The tip of the iceberg: Generalism in undergraduate medical education, a systems thinking analysis.

PURPOSE: There is a shortage of generalist physicians globally impacting health equity and access to care. An important way in which medical schools can demonstrate social accountability is by graduating learners interested in careers in generalism. While generalism is endorsed as a matter of principle in medical education, how this translates into curricula is less clear. The aim of this study was to identify how generalism is understood and supported by family physician educational leaders in undergraduate medical education (UME) in Canada. METHODS: We conducted a qualitative study, interviewing 38 family medicine leaders in UME across all 17 Canadian medical schools. We examined the data with template analysis, informed by the iceberg model of systems thinking. RESULTS: Four themes were identified: (1) Teaching and learning strategies in support of generalism-a consistent range existed across UME curricula; (2) Curriculum patterns-changes in leadership and curriculum reform created positive or negative feedback loops that promoted or hindered initiatives to support generalism; (3) Curriculum structures-organ-system-based curricula and availability of generalist faculty presented particular challenges to teaching generalist approaches; (4) Mental models and ways of knowing-the preponderance of biomedical frameworks of thinking in curricula unconsciously undermined generalist approaches to patient care. CONCLUSIONS: UME programmes promoted generalism through a range of teaching activities and strategies, but these efforts were countered by curriculum structures and mental models that perpetuate epistemic inequity between biomedical approaches to medical education and generalist models of care. Novel curricular frameworks are needed to align undergraduate programmes' commitment to social accountability with community-based need.

Health advocacy among medical learners: Unpacking contextual barriers and affordances.

INTRODUCTION: Learners and physicians are expected to practice as health advocates in Canadian contexts, but they rarely feel competent to practice this critical role when they complete their training. This is in part because advocacy is seen as "going above and beyond" routine practice and pushing the boundaries of systems that are resistant to change. Medical learning contexts are rife with barriers to learning about and practicing advocacy, and there is now a need to understand how contexts impact advocacy. METHODS: Using constructivist grounded theory study, we generated data through individual and group interviews with medical learners to explore the barriers and facilitators to advocacy in a variety of learning/practice contexts. We used purposeful and theoretical sampling to ensure that diverse learning contexts and learners who had different views on advocacy were represented. We constructed a theoretical model to understand advocacy decision-making through cycles of initial, focused and theoretical coding, using constant comparative analysis. RESULTS: Learners' thinking about health advocacy was framed by their own unique knowledge and beliefs, as well as their institutional and organisational contexts. With these influences in mind, learners made decisions about when to advocate within a local decision-making context, guided by affordances and barriers to advocacy involved in their perceptions of the patient, their own social position, resources available and social norms. CONCLUSIONS: This framework highlights critical aspects of context that influence learners' ability to learn about and practice as health advocates. If we are to adequately prepare learners for this important work, we must address aspects of their learning and practice contexts that make this work daunting, and we offer learners the tools required to intervene in contexts that do not support their efforts.

A Curricular Audit Method: Addressing the Erasure of Intersex, Trans and Two-Spirit People and the Imprecise Use of Gender and Sex Concepts in Undergraduate Medical Education.

Phenomenon: Intersex, trans, and Two-Spirit people report overwhelmingly negative experiences with health care providers, including having to educate their providers, delaying, foregoing, and discontinuing care due to discrimination and being denied care. Medical education is a critical site of intervention for improving the health and health care experiences of these patients. Medical research studies, clinical guidelines, textbooks, and medical education generally, assumes that patients will be white, endosex, and cisgender; gender and sex concepts are also frequently misused. Approach: We developed and piloted an audit framework and associated tools to assess the quantity and quality of medical education related to gender and sex concepts, as well as physician training and preparedness to meet the needs of intersex, trans, and Two-Spirit patients. We piloted our framework and tools at a single Canadian medical school, the University of British Columbia, focused on their undergraduate MD program. We were interested in assessing the extent to which endosexnormativity, cisnormativity, transnormativity, and the coloniality of gender were informing the curriculum. In this paper, we detail our audit development process, including the role of advisory committees, student focus groups, and expert consultation interviews. We also detail the 3-pronged audit method, and include full-length versions of the student survey, faculty survey, and purpose-built audit question list. Findings: We reflect on the strengths, limits, and challenges of our audit, to inform the uptake and adaptation of this approach by other institutions. We detail our strategy for managing the volume of curricular content, discuss the role of expertise, identify a section of the student survey that needs to be reworked, and look ahead to the vital task of curricular reform and recommendations implementation. Insights: Our findings suggest that curricular audits focused on these populations are lacking but imperative for improving the health of all patients. We detail how enhancing curriculum in these areas, including by adding content about intersex, trans, and Two-Spirit people, and by using gender and sex concepts more accurately, precisely and inclusively, is in line with the CanMEDS competencies, the Medical Council of Canada's Objectives for the Qualifying Examinations, many institutions' stated values of equity, inclusion and diversity, and physicians' ethical, legal and professional obligations.

Learner conceptions of health advocacy: 'Going above & beyond' or 'kind of an expectation'.

CONTEXT: Health advocacy is a core component of physician competency frameworks. However, advocacy has lacked a clear definition and is understood and enacted variably across contexts. Due to their mobility across contexts, learners are uniquely positioned to provide insight into the tensions that have made this role so difficult to define, but that may be central to this role. The purpose of this study was to map the tensions and contours in conceptions of health advocacy among learners across a variety of learning contexts. METHODS: We used constructivist grounded theory and interviewed nine medical students and twenty residents in family, paediatric and internal medicine from across our university's distributed programmes. Data were analysed concurrently using open, focussed and theoretical coding to establish themes and relationships between themes. RESULTS: Learners understood health advocacy in two overlapping but distinct ways: as a set of behaviours and as a sense of 'going above and beyond', through additional effort, time or risk. These two conceptions overlapped and were often in tension. 'Going above and beyond' sometimes aligned with identifiable advocacy behaviours; at other times, 'going above and beyond' did not align with definitions of health advocacy in competency frameworks and aligned more closely with 'patient-centred care'. CONCLUSIONS: Our findings suggest that learners perceive that there are important elements of health advocacy that cannot be captured in universal behaviours that apply across contexts. 'Going above and beyond' describes a sense of grappling with sociocultural barriers to patient-centred care and striving towards better systems and better care for individuals. This more abstract and contextually bound notion of health advocacy may not lend itself easily to definition in competency frameworks and thus adds challenges to both teaching and assessment.

Exploring the role of classroom-based learning in professional identity formation of family practice residents using the experiences, trajectories, and reifications framework.

BACKGROUND: Classroom-based learning such as academic half day has undervalued social aspects. We sought to explore its role in the professional identity development of family medicine residents. METHODS: In this case study, residents and faculty from four training sites in the University of British Columbia Department of Family Practice were interviewed. The "experiences, trajectories, and reifications (ETR) framework" was used as a sensitizing tool for modified inductive (thematic) analysis of the transcripts. RESULTS: Classroom-based learning provided a different context for residents' interpretation of their clinical experiences, characterized as a "home base" for rotating urban residents, and a connection to a larger academic community for residents in rural training sites. Both these aspects were important in creating a positive trajectory of professional identity formation. Teaching directed at the learning needs of family physicians, and participation of family practice faculty as teachers and role models was a precipitation of a curriculum "centered in family medicine." Interactions between family medicine residents and faculty in the classroom facilitated the necessary engagements to reify a shared understanding of the discipline of family practice. CONCLUSIONS: Classroom-based learning has substantial impact on professional identity formation at an individual and collective level.

Health advocacy.

In the medical profession, activities related to ensuring access to care, navigating the system, mobilizing resources, addressing health inequities, influencing health policy and creating system change are known as health advocacy. Foundational concepts in health advocacy include social determinants of health and health inequities. The social determinants of health (i.e. the conditions in which people live and work) account for a significant proportion of an individual's and a population's health outcomes. Health inequities are disparities in health between populations, perpetuated by economic, social, and political forces. Although it is clear that efforts to improve the health of an individual or population must consider "upstream" factors, how this is operationalized in medicine and medical education is controversial. There is a lack of clarity around how health advocacy is delineated, how physicians' scope of responsibility is defined and how teaching and assessment is conceptualized and enacted. Numerous curricular interventions have been described in the literature; however, regardless of the success of isolated interventions, understanding health advocacy instruction, assessment and evaluation will require a broader examination of processes, practices and values throughout medicine and medical education. To support the instruction, assessment and evaluation of health advocacy, a novel framework for health advocacy is introduced. This framework was developed for several purposes: defining and delineating different types and approaches to advocacy, generating a "roadmap" of possible advocacy activities, establishing shared language and meaning to support communication and collaboration across disciplines and providing a tool for the assessment of learners and for the evaluation of teaching and programs. Current approaches to teaching and assessment of health advocacy are outlined, as well as suggestions for future directions and considerations.

Not just 'for' but 'with': health advocacy as a partnership process.

CONTEXT: Health advocacy is often framed as an activity that physicians do for others. A physician uses her expertise to identify and address the health needs of patients or communities on their behalves. As part of a larger study, we uncovered data to suggest that effective health advocates work not just for but often with others to understand and address their health needs. OBJECTIVES: This paper explores and elaborates the important distinction between advocating with and for others. METHODS: We interviewed 10 physicians, identified by others as successful health advocates, about their advocacy activities. Informed by constructivist grounded theory, we gathered and evaluated data iteratively, continually revising the interview outline and concurrently refining our evolving themes. Once it had stabilised, the coding scheme was applied to the full set of transcripts. RESULTS: Health advocacy was framed by participants as an activity that was more often done with others, than for others. This manifested in two ways: (i) joining other voices: rather than always feeling a need to plan and act alone, our participants often described making efforts to find and join existing initiatives and to work collaboratively, and (ii) amplifying other voices: rather than authoritatively determining needs and enacting solutions on behalf of others, our participants often described making efforts to empower others to find their own voices, thereby fostering autonomy rather than reliance. Participants described factors and mechanisms that enabled them to approach advocacy in this manner. CONCLUSIONS: Successful health advocates often enact health advocacy with others, rather than exclusively for them. This partnership-based facilitative approach enables them to better appreciate the needs of those requiring support, and to ask: 'How can I help?' If this approach were more effectively reflected in formal constructions of the process, health advocacy might not only be practised more effectively, but might also be perceived as more achievable by trainees and physicians.

'We' not 'I': health advocacy is a team sport.

CONTEXT: Health advocacy, although recognised as a professional responsibility, is often seen as overwhelming, perhaps because it is framed conceptually as an activity that each physician should undertake alone rather than as a collaborative process. In the context of a study exploring how effective physician health advocates conceptualise their roles and their activities related to health advocacy, we uncovered data that speak directly of the issue of whether the activities of health advocates are enacted as individual or collective pursuits. METHODS: We interviewed ten physicians, identified by others as effective health advocates, regarding their advocacy activities. We collected and analysed data in an iterative process, informed by constructivist grounded theory, continuously refining the interview framework and examining evolving themes. The final coding scheme was applied to all transcripts. RESULTS: Health advocacy was viewed by these physicians as a collective activity. This collective construction of advocacy presented in three ways: (i) as teamwork by interprofessional teams of individuals with clearly defined roles and functional, task-oriented goals; (ii) as a process involving networks of resources or people that can be accessed for both support and reinforcement, and (iii) as a process involving collaborative think-tanks in which members contribute different perspectives to enact collective problem solving at a conceptual level. CONCLUSIONS: Effective health advocates do not conceptualise themselves as stand-alone experts who must do everything themselves. Their collective approach makes it possible for these physicians to incorporate health advocacy into their clinical practice. However, although conceptualising health advocacy as a collective activity may make it less daunting, this way of understanding health advocacy is not compatible with current formal descriptions of the associated competencies.

Shifts in the interpretation of health advocacy: a textual analysis.

CONTEXT: Health advocacy is widely accepted as a key element of competency-based education. We examined shifts in the language and description of the role of the health advocate and what these reveal about its interpretation and enactment within the context of medical education. METHODS: We conducted a textual analysis of three key documents that provide sequential depictions of the role of the health advocate in medical education frameworks: Educating Future Physicians for Ontario (1993), CanMEDS 2000 and CanMEDS 2005. We used a series of questions to examine shifts in the emphasis, focus and application of the role between documents. Theoretically, we drew upon Carlisle's conceptual framework to identify different approaches to advocacy. RESULTS: We identified three major shifts in the language associated with the role of health advocate across our textual documents. Firstly, activities and behaviours that were initially positioned as being the responsibility of the profession as a whole came to be described instead as competencies required of every physician. Secondly, the initial focus on health advocacy as representing collective action towards public policy and systems-level change was altered to a primary focus on individual patients and doctors. Thirdly, we observed a progression away from descriptions of concrete actions and behaviours. CONCLUSIONS: This study uncovers shifts in the language of physician advocacy that affect the discourse of health advocacy and expectations placed on physicians and trainees. Being explicit about expectations of the medical profession and individual practitioners may require renewed examination of societal needs. Although this study uses the CanMEDS role of Health Advocate as a specific example, it has implications for the conceptualisation of health advocacy in medicine and medical education globally.

Through a Tainted Lens: A Qualitatve Study of Medical Learners' Thinking About Patient 'Deservingness' of Health Advocacy.

Introduction: While health advocacy is a key component of many competency frameworks, mounting evidence suggests that learners do not see it as core to their learning and future practice. When learners do advocate for their patients, they characterize this work as 'going above and beyond' for a select few patients. When they think about advocacy in this way, learners choose who deserves their efforts. For educators and policymakers to support learners in making these decisions thoughtfully and ethically, we must first understand how they are currently thinking about patient deservingness. Methods: We conducted qualitative interviews with 29 undergraduate and postgraduate medical learners, across multiple sites and disciplines, to discuss their experiences of and decision-making about health advocacy. We then carried out a thematic analysis to understand how learners decided when and for whom to advocate. Stemming from initial inductive coding, we then developed a deductive coding framework, based in existing theory conceptualizing 'deservingness.' Results: Learners saw their patients as deserving of advocacy if they believed that the patient: was not responsible for their condition, was more in need of support than others, had a positive attitude, was working to improve their health, and shared similarities to the learner. Learners noted the tensions inherent in, and discomfort with, their own thinking about patient deservingness. Discussion: Learners' decisions about advocacy deservingness are rooted in their preconceptions about the patient. Explicit curriculum and conversations about advocacy decisions are needed to support learners in making advocacy decisions equitably.

Grappling with key questions about assessment of the Health Advocate role.

Introduction: Although the CanMEDS framework sets the standard for Canadian training, health advocacy competence does not appear to factor heavily into high stakes assessment decisions. Without forces motivating uptake, there is little movement by educational programs to integrate robust advocacy teaching and assessment practices. However, by adopting CanMEDS, the Canadian medical education community endorses that advocacy is required for competent medical practice. It's time to back up that endorsement with meaningful action. Our purpose was to aid this work by answering the key questions that continue to challenge training for this intrinsic physician role. Methods: We used a critical review methodology to both examine literature relevant to the complexities impeding robust advocacy assessment, and develop recommendations. Our review moved iteratively through five phases: focusing the question, searching the literature, appraising and selecting sources, and analyzing results. Results: Improving advocacy training relies, in part, on the medical education community developing a shared vision of the Health Advocate (HA) role, designing, implementing, and integrating developmentally appropriate curricula, and considering ethical implications of assessing a role that may be risky to enact. Conclusion: Changes to assessment could be a key driver of curricular change for the HA role, provided implementation timelines and resources are sufficient to make necessary changes meaningful. To truly be meaningful, however, advocacy first needs to be perceived as valuable. Our recommendations are intended as a roadmap for transforming advocacy from a theoretical and aspirational value into one viewed as having both practical relevance and consequential implications.

Introduction: Bien que le référentiel CanMEDS établisse les normes en matière de formation et de pratique médicale au Canada, la compétence de promotion de la santé (PS) ne semble pas peser lourd aux étapes décisives du continuum de la formation médicale. En l'absence de facteurs incitatifs, les programmes de formation sont peu enclins à intégrer des pratiques solides d'enseignement et d'évaluation en matière de PS. Un système de soins de santé marqué par l'iniquité appelle pourtant des efforts de sensibilisation. En adoptant le référentiel CanMEDS, le milieu canadien de l'éducation médicale a reconnu que la PS est nécessaire à la pratique compétente de la médecine. Il est temps que cet engagement soit traduit en actions concrètes. Méthodes: Employant une méthode d'analyse critique, nous avons examiné les écrits qui peuvent éclairer les obstacles à l'évaluation sérieuse de la PS et avons formulé des recommandations. L'examen a été effectué de manière itérative en cinq étapes : définition de la question de recherche, recherche documentaire, évaluation et sélection des sources, et analyse des résultats. Résultats: L'amélioration de la formation en matière de PS suppose, entre autres, que le milieu de l'éducation médicale s'attèle aux enjeux clés suivants : 1) l'élaborer une vision commune de la PS, 2) concevoir, mettre en œuvre et intégrer des programmes d'études évolutifs et 3) considérer les répercussions éthiques de l'évaluation d'un rôle qui comporte une part de risque. Conclusion: Le manque de visibilité et d'attention accordées à la PS dans la formation amène de nombreux apprenants à se demander si leur compétence en la matière compte vraiment. Nous estimons que la promotion de la santé est au cœur des soins centrés sur le patient. Nous lançons donc un appel à redoubler nos efforts collectifs pour faire passer la PS du statut de simple aspiration et de valeur théorique à celui d'une valeur ayant une pertinence et des incidences concrètes.

The ways social networks shape reflection on early significant clinical experiences in medical school.

Background: Medical curricula are increasingly providing opportunities to guide reflection for medical students. However, educational approaches are often limited to formalized classroom initiatives where reflection is prescriptive and measurable. There is paucity of literature that explores the personal ways students may experience authentic reflection outside of curricular time. The purpose of this study was to understand how social networks might shape dimensions of reflection. Methods: This study employed a qualitative social network analysis approach with a core sample of seven first year undergraduate medical students who described their relationships with 61 individuals in their networks. Data consisted of participant generated sociograms and individual semi-structured interviews. Results: Many learners struggled to find significant ways to involve their social networks outside of medicine in their new educational experiences. It appeared that some medical students began in-grouping, becoming more socially exclusive. Interestingly, participants emphasized how curricular opportunities such as reflective portfolio sessions were useful for capturing a diversity of perspectives. Conclusions: Our study is one of the first to characterize the social networks inside and outside of medical school that students utilize to discuss and reflect on early significant clinical experiences. Recent commentary in the literature has suggested reflection is diverse and personal in nature and our study offers empirical evidence to demonstrate this. Our insights emphasize the importance of moving from an instrumental approach to an authentic socially situated approach if we wish to cultivate reflective lifelong learning.

Contexte: Les cursus d'études en médecine offrent de plus en plus d'occasions de guider la réflexion des étudiants. Cependant, les approches pédagogiques se limitent souvent à des initiatives formelles en classe où la réflexion est obligatoire et évaluée. Il y a peu d'études scientifiques sur la réflexion personnelle et authentique des étudiants en dehors des cours. Cet article vise à explorer comment les réseaux sociaux peuvent façonner des dimensions de la réflexion. Méthodes: Cette étude est fondée sur une approche qualitative d'analyse des réseaux sociaux avec un échantillon de base de sept étudiants en première année de médecine qui ont décrit leurs relations avec 61 personnes issues de leurs réseaux. Les données sont constituées de sociogrammes créés par les participants et d'entretiens individuels semi-structurés. Résultats: De nombreux apprenants ont eu du mal à trouver une manière de partager leurs nouvelles expériences éducatives de façon significative avec leurs réseaux sociaux extérieurs à la médecine. Le fait que les participants soulignent l'utilité des occasions qu'offre leur programme, comme les séances de réflexion sur le portfolio, pour accéder à une diversité de perspectives est également intéressant à noter. Conclusions: Notre étude est l'une des premières à analyser l'utilisation que font les étudiants en médecine de réseaux sociaux tant l'intérieur qu'à l'extérieur de la faculté pour soutenir leur réflexion sur leurs premières expériences cliniques importantes et pour en discuter. Des publications scientifiques récentes suggèrent que ces réflexions sont personnelles et diversifiées et notre étude en apporte la preuve empirique. Nos observations soulignent l'importance de passer d'une approche instrumentale à une approche authentique et socialement située si nous souhaitons cultiver un apprentissage réflexif tout au long de la vie.

COVID as a catalyst: medical student perspectives on professional identity formation during the COVID-19 pandemic.

Background: As a result of the COVID-19 pandemic, a national decision was made to remove all medical students from clinical environments resulting in a major disruption to traditional medical education. Our study aimed to explore medical student perspectives of professional identity formation (PIF) during a nationally unique period in which there was no clinical training in medical undergraduate programs. Methods: We interviewed fifteen UBC medical students (years 1-4) regarding their perspectives on PIF and the student role in the setting of the COVID-19 pandemic. Data were analysed iteratively and continuously to create a codebook and identify themes of PIF based on interview transcripts. Results: We identified three key themes: (1) Medical students as learners vs contributing team members (2) Decreased competency as a threat to identity and (3) Doctors as heroes. Conclusions: The impact of disruptions due to COVID-19 catalyzed student reflections on their role within the healthcare system, as well as the role of self-sacrifice in physician identity. Simultaneously, students worried that disruptions to clinical training would prevent them from actualizing the identities they envisioned for themselves in the future. Ultimately, our study provides insight into student perspectives during a novel period in medical training, and highlights the unique ways in which PIF can occur in the absence of clinical exposure.

Contexte: En réponse à la pandémie de la COVID-19, la décision a été prise de retirer les étudiants en médecine des milieux cliniques à l'échelle nationale, ce qui a entraîné une perturbation majeure de l'enseignement médical traditionnel. Notre étude visait à explorer les opinions des étudiants en médecine sur la formation de l'identité professionnelle (FIP) au cours de cette période unique marquée par l'absence de formation clinique dans les programmes d'études médicales pré-doctorales. Méthodes: Nous avons sondé quinze étudiants en médecine de l'Université de Colombie-Britannique (1re à 4e année) pour recueillir leur point de vue sur la FIP et sur le rôle des étudiants dans le contexte de la pandémie. Les données ont été analysées de manière itérative et continue afin de créer une liste de codes et de dégager les thèmes en rapport avec la FIP à partir des transcriptions de ces entretiens. Résultats: Nous avons identifié trois thèmes clés : (1) les étudiants en médecine, en tant qu'apprenants versus en tant que membres actifs d'une équipe (2), la diminution des compétences comme menace pour l'identité et (3) les médecins comme héros. Conclusions: L'impact des perturbations dues à la COVID-19 a suscité chez les étudiants une réflexion sur leur rôle au sein du système de santé, ainsi que sur le rôle de l'abnégation dans l'identité du médecin. Parallèlement, les étudiants craignaient que les bouleversements de la formation clinique les empêchent de concrétiser leur identité professionnelle telle qu'ils l'envisageaient. En somme, notre étude donne un aperçu des réflexions des étudiants au cours d'une période inédite de la formation médicale et met en évidence les façons uniques dont l'identité professionnelle peut se construire en l'absence d'exposition clinique.

A proposed learning environment framework for virtual care.

The way in which health care is delivered has rapidly changed since the onset of the COVID-19 pandemic, with a rapid increase in virtual delivery of clinical care. As a result, the learning environment (LE) in health professions education, which has traditionally been situated in the bricks-and-mortar clinical context, now also requires attention to the virtual space. As a frequently examined topic in the health professions literature, the LE is a critical component in the development and training of future healthcare professionals. Based on a published conceptual framework for the LE from Gruppen et al. in 2019, a conceptual framework for how the LE can manifest through virtual care space is presented here. The four components of personal, social, organizational, physical/virtual spaces are explored, with a discussion of how they can be integrated into virtual care. The authors provide suggestions that health professions educators can consider when adapting their LE to the virtual environment and highlight aspects of its integration that require further research and investigation.

La prestation des soins de santé a connu un changement fulgurant depuis le début de la pandémie de la COVID-19, notamment en raison de la virtualisation des soins cliniques. Par conséquent, l'environnement d'apprentissage (EA) qui, dans l'enseignement traditionnel des professions de la santé, se situait dans un cadre clinique physique, doit désormais inclure l'espace virtuel. Sujet souvent exploré dans la littérature en sciences de la santé, l'environnement d'apprentissage est un élément essentiel de la formation des futurs professionnels de la santé. Nous proposons un cadre conceptuel, inspiré du cadre de l'EA élaboré par Gruppen et al. en 2019, sur la façon de définir un EA dans l'espace de soins virtuel. Après avoir exploré les quatre dimensions de l'espace, à savoir personnelle, sociale, organisationnelle et physique/virtuelle, les auteurs analysent la façon de les intégrer dans les soins virtuels. Ils formulent des suggestions à l'intention des enseignants des professions de la santé concernant l'adaptation de leur environnement d'apprentissage à l'environnement virtuel, tout en soulignant les aspects d'une telle intégration qui nécessitent des recherches plus approfondies.