On the advantages and disadvantages of virtual continuing medical education: a scoping review.

Introduction: With the COVID-19 pandemic, most continuing medical education activities became virtual (VCME). The authors conducted a scoping review to synthesize the advantages and disadvantages of VCME to establish the impact of this approach on inequities that physicians face along the intersections of gender, race, and location of practice. Methods: Guided by the methodological framework of Arksey and O'Malley, the search included six databases and was limited to studies published between January 1991 to April 2021. Eligible studies included those related to accredited/non-accredited post-certification medical education, conferences, or meetings in a virtual setting focused on physicians. Numeric and inductive thematic analyses were performed. Results: 282 studies were included in the review. Salient advantages identified were convenience, favourable learning formats, collaboration opportunities, effectiveness at improving knowledge and clinical practices, and cost-effectiveness. Prominent disadvantages included technological barriers, poor design, cost, lack of sufficient technological skill, and time. Analysis of the studies showed that VCME was most common in the general/family practice specialty, in suburban settings, and held by countries in the Global North. A minority of studies reported on gender (35%) and race (4%). Discussion: Most studies report advantages of VCME, but disadvantages and barriers exist that are contextual to the location of practice and medical subspecialty. VCME events are largely organized by Global North countries with suboptimized accessibility for Global South attendees. A lack of reported data on gender and race reveals a limited understanding of how VCME affects vulnerable populations, prompting potential future considerations as it evolves.

Introduction: Par suite de la pandémie de la COVID-19, la plupart des activités de formation médicale continue ont été offertes en ligne. Les auteurs ont effectué une revue exploratoire de la littérature visant à faire la synthèse des avantages et des inconvénients de la formation médicale continue en mode virtuel (FMCV) et à évaluer les effets de cette approche sur les inégalités qui affectent les médecins en fonction du sexe, de la race et du lieu d'exercice. Méthodes: Suivant le cadre méthodologique d'Arksey et O'Malley, nous avons effectué une recherche dans six banques de données, que nous avons limitée aux études publiées entre janvier 1991 et avril 2021. Les études incluses étaient celles relatives à la formation médicale post-certification, accréditée ou non, aux conférences et aux réunions destinées aux médecins qui se sont déroulées dans un cadre virtuel. Une analyse numérique et une analyse thématique inductive ont été réalisées. Résultats: Au total, 282 articles ont été inclus dans l'étude. Les principaux avantages identifiés sont la commodité, les formats favorables à l'apprentissage, les possibilités de collaboration, l'efficacité pour l'amélioration des connaissances et des pratiques cliniques et le rapport coût-efficacité. Les principaux inconvénients sont les obstacles technologiques, les défauts de conception, le coût, les compétences technologiques insuffisantes et le manque de temps. L'analyse des études a montré que la FMCV était plus courante dans la spécialité de la médecine générale/familiale, dans les banlieues et dans les pays du Nord. Quelques études prennent en compte sexe (35 %) et race (4 %). Discussion: La plupart des études évoquent les avantages de la FMCV, mais il existe des inconvénients et des obstacles liés au lieu de pratique et à la surspécialité médicale. La plupart des activités de FMCV sont organisées dans les pays du Nord et leur accessibilité n'est pas optimale pour les participants provenant des pays du Sud. Le manque de données sur e sexe et la race des participants limite à notre compréhension de la façon dont la FMCV affecte les populations vulnérables. Ces facteurs seraient à prendre en considération dans les recherches futures sur le sujet au fur et à mesure que la FMCV évolue.

Conceptualizations of "good death" and their relationship to technology: A scoping review and discourse analysis.

Background and Aims: By the 1960s, medicine experienced technological revolutions that enabled it to control and medicalize death in many circumstances. The modern conceptualization of "good death" emerged in the late 1960s with the beginning of the hospice movement, and palliative care became an official medical specialty in 1987. This project aims to elucidate how the idea of "good death" has been discussed and perceived since then, as well as the impact of medical technologies on death. Methods: The terms "good death," "technology," and "palliative care" were searched. One hundred ninety English sources that discussed "good death" explicitly or implicitly, published between 1987 and 2020, were included in the final analysis. Texts were analyzed for discursive themes related to "good death" and technology and demographic data related to authors, geographies, types of text, and date of publication. Results: The discourse of a "good death" with the patient being in control dominated the archive. Other discourses include a good death being peaceful and comfortable, one where the patient is not alone, and one that is not prolonged. Medical technology discourses are largely negative in the setting of death. Conclusion: Findings indicate a strong critique of the medicalization of death in the literature. This also complements the dominance of discourses on patient autonomy. Medical discourses of "good death" and technology permeate discussion outside of the healthcare context, and there is an absence of spirituality and neutrality in "good death" discourses. The results of this study are relevant for ethics and communication in geriatric and palliative care.

What makes a 'good doctor'? A critical discourse analysis of perspectives from medical students with lived experience as patients.

What constitutes a 'good doctor' varies widely across groups and contexts. While patients prioritise communication and empathy, physicians emphasise medical expertise, and medical students describe a combination of the two as professional ideals. We explored the conceptions of the 'good doctor' held by medical learners with chronic illnesses or disabilities who self-identify as patients to understand how their learning as both patients and future physicians aligns with existing medical school curricula. We conducted 10 semistructured interviews with medical students with self-reported chronic illness or disability and who self-identified as patients. We used critical discourse analysis to code for dimensions of the 'good doctor'. In turn, using concepts of Bakhtinian intersubjectivity and the hidden curriculum we explored how these discourses related to student experiences with formal and informal curricular content.According to participants, dimensions of the 'good doctor' included empathy, communication, attention to illness impact and boundary-setting to separate self from patients. Students reported that formal teaching on empathy and illness impact were present in the formal curriculum, however ultimately devalued through day-to-day interactions with faculty and peers. Importantly, teaching on boundary-setting was absent from the formal curriculum, however participants independently developed reflective practices to cultivate these skills. Moreover, we identified two operating discourses of the 'good doctor': an institutionalised discourse of the 'able doctor' and a counterdiscourse of the 'doctor with lived experience' which created a space for reframing experiences with illness and disability as a source of expertise rather than a source of stigma. Perspectives on the 'good doctor' carry important implications for how we define professional roles, and hold profound consequences for medical school admissions, curricular teaching and licensure. Medical students with lived experiences of illness and disability offer critical insights about curricular messages of the 'good doctor' based on their experiences as patients, providing important considerations for curriculum and faculty development.

Evolving discourses of COVID-19 and implications for medical education: a critical discourse analysis.

Background: The othering of individuals has been identified as a concern during the COVID-19 pandemic. The purpose of this study was to examine public commentary during early stages of the pandemic for: 1) emerging discourses that highlighted population-level inequities, and 2) the implications these discourses may have for medical education. Methods: Using a critical discourse analysis (CDA) approach, an archive of texts available in the public domain discussing COVID-19 was iteratively created, reviewed, and coded. We used an intersectional framework to analyze how COVID-19 highlighted structural and institutional inequity at the population level. Results: We found 86 representative texts published from March to June 2020. We focused our analysis on implications within Ontario. The two major discourses that emerged were "COVID-19 as Equalizer" and "COVID-19 as Discriminator." The former emerged in the early stages of the pandemic to mobilize public health recommendations and describe near-universal impacts on the public. The latter followed to highlight new and pre-existing forms of marginalization exacerbated by the pandemic. Conclusions: This study provides a unique perspective on how structural and systemic responses to COVID-19 were shaped through analysis of public discourse, and therefore, has implications for how the COVID-19 pandemic and future pandemics are framed for future medical learners.

Contexte: L'altérisation a été soulevée comme effet préoccupant de la pandémie de la COVID-19. L'objectif de cette étude était d'examiner les réactions du public au cours des premiers stades de la pandémie afin de dégager : 1) les discours émergents témoignant d'inégalités au sein de la population, et 2) les incidences potentielles de ces discours sur l'éducation médicale. Méthodes: L'approche adoptée est celle de l'analyse critique du discours (ACD). Nous avons constitué une archive de textes du domaine public contenant des commentaires relatifs à la COVID-19, que nous avons examinés, codés de manière itérative et analysés transversalement pour déceler dans quelle mesure la pandémie a mis en évidence les inégalités structurelles et institutionnelles au sein de la population. Résultats: Nous avons trouvé 86 textes représentatifs publiés entre mars et juin 2020. Nous avons concentré notre analyse sur les incidences en Ontario. Les deux principaux discours qui ont émergé sont «la COVID-19 comme facteur égalisateur¼ et «la COVID-19 comme facteur discriminant¼. Le premier est apparu au début de la pandémie pour inciter au respect des recommandations de santé publique et pour décrire les effets quasi universels sur la population. Il a été suivi par un second discours, mettant en lumière les formes nouvelles et préexistantes de marginalisation exacerbées par la pandémie. Conclusions: Cette étude offre une perspective unique de la pandémie telle qu'elle est perçue par le biais d'une analyse du domaine public. Elle peut donc éclairer la manière de présenter la gestion des pandémies aux futurs apprenants en médecine.

Transformative learning in the setting of religious healers: A case study of consultative mental health workshops with religious healers, Ethiopia.

Objective: Psychiatric interventions that consider the socio-cultural and spiritual traditions of patients are needed to address stigma and improve access to mental health services. Productive collaboration between traditional healers and biomedical practitioners hold promise in such efforts, and applying tenets of transformative learning hold potential for mitigating an overemphasis on biomedical models in such collaboration. We present a framework for how to engage in health system reform to enhance mental health services in communities that are distrustful of, or unfamiliar with biomedical approaches. Our research question was how to bridge two seemingly opposing paradigms of mental health care, and we sought to understand how the theory of transformational learning (TLT) can be applied to learning among Religious healers and biomedical practitioners in culturally appropriate ways to improve collaboration. Methods: TLT informed the development, implementation, and evaluation of an educational intervention in Addis Ababa, Ethiopia that aimed to improve delivery of mental health services at two Holy water sites. The initiative involved both psychiatrists and religious healers with extensive experience providing care to mentally ill patients. Using a focused ethnographic approach that incorporates document analysis methodology, this qualitative study examined recordings and minutes of stakeholder meetings, workshops and informal interviews with participants, analyzed for evidence of Mezirow's 11 stages of transformative learning. A participatory action approach was used to encourage practice change. Results: All participants exhibited a high degree of engagement with the of the collaborative project and described experiencing "disorienting dilemmas" by Mezirow's classic description. Opportunities to reflect separately and in large groups encouraged a re-examination of attitudes previously contributing to siloed approaches to care and led to instrumental changes in mental health care delivery and a higher degree of coordination and collaboration between psychiatrists and traditional healers. Conclusion: Our study demonstrates the utility of TLT in both the design and evaluation of initiatives aiming to bridge cross-cultural and cross-professional divides. The learning process was further enhanced by a collaborative participatory action model adjusted to accommodate Ethiopian socio-political and cultural relations.

(Re)producing "Whiteness" in Health Care: A Spatial Analysis of the Critical Literature on the Integration of Internationally Educated Health Care Professionals in the Canadian Workforce.

PURPOSE: There is a gap in the literature to understand how professionalizing systems intersect with socioeconomic and political realities such as globalization to (re)produce social inequities between those trained locally and those trained abroad. In this critical review, the question of how systemic racism is reproduced in health care is addressed. METHOD: Electronic databases and nontraditional avenues for searching literature such as reference chaining and discussions with experts were employed to build an archive of texts related to integration of internationally educated health care professionals (IEHPs) into the workforce. Data related to workplace racialization were sought out, particularly those that used antiracist and postcolonial approaches. Rather than an exhaustive summary of the data, a critical review contributes to theory building and a spatial analysis was overlayed on the critical literature of IEHP integration to conceptualize the material effects of the convergence of globalization and professional systems. RESULTS: The critical review suggests that professions maintain their value and social status through discourses of "Canadianness" that maintain the homogeneity of professional spaces through social closure mechanisms of credential nonrecognition and resocialization. Power relations are maintained through mechanisms of workplace racialization/spatialization and surveillance which operate through discourses of "foreign-trainedness." CONCLUSIONS: Movement of professionals supports a professional system that on the surface values diversity while maintaining its social status and power through the (re)production of the discourse of "Whiteness." The analysis shows how in the process domestic graduates are emplaced as the "rightful" citizens of professional paces while IEHPs are marginalized in the workforce.

Motivations for and Challenges in the Development of Global Medical Curricula: A Scoping Review.

PURPOSE: The aim of this scoping review is to understand the motivations for the creation of global medical curricula, summarize methods that have been used to create these curricula, and understand the perceived premises for the creation of these curricula. METHOD: In 2018, the authors used a comprehensive search strategy to identify papers on existing efforts to create global medical curricula published from 1998 to March 29, 2018, in the following databases: MEDLINE; MEDLINE Epub Ahead of Print, In-Process, and Other Non-Indexed Citations; Embase; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; PsycINFO; CINAHL; ERIC; Scopus; African Index Medicus; and LILACS. There were no language restrictions. Two independent researchers applied the inclusion and exclusion criteria. Demographic data were abstracted from publications and summarized. The stated purposes, methods used for the development, stated motivations, and reported challenges of curricula were coded. RESULTS: Of the 18,684 publications initially identified, 137 met inclusion criteria. The most common stated purposes for creating curricula were to define speciality-specific standards (50, 30%), to harmonize training standards (38, 23%), and to improve the quality or safety of training (31, 19%). The most common challenges were intercountry variation (including differences in health care systems, the operationalization of medical training, and sociocultural differences; 27, 20%), curricular implementation (20, 15%), and the need for a multistakeholder approach (6, 4%). Most curricula were developed by a social group (e.g., committee; 30, 45%) or Delphi or modified Delphi process (22, 33%). CONCLUSIONS: The challenges of intercountry variation, the need for a multistakeholder approach, and curricular implementation need to be considered if concerns about curricular relevance are to be addressed. These challenges undoubtedly impact the uptake of global medical curricula and can only be addressed by explicit efforts to make curricula applicable to the realities of diverse health care settings.

Transformative learning in an interprofessional student-run clinic: a qualitative study.

Student-run free clinics are increasingly seen as a way for students in health professions to have early authentic exposures to providing care to marginalized populations, often in the context of interprofessional teams. However, few studies characterize what and how students may learn from volunteering at a student-run free clinic. We aimed to examine shifts in attitude or practice that volunteers report after completing a placement at an interprofessional student-run clinic in Toronto, Ontario, Canada. Transcripts from semi-structured reflective focus groups were analyzed in an exploratory thematic manner and from the perspective of transformative learning theory. Volunteers reported attitude shifts toward greater self-awareness of assumptions, recognition of the need for systemic interventions, and seeing themselves as learning and contributing meaningfully in a team even without direct-client contact. Practice shifts emerged of individualizing assessment and treatment of patients as well as increased comfort working in interprofessional teams. Attitude and practice shifts were facilitated by authentic interactions with individuals from marginalized populations, taking a patient-centered approach, and an interprofessional context. Interprofessional student-run free clinics are suited to triggering disorienting dilemmas that set the stage for transformative learning, particularly when volunteers are guided to reflect.

Exploring Glocalization in the Construction and Implementation of Global Curricula.

Despite proposed advantages of global curricular harmonization including physician mobility and improving the quality of care, the challenges and unintended consequences require greater study. The aim of this study was to problematize the concept and implementation of global oncology curricula and their relationship to local contexts of power and culture. Fourteen international participants involved in the development and implementation of global oncology curricula completed in-depth, one-on-one semi-structured interviews lasting 40-60 min. Snowball sampling was employed. Through iterative analyses, using an abductive approach, the study team discussed and reviewed the data and made revisions through collaborative analysis to enhance comprehensiveness and to improve credibility. In the final analysis the meaning and implication of the themes were discussed yielding a conceptual analysis. Our data have articulated 5 key challenges for global curricula including 1) Ambiguous or conflicting perspectives on the purpose and scope of Global Oncology Curricula 2) Insufficient representation of diverse perspectives and realities in the creation of the final curricula 3) A rigid conceptualization of competency requirements 4) A mismatch between the curricular requirements and local context and 5) The influence of power relationships and decision makers. Leveraging the strengths of diversity including fostering representation, addressing power differentials and factoring local contexts may be an approach to mitigating these challenges. Global oncology curricula may serve important advocacy roles within the healthcare system. Leveraging diversity may positively impact the common challenges in the construction and implementation of global oncology curricula.

"It's Not Just About Getting Along": Exploring Learning Through the Discourse and Practice of Interprofessional Collaboration.

PURPOSE: Interprofessional collaboration (IPC) is a necessary competency for all professionals. However, IPC can be fraught with politics leading to variable uptake and execution. The authors set out to understand how trainees come to appreciate the value of the "team" in their learning and to describe the type of learning related to IPC afforded to trainees in a highly collaborative complex care context. METHOD: The authors conducted 72 hours of observations of pediatric rheumatology settings at a large pediatric hospital across 18 months. They interviewed 10 health professionals and analyzed an archive of texts to ascertain how the field of pediatric rheumatology conceptualizes the role of IPC. They used the concept of governmentality and critical discourse analysis to describe how values of collaboration enabled learning and theories of expertise to understand how learning was enacted and perceived. RESULTS: Collaboration was perceived to be a product of providing good rheumatological care, which in this case, aligned well with hospital model of IPC. This alignment afforded trainees learning opportunities beyond preparing them to get along with other health professionals. IPC, when role modeled during problem solving, created the conditions for learning "why" collaboration is important for clinical expertise. CONCLUSIONS: By critically examining the relationship between discourse, practice, and learning, the authors have described how practices that underpin collaboration as a clinical competency are distinct from collaboration as cultural work contributing to civility within teams and across the organization.

Exploring implementation of the ESTRO Core Curriculum at the national level.

BACKGROUND AND PURPOSE: Global curricula exist across medical specialties however, the factors which influence their implementation are not well understood. The purpose of this study is to report the perceived factors that impact the implementation of the ESTRO Core Curriculum. METHODS: An anonymous, 37-item, survey was designed and distributed to the Presidents of the National Societies who have endorsed the ESTRO Core Curriculum (n = 29). The survey addressed perceptions about implementation factors related to context, process and curriculum change. The data was summarized using descriptive statistics. RESULTS: Twenty-six (90%) National Societies completed the survey. One respondent perceived that the values of the training system of their country would be incompatible with the proposed ESTRO Core Curriculum. The most common contextual barriers to implementation was a lack of support from the government (57%), a lack of internal organizational support (35%) and a 'poor fit' between the ESTRO Core Curriculum and the broader political and economic context (35%). Perceived implementation process barriers included insufficient numbers of faculty (44%), poor coordination between the government and training institutions (48%), and a lack of an influential person leading the implementation (44%). Two barriers related to curriculum change were a lack of funding and lack of assessment tools. CONCLUSIONS: The content and values espoused in the ESTRO Core Curriculum are endorsed across diverse geopolitical and sociocultural regions. Barriers to curricular implementation are identified at the organizational and systems level and include insufficient teaching faculty, lack of coordination and the need for influential leadership.

A critical review of representation in the development of global oncology curricula and the influence of neocolonialism.

BACKGROUND: Global curricular homogenization is purported to have a multitude of benefits. However, homogenization, as typically practiced has been found to promote largely Western ideals. The purpose of this study was to explore the issue of representation in the development of global oncology curricula. METHODS: This systematic review of global oncology curricula involved a comprehensive search strategy of eight databases from inception to December 2018. Where available, both controlled vocabulary terms and text words were used. Two investigators independently reviewed the publications for eligibility. Full global/core oncology curricular documents were included. Data analysis included exploration of representation across a number of axes of power including sex and geographic sector, consistent with a neocolonial approach. RESULTS: 32,835 documents were identified in the search and 17 remained following application of the inclusion/exclusion criteria. Eleven of 17 papers were published from 2010 to 2018 and 13 curricula originated from Europe. The 17 curricula had 300 authors; 207 were male and most were from Europe (n = 190; 64%) or North America (n = 73; 24%). The most common curricular purposes were promoting quality patient care (n = 11), harmonization of training standards (n = 10), and facilitating physician mobility (n = 3). The methods for creation of these curricula were most commonly a committee or task force (n = 10). Over time there was an increase in the proportion of female authors and the number of countries represented in the authorship. CONCLUSION: Existing global oncology curricula are heavily influenced by Western male authors and as a result may not incorporate relevant socio-cultural perspectives impacting care in diverse geographic settings.

Should Wellness Be a Core Competency for Physicians?

There has been a recent rise in calls for action around wellness and physician health. In medical education, wellness has been proposed as a physician competency. In this article, the authors review the history of the "wellness as a competency" concept within U.S. and Canadian residency programs and medical schools. Drawing from literature on the discourses of wellness and competence in medical education, they argue that operationalizing wellness as a physician competency holds profound implications for curricula, admissions, evaluation, and licensure. While many definitions of "wellness" and "competency" are used within medical training environments, the authors argue that the definitions institutions ultimately use will have significant impacts for trainees who are considered "unwell." In particular, medical learners with disabilities-including those with mental health, chronic health, learning, sensory, and mobility disabilities-may not conform to dominant conceptions of "wellness," and there is a risk they will become further stigmatized or even be considered unsuitable to practice in the profession. The authors conclude that framing wellness as a competency has the potential to legitimize support-seeking and prioritize physician health, yet it may also have the potential unintended effect of excluding certain learners from the profession. They propose a universal design approach to understand wellness at a systems level and to remove barriers to wellness for all medical learners.

Same but Different: Exploring Mechanisms of Learning in a Longitudinal Integrated Clerkship.

PURPOSE: Longitudinal integrated clerkships (LICs) are a widely used method of delivering clerkship curricula. Although there is evidence that LICs work and core components of LIC training have been identified, there is insufficient understanding of which components are integral to why they work. To address this question, this research explored how students experienced the first year of an LIC program. The aim was to use participants' understanding of their learning experiences to identify potential mechanisms of the LIC curriculum model. METHOD: Thirty-two interviews were conducted with 13 University of Toronto students, 7 LIC and 6 block rotation students from the same site, from October 2014 to September 2015. A thematic analysis was performed iteratively to explore participants' understanding of their key learning experiences and outcomes. RESULTS: Participants in both cohorts described their key learning outcome as integration and application of knowledge during patient care. Experiences supporting this outcome were articulated as longitudinal variable practice and continuity of relationships with preceptors and patients. Critically, these experiences manifested differently for the 2 cohorts. For block students, these learning experiences appeared to reflect the informal curriculum, whereas for LIC students, learning experiences were better supported by the LIC formal curriculum. CONCLUSIONS: The results illustrate the importance of learning experiences that support longitudinality and continuity. By also emphasizing variability and knowledge integration, they align with literature on expert development. Notably, many of the learning experiences identified resulted from informal learning and thus support going beyond the formal curriculum when evaluating the effectiveness of curricula.

Myths and social structure: The unbearable necessity of mythology in medical education.

CONTEXT: Myth busting engages scholars in the critical examination of commonly accepted but poorly evidenced claims with the goal of instilling quality and trust in knowledge making. The debunking of such knowledge "myths" and associated misguided practices purportedly serves to avert resources and attention from wasteful and dangerous scholarship. We address the myth that "all myths in medical education deserve to be busted". METHODS: Using a critical narrative approach, we searched the medical education literature for orientations to myths and myth busting, and reviewed this literature analytically drawing from the sociology of science and Merton's concepts of manifest and latent functions. The results of this analysis are presented in the form of a narrative that deploys the articles reviewed to explore the utility of myth busting for medical education reform and begins with a brief exploration of the etymology of "myth" and how meaning making is related to symbols, practices and storytelling. RESULTS: Our analysis revealed the important function of myths in the social practice of medical education and practice. A deconstruction of five salient examples of the contemporary myth in medical education (the myth of the "ideal candidate", the myth of "cut-throats", the myth of "cadaver stories", the myth of "learning styles", and the myth of "patient information leaflets") demonstrates that myths continue to have material effects even after they have been busted. CONCLUSIONS: Our analysis makes evident that myth busting disrupts, renegotiates and reconstitutes socio-epistemic relationships rather than simply correcting falsehoods. We also argue that myths play important and inescapable roles in the social practice of medical education and the negotiation of values, and in constructing the conditions for group change and transformation. Imperatives related to humanism, compassion and patient engagement offer a healthy humanising counter-mythologising that we suggest must survive any contemporary myth-busting endeavour aimed at improving medical education practice.