Narrative Intersectionality in Caring for Marginalized or Disadvantaged Patients: Thinking Beyond Categories in Medical Education and Care.

Categories are essential to doctors' thinking and reasoning about their patients. Much of the clinical categorization learned in medical school serves useful purposes, but an extensive literature exists on students' reliance on broad systems of social categorization. In this article, the authors challenge some of the orthodoxies of categorization by combining narrative approaches to medical practice with the theoretical term "intersectionality" to draw students' attention to the important intersecting, but often overlooked, identities of their patients. Although intersectionality applies for all patients, the focus here is on its importance in understanding and caring for marginalized or disadvantaged persons.Intersectionality posits that understanding individual lives requires looking beyond categories of identity in isolation and instead considering them at their intersection, where interrelated systems of power and oppression, advantage and discrimination are at play and determine access to social and material necessities of life. Combined with narrative approaches that emphasize the singularity of a person's story, narrative intersectionality can enable a more robust understanding of how injustice and inequality interrelate multidimensionally to produce social disadvantage.The authors apply this framework to two films that present characters whose lives are made up of numerous and often-contradictory identities to highlight what physicians may be overlooking in the care of patients. If the education of physicians encourages synthesis and categorization aimed at the critically useful process of making clinical "assessments" and "plans," then there must also be emphasis in their education on what might be missing from that process.

Remembering Freddie Gray: Medical Education for Social Justice.

Recent attention to racial disparities in law enforcement, highlighted by the death of Freddie Gray, raises questions about whether medical education adequately prepares physicians to care for persons particularly affected by societal inequities and injustice who present to clinics, hospitals, and emergency rooms. In this Perspective, the authors propose that medical school curricula should address such concerns through an explicit pedagogical orientation. The authors detail two specific approaches-antiracist pedagogy and the concept of structural competency-to construct a curriculum oriented toward appropriate care for patients who are victimized by extremely challenging social and economic disadvantages and who present with health concerns that arise from these disadvantages. In memory of Freddie Gray, the authors describe a curriculum, outlining specific strategies for engaging learners and naming specific resources that can be brought to bear on these strategies. The fundamental aim of such a curriculum is to help trainees and faculty understand how equitable access to skilled and respectful health care is often denied; how we and the institutions where we learn, teach, and work can be complicit in this reality; and how we can work toward eliminating the societal injustices that interfere with the delivery of appropriate health care.

Slow medical education.

Slow medical education borrows from other "slow" movements by offering a complementary orientation to medical education that emphasizes the value of slow and thoughtful reflection and interaction in medical education and clinical care. Such slow experiences, when systematically structured throughout the curriculum, offer ways for learners to engage in thoughtful reflection, dialogue, appreciation, and human understanding, with the hope that they will incorporate these practices throughout their lives as physicians. This Perspective offers several spaces in the medical curriculum where slowing down is possible: while reading and writing at various times in the curriculum and while providing clinical care, focusing particularly on conducting the physical exam and other dimensions of patient care. Time taken to slow down in these ways offers emerging physicians opportunities to more fully incorporate their experiences into a professional identity that embodies reflection, critical awareness, cultural humility, and empathy. The authors argue that these curricular spaces must be created in a very deliberate manner, even on busy ward services, throughout the education of physicians.

Commentary: narrative lessons from a Nigerian novelist: implications for medical education and care.

In her TED Talk entitled "The danger of a single story," Nigerian novelist Chimamanda Adichie shares stories about her life that illustrate the natural human tendency to interpret the lives of others in the context of what she describes as narrowly constructed and often stereotypical "single stories." These single-story views often portray others as wholly different from those constructing the stories, thereby diminishing the possibilities for genuine human connection. Referencing Adichie's talk, the author describes the narrative dissonance that so often distances patients from their physicians. He illustrates the dangers to patients that can result from single-story caregiving by physicians, sharing an example from his own experience in which unnecessary harm came to his patient because of his own single-story thinking. The author argues that these single-story dangers must be openly and consciously addressed in the training of doctors to counteract the tendency for their clinical and educational experiences to inculcate single stories by which physicians come to interpret their patients. He offers suggestions as to why single-story thinking arises in clinical practice and how to mitigate these forces in medical education. The author concludes by contending that the education of physicians, and caring for the sick, should be aimed at preserving the dignity of those being served, and he argues for an "equal humanity" model of the patient-physician relationship that engages patients in all dimensions of their multiple stories.

Cultural competency 2.0: exploring the concept of "difference" in engagement with the other.

Cultural competency efforts have received much attention in medical education. Most efforts focus on the acquisition of knowledge and skills about various groups based on race and ethnic identity, national origins, religion, and the like. The authors propose an approach, "Cultural Competency 2.0," that does not reject such efforts but, rather, adds a more critical and expanded focus on learners' attitudes and beliefs toward people unlike themselves. Cultural Competency 2.0 includes learners' examination of the social position of most U.S. medical students, Bourdieu's concept of habitus, and the phenomenon of countertransference to come to new critical insights on learners' attitudes, beliefs, and, ultimately, interactions with all patients. Suggestions are offered for how and where Cultural Competency 2.0 can be used in the curriculum through narrative medicine, particularly through the development of reading practices that unmask illusions of "pure" objectivity often assumed in clinical settings, and that make visible how words and images constrain, manipulate, or empower individuals, groups, ideas, or practices.The authors argue that these educational approaches should be sustained throughout the students' clinical experiences, where they encounter patients of many kinds and see clinicians' varied approaches to these patients. Further, these educational approaches should include assisting students in developing strategies to exercise moral courage within the limitations of their hierarchical learning environments, to strengthen their voices, and, when possible, to develop a sense of fearlessness: to always be advocates for their patients and to do what is right, fair, and good in their care.

Reflection in/and writing: pedagogy and practice in medical education.

During the past decade, "reflection" and "reflective writing" have become familiar terms and practices in medical education. The authors of this article argue that the use of the terms requires more thoughtfulness and precision, particularly because medical educators ask students to do so much reflection and reflective writing. First, the authors discuss John Dewey's thoughts on the elements of reflection. Then the authors turn the discussion to composition studies in an effort to form a more robust conception of reflective writing. In particular, they examine what the discipline of composition studies refers to as the writing process. Next, they offer two approaches to teaching composition: the expressivist orientation and the critical/cultural studies orientation. The authors examine the vigorous debate over how to respond to reflective writing, and, finally, they offer a set of recommendations for incorporating reflection and reflective writing into the medical curriculum.

The treachery of images: how René Magritte informs medical education.

Using René Magritte's well-known painting The Treachery of Images (This is not a pipe), we argue that the current focus on competencies throughout medical education can sometimes lead educators to rely too heavily on scores, checkmarks, or other forms of assessment that come to be viewed as equivalents for the actual existence of what is being measured. Magritte insisted that the image he created on the canvas was not a pipe but rather a representation of a pipe, an important distinction for educators to remember as we seek ways to evaluate trainees' attainment of the fundamental knowledge and skills of the profession. We also urge that the focus on broader skills, values, flexibility, reflection, and insight development should fall outside the net of a competency orientation in a supportive environment spared from traditional assessment methods, using a classroom in undergraduate medical education as an example of working toward this end.

Derogatory and cynical humour directed towards patients: views of residents and attending doctors.

CONTEXT: A study of medical students' perspectives on derogatory and cynical humour was published in 2006. The current study examines residents' and attending doctors' perspectives on the same phenomenon in three clinical departments of psychiatry, internal medicine and surgery. METHODS: Two focus groups were conducted in each of the three clinical departments, one with residents and one with attending doctors,during the 2006-07 academic year. Seventy doctors participated, including 49 residents and 21 attendings. The same semi-structured format was used in each group. Questions focused on characterisations of derogatory and cynical humour along with motives and rules for its use.All focus groups were audiotaped and the tapes transcribed. Each transcript was read independently by each researcher as part of an inductive process to discover the categories that describe and explain the uses, motives and effects of such humour. RESULTS: Three categories that appeared in the first study with medical students - locations for humour, the humour game, and not-funny humour - emerged as virtually identical,whereas two others--objects of humour and motives for humour - were more fully elaborated. DISCUSSION: Discussions of derogatory and cynical humour should occur in any department where teaching and role modelling are priorities. In addition, the tenets of appreciative inquiry and the complex responsive process,particularly as they are used at the Indiana University School of Medicine, offer medical educators valuable tools for addressing this phenomenon.

Can compassion be taught? Let's ask our students.

BACKGROUND: Medical educators act on the belief that students benefit from formal and informal educational experiences that foster virtues such as compassion, altruism, and respect for patients. OBJECTIVE: The purpose of this study is to examine fourth year medical students' perspectives on how, where, and by whom they believe the virtues associated with good physicianhood have been taught to them. DESIGN: Fourth year students were assigned a two- to three-page essay that asked them to reflect on how their medical education had "fostered and hindered" their conceptions of compassion, altruism, and respect for patients. PARTICIPANTS: All 112 students completed this assignment, and 52 (46%) gave us permission to use their essays for this study. APPROACH: An inductive, qualitative approach was used to develop themes derived from students' essays. RESULTS: Students' thoughts were organized around the idea of influences in three areas to which they consistently referred. Foundational influences included parents and "formative years," religious faith, and other experiences preceding medical school. Preclinical education influences comprised formal classroom experiences (both positive and negative effects). Clinical education influences included role modeling (both positive and negative) and the clinical environment (notable for emphasis on efficiency and conflicting cues). Students' essays drew most heavily on the effects of role modeling. DISCUSSION: Medical students arrive at our doors as thoughtful, compassionate people. Positive role models and activities to promote critical self-reflection may help nurture these attitudes.

Making fun of patients: medical students' perceptions and use of derogatory and cynical humor in clinical settings.

PURPOSE: It has long been known that medical students become more cynical as they move through their training, and at times even exhibit "ethical erosion." This study examines one dimension of this phenomenon: how medical students perceive and use derogatory and cynical humor directed at patients. METHOD: The authors conducted five voluntary focus groups over a three-month period with 58 third- and fourth-year medical students at the Northeastern Ohio Universities College of Medicine in 2005. After transcribing the taped interviews, the authors analyzed the data using qualitative methods and identified themes found across groups. RESULTS: The categories that emerged from the data were (1) categories of patients who are objects of humor, including those deemed "fair game" due to obesity or other conditions perceived as preventable or self-inflicted; (2) locations for humor; (3) the "humor game," including student, resident, and faculty interaction and initiation of humor; (4) not-funny humor; and (5) motives for humor, including coping and stress relief. CONCLUSIONS: The authors offer recommendations for addressing the use of derogatory humor directed at patients that include a more critical, open discussion of these attitudes and behaviors with medical students, residents, and attending physicians, and more vigorous attention to faculty development for residents.