Shifting paradigms: A collective and structural strategy for addressing healthcare inequity.

Healthcare inequity is a persistent systemic problem, yet many solutions have historically focused on "debiasing" individuals. Individualistic strategies fit within a competency-based medical education and assessment paradigm, whereby professional values of social accountability, patient safety, and healthcare equity are linked to an individual clinician's competence. Unfortunately, efforts to realise the conceptual linkages between medical education curricula and goals to improve healthcare equity fail to address the institutional values, policies, and practices that enable structural racism. In this article, we explore alternative approaches that target collective and structural causes of health inequity. We first describe the structural basis of healthcare inequity by identifying the ways in which institutional culture, power and privilege erode patient-centred care and contribute to epistemic injustice. We then outline some reasons that stereotypes, which are a culturally supported foundation for discrimination, bias and racism in healthcare, cannot be modified effectively through individualistic strategies or education curricula. Finally, we propose a model that centres shared values for leadership by individuals and institutions with consistency in goal setting, knowledge translation, and talent development. Figure 1 summarises the key recommendations. We have provided cases to supplement this work and facilitate discussion about the model's application to practice.

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.

His opportunity, her burden: A narrative critical review of why women decline academic opportunities.

OBJECTIVES: This paper stems from a desire to deepen our own understanding of why women might 'say no' when allies and sponsors offer or create opportunities for advancement, leadership or recognition. The resulting disparity between representation by men and women in leadership positions, invited keynote speakers and publication counts in academic medicine is a stubborn and wicked problem that requires a synthesis of knowledge across multidisciplinary literature. Acknowledging the complexity of this topic, we selected a narrative critical review methodology to explore reasons why one man's opportunity might be a woman's burden in academic medicine. METHODS: We engaged with an iterative process of identifying, reviewing and interpreting literature from Psychology (cognitive, industrial and educational), Sociology, Health Professions Education and Business, placing no restrictions on context or year of publication. Knowledge synthesis and interpretation were guided by our combined expertise, lived experience, consultations with experts outside the author team and these guiding questions: (1) Why might women have less time for career advancement opportunities? (2) Why do women have less time for research and leadership? (3) How are these disparities maintained? RESULTS: Turning down an opportunity may be a symptom of a much larger issue. The power of social expectations, culture and gender stereotypes remains a resistant force against calls for action. Consequently, women disproportionately take on other tasks that are not as well recognised. This disparity is maintained through social consequences for breaking with firmly entrenched stereotypes. CONCLUSIONS: Popular strategies like 'lean into opportunities', 'fake it till you make it' and 'overcome your imposter syndrome' suggest that women are standing in their own way. Critically, these axioms ignore powerful systemic barriers that shape these choices and opportunities. We offer strategies that allies, sponsors and peers can implement to offset the power of stereotypes.

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.

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 Critical Review of Professional Identity Formation Interventions in Medical Education.

PURPOSE: Professional identity formation (PIF) can be defined as the integration of the knowledge, skills, values, and behaviors of a profession with one's preexisting identity and values. Several different, and sometimes conflicting, conceptualizations and theories about PIF populate the literature; applying these different theories in PIF curricula and pedagogic strategies can profoundly impact the PIF of future physicians. The authors conducted a critical review of the recent literature on PIF interventions in medical education to explore the conceptualizations of and theoretical approaches to PIF that underlie them. METHOD: The authors searched articles on PIF educational interventions published in 5 major medical education journals between 2010 and March 2021. The articles' context and findings were extracted, analyzed, and summarized to identify conceptualizations and theoretical approaches to PIF. RESULTS: The authors identified 43 studies examining medical education interventions aimed at influencing PIF. The majority of the studies (n = 31) focused on undergraduate medical education. Reflective writing and the use of narrative reflections were the dominant modes of student activity in PIF interventions, supporting the dominant individualist approach to PIF. Less commonly PIF was understood as a socialization process or as an active process with both individually and socially focused influences. CONCLUSIONS: Relying on reflective writing as the intervention of choice to impact PIF feeds the dominant individualist perspective on PIF. An unintended consequence of this individualist orientation is that cultural problems embedded in the profession can become burdens for individual physicians to personally bear. Future education and research into PIF should account for theoretical preferences and the impact of these preferences.

A practical guide to reflexivity in qualitative research: AMEE Guide No. 149.

Qualitative research relies on nuanced judgements that require researcher reflexivity, yet reflexivity is often addressed superficially or overlooked completely during the research process. In this AMEE Guide, we define reflexivity as a set of continuous, collaborative, and multifaceted practices through which researchers self-consciously critique, appraise, and evaluate how their subjectivity and context influence the research processes. We frame reflexivity as a way to embrace and value researchers' subjectivity. We also describe the purposes that reflexivity can have depending on different paradigmatic choices. We then address how researchers can account for the significance of the intertwined personal, interpersonal, methodological, and contextual factors that bring research into being and offer specific strategies for communicating reflexivity in research dissemination. With the growth of qualitative research in health professions education, it is essential that qualitative researchers carefully consider their paradigmatic stance and use reflexive practices to align their decisions at all stages of their research. We hope this Guide will illuminate such a path, demonstrating how reflexivity can be used to develop and communicate rigorous qualitative research.

Complexities of Continuing Professional Development in Context: Physician Engagement in Clinical Coaching.

INTRODUCTION: Effective continuing professional development (CPD) is critical for safe and effective health care. Recent shifts have called for a move away from didactic CPD, which often fails to affect practice, toward workplace learning such as clinical coaching. Unfortunately, coaching programs are complex, and adoption does not guarantee effectiveness. To resolve this problem, thus ensuring resources are well spent, there is a critical need to understand what physicians try to achieve and how they engage. Therefore, we examined the types of change physicians pursue through clinical coaching and the impact of context on their desired changes. METHODS: In the context of two clinical coaching programs for rural physicians, we applied a generic qualitative approach. Coachees (N = 15) participated in semistructured interviews. Analysis involved iterative cycles of initial, focused, and theoretical coding. RESULTS: Coachees articulated desired practice changes along a spectrum, ranging from honing their current practice to making larger changes that involved new skills outside their current practice; changes also ranged from those focused on individual physicians to those focused on the practice system. Desired changes were affected by factors in the learning/practice environment, including those related to the individual coachee, coach, and learning/practice context. DISCUSSION: These results suggest that the current focus on acquiring new knowledge through CPD may miss important learning that involves subtle shifts in practice as well as learning that focusses on systems change. Moreover, an appreciation of the contextual nature of CPD can ensure that contextual affordances are leveraged and barriers are acknowledged.

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.

The disconnect between knowing and doing in health professions education and practice.

Safe and effective healthcare requires that new knowledge or skills, once learned, are incorporated into professional practice. However, this process is not always straightforward. Learning takes place in complex contexts, requiring practitioners to overcome various motivational, systemic, emotional, and social barriers to the application of knowledge. This paper explores the mechanisms through which individuals translate knowledge into action to provide insight into why disconnects between knowledge and action can arise. As a critical review, the aim was to draw on key literature from multiple fields to analyse and synthesize existing schools of thought and lay a strong conceptual foundation on which knowledge to action gaps might be considered. We iteratively consulted clinicians and experts in various fields to guide literature searches focused on theoretical perspectives that could inform educational and research efforts around knowledge-to-action gaps. Key theoretical perspectives on motivation address when and how individuals decide to take action. Literatures from cognitive science address how clinicians and learners self-regulate to (sometimes) overcome barriers to action. Sociocultural theories examine the ways in which action might be prevented by social norms that conflict with what the individual knows and believes, potentially also giving rise to counter-normative action. No single perspective will entirely explain how health professionals and learners implement knowledge in practice. As a result, the authors offer multiple lenses through which to view the problem, and then propose how each of these lenses might better guide educational and research efforts to untangle this challenging but important issue.

Positioning the Work of Health Professions Education Scholarship Units: How Canadian Directors Harness Institutional Logics Within Institutional Orders to Convey Unit Legitimacy.

PURPOSE: Health professions education scholarship unit (HPESU) leaders often struggle to articulate their impact within local contexts. Previous research has described what markers of success and institutional logics to consider when crafting statements of impact; there is a need to clarify how HPESU leaders convey their messages to navigate competing demands. This study examined how leaders argue the legitimacy of their HPESUs' activities. METHOD: The institutional logics perspective offered a lens for understanding how legitimacy claims are constructed through larger institutional orders. Interviews with leaders from 12 Canadian HPESUs discussed their unit's work, the stakeholders that leaders sought to satisfy, and how they defined success. Data were generated in 2011-2012 and analyzed anew in 2017-2018. The authors inductively analyzed the data, using institutional logics and institutional orders as sensitizing concepts to identify the linguistic constructions harnessed by participants. RESULTS: HPESU leaders engaged with 2 dominant logics: research and service. These aligned with institutional orders: the profession and community, respectively. While a few HPESU leaders deployed only one logic throughout the course of an interview, many engaged with more than one, compartmentalizing logics specific to different audiences and activities or blending logics to create novel ways of framing their work. CONCLUSIONS: The institutional logics available in a context vary. What constitutes a compelling legitimacy claim is different from one institutional context to the next. The authors identify strategies that leaders used to position their HPESU for success and discuss the basis on which these claims are made.

Constructing critical thinking in health professional education.

INTRODUCTION: Calls for enabling 'critical thinking' are ubiquitous in health professional education. However, there is little agreement in the literature or in practice as to what this term means and efforts to generate a universal definition have found limited traction. Moreover, the variability observed might suggest that multiplicity has value that the quest for universal definitions has failed to capture. In this study, we sought to map the multiple conceptions of critical thinking in circulation in health professional education to understand the relationships and tensions between them. METHODS: We used an inductive, qualitative approach to explore conceptions of critical thinking with educators from four health professions: medicine, nursing, pharmacy, and social work. Four participants from each profession participated in two individual in-depth semi-structured interviews, the latter of which induced reflection on a visual depiction of results generated from the first set of interviews. RESULTS: Three main conceptions of critical thinking were identified: biomedical, humanist, and social justice-oriented critical thinking. 'Biomedical critical thinking' was the dominant conception. While each conception had distinct features, the particular conceptions of critical thinking espoused by individual participants were not stable within or between interviews. DISCUSSION: Multiple conceptions of critical thinking likely offer educators the ability to express diverse beliefs about what 'good thinking' means in variable contexts. The findings suggest that any single definition of critical thinking in the health professions will be inherently contentious and, we argue, should be. Such debates, when made visible to educators and trainees, can be highly productive.