Medical Education to Enhance Critical Consciousness: Facilitators' Experiences

Exploring the implicit meanings of 'cultural diversity': a critical conceptual analysis of commonly used approaches in medical education

Existing approaches to cultural diversity in medical education may be implicitly based on different conceptualisations of culture. Research has demonstrated that such interpretations matter to practices and people concerned. We therefore sought to identify the different conceptualisations espoused by these approaches and investigated their implications for education. We critically reviewed 52 articles from eight top medical education journals and subjected these to a conceptual analysis. Via open coding, we looked for references to approaches, their objectives, implicit notions of culture, and to implementation practices. We iteratively developed themes from the collected findings. We identified several approaches to cultural diversity teaching that used four different ways to conceptualise cultural diversity: culture as 'fixed patient characteristic', as 'multiple fixed characteristics', as 'dynamic outcome impacting social interactions', and as 'power dynamics'. We discussed the assumptions underlying these different notions, and reflected upon limitations and implications for educational practice. The notion of 'cultural diversity' challenges learners' communication skills, touches upon inherent inequalities and impacts how the field constructs knowledge. This study adds insights into how inherent inequalities in biomedical knowledge construction are rooted in methodological, ontological, and epistemological principles. Although these insights carry laborious implications for educational implementation, educators can learn from first initiatives, such as: standardly include information on patients' multiple identities and lived experiences in case descriptions, stimulate more reflection on teachers' and students' own values and hierarchical position, acknowledge Western epistemological hegemony, explicitly include literature from diverse sources, and monitor diversity-integrated topics in the curriculum.

Educational approaches to teach students to address colonialism in global health: a scoping review

INTRODUCTION

The enduring legacy of colonisation on global health education, research and practice is receiving increased attention and has led to calls for the 'decolonisation of global health'. There is little evidence on effective educational approaches to teach students to critically examine and dismantle structures that perpetuate colonial legacies and neocolonialist control that influence in global health.

METHODS

We conducted a scoping review of the published literature to provide a synthesis of guidelines for, and evaluations of educational approaches focused on anticolonial education in global health. We searched five databases using terms generated to capture three concepts, 'global health', 'education' and 'colonialism'. Pairs of study team members conducted each step of the review, following Preferred Reporting Items for Systematic reviews and Meta-Analyse guidelines; any conflicts were resolved by a third reviewer.

RESULTS

This search retrieved 1153 unique references; 28 articles were included in the final analysis. The articles centred North American students; their training, their evaluations of educational experiences, their individual awareness and their experiential learning. Few references discussed pedagogical approaches or education theory in guidelines and descriptions of educational approaches. There was limited emphasis on alternative ways of knowing, prioritisation of partners' experiences, and affecting systemic change.

CONCLUSION

Explicit incorporation of anticolonial curricula in global health education, informed by antioppressive pedagogy and meaningful collaboration with Indigenous and low-income and middle-income country partners, is needed in both classroom and global health learning experiences.

Implementing a Social Determinants of Health Curriculum in Undergraduate Medical Education: A Qualitative Analysis of Faculty Experience

PURPOSE

Following shifts that broadened the medical profession's conceptualization of the underlying drivers of health, medical schools are required to integrate curricula on health disparities and the social context of medicine into undergraduate medical education. Although previous research has focused on student experiences and outcomes in these curricula, less attention has been paid to the experiences of the physician-faculty involved. This study aimed to capture faculty insights to improve understanding of the challenges and opportunities of implementing this curricular reform.

METHOD

In-depth, semistructured interviews were conducted with 10 faculty members at one U.S. medical school in spring 2019 to capture their experiences designing and teaching a new curriculum related to the social determinants of health and health disparities. Study design, including interview guide development, was informed by the critical pedagogy perspective and social constructionist approaches to curriculum implementation. With the use of a constructivist grounded theory approach, interview transcripts were analyzed using open, thematic, and axial coding techniques. Primary themes were categorized as professional, organizational, interactional, or intrapersonal and organized into the final model.

RESULTS

Participants processed their experiences at 4 concentric levels: professional, organizational, interactional, and intrapersonal. Faculty generally embraced the movement to incorporate more discussion of social context as a driver of health outcomes. However, they struggled with the shortcomings of their training and navigating structural constraints within their school when developing and delivering content. When confronted with these limitations, faculty experienced unexpected tension in the classroom setting that catalyzed self-reflection and reconstruction of their teaching approach.

CONCLUSIONS

Findings highlight the challenges that faculty encounter when integrating social determinants of health and related curricula into undergraduate medical education. They also speak to the need for a broader conceptualization of relevant expertise and have implications for how medical schools select, train, and support medical educators in this work.

The power struggle: exploring the reality of clinical reasoning

PURPOSE

Historically, clinical reasoning has largely been considered from an empirical, biomedical standpoint. This epistemology, rooted in imperial rule, is influential in how healthcare practitioners practice. An empirical approach to healthcare often oversimplifies the complex nature of clinical reasoning by obscuring the influence of imperial ideologies on decision-making. This can perpetuate inequitable approaches to healthcare delivery which deepen social, political and economic divides globally. This paper aims to explore and challenge this standpoint by exploring how power, imperialism and performativity influences healthcare provision and decision-making amongst healthcare practitioners in dysphagia rehabilitation.

METHODS

Qualitative exploratory interviews were undertaken with seven South African trained SLPs with experience working in dysphagia. To allow for participation and collaboration from participants, three data collection tools were employed within the interviews: oral histories, cognitive mapping and arts-based tasks. An initial modified thematic analysis followed by a further ideological analysis were undertaken to analyse the data collected.

RESULTS

The results suggest that the participants felt influenced by several manifestations of power within healthcare. We argue that this demonstrates that imperial practices can influence knowledge, interaction and context and therefore affect how healthcare practitioners make decisions.

CONCLUSION

By acknowledging the impact of imperialism and power dynamics on healthcare provision and clinical reasoning we can potentially begin to transform the epistemology from which we approach healthcare provision in favour of one which is better suited to the current realities of healthcare to allow for equitable service provision.

Exploring how physician educators approach politically charged topics with learners

CONTEXT

Medical educators hold and encounter different beliefs and values on politically charged health-related topics such as reproductive rights and immigration. Their views on these topics have implications for how they approach them with learners, yet little work has explored medical educators' views and pedagogical approaches. In this study, we used Hess's approaches to controversial topics (avoidance, denial, privilege, balance) as a guiding conceptual framework to explore physician educators' views on and approaches to politically charged topics. We used this understanding to provide guidance on how best to address politically charged issues within medical education.

METHOD

We used a constructivist qualitative approach to explore medical educators' approaches to politically charged topics. We interviewed 37 physician educators from two medical schools in different regions of the United States. In these semi-structured interviews, we presented participants with vignettes depicting politically charged topics arising in an educational setting. Participants described and explained their response to each vignette. Interviews were recorded, transcribed and analysed using constructivist-oriented thematic analysis.

RESULTS

Participants were thoughtful about preparing learners for participation in a professional community that holds certain responsibilities to a politically and culturally diverse society. Although some adopted clear approaches on politically charged topics and declared their stance on the topic to learners, others took a balanced approach, focused only on the medical aspects and withheld their views. The context and location of practice played a role in the approaches participants adopted. Additionally, they had varied views on which topics had a place in medical education.

CONCLUSION

Our findings provide insights that can help guide medical educators and training programmes in decisions about their role in facilitating conversations about politically charged, health-related topics and helping learners form their own perspectives and approaches to such topics.

Seeing the Window, Finding the Spider: Applying Critical Race Theory to Medical Education to Make Up Where Biomedical Models and Social Determinants of Health Curricula Fall Short

A professional and moral medical education should equip trainees with the knowledge and skills necessary to effectively advance health equity. In this Perspective, we argue that critical theoretical frameworks should be taught to physicians so they can interrogate structural sources of racial inequities and achieve this goal. We begin by elucidating the shortcomings in the pedagogic approaches contemporary Biomedical and Social Determinants of Health (SDOH) curricula use in their discussion of health disparities. In particular, current medical pedagogy lacks self-reflexivity; encodes social identities like race and gender as essential risk factors; neglects to examine root causes of health inequity; and fails to teach learners how to challenge injustice. In contrast, we argue that Critical Race Theory (CRT) is a theoretical framework uniquely adept at addressing these concerns. It offers needed interdisciplinary perspectives that teach learners how to abolish biological racism; leverage historical contexts of oppression to inform interventions; center the scholarship of the marginalized; and understand the institutional mechanisms and ubiquity of racism. In sum, CRT does what biomedical and SDOH curricula cannot: rigorously teach physician trainees how to combat health inequity. In this essay, we demonstrate how the theoretical paradigms operationalized in discussions of health injustice affect the ability of learners to confront health inequity. We expound on CRT tenets, discuss their application to medical pedagogy, and provide an in-depth case study to ground our major argument that theory matters. We introduce MedCRT: a CRT-based framework for medical education, and advocate for its implementation into physician training.

Medical students' affective reactions to workplace experiences: qualitative investigation in a Chinese cultural context

BACKGROUND

Compassion fatigue, unprofessional behavior, and burnout are prompting educators to examine medical students' affective reactions to workplace experiences. Attributes of both students and learning environments are influenced by their socio-cultural backgrounds. To prevent 'educational cultural hegemony', opinion leaders have advocated research in under-represented cultural contexts, of which Asia is a prime example. This study aimed to broaden the discourse of medical education by answering the question: how do students react affectively to workplace experiences in a Chinese cultural context?

METHODS

In 2014, the authors recruited five female and seven male Taiwanese clerkship students to make 1-2 audio-diary recordings per week for 12 weeks describing affective experiences, to which they had consciously reacted. The authors analyzed transcripts of these recordings thematically in the original Mandarin and prepared a thick description of their findings, including illustrative extracts. An English-speaking education researcher helped them translate this into English, constantly comparing the interpretation with the original, untranslated data.

RESULTS

(Mis) matches between their visions of future professional life and clerkship experiences influenced participants' affective reactions, thoughts, and behaviors. Participants managed these reactions by drawing on a range of personal and social resources, which influenced the valence, strength, and nature of their reactions. This complex set of interrelationships was influenced by culturally determined values and norms, of which this report provides a thick description.

CONCLUSION

To avoid educational cultural hegemony, educators need to understand professional behavior in terms of complex interactions between culturally-specific attributes of individual students and learning environments.

TRIAL REGISTRATION

The ethics committee of the National Taiwan University (NTU) Hospital gave research ethics approval ( 20130864RINB ).

Medical teachers' discursive positioning of doctors in relation to patients

CONTEXT

An important part of a doctor's identity is the social position he or she adopts relative to patients. Dialogic theory predicts that medical school discourses influence the positions students incorporate into their professional identities. As this may affect how students later exercise power in doctor-patient relationships, we set out to examine how medical teachers position doctors in relation to patients.

METHODS

Informed by Holland's Figured Worlds theory, which draws important assumptions from Bakhtin, we chose dialogic research methodology to examine how educators' language positions doctors and may influence students' identity formation. We recruited a maximum variation sample of 10 teaching staff and used open prompts in individual semi-structured interviews to elicit discourses of doctors' social position. We used Sullivan's dialogic methodology reflexively to identify informative speech acts (utterances) and to examine how the language used in these constructed doctors' positions.

RESULTS

Dominant discourses of Social Superiority, Technical Effectiveness, and Benevolence elevated doctors' positions based on their social status, applied knowledge and trustworthiness, respectively. These positions were defended by predicating medical care on doctors' mastery of treatments and their superior knowledge. A non-dominant discourse of Distributed Power and Responsibility narrowed the positional gap by constructing doctors as empowering patients.

CONCLUSIONS

Whereas three conservative discourses upheld doctors' elevated social position, a non-dominant, transformative discourse distributed power. We suggest that doctors will form the best relationships with patients when they are aware of these discourses and know how to navigate them. In pursuit of effective and compassionate patient care, we commend critical pedagogy as a means of articulating non-dominant discourses and increasing students', educators' and doctors' awareness of how they learn the positions of doctors.

Honoring Medicine's Social Contract: A Scoping Review of Critical Consciousness in Medical Education

PURPOSE

To explore how the construct of critical consciousness has been conceptualized within the medical education literature and identify the main elements of critical consciousness in medical education so as to inform educational strategies to foster socially conscious physicians.

METHOD

In March 2019, the authors conducted a literature search of 4 databases and Google Scholar, seeking articles discussing critical consciousness in medical education published any time after 1970. Three of the authors screened articles for eligibility. Two transcribed data using a data extraction form and identified preliminary emerging themes, which were then discussed by the whole research team to ensure agreement.

RESULTS

Of the initial 317 articles identified, 20 met study inclusion criteria. The publication of academic articles around critical consciousness in medical education has expanded substantially since 2017. Critical consciousness has been conceptualized in the medical education literature through 4 overlapping themes: (1) social awareness, (2) cultural awareness, (3) political awareness, and (4) awareness of educational dynamics.

CONCLUSIONS

Critical consciousness has been conceptualized in medical education as an intellectual construct to foster a reflexive awareness of professional power in health care, to unearth the values and biases legitimizing medicine as currently practiced, and to foster transformation and social accountability. Scholars highlighted its potential to improve sociocultural responsibility and to foster compassion in doctors. Adopting a critical pedagogy approach in medical education can help uphold its social accountability through an intrinsic orientation to action, but any enterprise working toward embedding critical pedagogy within curricula must acknowledge and challenge the current structure and culture of medical education itself.

How to Make or Break Implicit Bias Instruction: Implications for Curriculum Development

PURPOSE

To analyze faculty experiences regarding facilitating discussions as part of the institution's curriculum on racial and ethnic implicit bias recognition and management.

METHOD

Between July 2014 and September 2016, the authors conducted 21 in-depth interviews with faculty who had experience teaching in implicit bias instruction or were interested in facilitating discussions related to implicit bias and the Implicit Association Test. Grounded theory methodology was used to analyze interview transcripts.

RESULTS

Participants identified challenges that affect their ability to facilitate instruction in implicit bias. Faculty described the influence of their own background and identities as well as the influence of institutional values on their ability to facilitate implicit bias discussions. They noted the impact of resistant learners and faculty during discussions and made suggestions for institutional measures including the need for implementation of formalized longitudinal implicit bias curricula and faculty development.

CONCLUSIONS

Faculty facilitating sessions on implicit bias must attend faculty development sessions to be equipped to deal with some of the challenges they may face. Buy-in from institutional leadership is essential for successful implementation of implicit bias teaching, and medical educators need to consider formalized longitudinal curricula addressing the recognition and management of implicit biases.

Commentary: Racism and Bias in Health Professions Education: How Educators, Faculty Developers, and Researchers Can Make a Difference

The Research in Medical Education (RIME) Program Planning Committee is committed to advancing scholarship in and promoting dialogue about the critical issues of racism and bias in health professions education (HPE). From the call for studies focused on underrepresented learners and faculty in medicine to the invited 2016 RIME plenary address by Dr. Camara Jones, the committee strongly believes that dismantling racism is critical to the future of HPE.The evidence is glaring: Dramatic racial and ethnic health disparities persist in the United States, people of color remain deeply underrepresented in medical school and academic health systems as faculty, learner experiences across the medical education continuum are fraught with bias, and current approaches to teaching perpetuate stereotypes and insufficiently challenge structural inequities. To achieve racial justice in HPE, academic medicine must commit to leveraging positions of influence and contributing from these positions. In this Commentary, the authors consider three roles (educator, faculty developer, and researcher) represented by the community of scholars and pose potential research questions as well as suggestions for advancing educational research relevant to eliminating racism and bias in HPE.