(Re)producing "Whiteness" in Health Care: A Spatial Analysis of the Critical Literature on the Integration of Internationally Educated Health Care Professionals in the Canadian Workforce

Selection of international medical graduates into postgraduate training positions in Canada. Who applies? Who is selected?

Background

International medical graduates (IMGs) are an essential part of the Canadian physician workforce. Considering current pressures on the health care system, an update regarding application numbers and match rates for IMGs to postgraduate positions in Canada is needed.

Methods

We conducted a quantitative cross-sectional study to explore the characteristics of IMGs who are currently applying to the Canadian Residency Matching Service (CaRMS) positions to gain a broad understanding of the composition of this group and the factors associated with successful matching.

Results

Out of 1,725 applicants in 2019, 14.1% matched on the first attempt and 6.4% after two to three attempts. Only 22.7% matched with a position (57.6% women). Applicants submitted an average 19.6 site/program applications. The percentage of IMGs matched did not statistically differ by gender. The relationship between the year of graduation or geographic area of medical school qualified and matching was significant for the first and second iterations, with current-year graduates and Oceania/Pacific Islands applicants more likely to match.

Conclusions

This study provided us with accurate numbers and information about the Canadians studying abroad and IMG groups applying, and factors associated with being matched to the IMG positions through CaRMS, which will be instrumental in informing future selection implications for Canada.

Inequity is woven into the fabric: a discourse analysis of assessment in pediatric residency training

Intrinsic inequity in assessment refers to sources of harmful discrimination inherent in the design of assessment tools and systems. This study seeks to understand intrinsic inequity in assessment systems by studying assessment policies and associated procedures in residency training, using general pediatrics as a discourse case study. Foucauldian discourse analysis (FDA) was conducted on assessment policy and procedure documents. Two authors independently prepared structured analytic notes using guiding questions. Documents and respective analytic notes were subsequently reviewed independently by all authors. Each author prepared further unstructured analytic notes on the documents' discourse. The authors then compared notes and constructed truth statements (i.e., interpretations of what the discourse establishes as true about the construct under study) and sub-strands (i.e., themes) that were repeated and legitimized across the documents via iterative discussion. Based on analysis, the authors constructed two truth statements. These truth statements, "good assessment is equitable assessment," and "everyone is responsible for inequity," conceptualized inequity in assessment as an isolated or individual-level aberration in an otherwise effective or neutral system. Closer examination of the truth statements and sub-strands in the discourse presented an alternative view, suggesting that inequity may in fact not be an aberration but rather an inherent feature of assessment systems.

Whiteness theory and the (in)visible hierarchy in medical education

CONTEXT

The theory of whiteness in medical education has largely been ignored, yet its power continues to influence learners within our medical curricula and our patients and trainees within our health systems. Its influence is even more powerful given the fact that society maintains a 'possessive investment' in its presence. In combination, these (in)visible forces create environments that favour White individuals at the exclusion of all others, and as health professions educators and researchers, we have the responsibility to uncover how and why these influences continue to pervade medical education.

PROPOSAL

To better understand how whiteness and the possessive investment in its presence create (in)visible hierarchies, we define and explore the origin of whiteness by examining whiteness studies and how we have come to have a possessive investment in its presence. Next, we provide ways in which whiteness can be studied in medical education so that it can be disruptive.

CONCLUSION

We encourage health profession educators and researchers to collectively 'make strange' our current hierarchical system by not just recognising the privileges afforded to those who are White but also recognising how these privileges are invested in and maintained. As a community, we must develop and resist established power structures to transform the current hierarchy into a more equitable system that supports everyone, not just those who are White.

How Do Academic Medicine Pathways Differ for Underrepresented Trainees and Physicians? A Critical Scoping Review

PURPOSE

Academic medicine faces difficulty recruiting and retaining a diverse workforce. The proportion of medical students who are underrepresented in medicine (URiM) is smaller than the proportion of URiM's in the general population, and these numbers worsen with each step up the academic medicine ladder. Previously known as the "leaky pipeline," this phenomenon may be better understood as disparate "pathways with potholes," which acknowledges the different structural barriers that URiM trainees and faculty face in academic medicine. This critical scoping review analyzed current literature to determine what variables contribute to the inequitable "pathways and potholes" URiM physicians experience in academic medicine.

METHOD

The authors combined scoping review methodology with a critical lens. The comprehensive search strategy used terms about academic medicine, underrepresented groups, and leaving academic medical careers. One reviewer conducted screening, full text review, and data extraction while in consultation with members of the research team. Data extraction focused on themes related to pathways and potholes, such as attrition, recruitment, and retention in academic medicine. Themes were iteratively merged, and quality of contribution to the field and literature gaps were noted.

RESULTS

Included papers clustered into attrition, recruitment, and retention. Those pertaining to attrition noted that URiM faculty are less likely to get promoted even when controlling for scholarly output, and a hostile work environment may exacerbate attrition. Recruitment and retention strategies were most effective when multi-pronged approaches changed every step of the recruitment and promotion processes.

CONCLUSIONS

These studies provide examples of various "potholes" that can affect representation in academic medicine of URiM trainees and faculty. However, only a few studies examined the link between isolating and hostile work environments, the so-called "chilly climate," and attrition from academic medicine. Understanding these concepts is key to producing the most effective interventions to improve diversity in medicine.

Canadian fellowship experience: the different challenges and emotions faced by an International Medical Graduate and mitigation strategies

Acknowledging the mental remodeling that a foreign physician goes through and attempting to mitigate the difficulties of this process is crucial to achieving better outcomes in education and patient care. Canada's Healthcare System offers Clinical Fellowship Programs that allow physicians specialists to obtain advanced expertise in a chosen subspecialty. In a Clinical Fellowship, Canadian Medical Graduates (CMGs) practice alongside International Medical Graduates (IMGs); however, there is evidence that they undergo different challenges in the learning experience. IMGs usually have a higher cognitive load during the adaptation period, which can be due to multiple factors, such as the transition to practice in a foreign country, language, level of supervision, teaching methods applied, feeling disconnected from home, and other competing needs fellows face outside of the clinical context. We propose strategies that may help mitigate the transition to practice process that IMGs undergo when starting a Canadian fellowship, such as Self-Efficacy Encouraging Approach, Thinking Framework Across Cultures, and Social Engagement and Wellbeing.

Disruption and Dissonance: Exploring Constructive Tensions Within Research in Medical Education

The academic medicine community has experienced an unprecedented level of disruption in recent years. In this context, the authors consider how the disruptions have impacted the state of research in medical education (RIME). The articles in this year's RIME supplement reflect several constructive tensions that provide insight on future for the field. In this commentary, the authors discuss themes and propose a framework for the future. Recommendations include: normalizing help seeking during times of disruption and uncertainty, contextualizing the application of complex approaches to assessment, advancing and problematizing innovation, and recognizing the deeply embedded and systemic nature of inequities.