Competing discourses, contested roles: Electronic health records in medical education.

INTRODUCTION: The integration of electronic health records (EHRs) into medical education remains contested despite their widespread use in clinical practice. For medical trainees, this has resulted in idiosyncratic and often ad hoc methods of instruction on EHR use. The purpose of this study was to understand the currently fragmented nature of EHR instruction by examining discourses of EHR use within the medical education literature. METHODS: We conducted a Foucauldian critical discourse analysis to identify discourses of EHRs in the medical education literature. We found our texts through a systematic search of widely cited medical education journals from 2013-2023. Each text was analysed for recurring truth statements-claims framed as self-evidently true and thus not needing supporting evidence-about the role of EHRs in medical education. RESULTS: We identified three major discourses: (1) EHRs as a clinical skill and competency, emphasising training of physical interactions between learners, patients and computers; (2) EHRs as a system, emphasising the creation and facilitation of networks of people, technologies, institutions and standards; and (3) EHRs as a cognitive process, framed as a method to shape processes like clinical reasoning and bias. Each discourse privileged certain stakeholders over others and served to rationalise educational interventions that could be seen as beneficial in isolation yet were often disjointed in combination. CONCLUSIONS: Competing discourses of EHR use in medical education produce divergent interventions that exacerbate their contested role in contemporary medical education. Identifying different claims for the benefits of EHR use in these settings allows educators to make rational choices between competing educational directions.

Playing well with others: lessons from theatre for the health professions about collaboration, creativity and community.

Despite collaboration among different professions being recognized as fundamentally important to contemporary and future healthcare practice, the concept is woefully undertheorized. This has implications for how health professions educators might best introduce students to interprofessional collaboration and support their transition into interprofessional, collaborative workplaces. To address this, we engage in a conceptual analysis of published collaborative, interprofessional practices and conceptual understandings in theatre, as a highly collaborative art form and industry, to advance thinking in the health professions, specifically to inform interprofessional education. Our analysis advances a conceptualization of collaboration that takes place within a work culture of creativity and community, that includes four modes of collaboration, or the ways theatre practitioners collaborate, by: (1) paying attention to and traversing roles and hierarchies; (2) engaging in reciprocal listening and challenging of others; (3) developing trust and communication, and; (4) navigating uncertainty, risk and failure. We conclude by inviting those working in the health professions to consider what might be gleaned from our conceptualization, where the embodied and human-centred aspects of working together are attended to alongside structural and organizational aspects.

Writing administrative staff back in: a Foucauldian-inspired discourse analysis of power relations in a faculty of medicine.

Administrative staff in higher and health professions education have been described as invisible and been characterized by what they are not: non-academics, non-teachers, non-faculty and non-professionals. Staff appear as passive objects in literature and minimized in institutional reports. These characterizations contribute to the undervaluing of staff and can lead to inefficiencies or tensions in the working environment within health professions education. This study sought to identify discourses connected to the undervaluing of staff work.This study used a Foucauldian-inspired critical discourse analysis approach within the context of a single Canadian Faculty of Medicine. Data collection involved compiling an archive of published literature and institutional archival documents extending approximately 150 years, interviews with twelve staff members and nine faculty members, and the author's lived experience as staff.Three primary discourses of staff were identified: staff as caregiver, matriarch, and professional. These discourses regulate staff (and their relations with faculty) differently, creating differences in what staff and faculty can do, be, or say (or not do, be, or say). While in the first two discourses of caregiver and matriarch, staff power is largely absent or obscured, in the third discourse, differing constructs of the concept of "professional" used by faculty and staff demonstrate a rise in power of staff and the declining authority of faculty.Writing administrative staff back in and centring staff voices can help provide agency to staff and reduce or help navigate possible tensions in the workplace.

Group concept mapping for health professions education scholarship.

While explicit conceptual models help to inform research, they are left out of much of the health professions education (HPE) literature. One reason may be the limited understanding about how to develop conceptual models with intention and rigor. Group concept mapping (GCM) is a mixed methods conceptualization approach that has been used to develop frameworks for planning and evaluation, but GCM has not been common in HPE. The purpose of this article is to describe GCM in order to make it more accessible for HPE scholars. We recount the origins and evolution of GCM and summarize its core features: GCM can combine multiple stakeholder perspectives in a systematic and inclusive manner to generate explicit conceptual models. Based on the literature and prior experience using GCM, we detail seven steps in GCM: (1) brainstorming ideas to a specific "focus prompt," (2) preparing ideas by removing duplicates and editing for consistency, (3) sorting ideas according to conceptual similarity, (4) generating the point map through quantitative analysis, (5) interpreting cluster map options, (6) summarizing the final concept map, and (7) reporting and using the map. We provide illustrative examples from HPE studies and compare GCM to other conceptualization methods. GCM has great potential to add to the myriad of methodologies open to HPE researchers. Its alignment with principles of diversity and inclusivity, as well as the need to be systematic in applying theoretical and conceptual frameworks to practice, make it a method well suited for the complexities of contemporary HPE scholarship.

Blind spots in medical education - International perspectives.

BACKGROUND: All individuals and groups have blind spots that can create problems if unaddressed. The goal of this study was to examine blind spots in medical education from international perspectives. METHODS: From December 2022 to March 2023, we distributed an electronic survey through international networks of medical students, postgraduate trainees, and medical educators. Respondents named blind spots affecting their medical education system and then rated nine blind spot domains from a study of U.S. medical education along five-point Likert-type scales (1 = much less attention needed; 5 = much more attention needed). We tested for differences between blind spot ratings by respondent groups. We also analyzed the blind spots that respondents identified to determine those not previously described and performed content analysis on open-ended responses about blind spot domains. RESULTS: There were 356 respondents from 88 countries, including 127 (44%) educators, 80 (28%) medical students, and 33 (11%) postgraduate trainees. At least 80% of respondents rated each blind spot domain as needing 'more' or 'much more' attention; the highest was 88% for 'Patient perspectives and voices that are not heard, valued, or understood.' In analyses by gender, role in medical education, World Bank country income level, and region, a mean difference of 0.5 was seen in only five of the possible 279 statistical comparisons. Of 885 blind spots documented, new blind spot areas related to issues that crossed national boundaries (e.g. international standards) and the sufficiency of resources to support medical education. Comments about the nine blind spot domains illustrated that cultural, health system, and governmental elements influenced how blind spots are manifested across different settings. DISCUSSION: There may be general agreement throughout the world about blind spots in medical education that deserve more attention. This could establish a basis for coordinated international effort to allocate resources and tailor interventions that advance medical education.

Perceptions of readiness for interprofessional learning among Ethiopian medical residents at Addis Ababa University: a mixed methods study.

BACKGROUND: Interprofessional learning is an important approach to preparing residents for collaborative practice. Limited knowledge and readiness of residents for interprofessional learning is considered one of the barriers and challenges for applying Interprofessional learning. We aimed to assess the perceptions of readiness of medical residents for interprofessional learning in Ethiopia. METHODS: We conducted a parallel mixed-methods study design to assess the perceptions of readiness for interprofessional learning among internal medicine and neurology residents of Tikur Anbessa Specialized Teaching Hospital in Addis Ababa, Ethiopia, from May 1 to June 30, 2021. One hundred one residents were included in the quantitative arm of the study, using the Readiness for Interprofessional Learning Scale (RIPLS) tool. All internal medicine and neurology residents who consented and were available during the study period were included. SPSS/PC version 25 software packages for statistical analysis (SPSS) was used for statistical analysis. Descriptive statistics were summarized as mean and standard deviation for continuous data as well as frequencies and percentages to describe categorical variables. Data were presented in tables. In addition, qualitative interviews were undertaken with six residents to further explore residents' knowledge and readiness for IPL. Data were analyzed using a six-step thematic analysis. RESULTS: Of the 101 residents surveyed, the majority of the study participants were male (74.3%). The total mean score of RIPLS was 96.7 ± 8.9. The teamwork and collaboration plus patient-centeredness sub-category of RIPLS got a higher score (total mean score: 59.3 ± 6.6 and 23.5 ± 2.5 respectively), whereas the professional identity sub-category got the lowest score (total mean score: 13.8 ± 4.7). Medical residents' perceptions of readiness for interprofessional learning did not appear to be significantly influenced by their gender, age, year of professional experience before the postgraduate study, and department. Additionally, the qualitative interviews also revealed that interprofessional learning is generally understood as a relevant platform of learning by neurology and internal medicine residents. CONCLUSIONS: We found high scores on RIPLS for internal medicine and neurology postgraduate residents, and interprofessional learning is generally accepted as an appropriate platform for learning by the participants, which both suggest readiness for interprofessional learning. This may facilitate the implementation of interprofessional learning in the postgraduate medical curriculum in our setting. We recommend medical education developers in Ethiopia consider incorporating interprofessional learning models into future curriculum design.

Power/knowledge: A sociomaterial perspective on a new accreditation process during COVID-19.

INTRODUCTION: The COVID-19 pandemic had significant impacts on many aspects of health care and education, including the accreditation of medical education programmes. As a community of international educators, it is important that we study changes that resulted from the pandemic to help us understand educational processes more broadly. As COVID-19 unfolded in Canada, a revised format of undergraduate medical accreditation was implemented, including a shift to virtual site visits, a two-stage visit schedule, a focused approach to reviewing standards and the addition of a field secretary to the visit team. Our case study research aimed to evaluate the sociomaterial implications of these changes in format on the process of accreditation at two schools. METHODS: We interviewed key informants to understand the impacts, strengths and limitations of changes made to the accreditation format. We used an abductive approach to analyse transcripts and applied a sociomaterial lens in looking for interconnections between the material and social changes that were experienced within the accreditation system. RESULTS: Stakeholders within the accreditation system did not anticipate that changes to the accreditation format would have significant impacts on how accreditation functioned or on its overall outcomes. However, key informants described how the revised format of accreditation reconstructed how power was distributed and how knowledge was produced. The revised format contributed to changes in who held power within each of the programmes, within each of the visiting teams and between site members and visiting team members. As power shifted across stakeholders in response to material changes to the accreditation format, key informants described changes in how knowledge was produced. CONCLUSIONS: Our findings suggest that the most powerful knowledge about any given programme might best be obtained through individualised tools, technologies and voices that are most meaningful to the unique context of each programme. Deliberate attention to how knowledge and power are influenced by the interactions between material and social processes within accreditation may help educators and leaders see the effects of change.

Examining the WFME Recognition Programme at 10 years.

BACKGROUND: In 2012, the World Federation for Medical Education (WFME) evaluated and formally recognized the first agency in its Recognition Programme (RP). The RP was developed to review accrediting authorities in response to a 2010 policy by the Educational Commission for Foreign Medical Graduates (ECFMG) to require international medical graduates (IMGs) seeking to practice in the U.S. to graduate from an appropriately accredited medical school. By the end of 2022, WFME had recognized 33 accrediting bodies and received applications from another 16, which accounted for over three-quarters of the world's medical schools. In 2023, WFME leadership changed hands, and the ECFMG will take its first steps toward implementing its Recognized Accreditation Policy. APPROACH: In this article, we look back at the genesis of the RP and describe its first decade as informed by the limited existing peer-reviewed literature and the emerging activities of accrediting agencies that could have significant implications for the quality of medical education internationally. CONCLUSIONS: The rapidly growing influence of WFME on medical education worldwide has largely occurred without significant awareness or scrutiny, and there is a need for the WFME to demonstrate greater transparency, proactively engage its stakeholders, and support research and evaluation.

Reconsidering a Global Agency for Medical Education: Back to the Drawing Board?

Issue: The World Federation for Medical Education (WFME) was established in 1972 and in the five decades that followed, has been the de facto global agency for medical education. Despite this apparently formidable remit, it has received little analysis in the academic literature. Evidence: In this article, we examine the historical context at the time WFME was established and summarize the key decisions it has taken in its history to date, highlighting particularly how it has adopted positions and programmes that have seemingly given precedence to the values and priorities of countries in the Global North. In doing so, we challenge the inevitability of the path that it has taken and consider other possible avenues that such a global agency in medical education could have taken, including to advocate for, and to develop policies that would support countries in the Global South. Implications: This article proposes a more democratic and equitable means by which a global organization for medical education might choose its priority areas, and a more inclusive method by which it could engage the medical education community worldwide. It concludes by hypothesizing about the future of global representation and priority-setting, and outlines a series of principles that could form the basis for a reimagined agency that would have the potential to become a force for empowerment and global justice in medical education.

Competent to provide compassionate care? A critical discourse analysis of accreditation standards.

BACKGROUND: Medical school accreditation is recognised internationally as an important quality control process for programmes that lead to the Medical Doctor (MD) degree. Accreditation standards govern the accreditation process which in turn drives educational objectives. Given the power of these standards to shape what becomes valued in the curricula, it is therefore imperative to ensure that core values and ideals of the profession are meaningfully incorporated. As the provision of compassionate care has long been a central medical value, this value should be clearly articulated in MD programme accreditation standards. METHODS: We conducted a Critical Discourse Analysis of compassionate care within Undergraduate Medical Education (UME) Accreditation Standards governing North American medical schools since 1957. We explored how and to what extent the written language of the accreditation standards incorporated compassionate care. RESULTS: References to compassionate care in the UME Accreditation Standards were few and far between. Historically, a statement of 'The Objectives of Undergraduate Medical Education' published by the Association of American Medical Colleges (AAMC) was referenced for the first and only time in the 1957 standards, describing the development of attributes such as the provision of compassionate care as a basic objective of UME. Thereafter, there was infrequent mention of this value. Terms that could potentially incorporate aspects of compassionate care were identified, yet these were explicated in ways that limited connection to compassion. Instead, the term 'care' has increasingly been used instrumentally (ie acute care, chronic care). CONCLUSION: The relative absence of language pertaining to compassionate care in accreditation standards is troubling as compassion is integral to good medical care. This absence is particularly important to attend to in the current era of competency-based training where we must be explicit about all important curricular objectives lest essential values and practices be unintentionally lost.

Tackling the void: the importance of addressing absences in the field of health professions education research.

Many processes and practices in the field of health professions education have been based more on tradition and assumption than on evidence and theory. As the field matures, researchers are increasingly seeking evidence to support various teaching and assessment methods. However, there is a tendency to focus on a limited set of topics, leaving other areas under-examined and limiting our understanding of the field. By explicitly examining areas that are undescribed, i.e. absences in the literature, researchers and scholars have the potential to enrich our practice and our field's understanding of what counts as legitimate research. Using the theoretical framework of Bourdieu's concept of field, we conducted an instrumental case study of three published research projects that each had a finding of absence. We examined each case individually, and then analyzed across cases. Our dataset included published papers, peer-review feedback, and reflective notes. Each of the cases interrogated a different form of absence: absence of content, absence of research, and absence of evidence. While the typology suggests that each absence was different, there were similarities across cases in terms of challenges in 'proving' the reality of the absence and some disbelief or discomfort with accepting the findings as rigorous and/or legitimate. Absence research has potential to add to our theoretical and methodological approaches to the field. This type of research is potentially an exciting and productive new way for scholars to shed light on aspects of health professions education that have received limited attention to date.

Interprofessional and multiprofessional approaches in quality improvement education.

The imperative for all healthcare professionals to partake in quality improvement (QI) has resulted in the development of QI education programs with participants from different professional backgrounds. However, there is limited empirical and theoretical examination as to why, when and how interprofessional and multiprofessional education occurs in QI and the outcomes of these approaches. This paper reports on a qualitative collective case study of interprofessional and multiprofessional education in three longitudinal QI education programs. We conducted 58 interviews with learners, QI project coaches, program directors and institutional leads and 135 h of observations of in-class education sessions, and collected relevant documents such as course syllabi and handouts. We used an interpretive thematic analysis using a conventional and directed content analysis approach. In the directed content approach, we used sociology of professions theory with particular attention to professional socialization, hierarchies and boundaries in QI, to understand the ways in which individuals' professional backgrounds informed the planning and experiences of the QI education programs. Findings demonstrated that both interprofessional and multiprofessional education approaches were being used to achieve different education objectives. While each approach demonstrated positive learning and practice outcomes, tensions related to the different ways in which professional groups are engaging in QI, power dynamics between professional groups, and disconnects between curricula and practice existed. Further conceptual clarity is essential for a more informed discussion about interprofessional and multiprofessional education approaches in QI and explicit attention is needed to professional processes and tensions, to optimize the impact of education on practice.

Contending with Our Racial Past in Medical Education: A Foucauldian Perspective.

ISSUE: Practices of systemic and structural racism that advantage some groups over others are embedded in American society. Institutions of higher learning are increasingly being pressured to develop strategies that effectively address these inequities. This article examines medical education's diversity reforms and inclusion practices, arguing that many reify preexisting social hierarchies that privilege white individuals over those who are minoritized because of their race/ethnicity. Evidence: Drawing on the work of French theorist Michel Foucault, we argue that medical education's curricular and institutional practices reinforce asymmetrical power differences and authority in ways that disadvantage minoritized individuals. Practices, such as medical education's reliance on biomedical approaches, cultural competency, and standardized testing reinforce a racist system in ways congruent with the Foucauldian concept of "normalization." Through medical education's creation of subjects and its ability to normalize dominant forms of knowledge, trainees are shaped and socialized into ways of thinking, being, and acting that continue to support racial violence against minoritized groups. The systems, structures, and practices of medical education need to change to combat the pervasive forces that continue to shape racist institutional patterns. Individual medical educators will also need to employ critical approaches to their work and develop strategies that counteract institutional systems of racial violence. Implications: A Foucauldian approach that exposes the structural racism inherent in medical education enables both thoughtful criticism of status-quo diversity practices and practical, theory-driven solutions to address racial inequities. Using Foucault's work to interrogate questions of power, knowledge, and subjectivity can expand the horizon of racial justice reforms in medicine by attending to the specific, pervasive ways racial violence is performed, both intra- and extra-institutionally. Such an intervention promises to take seriously the importance of anti-racist methodology in medicine.

The compatibility principle: on philosophies in the assessment of clinical competence.

The array of different philosophical positions underlying contemporary views on competence, assessment strategies and justification have led to advances in assessment science. Challenges may arise when these philosophical positions are not considered in assessment design. These can include (a) a logical incompatibility leading to varied or difficult interpretations of assessment results, (b) an "anything goes" approach, and (c) uncertainty regarding when and in what context various philosophical positions are appropriate. We propose a compatibility principle that recognizes that different philosophical positions commit assessors/assessment researchers to particular ideas, assumptions and commitments, and applies ta logic of philosophically-informed, assessment-based inquiry. Assessment is optimized when its underlying philosophical position produces congruent, aligned and coherent views on constructs, assessment strategies, justification and their interpretations. As a way forward we argue that (a) there can and should be variability in the philosophical positions used in assessment, and these should be clearly articulated to promote understanding of assumptions and make sense of justifications; (b) we focus on developing the merits, boundaries and relationships within and/or between philosophical positions in assessment; (c) we examine a core set of principles related to the role and relevance of philosophical positions; (d) we elaborate strategies and criteria to delineate compatible from incompatible; and (f) we articulate a need to broaden knowledge/competencies related to these issues. The broadened use of philosophical positions in assessment in the health professions affect the "state of play" and can undermine assessment programs. This may be overcome with attention to the alignment between underlying assumptions/commitments.

When logics of learning conflict: an analysis of two workplace-based continuing education programs.

Educators, practitioners, and policy makers are calling for stronger connections between continuing education (CE) for professionals and the concerns of workplaces where these professionals work. This call for greater alignment is not unique to the health professions. Researchers within the field of higher education have long wrestled with the complexities of aligning professional learning and workplace concerns. In this study, we extend this critical line of inquiry to explore the possible conceptual intersections between two CE programs acting within a single healthcare organization. Both programs are concerned with improving patient care, primarily by changing the ways professionals think and talk with one another. However, the two programs have different historical origins: one in a workplace, the other within a university setting. Introducing the concept of "modes of ordering" as a way to analyze the curricula, we argue the programs are operating through separate logics of learning. We label these two modes of ordering: (1) learning as standardization and (2) learning as identification. Through our discussion, we explore how these different modes demand different roles for educators and participants. Ultimately, we argue that both have value. However, we also argue that educators require conceptual tools to sensitize them to the possibility of competing logics of learning and the subsequent implications for their practice as educators. In conclusion, we offer the metaphor of CE educator as choreographer, connecting concepts and practices within these logics in productive ways while continually navigating the various learning imperatives acting on professionals at any given time.

Dismantling the master's house: new ways of knowing for equity and social justice in health professions education.

Health professions education (HPE) is built on a structural foundation of modernity based on Eurocentric epistemologies. This foundation privileges certain forms of evidence and ways of knowing and is implicated in how dominant models of HPE curricula and healthcare practice position concepts of knowledge, equity, and social justice. This invited perspectives paper frames this contemporary HPE as the "Master's House", utilizing a term referenced from the writings of Audre Lorde. It examines the theoretical underpinnings of the "Master's House" through the frame of Quijano's concept of the Colonial Matrix of Power (employing examples of coloniality, race, and sex/gender). It concludes by exploring possibilities for how these Eurocentric structures may be dismantled, with reflection and discussion on the implications and opportunities of this work in praxis.

Family physicians and health advocacy: Is it really a difficult fit?

OBJECTIVE: To examine whether family medicine residents and faculty members appreciate the full spectrum of health advocacy as described in articles published in Canadian Family Physician in 2016 and to identify the perceived challenges and enablers of advocating across the entire spectrum. DESIGN: Analysis of a subset of data from a qualitative study using semistructured interviews and focus groups. SETTING: University of Toronto in Ontario. PARTICIPANTS: A total of 9 family medicine faculty members and 6 family medicine residents. METHODS: A subset of transcripts from a 2015 qualitative study that explored family medicine and psychiatry residents' and faculty members' understanding of the CanMEDS-Family Medicine health advocate role were reviewed, guided by interpretive descriptive methodology. MAIN FINDINGS: Results indicated that family medicine physicians and residents were able to identify the full spectrum of advocacy described in the Canadian Family Physician articles and that they valued the role. Further, there was widespread agreement that being a health advocate was linked with their identities as health professionals. The time it takes to be a health advocate was seen as a barrier to being effective in the role, and the work was seen as extremely challenging owing to system constraints. Participants also described a gap in training relating to advocacy at the system level as a challenge. CONCLUSION: Team-based care was seen as one of the most important enablers for becoming involved in the full spectrum of advocacy, as was time for personal reflection.

Stethoscope of the 21st century: dominant discourses of ultrasound in medical education.

CONTEXT: In recent years, point-of-care ultrasound (POCUS) has become a widely used clinical tool in a number of clinical specialties. In response, POCUS has been incorporated into medical curricula across the learning continuum, bolstered by enthusiastic appraisals of the technology's benefits for learners, clinicians and patients. In this project, we have sought to identify and understand the effects of dominant discourses influencing the integration of POCUS into medical education. METHODS: We conducted a Foucauldian critical discourse analysis (CDA) to identify and analyse discourses that legitimise and privilege the use of POCUS in medical education. We assembled an archive of 473 texts published between 1980 and 2017. Each article in the archive was analysed to identify frequently occurring truth statements (expressing concepts whose truths are unquestioned within particular discourses) that we used to characterise the major discourses that construct representations of POCUS in medical education. RESULTS: We identified three dominant discourses: (i) a visuo-centric discourse prioritising the visual information as truth over other clinical data; (ii) a utilitarian discourse emphasising improvements in patient care; and (iii) a modernist discourse highlighting the current and future needs of clinicians in our technological world. These discourses overlap and converge; the core discursive effect makes the further elevation of POCUS in medical education, and the resulting attenuation of other curricular priorities, appear inevitable. CONCLUSIONS: The three dominant discourses identified in this paper engender ideal conditions for the proliferation of POCUS in medical education through curricular guidelines, surveys of adherence to these guidelines and authoritative position statements. By identifying and analysing these dominant discourses, we can ask questions that do not take for granted the assumed truths underpinning the discourses, highlight potential pitfalls of proposed curricular changes and ensure these changes truly improve medical education.