuss the hidden expertise and insights that assessors contribute to the conversation around WA. METHODS: Ten MMI assessors (1-10 years' experience) participated in semi-structured interviews exploring factors influencing equitable medical school recruitment. Given their thoughtfulness during initial interviews, we invited them for follow-up interviews to gain further insight into their perceived role in WA. Fourteen interviews were conducted and analyzed using a thematic analysis approach. RESULTS: Assessors expressed concerns with diversity in medicine; dissatisfaction with the status quo fueled their contributions to the selection process. Assessors advocated for greater diversity among the assessor pool, citing benefits for all students, not only those from underrepresented groups. They noted that good intentions were not enough and that medical schools can do more to include underrepresented groups' perspectives in the admissions process. CONCLUSION: Our analysis reveals that MMI assessors are committed to WA and make thoughtful contributions to the selection process. A medical school selection process, inclusive of assessors' expertise is an important step in WA.

"There's an Etiquette to Zoom That's Not Really Present In-Person": A Qualitative Study Showing How the Mute Button Shapes Virtual Postpartum Support for New Parents.

Virtual spaces that allow parents in the postpartum period to connect, support each other, and exchange information have been increasing in popularity. With the COVID-19 pandemic, many parents had to rely on virtual platforms as a primary means to connect with others and attend to their postpartum health. This study explored virtual postpartum support sessions through the web-based videoconferencing software, Zoom. Guided by feminist poststructuralism and sociomaterialism, we held seven virtual support sessions for parents caring for a baby 0-12 months in age, in Canada, and interviewed 19 participants about their experiences in the sessions. Our methodological approach allowed us to analyze discourses of (1) parenthood, (2) material realities of virtual environments, and (3) support and information on this virtual platform. The purpose of this research was to understand how technology influences postpartum support and learning through online videoconferencing for parents. Our findings document an overarching discourse of Zoom etiquette by which muting was a discursive practice that all participants used. The consistent use of the mute button while not talking structured conversation in virtual postpartum sessions and resulted in three themes: (1) minimizing disruptions; (2) taking turns; and (3) staying on task. The norm of using the mute button changed how parents received and gave support and information. Based on findings and broader literature, we discuss considerations for facilitation of virtual postpartum support sessions.

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.

A national pilot of donation after circulatory death (DCD) heart transplantation within the United Kingdom.

BACKGROUND: The United Kingdom (UK) was one of the first countries to pioneer heart transplantation from donation after circulatory death (DCD) donors. To facilitate equity of access to DCD hearts by all UK heart transplant centers and expand the retrieval zone nationwide, a Joint Innovation Fund (JIF) pilot was provided by NHS Blood and Transplant (NHSBT) and NHS England (NHSE). The activity and outcomes of this national DCD heart pilot program are reported. METHODS: This is a national multi-center, retrospective cohort study examining early outcomes of DCD heart transplants performed across 7 heart transplant centers, adult and pediatric, throughout the UK. Hearts were retrieved using the direct procurement and perfusion (DPP) technique by 3 specialist retrieval teams trained in ex-situ normothermic machine perfusion. Outcomes were compared against DCD heart transplants before the national pilot era and against contemporaneous donation after brain death (DBD) heart transplants, and analyzed using Kaplan-Meier analysis, chi-square test, and Wilcoxon's rank-sum. RESULTS: From September 7, 2020 to February 28, 2022, 215 potential DCD hearts were offered of which 98 (46%) were accepted and attended. There were 77 potential donors (36%) which proceeded to death within 2 hours, with 57 (27%) donor hearts successfully retrieved and perfused ex situ and 50 (23%) DCD hearts going on to be transplanted. During this same period, 179 DBD hearts were transplanted. Overall, there was no difference in the 30-day survival rate between DCD and DBD (94% vs 93%) or 90 day survival (90% vs 90%) respectively. There was a higher rate of ECMO use post-DCD heart transplants compared to DBD (40% vs 16%, p = 0.0006), and DCD hearts in the pre pilot era, (17%, p = 0.002). There was no difference in length of ICU stay (9 DCD vs 8 days DBD, p = 0.13) nor hospital stay (28 DCD vs 27 DBD days, p = 0.46). CONCLUSION: During this pilot study, 3 specialist retrieval teams were able to retrieve DCD hearts nationally for all 7 UK heart transplant centers. DCD donors increased overall heart transplantation in the UK by 28% with equivalent early posttransplant survival compared with DBD donors.

Learning by doing: A phenomenological study of medical student leaders.

INTRODUCTION: Despite being recognised as a key physician competency, leadership development is an area of improvement especially in undergraduate medical education. We sought to explore the lived experience of leaders who served in elected, representative roles during their time in medical school. METHODS: We used a hermeneutic phenomenological approach to uncover the essence of the medical student leader experience. From late 2020 to early 2021, we interviewed 12 medical residents who served in elected leadership roles from 2015 to 2019. Each participant graduated from a different Canadian medical school. We deliberately chose a limited and historic time period in order for participants to be able to reflect on their past experiences while accounting for differences in the medical student leadership experience over time. We then engaged in a reflexive thematic analysis to generate the final themes. RESULTS: We identified the following five themes: (i) living with busyness, (ii) the role of faculty mentorship and support, (iii) competing demands of leadership, (iv) medical student leadership as enriching and (v) creating better physicians. Though demanding, medical student leadership was found to be rewarding and particularly key in the development of a more well-rounded physician. Furthermore, being well supported by faculty contributed to an overall positive leadership experience. DISCUSSION: In addition to describing the hardships and rewards that make up their experience, this study suggests that medical student leadership can enhance core physician competencies. The findings also support the notion that faculties have an important role to play in supporting medical student leaders.

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.

CARDA: Guiding document analyses in health professions education research.

INTRODUCTION: Documents, from policies and procedures to curriculum maps and examination papers, structure the everyday experiences of health professions education (HPE), and as such can provide a wealth of empirical information. Document analysis (DA) is an umbrella term for a range of systematic research procedures that use documents as data. METHODS: A meta-study review was conducted with the aims of describing the current state of DA in HPE, guiding researchers engaging in DA and improving methodological, analytical and reporting rigour. Structured searches were conducted, returns were filtered for inclusion and the 115 remaining articles were critically analysed for their use of DA methods and methodologies. RESULTS: There was a significant increase in the number of articles reporting the use of DA over time. Sixty-three articles were single method (DA only), while the others were mixed methods research (MMR). Overall, there were major lacunae in terms of why documents were used, how documents were identified, what the authors did and what they found from the documents. This was particularly apparent in MMR where DA reporting was typically poorer than the reporting of other methods in the same paper. DISCUSSION: Given these many lacunae, a framework for reporting on DA research was developed to facilitate rigorous DA research and transparent, complete and accurate reporting of the same, to help readers assess the trustworthiness of the findings from document use and analysis in HPE and, potentially, other domains. It was also noted that there are gaps in HPE knowledge that could be addressed through DA, particularly where documents are conceptualised as more than passive holders of information. Scholars are encouraged to reflect more deeply on the applications and practices of DA, with the ultimate aim of ensuring more substantive and more rigorous use of documents for understanding and constructing meaning in our field.

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.

Moving beyond 'think leadership, think white male': the contents and contexts of equity, diversity and inclusion in physician leadership programmes.

The lack of both women and physicians from groups under-represented in medicine (UIM) in leadership has become a growing concern in healthcare. Despite increasing recognition that diversity in physician leadership can lead to reduced health disparities, improved population health and increased innovation and creativity in organisations, progress toward this goal is slow. One strategy for increasing the number of women and UIM physician leaders has been to create professional development opportunities that include leadership training on equity, diversity and inclusivity (EDI). However, the extent to which these concepts are explored in physician leadership programming is not known. It is also not clear whether this EDI content challenges structural barriers that perpetuate the status quo of white male leadership. To explore these issues, we conducted an environmental scan by adapting Arksey and O'Malley's scoping review methodology to centre on three questions: How is EDI currently presented in physician leadership programming? How have these programmes been evaluated in the peer-reviewed literature? How is EDI presented and discussed by the wider medical community? We scanned institutional websites for physician leadership programmes, analysed peer-reviewed literature and examined material from medical education conferences. Our findings indicate that despite an apparent increase in the discussion of EDI concepts in the medical community, current physician leadership programming is built on theories that fail to move beyond race and gender as explanatory factors for a lack of diversity in physician leadership. To address inequity, physician leadership curricula should aim to equip physicians to identify and address the structural factors that perpetuate disparities.

Lower-class origin professionals in Canadian health and social service professions: "A different level of understanding".

As health and social service professions increasingly emphasize commitments to equity, advocacy and social justice, non-traditional entrants to the professions increasingly bring much-needed diversity of social backgrounds and locations. Long the domain of elite social classes, the professions are not always welcoming cultures for those from lower social class backgrounds. This paper draws on notions of material, social and cultural capital, along with habitus, to examine the experiences of professionals with lower-class backgrounds, in educational programs and in their professions. The critical interpretive qualitative study draws on interviews with 27 professionals across Canada in medicine, nursing, social work and occupational therapy. While participants were clearly set apart from their colleagues by class origins, which posed distinct struggles, they also brought valuable assets to their work: enhanced connection and rapport with clients/patients, approachability, structural analysis and advocacy, plus nuanced re-envisioning of professional ethics to minimize power dichotomies. Rather than helping lower-class entrants adapt to the professions, it may be more beneficial to alter normative professional cultures to better suit these practitioners.

How an Arts-Based Clinical Skills Set Can Be Assessed During OSCEs.

Background: Arts-based activities' roles in medical education is to challenge students to cultivate clinical skills using ART (aesthetics, reflection, time). ART activities offer opportunities for students to cultivate creative dimensions of their clinical skills and to reflect on their responses to uncertainty and ambiguity. Faculty, however, are challenged to structure these learning activities in diverse, sometimes unfamiliar, health care settings. Methods: This study explored preclerkship medical students' responses to participating in ART activities presented in the common medical educational format of an objective structured clinical exam (OSCE). Activities included interpreting fine art (eg, images and poetry) and drawing a simulated patient. The discussion section transcript and student sketchbooks were analyzed to identify themes related to participating in the study. Results: Use of arts-based activities elicited behaviors similar to those observed in students' responses to formal summative OSCEs, although students also wrestled with challenges and expressed their subjective impressions. Conclusions: This study offers an arts-based tool set capable of being delivered within the familiar medical education setting and established structure of the OSCE.

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.