Occupying liminal spaces: The figured worlds of student affairs senior leaders in the United States.

INTRODUCTION: Student Affairs Senior Leaders (SASLs) in the United States lead offices responsible for academic advising, administrative documentation, scheduling, student health, financial aid, and transition to residency, yet they infrequently draw attention in the field's literature. We explore the role of SASLs and how they describe the social space of medical education. METHODS: Using a constructivist approach informed by Figured Worlds theory, we conducted a sequential narrative and thematic analysis of the stories SASLs tell about their roles and experiences in the world of medical education. RESULTS: SASLs inhabit complex roles centred on advocating for medical students' academic, personal and social well-being. Their unique position within the medical school allows them to see the harm to vulnerable students made possible by misalignments inherent within medical education. Yet even with the challenges inherent in the environment, SASLs find reasons for hope. CONCLUSION: SASLs' identities are full of potential contradictions, but they have a unique view into the often-chaotic world of medical education.

In Their Own Voices: A Critical Narrative Review of Black Women Faculty Members' First-Person Accounts of Racial Trauma Across Higher Education.

Phenomenon: Black women often face more challenges in academic medicine than others and are leaving the profession due to unsupportive work environments, systematic neglect, and experiences of invisibility. Research offers insight into Black women faculty experiences, but studies have largely been conducted on their experiences rather than written by them. We analyzed first-person narratives exploring Black women faculty members' experiences with racial trauma across the academy considering the intersectionality of racism and sexism to lay the foundation for understanding Black women physicians' faculty experiences in similar spaces. Approach: We gathered first-person narratives of Black women faculty members in the U.S. from ERIC, Web of Science, and Ovid Medline. We used a variety of terms to draw out potential experiences with trauma (e.g., microaggressions, stigma, prejudice). Articles were screened by two researchers, with a third resolving conflicts. Drawing on constructs from Black feminist theory, two researchers extracted from each article authors' claims about: (a) their institutions, (b) their experiences in those spaces, and (c) suggestions for change. We then analyzed these data through the lens of racial trauma while also noting the effects of gendered racism. Findings: We identified four key themes from the 46 first-person accounts of racial trauma of Black faculty members in higher education: pressures arising from being "the only" or "one of few"; elimination of value through the "cloak of invisibility" and "unconscious assumptions"; the psychological burden of "walking a tightrope"; and communal responsibility, asking "if not us, then who?" Insights: Black women's narratives are necessary to unearth their specific truths as individuals who experience intersectional oppression because of their marginalized racial and gender identities. This may also assist with better understanding opportunities to dismantle the oppressive structures and practices hindering more diverse, equitable, and inclusive institutional environments where their representation, voice, and experience gives space for them to thrive and not simply survive within the academy, including and not limited to medicine.

How Theory Can Inform Practice: A Case of Easing Transition Into Residency.

Health professions educators aim to optimally prepare trainees for future practice; educational theory can help reach this goal. Below we present an authentic case, I Just Need to Speak With My Eyes, that displays the significant struggles of transitioning into residency training. Using this case, we show how the application of 4 learning mechanisms described in Lave and Wenger's 1,2 theories of situated learning and communities of practice can help ease the transition into residency by addressing issues like self-questioning and emotional turmoil (see the colored boxes below). Situated learning refers to learning in everyday practice and highlights its fundamentally social nature as well as the progressive participation of the learner. 1 Communities of practice builds on the notion of people learning from each other, viewing learning as a shared enterprise among a group of people with a common purpose. 2.

The figured world of medical education senior leaders: Making meaning and enacting agency.

INTRODUCTION: The field of medical education is relatively new, and its boundaries are not firmly established. If we had a better understanding of the intricacies of the domain, we might be better equipped to navigate the ever-changing demands we must address. To that end, we explore medical education as a world wherein leaders harness agency, improvisation, discourse, positionality and power to act. METHODS: Using the constructivist theory of figured worlds (FW), we conducted a narrative analysis of the stories medical education senior leaders tell about their roles and experiences in the world of medical education (n = 9). RESULTS: We identified four foundational premises about the world of medical education: (i) medical education stands at the intersection of three interrelated worlds of clinical medicine, hospital administration and university administration; (ii) medical education is shaped by and shapes the clinical learning environment at the local level; (iii) medical education experiences ubiquitous change which is a source of power; and (iv) medical education is energised by relationships between individuals. DISCUSSION: Focusing on the FW theory's notions of agency, improvisation, discourse, positionality and power enabled us to describe the world of medical education as a complex domain existing in a space of conflicting power hierarchies, identities and discourses. Using FW allowed us to see the powerful affordances offered to medical education due to its position between worlds amid unceasing change.

Teaching at the Convergence of Pandemics and Historically Excluded Patient Populations: The Challenges, and Importance, of Culturally Responsive Communication.

Issue: Historically excluded patient populations-particularly racial, ethnic, and sexually and gender minoritized people-experience gross inequities in health, worsened by the HIV and COVID-19 pandemics. Culturally responsive communication (CRC) is a vital tool health professionals can use to address these inequities. Yet, CRC can be challenging to teach, particularly during pandemics. The authors argue that pandemics magnify the powerful intersecting oppressions of heterosexism, racism, transphobia, nationalism, and sexism, essentially targeting Othered bodies for dying, a phenomenon known as necropolitics. Evidence: Five aspects of pandemics make teaching CRC more difficult and, because of the magnification of necropolitics, more critical. First, pandemics heighten teachers' and learners' personal frailties, engendering worries about their own and their families' health and increasing cognitive load. This can make it difficult for them to embrace the discomfort required of CRC, particularly when an increased patient load is squeezing instructional time. Second, guidelines for HIV and COVID-19 testing, prevention, and treatment are ever-changing, often faster than the pace of curriculum development and instructor professional development. Third, for instructors who may already be stretched thin, it is challenging to prepare learners for the variability in how their future practice contexts may address HIV and COVID-19 and, further, how to take a social justice approach to assess and resist the distinct equity issues of each of these contexts. Fourth, pandemics cause uncertain access to patient information about testing, disease status, and vaccination or pre-exposure prophylaxis. This worsens already disparate outcomes for minoritized patients and adds to the complexity of CRC curricula. Finally, virtual care is more prevalent in pandemics and teaching CRC in online contexts can be difficult. Implications: To address these challenges, we adopt the Dimensionality and R4P Health Equity Framework as a tool for evaluating academic programs for CRC so that it remains robust amidst pandemics. This tool addresses the varied social positions and identities (i.e., "dimensions") that present different opportunities for health. We offer specific evaluation questions programs can ask and approaches they can take to (a) redress past harms through removing existing racist, heteronormative and transphobic structures and repairing the damage they have done; (b) plan for a more equitable future by restructuring via policy and organizational change and providing programs that address intersectional disadvantage; and (c) critically evaluate the present by remediating current damage immediately until restructuring efforts are fully functional. As Martin Luther King, Jr. stated, "Of all the forms of inequality, injustice in healthcare is the most shocking and inhuman because it often results in physical death." It is our imperative to teach CRC with intentionality; otherwise we will support necropolitics as we continue to condone disproportionate morbidity and mortality for racialized and queer bodies.

Do All Roads Lead to Full Participation? Examining Trajectories of Clinical Educators in Graduate Medical Education through Situated Learning Theory.

Phenomenon: As new faculty members begin their careers in Graduate Medical Education, each begins a journey of Professional Identity Formation from the periphery of their educational communities. The trajectories traveled vary widely, and full participation in a given educational community is not assured. While some medical school and post-graduate training programs may nurture Professional Identity Formation, there is scant support for faculty. To date, the trajectories that Graduate Medical Education faculty travel, what may derail inbound trajectories, and what tools Graduate Medical Education faculty use to navigate these trajectories have not been explicitly described. We explore these three questions here. Approach: Communities of Practice, a component of Situated Learning Theory, serves as a helpful framework to explore trajectories of educator identity development among Graduate Medical Educators. We used a inductive and deductive approach to Thematic Analysis, with Situated Learning Theory as our interpretive frame. Semi-structured interviews of faculty members of GME programs matriculating into a Health Professions Education Program were conducted, focusing on participants' lived experiences in medical education and how these experiences shaped their Professional Identity Formation. Findings: Participants noted peripheral, inbound, boundary, and outbound trajectories, but not an insider trajectory. Trajectory derailment was attributed to competing demands, imposter syndrome and gendered marginality. Modes of belonging were critical tools participants used to shape PIF, not only engagement with educator roles but disengagement with other roles; imagination of future roles with the support of mentors; and fluid alignment with multiple mutually reinforcing identities. Participants identified boundary objects like resumes and formal roles that helped them negotiate across Community of Practice boundaries. Insights: Despite a desire for full participation, some clinical educators remain marginal, struggling along a peripheral trajectory. Further research exploring this struggle and potential interventions to strengthen modes of belonging and boundary objects is critical to create equitable access to the inbound trajectory for all of our colleagues, leaving the choice of trajectories up to them.

How to use theory as method in HPE research.

Recognising that scholars in health professions education (HPE) are often unfamiliar with theory-informed research, we provide guidance on a robust method for using theory as a method to inform every aspect of research design from research question formation to data analysis and reporting. Using the Figured Worlds theory to illustrate the process, we mapped six concepts of particular importance to HPE: the figured world, agency, improvisation, discourse, positionality and power. Together the concepts were helpful analytic tools for our topic of interest. The concept of the figured world informed the construction of our program of research. Agency was useful in exploring the ways that subjects acted or did not act. We crafted interview questions to illustrate participants' unique improvisations. Discourse, or the world's artefacts both verbal and embodied, informed our understanding of the world's norms. Positionality allowed us to compare the agentic action of different participants. Finally, power offered an opportunity to recognise the intersection of the positional identities of participants and their stories of action or inaction. While theory-informed analytic tools offer an opportunity to construct nuanced understanding, generating new insights into study subjects and their worlds, caution is necessary as qualitative inquiry is an evolving process of give and take. Everything from the study's questions, methods and even theories might need to flex in response to the data. Ultimately, though initially intimidating, theories offer concrete methodological tools HPE scholars can rely on.

Making allyship visible: evaluation of a faculty development DEI curriculum.

Undergraduate medical learners from historically marginalized groups face significant barriers, which was made concrete at our institution when a student presented her research indicating that Black students felt unsure about which faculty members to approach. To better support our students, we used Kern's model for curriculum development and a critical pedagogy approach to create a Faculty Allyship Curriculum (FAC). A total of 790 individuals attended 90 workshops across 16 months and 20 individuals have completed the FAC. A majority of participants reported they felt at least moderately confident in their ability to teach learners who are underrepresented in medicine, mentor learners who are different than they are, and teach allyship topics. An informal content analysis of open-ended responses indicated changes in awareness, attitude, insight, and use of language and being more likely to display advocacy. For others considering creating a similar program, partnering with an existing program allows for rapid implementation and reach to a wide audience. We also recommend: beginning with a coalition of willing learners to quickly build community and culture change; ensuring that the curriculum supports ongoing personal commitment and change for the learners; and supporting facilitators in modeling imperfection and upstanding, 'calling in' rather than 'calling out' learners.

Past resources, future envisioning, and present positioning: how women who are medical students at one institution draw upon temporal agency for resistance.

While women entering medical school are faced with a patriarchal system, they also enter into a community with other women and the potential for resistance. The purpose of this study is to use the theory of temporal agency to explore how first-year medical students who identify as women draw upon past, future, and present agency to resist the patriarchal system of medicine.The data for this study were drawn from the first year (October 2020-April 2021) of a longitudinal project using narrative inquiry to understand the socialization of women students in undergraduate medical education. Fifteen participants performed two interviews and a series of written reflection prompts about their childhood and medical school experiences, each lasting approximately 45 min.Participants' resistance drew on past resources, recognizing themselves as Other, which contributed to categorically locating themselves as part of a broader resisting community, even outside their institution. They also hypothesized future possibilities as part of resistance, either an ideal future where they would exercise power, or an unchanged one and the hypothetical resolutions they would use to manage it. Finally, they contextualized past and future in the present, identifying problems to make strategic decisions and execute actions.Our creative interweaving of the constructs of temporal agency, communal agency, and resistance allows us to paint a nuanced picture of how these women conceive of themselves as part of a larger group of women amidst the hierarchical, patriarchal structures of medical school while, at times, internalizing these hierarchies.

Putting on Academic Armor: How Black Physicians and Trainees Take Stances to Make Racism Visible Amid Publishing Constraints.

Starting with reflexivity: As a Black woman medical student at a predominately white institution, a white woman full professor and deputy editor-in-chief of a journal, and a white woman associate professor with a deep interest in language, we understand that medicine and medical education interpellate each of us as a particular kind of subject. As such, we begin with a narrative grounding in our personal stances. Phenomenon: While there are a growing number of empirical studies of Black physicians' and trainees' experiences of racism, there are still few accounts from a first-person perspective. Black authors of these personal commentaries or editorials, who already experience microaggressions and racial trauma in their work spaces, must put on their academic armor to further experience them in publishing spaces. This study seeks to understand the stances Black physicians and trainees take as they share their personal experiences of racism. Approach: We searched four databases, identifying 29 articles authored by Black physicians and trainees describing their experiences. During initial analysis, we identified and coded for three sets of discursive strategies: identification, intertextuality, and space-time. Throughout the study, we reflected on our own stances in relation to the experience of conducting the study and its findings. Findings: Authors engaged in stance-taking, which aligned with the concept of donning academic armor, by evaluating and positioning themselves with respect to racism and the norms of academic discourse in response to ongoing conversations both within medicine and in the broader U.S. culture. They did this by (a) positioning themselves as being Black and, therefore, qualified to notice and name personal racist experiences while also aligning themselves with the reader through shared professional experiences and goals; (b) intertextual connections to other related events, people, and institutions that they-and their readers-value; and (c) aligning themselves with a hoped-for future rather than a racist present. Personal insights: Because the discourses of medicine and medical publishing interpellate Black authors as Others they must carefully consider the stances they take, particularly when naming racism. The academic armor they put on must be able to not only defend them from attack but also help them slip unseen through institutional bodies replete with mechanisms to eject them. In addition to analyzing our own personal stance, we leave readers with thought-provoking questions regarding this armor as we return to narrative grounding.

Relationship Between Gender and Academic and Military Achievement Among USU Medical School Graduates.

INTRODUCTION: Despite increases in the number of female matriculants in medical school, civilian data demonstrate that women still struggle to reach parity in attainment of leadership positions. In military medicine, we have seen a major increase in the number of women graduating from the USU. Yet, we still know little about the representation of female military physicians in leadership positions. The aim of this study is to examine the relationship between gender and academic and military achievement among USU School of Medicine graduates. METHODS: Utilizing the USU alumni survey sent to graduates from the classes of 1980 to 2017, items of interest, such as highest military rank, leadership positions held, academic rank, and time in service, were used to evaluate the relationship between gender and academic and military achievement. Contingency table statistical analysis was conducted to compare the gender distribution on the survey items of interest. RESULTS: Pairwise comparison demonstrated significant differences between gender in the O-4 (P = .003) and O-6 (P = .0002) groups, with females having a higher-than-expected number of O-4 officers and males having a higher-than-expected number of O-6 officers. These differences persisted in a subsample analysis that excluded those who separated from active duty prior to 20 years of service. There was a significant association between gender and holding the position of commanding officer (χ2(1) = 6.61, P < .05) with fewer females than expected. In addition, there was a significant association between gender and the highest academic rank achieved (χ2(3) = 9.48, P < 0.05) with lower-than-expected number of females reaching the level of full professor, in contrast to males who exceed the expected number. CONCLUSIONS: This study suggests that female graduates of USU School of Medicine have not achieved promotion to the highest levels of rank, military, or academic leadership at the projected rate. Efforts to explore what barriers may impact military medicine's desire to have more equal representation of women in higher ranks and positions should be undertaken with specific attention to what drives retention versus separation of medical officers and if systematic changes are needed to help promote equity for women in military medicine.

Experiences of agency in historically underrepresented racial and ethnic dental faculty at predominantly white institutions.

PURPOSE/OBJECTIVES: Historically underrepresented racial and ethnic (HURE) dentists remain underrepresented in dental education and dental practice, and surprisingly, little is known about the factors that enable them to thrive. The lack of information about their experiences is a critical gap in the literature. The purpose of this critical qualitative study is to describe how HURE dental faculty in predominantly white institutions (PWIs) exercise agency to thrive and advance in academic promotion when faced with challenges and adversity in the workplace. METHODS: Thirteen semi-structured interviews were conducted in 2021 and 2022 with HURE dental faculty from 10 different institutions. Interviews were audio recorded, transcribed, and analyzed using the construct of agency and tenets of critical race theory to understand how they thrive in their institutions. RESULTS: HURE dental faculty experienced racism as normal from both faculty and students. Racism centered around white faculty guarding access to white spaces, including things that should be open to everyone like meetings and information about promotion. To counter this, HURE faculty engaged in individual agency by fighting for their perspectives to be heard, proxy agency by seeking and building relationships with mentors and colleagues who could use their whiteness to create change, and improvisational agency by going outside their institutions for support. CONCLUSION(S): To thrive in PWIs requires HURE faculty to exercise various forms of agency to directly or indirectly advocate for themselves as professionals. These findings have implications for dental leaders to change their existing structures and improve the work environments for HURE dental faculty.

Exploring procedure-based management reasoning: a case of tension pneumothorax.

OBJECTIVES: Management reasoning has not been widely explored but likely requires broader abilities than diagnostic reasoning. An enhanced understanding of management reasoning could improve medical education and patient care. We conducted a novel exploratory study to gain further insights into procedure-based management reasoning. METHODS: Participant physicians managed a simulated patient who acutely decompensates in a team-based, time-pressured, live scenario. Immediately following the scenario, physicians perform a think-aloud protocol by watching video recordings of their performance and narrating their reflections in real-time. Verbatim transcripts of the think-aloud protocol were inductively coded using a constant comparative method and evaluated for themes. RESULTS: We recruited 19 physicians (15 internal medicine, one family medicine, and three general surgery) for this study. Recognizing that diagnostic and management reasoning intertwine, this paper focuses on management reasoning's characteristics. We developed three categories of management reasoning factors with eight subthemes. These are Patient factors: Acuity and Preferences; Physician factors: Recognized Errors, Anxiety, Metacognition, Monitoring, and Threshold to Treat; and one Environment factor: Resources. CONCLUSIONS: Our findings on procedure-based management reasoning are consistent with Situation Awareness and Situated Cognition models and the extant work on management reasoning, demonstrating that management is inherently complex and contextually bound. Unique to this study, all physicians focused on prognosis, indicating that attaining competency in procedural management may require planning and prediction abilities. Physicians also expressed concerns about making mistakes, potentially resulting from the scenario's emphasis on a procedure and our physicians' having less expertise in the treatment of tension pneumothorax.

Can We Realize Our Collaborative Potential? A Critical Review of Faculty Roles and Experiences in Interprofessional Education.

PURPOSE: Faculty within interprofessional education (IPE) are essential contributors to IPE implementation efforts. Although the majority of existing IPE literature consists of reports on IPE innovations, few insights are available into the experiences of the faculty members who deliver IPE. This critical narrative review was designed to synthesize the knowledge available about (1) roles assigned to IPE educators and (2) IPE faculty members' experiences of fulfilling these roles. METHOD: Six databases for English-language studies published between 2000 and March 2021 were searched: PubMed, Embase, Web of Science, MEDLINE, CINAHL, PsycINFO, ERIC, and MedEdPortal. A total of 1,717 manuscripts were identified for possible inclusion. After applying inclusion/exclusion criteria, 214 articles constituted the final literature corpus. Harden and Crosby's original framework of 6 roles of medical educators augmented with the manager role introduced in Harden and Lilley's 2018 framework informed the analysis. RESULTS: IPE faculty take on all 6 roles identified by Harden and Crosby: facilitator, planner, information provider, examiner, role model, and resource developer, as well as the manager role. Faculty were most commonly identified as facilitator and planner, and rarely as role models. The authors identified 3 main struggles experienced by IPE faculty: personal (e.g., confidence as a cross-professions educator), interpersonal (e.g., co-teaching IPE), and institutional (e.g., supporting IPE logistics). CONCLUSIONS: This review highlights the complexity of the roles taken on by IPE faculty and the struggles they experience in the process. The results suggest that attention to the different roles that IPE faculty play in educational interventions and to equipping faculty with the necessary competencies, tools, and support, is fundamental to the success of IPE. Future research should harness the explanatory power of theories to help explain dynamics at play between personal, interpersonal, and institutional barriers to identify interventions that can aid IPE faculty in delivering collaboration-ready professionals.

I, we and they: A linguistic and narrative exploration of the authorship process.

INTRODUCTION: While authorship plays a powerful role in the academy, research indicates many authors engage in questionable practices like honorary authorship. This suggests that authorship may be a contested space where individuals must exercise agency-a dynamic and emergent process, embedded in context-to negotiate potentially conflicting norms among published criteria, disciplines and informal practices. This study explores how authors narrate their own and others' agency in making authorship decisions. METHOD: We conducted a mixed-methods analysis of 24 first authors' accounts of authorship decisions on a recent multi-author paper. Authors included 14 females and 10 males in health professions education (HPE) from U.S. and Canadian institutions (10 assistant, 6 associate and 8 full professors). Analysis took place in three phases: (1) linguistic analysis of grammatical structures shown to be associated with agency (coding for main clause subjects and verb types); (2) narrative analysis to create a 'moral' and 'title' for each account; and (3) dialectic integration of (1) and (2). RESULTS: Descriptive statistics suggested that female participants used we subjects and material verbs (of doing) more than men and that full professors used relational verbs (of being and having) more than assistant and associate. Three broad types of agency were narrated: distributed (n = 15 participants), focusing on how resources and work were spread across team members; individual (n = 6), focusing on the first author's action; and collaborative (n = 3), focusing on group actions. These three types of agency contained four subtypes, e.g. supported, contested, task-based and negotiated. DISCUSSION: This study highlights the complex and emergent nature of agency narrated by authors when making authorship decisions. Published criteria offer us starting point-the stated rules of the authorship game; this paper offers us a next step-the enacted and narrated approach to the game.

Expanding Opportunities: An Evaluation of Uniformed Services University's Premedical Program for Enlisted Service Members.

INTRODUCTION: Medical school leaders are seeking strategies to increase the diversity of their student populations. Post-baccalaureate premedical (PBPM) programs are one such pipeline that has supported diversity in medicine. The purpose of this study was to evaluate the Uniformed Services University's (USU's) PBPM program (the Enlisted to Medical Degree Preparatory Program, EMDP2) to determine how well it prepares its learners for the School of Medicine (SOM). MATERIALS AND METHODS: The National Board of Medical Examiners Clinical Science Subject Examination scores of EMDP2 learners from the SOM classes of 2020-2023 were compared to those of four similarly sized cohorts of their peers that varied by age and prior military service. RESULTS: We found that the performance of program graduates was comparable to their peers who followed more traditional and other alternative preparatory paths. CONCLUSIONS: The EMDP2 appears to prepare medical students on a par with their non-EMDP2 peers. The EMDP2 contributes to USU's commitment to train physicians who represent the nation and its citizens by making medical education available to enlisted service members, a population that closely mirrors the diversity of the nation.

The importance of theory and method: A brief reflection on an innovative program of research examining how situational factors influence physicians' clinical reasoning.

Clinical reasoning, a complex process that involves gathering and synthesizing information to make diagnostic and treatment decisions, is a topic researchers frequently study to mitigate errors. Scientific reasoning has several similarities with clinical reasoning, including the need to generate hypotheses; observe, gather, and interpret evidence; engage in the process of elimination; draw conclusions; and refine and test new hypotheses. However, researchers have only recently begun to take into consideration the role that situational factors (also known as contextual factors), such as language barriers or the lack of diagnostic test results, can play in diagnostic error. Additionally, questions remain about the best ways to teach these complex processes.