Transformative medical education: must community-based traineeship experiences be part of the curriculum? A qualitative study.

BACKGROUND: There are shortcomings in medical practitioners' capacity to adapt to the particular needs of people experiencing circumstances of social vulnerability. Clinical traineeships create opportunities for the acquisition of knowledge, competencies, attitudes, and behaviors. However, some authors question the learnings to be made through classical clinical training pathways. This article explores the learnings gained from a traineeship experience within a community-based clinical setting intended for patients experiencing social vulnerability and operating under an alternative paradigm of care. To our knowledge, there is little research intended to identify and understand what medical trainees gain from their experience in such contexts. METHODS: This exploratory qualitative study is based on twelve interviews with practicing physicians who completed a traineeship at La Maison Bleue (Montreal, Canada) and three interviews conducted with key informants involved in traineeship management. Based on Mezirow's theory of transformational learning, data were analyzed according to L'Écuyer's principles of qualitative content analysis. NVivo software was used. RESULTS: The main learnings gained through the traineeship are related to (1) greater awareness of beliefs, assumptions and biases through prejudice deconstruction, cultural humility and critical reflection on own limitations, power and privileges; (2) the development of critical perspectives regarding the health care system; (3) a renewed vision of medical practice involving a less stigmatizing approach, advocacy, empowerment, interdisciplinarity and intersectorality; and (4) strengthened professional identity and future practice orientation including confirmation of interest for community-based practice, the identification of criteria for choosing a future practice setting, and commitment to becoming an actor of social change. Certain characteristics of the setting, the patients and the learner's individual profile are shown to be factors that promote these learnings. CONCLUSIONS: This article highlights how a traineeship experience within a clinical setting intended for a clientele experiencing circumstances of social vulnerability and operating under an alternative paradigm presents an opportunity for transformative learning and health practice transformation toward renewed values of health equity and social justice. Our findings suggest medical traineeships in community-based clinical settings are a promising lead to foster the development of fundamental learnings that are conducive to acceptable and equitable care for people experiencing social vulnerability.

Ideological roadblocks to humanizing dentistry, an evaluative case study of a continuing education course on social determinants of health.

BACKGROUND: Front line providers of care are frequently lacking in knowledge on and sensitivity to social and structural determinants of underprivileged patients' health. Developing and evaluating approaches to raising health professional awareness and capacity to respond to social determinants is a crucial step in addressing this issue. McGill University, in partnership with Université de Montréal, Québec dental regulatory authorities, and the Québec anti-poverty coalition, co-developed a continuing education (CE) intervention that aims to transfer knowledge and improve the practices of oral health professionals with people living on welfare. Through the use of original educational tools integrating patient narratives and a short film, the onsite course aims to elicit affective learning and critical reflection on practices, as well as provide staff coaching. METHODS: A qualitative case study was conducted, in Montreal Canada, among members of a dental team who participated in this innovative CE course over a period of four months. Data collection consisted in a series of semi-structured individual interviews conducted with 15 members of the dental team throughout the training, digitally recorded group discussions linked to the CE activities, clinic administrative documents and researcher-trainer field notes and journal. In line with adult transformative learning theory, interpretive analysis aimed to reveal learning processes, perceived outcomes and collective perspectives that constrain individual and organizational change. RESULTS: The findings presented in this article consist in four interactive themes, reflective of clinic culture and context, that act as barriers to humanizing patient care: 1) belief in the "ineluctable" commoditization of dentistry; 2) "equal treatment", a belief constraining concern for equity and the recognition of discriminatory practices; 3) a predominantly biomedical orientation to care; and 4) stereotypical categorization of publically insured patients into "deserving" vs. "non-deserving" poor. We discuss implications for oral health policy, orientations for dental education, as well as the role dental regulatory authorities should play in addressing discrimination and prejudice. CONCLUSION: Humanizing care and developing oral health practitioners' capacity to respond to social determinants of health, are challenged by significant ideological roadblocks. These require multi-level and multi-sectorial action if gains in social equity in oral health are to be made.

Social Values, Regulatory Tensions and Professional Practices with Underprivileged Populations: The Case of Quebec's Oral Healthcare System.

OBJECTIVE: Dentists may experience frustration in their practice with people living on welfare, often perceiving them in a negative light. The difficulties encountered are detrimental to the patient-professional relationship and contribute to compromising access to care for this underprivileged population. In order to fully understand patient-professional interactions, we must consider the macroscopic contexts in which they occur. This paper examines the systemic influences of these interpersonal relationships to deepen our understanding of an important access-to-care determinant for people living on welfare. METHODS: Two frameworks are applied to the analysis of Quebec's oral healthcare system: the social values framework and the regulatory logics framework. RESULTS: Our assessment leads us to posit two phenomena: (1) certain negative stereotypes regarding patients living on welfare allow dentists to manage the inevitable regulatory conflicts (i.e., economic vs. professional) involved in their practice and (2) the behaviours of people living on welfare are frequently judged according to the social values embodied in the organization of Quebec's oral healthcare system, delivery and financing. CONCLUSION: Quebec's oral healthcare system fails to provide effective access to care for individuals living in poverty, and the government must significantly augment its involvement in this healthcare sector. Dentists should also understand the impact that systemic influences have on their rapport with people living on welfare. We argue that new orientations for the field of dental professional education should be considered.This paper was originally published in French, in the journal Pratiques et Organisation des Soins 2011 42(3).

Bridging the poverty gap in dental education: how can people living in poverty help us?

Dental education on specific knowledge and intervention approaches for working with people living on welfare is crucial to the therapeutic success of the relationships dental professionals establish with this clientele. Despite growing attention to the importance of cultural competence and communication skills training in dentistry, very few initiatives have been documented in relation to serving low-income populations. Following discussions at a 2006 Montreal-based colloquium on access to dental care, academics, dental association administrators, and public health agency and antipoverty coalition representatives began collaborating to develop innovative pedagogy designed to increase providers' competence in interacting with their underprivileged patients. The group's first round of workshops (November 2006-October 2007) resulted in the creation of an original video-based tool containing testimonies from six individuals living currently or formerly on welfare. The videotaped interview data represent their perceptions and experiences regarding their oral health, dental care service provision, and poverty in general. This article describes the participative methods, the content of the resulting DVD, and the implications of the "Listening to Each Other" program, a collaborative knowledge translation approach for improving interaction between underprivileged people and dental care providers.