Pushing, standing and bringing to light: How medical trainees conceptualise professional resistance.

BACKGROUND: Much of the literature on harm and injustice in medical education focuses on the impact of oppression rather than trainees' efforts to create change. To acknowledge and make visible these efforts, medical education professionals must grasp how trainees perceive resistance and their role in effecting change. Employing functional linguistic and 'everyday' resistance theories, this critical qualitative study aims to understand trainees' conceptions of resistance practices and their representational choices in moments when they talked about and conceptualised resistance. METHODS: Gathering participants through professional networks and snowball sampling, this study employed in-depth interviews to explore the conceptualisations of resistance among North American medical trainees (9 medical students, 9 residents and fellows). With the use of an applied functional linguistic analysis framework, we analysed the representational metafunction in trainees' conceptualisation of their resistance efforts against social injustice. We began with open coding for 'everyday' acts of resistance and then shifted to focused coding on verbal process types in participants' language to characterise their conceptualisations of resistance. FINDINGS: Participants conceptualised their resistance practices in three distinct ways: first, an almost physical pushing back, drawing largely on material process types (doing); second, an embodied standing up and being present, based predominantly on material and relational process types (being); and third, an epistemic bringing to light, grounded mostly in mental and verbal process types (thinking). These processes of resistance reflect participants' conceptualisations of their efforts to challenge the status quo around inequity, harm and injustice in medical education. CONCLUSION: This study builds on resistance literature, offering a potential typology of resistance practices as pushing back, being and bringing to light. Because these are 'everyday' acts of resistance, these are tactics available to everyone, including faculty; we all have the power to resist, whether it is in teaching and learning or interacting with larger structures in medicine.

"Those Darn Kids": Having Meaningful Conversations about Learner Resistance in Medical Education.

The concept of professional resistance describes the principles professionals should follow when they seek to counter social harm and injustice. Applied to medical education, the principles of professional resistance can help learners and teachers balance the responsibilities to respond to harm and injustice with their roles and responsibilities as health professionals. However, there remains the problem of how educators and leaders can constructively respond to learner acts of resistance. It would seem that many leaders have dismissed learner resistance with variations on "Those Darn Kids!", a complaint that has long been levied at those in younger generations who challenge power and authority. How can productive change in medical education be achieved if learners' complaints are not taken seriously? Rather than dismissal, leaders and educators in these situations need the tools to engage learners in conversations that draw out their concerns.

Professionalism Policies and Practices as Experienced by First-Generation Medical Students, Residents, and Physicians.

Phenomenon: While professionalism is largely understood to be complex and dynamic, it is oftentimes implemented as if it were static and concrete. As a result, policies and practices reflect dominant historical norms of the medical profession, which can cause tension for trainees from marginalized groups. One such group comprises those who identify as first-generation physicians - those whose parents have not earned an associate's degree or higher. This group is highly diverse in terms of gender, race, ethnicity, and socioeconomic status; however, their experiences with institutional professionalism policies and practices has not yet been fully explored. In this study, our aims were to understand the ways in which these participants experience professionalism, and to inform how professionalism can be more inclusively conceptualized. Approach: In November 2022-March 2023, we conducted semi-structured interviews with 11 first-generation medical students, residents, and physicians and analyzed select national and institutional professionalism policies in relation to key themes identified in the interviews. The interviews were designed to elicit participants' experiences with professionalism and where they experienced tension and challenges because of their first-gen identity. Data were analyzed using thematic analysis through a critical perspective, focused on identifying tensions because of systemic and historical factors. Findings: Participants described the ways in which they experienced tension between what was written, enacted, desirable, and possible around the following elements of professionalism: physical appearance; attendance and leaves of absence; and patient care. They described a deep connection to patient care but that this joy is often overshadowed by other elements of professionalism as well as healthcare system barriers. They also shared the ways in which they wish to contribute to changing how their institutions conceptualize professionalism. Insights: Given their unique paths to and through medicine and their marginalized status in medicine, first-generation interviewees provided a necessary lens for viewing the concept of professionalism that has been largely absent in medicine. These findings contribute to our understanding of professionalism conceptually, but also practically. As professionalism evolves, it is important for institutions to translate professionalism's complexity into educational practice as well as to involve diverse voices in refining professionalism definitions and policies.

"I never wanted to burn any bridges": discerning between pushing too hard and not enough in trainees' acts of professional resistance.

As trainees resist social harm and injustice in medicine, they must navigate the tension between pushing too hard and risking their reputation, or not enough and risking no change at all. We explore the discernment process by examining what trainees attend to moments before and while they are resisting to understand how they manage this tension. We interviewed 18 medical trainees who shared stories of resisting social harm and injustice in their training environments. Interviews were analyzed using open and focused coding using Vinthagen and Johansson's work, which conceptualizes resistance as a dynamic process that includes an individual's subjectivity within a larger system, the context in which they find themselves, and the interactions they have with others. We framed these acts as an individuals' attempt to undermine power, while also being entangled with that power and needing it for their efforts. When deciding on how and whether to resist, trainees underwent a cost-benefit analysis weighing the potential risk against their chances at change. They considered how their acts may influence their relationship with others, whether resisting would damage personal and programmatic reputations, and the embodied and social cues of other stakeholders involved. Trainees undergo a dynamic assessment process in which they analyze large amounts of information to keep themselves safe from potential retaliation. It is by attending to these various factors in their environment that trainees are able to keep their acts professional, and continue to do this challenging work in medical education.

Centering Justice in Health Professions Education by Owning Limitations of Anti-Bias Checklists.

This article argues that, although efforts to integrate checklists for assessing bias in educational content represent a sincere effort to address or mitigate harm, such efforts will likely have limited (if any) impact on curricular reform or the actual lived experiences of minoritized students. This is because checklists are not designed for justice-oriented assessment and thus will not create the kind of change needed to transform health professions, especially medical education. What is needed is more attention to the ways whiteness is used to organize health professions education and a deep commitment to faculty development focused on raising educators' critical consciousness.

When Taking Pay off the Table: A Qualitative Study of Gender Equity for Academic Leaders in the US Military.

INTRODUCTION: Although gender inequity persists globally in academic leadership positions, the United States Military has equitable pay and, in academic pediatrics, has equitable gender representation in leadership positions. To better understand how the US Military framework affects physician leaders, pediatricians were interviewed to illuminate the factors that facilitated their success and what barriers they faced in their career. MATERIALS AND METHODS: In 2022, following institutional review board approval, semi-structured interviews were conducted with 13 total participants (69% female, 31% male) serving as general pediatricians or pediatric subspecialists in the US Military. These pediatricians were in leadership positions of military academic medicine across seven graduate medical education (GME) sites. The interviews examined the leaders' perceptions of facilitators and barriers to their success. The authors analyzed the interviews using Acker's theory of gendered organizations as a theoretical framework, which explains embedded gender roles within work environments. RESULTS: Drawing on the theory of gendered organizations, the authors identified that participants described several facilitators to their success, including the availability of mentorship/sponsorship, inclusive leadership, and early and persistent exposure to women leaders in GME training and beyond. Because medicine's ideal worker was normed around the traditional roles of men, men observed and women experienced barriers to leadership success around issues related to childbearing, maternity leave, and microaggressions. CONCLUSIONS: This study revealed that equitability for pediatric GME leadership in the military heavily relied on structures and support created by former leaders and mentors. Isolating these structures within a unique context of military academic medicine can illuminate physicians' experiences to address barriers and better support equitable leadership roles in both military and civilian academic medicine.

Voices of Silence: Experiences in Disseminating Scholarship as a Global South Researcher.

Issue: There is an unspoken requirement that medical education researchers living in the Global South must disseminate their work using dominant frames constructed by individuals living in the Global North. As such, the published literature in our field is dominated by researchers whose work primarily benefits the Western world, casting the rest of what is published as localized and unhelpful knowledge. In this article, we use Audre Lorde's conception of the Master's house as a metaphor to narrate the experiences of two South African medical education researchers trying to disseminate their work into North American venues. In addition to narrating these stories, we describe the personal and professional consequences they experienced as a result of their efforts. Evidence: For researchers working outside of the Global North, entering the Master's formidable house is daunting, and there is no clear pathway in. These narratives illustrate how reviewers and editorial staff act as gatekeepers, continuously shaping ideas about what it means to do acceptable research, and who is allowed to disseminate it within the field. These narratives also show that those who have been rejected by these gatekeepers are often conflicted about their position within the larger field of medical education. Implications: To begin to address this issue, we have made several suggestions for the research community to consider. First, medical education research journals need to create spaces for researchers publishing from the Global South. One suggestion is for journals to create a submission type that is dedicated to researchers working outside of North America. Second, journals should also include more Global South editors and reviewers to help with knowledge translation when articles are submitted from outside North America. If our collective goal is to improve the training of physicians and the health outcomes of humanity, then we need to renovate the Master's house and begin to break down the barriers that separate us from truly building together.

'When I stood up for something it's because I felt a moral violation': Trainees' acts of resistance against social harm and injustice.

INTRODUCTION: As medical students around the world enter their chosen profession, they inherit a system that they did not design nor create, yet are still responsible for it. This system is rooted in centuries of social harm and inequity. This study examines trainees' professional acts of resistance to understand what trainees hope to accomplish in their resistance efforts, why they are resisting, and the tactics they use. METHODS: Drawing on counter-storytelling and critical theory, we collected in-depth qualitative interviews from nine medical students and nine residents/fellows across North America. Using theoretical guidance on how to study acts of resistance, data were analysed using a combination of coding techniques to understand resistors' intentions in resisting and the tactics they used to understand what, why, and how trainees were resisting. The analysis was returned to participants for member checking. RESULTS: Trainees described resisting systems of harm and injustice bequeathed to them by an older generation whose values and practices were reflective of a different time. Their motivations stemmed from deep-seated moral distress from the mistreatment of patients and learners. They hoped to re-envision medical education to be patient- and learner-centred. The tactics they chose depended on the level of power they had in the system and the extent to which they wished to have their efforts known. DISCUSSION: Trainees described intentional and deliberate acts of resistance to the social harm and injustice embedded in the broader profession to re-create the profession. Given that these acts spanned a large geographical area, this study suggests that trainees may be part of a larger social movement aimed at creating widespread change within the profession.

'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.

Challenges Facing First-Generation College Graduates in Medical School: A Qualitative Analysis.

Importance: First-generation (FG) medical students remain underrepresented in medicine despite ongoing national efforts to increase diversity; understanding the challenges faced by this student population is essential to building holistic policies, practices, and learning environments that promote professional actualization. Although FG students have been extensively studied in the undergraduate literature, there is little research investigating how FG students experience medical education or opportunities for educators to intervene. Objective: To explore challenges that FG students experience in undergraduate medical education and identify opportunities to improve foundational FG support. Design, Setting, and Participants: This qualitative study was conducted using an online platform with 37 FG students enrolled in 27 US medical schools. An interprofessional team of medical educators and trainees conducted semistructured interviews from November 2021 through April 2022. Participants were recruited using a medical student listserv. Data were analyzed from April to November 2022. Main Outcomes and Measures: After conducting a preliminary analysis using open coding, a codebook was created and used in a thematic analysis; the codebook used a combination of deductive and inductive coding. Results: Among the 37 students recruited for this study, 21 (56.8%) were female; 23 (62.2%) were in the clinical phase of training; 1 (2.7%) was American Indian or Alaska Native, 7 (18.9%) were Hispanic, Latino, or of Spanish origin, 8 (21.6%) were non-Hispanic Asian or Asian American, 9 (24.3%) were non-Hispanic Black or African American, and 23 (32.4%) were non-Hispanic White; mean (SD) age was 27.3 (2.8) years. Participants described 4 major themes: (1) isolation and exclusion related to being a newcomer to medicine; (2) difficulty with access to basic resources (eg, food, rent, transportation) as well as educational (eg, books); (3) overall lack of faculty or institutional support to address these challenges; and (4) a sense of needing to rely on grit and resilience to survive. Conclusions and Relevance: Although grit and resilience are desirable traits, results of this study suggest that FG medical students face increased adversity with inadequate institutional support, which forces them to excessively rely on grit and resilience as survival (rather than educational) strategies. By applying the holistic model often used in admissions to the postmatriculation educational process, targeted and flexible initiatives can be created for FG students so that all students, regardless of background, can achieve robust professional actualization.

Past resources, future envisioning, and present positioning: how women who are medical students at one institution draw upon temporal agency for resistance.

While women entering medical school are faced with a patriarchal system, they also enter into a community with other women and the potential for resistance. The purpose of this study is to use the theory of temporal agency to explore how first-year medical students who identify as women draw upon past, future, and present agency to resist the patriarchal system of medicine.The data for this study were drawn from the first year (October 2020-April 2021) of a longitudinal project using narrative inquiry to understand the socialization of women students in undergraduate medical education. Fifteen participants performed two interviews and a series of written reflection prompts about their childhood and medical school experiences, each lasting approximately 45 min.Participants' resistance drew on past resources, recognizing themselves as Other, which contributed to categorically locating themselves as part of a broader resisting community, even outside their institution. They also hypothesized future possibilities as part of resistance, either an ideal future where they would exercise power, or an unchanged one and the hypothetical resolutions they would use to manage it. Finally, they contextualized past and future in the present, identifying problems to make strategic decisions and execute actions.Our creative interweaving of the constructs of temporal agency, communal agency, and resistance allows us to paint a nuanced picture of how these women conceive of themselves as part of a larger group of women amidst the hierarchical, patriarchal structures of medical school while, at times, internalizing these hierarchies.

Editors as Gatekeepers: One Medical Education Journal's Efforts to Resist Racism in Scholarly Publishing.

PURPOSE: Journals have begun to expand the racial diversity of editors as a first step to countering institutional racism. Given the power editors hold as gatekeepers, a diverse team helps ensure that minoritized scholars have equal opportunity to contribute. In 2021, Teaching and Learning in Medicine ( TLM ) created an editorial internship for racially minoritized individuals. This study examines the first 6 months of this program to better understand its creation and initial successes. METHOD: The authors employed critical collaborative autoethnography, a qualitative methodology, focusing on the underlying assumptions around power and hierarchy that are implicit in the design and implementation of the TLM internship. Participants included 13 TLM editorial board members (10 internship selection committee members, 3 mentors, 2 independent researchers), 3 external selection committee members, and 3 interns, with some holding multiple roles. Ten participants served as authors of this report. Data included archival emails, planning documents, and focus groups. The initial analysis explored what happened and how and was followed by a thematic analysis in which participants reflected on their responsibility for implementing an antiracist program. RESULTS: While the program developed interns' editorial skills, which they greatly valued, and diversified the TLM editorial board, it did not achieve the goal of fostering antiracism. Mentors focused on conducting joint peer reviews with interns, assuming that racial experiences can and should be separate from the editorial process, thus working within, rather than trying to change, the existing racist system. CONCLUSIONS: Given these findings, greater structural change is needed to disrupt the existing racist system. These experiences underscore the importance of recognizing the harmful impact a race-neutral lens can have on antiracist efforts. Moving forward, TLM will implement lessons learned ahead of offering the internship again with the goal of creating the transformative change intended with the creation of the program.

Exploring the Professional Identity Formation of Racial/Ethnic Minoritized Physician Assistants.

INTRODUCTION: The purpose of this article is to (1) describe how professional identity intersects with physician assistants' (PAs') and PA students' racial and ethnic identities and cultural backgrounds; (2) examine how sociohistorical contexts shape professional identity in racial/ethnic minoritized PAs and PA students; and (3) identify the role of PA program administrators and faculty to address the needs of racial/ethnic minoritized PAs and PA students. METHODS: This study draws on elements of constructivist grounded theory to investigate the professional identity formation (PIF) experiences of 45 PA students and alumni from 3 institutions. Participants were recruited using a snowball method and identified as 23 Black/African American, 12 Hispanic/Latino, 6 mixed race, and 4 Native American/Indigenous. Interview data were analyzed using sociocultural theory as an analytic framework. RESULTS: The results suggest that participants felt that their racial/ethnic identity was an important part of their identity, yet many indicated they experienced frequent micro- and macroaggressions from fellow students, faculty, lecturers, administrators, preceptors, patients, and supervisors. Additionally, they indicated that they need more support from their programs than what is currently provided. DISCUSSION: The results of this study suggest that social experiences before, during, and after PA training strongly influence PIF development in racial/ethnic minoritized PAs. Administrators and professional PA organizations should evaluate methods to support those individuals who identify as a racial/ethnic minority throughout their careers.

Experiences of agency in historically underrepresented racial and ethnic dental faculty at predominantly white institutions.

PURPOSE/OBJECTIVES: Historically underrepresented racial and ethnic (HURE) dentists remain underrepresented in dental education and dental practice, and surprisingly, little is known about the factors that enable them to thrive. The lack of information about their experiences is a critical gap in the literature. The purpose of this critical qualitative study is to describe how HURE dental faculty in predominantly white institutions (PWIs) exercise agency to thrive and advance in academic promotion when faced with challenges and adversity in the workplace. METHODS: Thirteen semi-structured interviews were conducted in 2021 and 2022 with HURE dental faculty from 10 different institutions. Interviews were audio recorded, transcribed, and analyzed using the construct of agency and tenets of critical race theory to understand how they thrive in their institutions. RESULTS: HURE dental faculty experienced racism as normal from both faculty and students. Racism centered around white faculty guarding access to white spaces, including things that should be open to everyone like meetings and information about promotion. To counter this, HURE faculty engaged in individual agency by fighting for their perspectives to be heard, proxy agency by seeking and building relationships with mentors and colleagues who could use their whiteness to create change, and improvisational agency by going outside their institutions for support. CONCLUSION(S): To thrive in PWIs requires HURE faculty to exercise various forms of agency to directly or indirectly advocate for themselves as professionals. These findings have implications for dental leaders to change their existing structures and improve the work environments for HURE dental faculty.

Physician resistance to injustice: A scoping review.

Throughout history, physicians have been involved in acts of resistance to systems of harm and injustice. However, resistance has seemed to have had little legitimate place in physician professionalism or in formal professional practice. As the challenges to physicians and the profession continue to mount, there is a pressing need to understand how it might be articulated and understood. To do that we need to consider past instances of physician resistance to injustice and harm. A scoping review was conducted to understand how often and in what contexts physicians have been engaged in resistance. A search of multiple bibliographic databases returned 2123 papers, which, after filtering for relevance and inclusion, left 60 articles for full-text review. Of these, 95% were from the United States, suggesting that issues of legitimacy are even more acute outside the U.S. Narrative findings were organized around four themes: professional responsibility to resist, legitimate resistance, resistance to perceived threats, and resistance as moral agency. When physicians have resisted, they have done so with a sense of moral agency albeit with different levels of altruism. They have often engaged in resistance when they felt their personal and professional interests are threatened, with particular emphasis on threats to physician autonomy. The study suggests that, within the U.S. at least, physician resistance is a matter for concern but, it has been approached with little or no guidance or grounding. Moreover, there is a longstanding tension between those who have argued that physicians have a professional responsibility to resist and those who have considered resistance to be extraneous and even harmful to their work as healers. At a time when physicians are facing an ever-growing number of practical, ethical, and moral challenges, professional acts of resistance are of critical concern within the profession.

Patient care ownership in medical students: a validation study.

BACKGROUND: Psychological Ownership is the cognitive-affective state individuals experience when they come to feel they own something. The construct is context-dependent reliant on what is being owned and by whom. In medical education, this feeling translates to what has been described as "Patient Care Ownership," which includes the feelings of responsibility that physicians have for patient care. In this study, we adapted an instrument on Psychological Ownership that was originally developed for business employees for a medical student population. The aim of this study was to collect validity evidence for its fit with this population. METHODS: A revised version of the Psychological Ownership survey was created and administered to 182 medical students rotating on their clerkships in 2018-2019, along with two other measures, the Teamwork Assessment Scale (TSA) and Maslach Burnout Inventory (MBI) Survey. A confirmatory factor analysis (CFA) was conducted, which indicated a poor fit between the original and revised version. As a result, an exploratory factor analysis (EFA) was conducted and validity evidence was gathered to assess the new instruments' fit with medical students. RESULTS: The results show that the initial subscales proposed by Avey et al. (i.e. Territoriality, Accountability, Belongingness, Self-efficacy, and Self-identification) did not account for item responses in the revised instrument when administered to medical students. Instead, four subscales (Team Inclusion, Accountability, Territoriality, and Self-Confidence) better described patient care ownership for medical students, and the internal reliability of these subscales was found to be good. Using Cronbach's alpha, the internal consistency among items for each subscale, includes: Team Inclusion (0.91), Accountability (0.78), Territoriality (0.78), and Self-Confidence (0.82). The subscales of Territoriality, Team Inclusion, and Self-Confidence were negatively correlated with the 1-item Burnout measure (P = 0.01). The Team Inclusion subscale strongly correlated with the Teamwork Assessment Scale (TSA), while the subscales of Accountability correlated weakly, and Self-Confidence and Territoriality correlated moderately. CONCLUSION: Our study provides preliminary validity evidence for an adapted version of Avey et al.'s Psychological Ownership survey, specifically designed to measure patient care ownership in a medical student population. We expect this revised instrument to be a valuable tool to medical educators evaluating and monitoring students as they learn how to engage in patient care ownership.