'Yourself in all your forms': A grounded theory exploration of identity safety in medical students

'The program director's word … it's stronger than the word of God': Epistemic injustice revealed through narratives of remediated graduate medical education residents

BACKGROUND

Though graduate medical education (GME) residency training provides positive experiences for many trainees, it may also result in major stressors and negative experiences, particularly for those requiring remediation. Residents requiring remediation may experience feelings of dismay, shame and guilt that can negatively affect their training, self-efficacy and their medical careers. Power differentials between educators and residents may set the stage for epistemic injustice, which is injustice resulting from the silencing or dismissing a speaker based on identity prejudice. This can lead to decreased willingness of trainees to engage with learning. There is a paucity of literature that explores GME experiences of remediation from the resident perspective.

OBJECTIVE

To synthesise the narratives of physician experiences of remediation during residency through the lens of epistemic injustice.

METHODS

Between January and July 2022, we interviewed US physicians who self-identified as having experienced remediation during residency. They shared events that led to remediation, personal perspectives and emotions about the process and resulting outcomes. Interviews were analysed using narrative analysis with attention to instances of epistemic injustice.

RESULTS

We interviewed 10 participants from diverse backgrounds, specialties and institutions. All participants described contextual factors that likely contributed to their remediation: (1) previous academic difficulty/nontraditional path into medicine, (2) medical disability or (3) minoritised race, gender or sexual identity. Participants felt that these backgrounds made them more vulnerable in their programmes despite attempts to express their needs. Participants reported instances of deflated credibility and epistemic injustices with important effects.

CONCLUSIONS

Participant narratives highlighted that deep power and epistemic imbalances between learners and educators can imperil GME trainees' psychological safety, resulting in instances of professional and personal harm. Our study suggests applying an existing framework to help programme directors (PDs) approach remediation with epistemic humility.

Critically re-examining professional norms: Medicine's urgent need to look inwards

'Are physicians who they ought to be?' This commentary advocates for a critical re‐examination of what is at the core of being a physician via a process of inclusive co‐construction

Navigating the paradox: Exploring resident experiences of vulnerability

INTRODUCTION

Learning and growth in postgraduate medical education (PGME) often require vulnerability, defined as a state of openness to uncertainty, risk, and emotional exposure. However, vulnerability can threaten a resident's credibility and professional identity. Despite this tension, studies examining vulnerability in PGME are limited. As such, this study aims to explore residents' experiences of vulnerability, including the factors that influence vulnerability in PGME.

METHODS

Using a constructivist grounded theory approach, individual semi-structured interviews were conducted with 15 residents from 10 different specialities. Interview transcripts were coded and analysed iteratively. Themes were identified and relationships among themes were examined to develop a theory describing vulnerability in PGME.

RESULTS

Residents characterised vulnerability as a paradox represented by two overarching themes. 'Experiencing the tensions of vulnerability' explores the polarities between being a fallible, authentic learner and an infallible, competent professional. 'Navigating the vulnerability paradox' outlines the factors influencing the experience of vulnerability and its associated outcomes at the intrapersonal, interpersonal, and systems levels. Residents described needing to have the bandwidth to face the risks and emotional labour of vulnerability. Opportunities to build connections with social agents, including clinical teachers and peers, facilitated vulnerability. The sociocultural context shaped both the experience and outcomes of vulnerability as residents faced the symbolic mask of professionalism.

CONCLUSION

Residents experience vulnerability as a paradox shaped by intrapersonal, interpersonal, and systems level factors. These findings capture the nuance and complexity of vulnerability in PGME and offer insight into creating supportive learning environments that leverage the benefits of vulnerability while acknowledging its risks. There is a need to translate this understanding into systems-based change to create supportive PGME environments, which value and celebrate vulnerability.

Cheating is a professional identity formation problem

.@kmcowen outlines how medical education could better support students connect their behavior during medical school to their future identities as physicians.

In Their Own Voices: A Critical Narrative Review of Black Women Faculty Members' First-Person Accounts of Racial Trauma Across Higher Education

Phenomenon: Black women often face more challenges in academic medicine than others and are leaving the profession due to unsupportive work environments, systematic neglect, and experiences of invisibility. Research offers insight into Black women faculty experiences, but studies have largely been conducted on their experiences rather than written by them. We analyzed first-person narratives exploring Black women faculty members' experiences with racial trauma across the academy considering the intersectionality of racism and sexism to lay the foundation for understanding Black women physicians' faculty experiences in similar spaces. Approach: We gathered first-person narratives of Black women faculty members in the U.S. from ERIC, Web of Science, and Ovid Medline. We used a variety of terms to draw out potential experiences with trauma (e.g., microaggressions, stigma, prejudice). Articles were screened by two researchers, with a third resolving conflicts. Drawing on constructs from Black feminist theory, two researchers extracted from each article authors' claims about: (a) their institutions, (b) their experiences in those spaces, and (c) suggestions for change. We then analyzed these data through the lens of racial trauma while also noting the effects of gendered racism. Findings: We identified four key themes from the 46 first-person accounts of racial trauma of Black faculty members in higher education: pressures arising from being "the only" or "one of few"; elimination of value through the "cloak of invisibility" and "unconscious assumptions"; the psychological burden of "walking a tightrope"; and communal responsibility, asking "if not us, then who?" Insights: Black women's narratives are necessary to unearth their specific truths as individuals who experience intersectional oppression because of their marginalized racial and gender identities. This may also assist with better understanding opportunities to dismantle the oppressive structures and practices hindering more diverse, equitable, and inclusive institutional environments where their representation, voice, and experience gives space for them to thrive and not simply survive within the academy, including and not limited to medicine.

What does 'belongingness' mean in relation to diverse medical student groups?

Kitchuk comments on ways in which identity threats and identity safety impact ‘belongingness’ for diverse students, highlighting that there remains need to further explore what is meant by belonging and the effects this has on students.

Academic Leadership Academy Summer Program: Clerkship Transition Preparation for Underrepresented in Medicine Medical Students

PROBLEM

Enhancing workforce diversity by increasing the recruitment of students who have been historically excluded/underrepresented in medicine (UIM) is critical to addressing healthcare inequities. However, these efforts are inadequate when undertaken without also supporting students' success. The transition to clerkships is an important and often difficult to navigate inflection point in medical training where attention to the specific needs of UIM students is critical.

INTERVENTION

We describe the design, delivery, and three-year evaluation outcomes of a strengths-based program for UIM second year medical students. The program emphasizes three content areas: clinical presentations/clinical reasoning, community building, and surfacing the hidden curriculum. Students are taught and mentored by faculty, residents, and senior students from UIM backgrounds, creating a supportive space for learning.

CONTEXT

The program is offered to all UIM medical students; the centerpiece of the program is an intensive four-day curriculum just before the start of students' second year. Program evaluation with participant focus groups utilized an anti-deficit approach by looking to students as experts in their own learning. During focus groups mid-way through clerkships, students reflected on the program and identified which elements were most helpful to their clerkship transition as well as areas for programmatic improvement.

IMPACT

Students valued key clinical skills learning prior to clerkships, anticipatory guidance on the professional landscape, solidarity and learning with other UIM students and faculty, and the creation of a community of peers. Students noted increased confidence, self-efficacy and comfort when starting clerkships.

LESSONS LEARNED

There is power in learning in a community connected by shared identities and grounded in the strengths of UIM learners, particularly when discussing aspects of the hidden curriculum in clerkships and sharing specific challenges and strategies for success relevant to UIM learners. We learned that while students found unique benefits to preparing for clerkships in a community of UIM students, near peers, and faculty, future programs could be enhanced by pairing this formal intensive curriculum with more longitudinal opportunities for community building, mentoring, and career guidance.