Exploring Diversity, Equity, and Inclusion-Related Pedagogy Across Different Professions.

PURPOSE: Diversity, equity, and inclusion (DEI) have become an important priority for academic medicine. However, several barriers challenge the effective implementation of DEI-related pedagogy. An exploration of the barriers to and enablers of DEI-related pedagogy-as they relate to professional contexts-can inform how to advance DEI in medical education. Shulman's notion of signature pedagogies offers a foundation for understanding and exploring the influence of such contexts on teaching and learning. Comparisons across professions may help make signature pedagogies more visible and may facilitate change. In this study, the authors aim to explore how the professional contexts of medicine, nursing, and teacher education approach DEI-related pedagogy. METHOD: The authors conducted a qualitative exploratory study using constructivist grounded theory methodology. Using both purposive and theoretical sampling, 24 participants from across the United States and Canada were interviewed, including physicians, nurses, and K-12 teachers in practice as well as professional educators in each discipline (May-December 2022). Interviews included a case-based elicitation approach, and data were analyzed iteratively across the data collection period using constant comparative analysis. RESULTS: Medicine and nursing tend to prioritize objectivity and seek to avoid or neutralize emotions that are intrinsic to DEI-related learning, view DEI expertise as being outside the purview of their profession, and view time for DEI as limited in a clinical learning environment. In contrast, teaching is built on the assumption that DEI expertise is co-constructed and inclusive of community voices and lived experiences. DEI-related pedagogy in teaching allowed for exploration of deep assumptions and learning about structural inequities. CONCLUSIONS: Findings suggest that assumptions and values held in professions, such as medicine and nursing, that valorize objectivity and neutrality, while stigmatizing vulnerability and suppressing emotions, may constrain DEI-related teaching and learning in such contexts.

Twelve tips for maximizing the potential of reflective writing in medical education.

Reflective writing (RW) is a popular tool in medical education, but it is being used in ways that fail to maximize its potential. Literature in the field focuses on why RW is used - that is to develop, assess, and remediate learner competencies - but less so on how to use it effectively. The emerging literature on how to integrate RW in medical education is haphazard, scattered and, at times, reductionist. We need a synthesis to translate this literature into cohesive strategies for medical educators using RW in a variety of contexts. These 12 tips offer guidelines for the principles and practices of using RW in medical education. This synthesis aims to support more strategic and meaningful integration of RW in medical education.

The writer's voice repertoire: Exploring how health researchers accomplish a distinctive 'voice' in their writing.

INTRODUCTION: Much published research writing is dull and dry at best, impenetrable and off-putting at worst. This state of affairs both frustrates readers and impedes research uptake. Scientific conventions of objectivity and neutrality contribute to the problem, implying that 'good' research writing should have no discernible authorial 'voice'. Yet some research writers have a distinctive voice in their work that may contribute to their scholarly influence. In this study, we explore this notion of voice, examining what strong research writers aim for with their voice and what strategies they use. METHODS: Using a combination of purposive, snowball and theoretical sampling, we recruited 21 scholars working in health professions education or adjacent health research fields, representing varied career stages, research paradigms and geographical locations. We interviewed participants about their approaches to writing and asked each to provide one to three illustrative publications. Iterative data collection and analysis followed constructivist grounded theory principles. We analysed interview transcripts thematically and examined publications for evidence of the writers' described approaches. RESULTS: Participants shared goals of a voice that was clear and logical, and that engaged readers and held their attention. They accomplished these goals using approaches both conventional and unconventional. Conventional approaches included attention to coherence through signposting, symmetry and metacommentary. Unconventional approaches included using language that was evocative (metaphor, imagery), provocative (pointed critique), plainspoken ('non-academic' phrasing), playful (including humour) and lyrical (attending to cadence and sound). Unconventional elements were more prominent in non-standard genres (e.g. commentaries), but also appeared in empiric papers. DISCUSSION: What readers interpret as 'voice' reflects strategic use of a repertoire of writing techniques. Conventional techniques, used expertly, can make for compelling reading, but strong writers also draw on unconventional strategies. A broadened writing repertoire might assist health professions education research writers in effectively communicating their work.

The Art of Revising.

In the writer's craft section we offer simple tips to improve your writing in one of three areas: Energy, Clarity and Persuasiveness. Each entry focuses on a key writing feature or strategy, illustrates how it commonly goes wrong, teaches the grammatical underpinnings necessary to understand it and offers suggestions to wield it effectively. We encourage readers to share comments on or suggestions for this section on Twitter, using the hashtag: #how'syourwriting?

Inequalities in access to NHS primary care dental services in Scotland during the COVID-19 pandemic.

Introduction This study aimed to quantify the impact of the COVID-19 pandemic on access and inequalities in primary care dental services among children and adults in Scotland.Methods Access was measured as any NHS Scotland primary care dental contacts derived from administrative data from January 2019 to May 2022, linked to the area-based Scottish Index of Multiple Deprivation for children and adults, and related to population denominator estimates from National Record Scotland. Inequalities for pre-pandemic (January 2019-January 2020) and recent (December 2021-February 2022, and March 2022-May 2022) periods for both children and adults were calculated and compared using the slope index of inequality and relative index of inequality.Results Following the first lockdown (March 2020) there was a dramatic fall to near zero dental contacts, followed by a slow recovery to 64.8% of pre-pandemic levels by May 2022. There was initial widening of relative inequalities in dental contacts in early 2022, which, more recently, had begun to return to pre-pandemic levels.Conclusion COVID-19 had a major impact on access to NHS primary dental care, and while inequalities in access are apparent as services recover from lockdown, these inequalities are not a new phenomenon.

Meaning making about performance: A comparison of two specialty feedback cultures.

INTRODUCTION: Specialty trainees often struggle to understand how well they are performing, and feedback is commonly seen as a solution to this problem. However, medical education tends to approach feedback as acontextual rather than located in a specialty-specific cultural world. This study therefore compares how specialty trainees in surgery and intensive care medicine (ICM) make meaning about the quality of their performance and the role of feedback conversations in this process. METHODS: We conducted a qualitative interview study in the constructivist grounded theory tradition. We interviewed 17 trainees from across Australia in 2020, eight from ICM and nine from surgery, and iterated between data collection and analytic discussions. We employed open, focused, axial and theoretical coding. FINDINGS: There were significant divergences between specialties. Surgical trainees had more opportunity to work directly with supervisors, and there was a strong link between patient outcome and quality of care, with a focus on performance information about operative skills. ICM was a highly uncertain practice environment, where patient outcome could not be relied upon as a source of performance information; valued performance information was diffuse and included tacit emotional support. These different 'specialty feedback cultures' strongly influenced how trainees orchestrated opportunities for feedback, made meaning of their performance in their day-to-day patient care tasks and 'patched together' experiences and inputs into an evolving sense of overall progress. DISCUSSION: We identified two types of meaning-making about performance: first, trainees' understanding of an immediate performance in a patient-care task and, second, a 'patched together' sense of overall progress from incomplete performance information. This study suggests approaches to feedback should attend to both, but also take account of the cultural worlds of specialty practice, with their attendant complexities. In particular, feedback conversations could better acknowledge the variable quality of performance information and specialty specific levels of uncertainty.

Improving participation and engagement with a COVID-19 surveillance programme in an outpatient setting.

BACKGROUND: On 3 August 2020, Public Health Scotland commenced a prospective surveillance study to monitor the prevalence of COVID-19 among asymptomatic outpatients attending dental clinics across 14 health boards in Scotland. OBJECTIVES: The primary aim of this quality improvement project was to increase the number of COVID-19 tests carried out in one of the participating sites, Glasgow Dental Hospital and School. The secondary aim was to identify barriers to patient participation and staff engagement when implementing a public health initiative in an outpatient setting. METHOD: A quality improvement working group met weekly to discuss hospital findings, identify drivers and change ideas. Details on reasons for patient non-participation were recorded and questionnaires on project barriers were distributed to staff. In response to findings, rapid interventions were implemented to fast-track increases in the numbers of tests being carried out. RESULTS: Over 16 weeks, 972 tests were carried out by Glasgow Dental Hospital and School Secondary Care Services. The number of tests per week increased from 19 (week 1) to 129 (week 16). This compares to a similar 'control' site, where the number of tests carried out remained unchanged; 38 (week 1) to 36 (week 16). The most frequent reason given for non-participation was fear that the swab would hurt. For staff, lack of time and forgetting to ask patients were identified as the most significant barriers. CONCLUSION: Public health surveillance programmes can be integrated rapidly into outpatient settings. This project has shown that a quality improvement approach can be successful in integrating such programmes. The key interventions used were staff engagement initiatives and front-line data collection. Implementation barriers were also identified using staff questionnaires.

Dual and duelling purposes: An exploration of educators' perspectives on the use of reflective writing to remediate professionalism in residency.

CONTEXT: Professionalism lapses have high stakes for learners and educators. Problems with professionalism, unless appropriately and effectively remediated, may portend serious problems in practice. Yet, remediation for unprofessional behaviour is particularly challenging-and understudied. Increasingly, educators are turning to reflective writing as a remediation strategy in residency, yet little is known about what educators expect reflective writing to accomplish, how they choose reflective writing tasks, why they use reflective writing, or how they evaluate whether a learner has met expectations. We aimed to understand why and how postgraduate medical educators use reflective writing as an educational intervention to remediate professionalism. METHOD: In this constructivist grounded theory study, we interviewed 13 medical education professionals with experience using reflective writing to remediate professionalism across five Canadian medical schools. Data collection and analysis occurred iteratively using constant comparison to identify themes and to understand the relationships among them. RESULTS: Medical educators reported using reflective writing as a learning tool to develop insight and as an assessment tool to unearth evidence of insight. The goal of learning may compete with the goal of assessment, creating tension that leads to uncertainty about the sincerity, quality and effectiveness of reflective writing as well as concerns about learner safety. Educators reported uncertainty about whether learners write to pass or to introspect and about how to judge the effectiveness of reflective writing as a learning tool. They expressed concern about creating a safe environment for learners-one that enables the genuine reflection required for insight development-while meeting requirements of remediation. CONCLUSIONS: Educators express ambivalence about using reflective writing to remediate professionalism in residency. Understanding the potential and pitfalls of reflective writing may inform more tailored and effective approaches to remediate professionalism.

Not wanted on the voyage: highlighting intrinsic CanMEDS gaps in Competence by Design curricula.

BACKGROUND: As governing bodies design new curricula that seek to further incorporate principles of competency-based medical education within time-based models of training, questions have been raised regarding the continued centrality of existing CanMEDS competencies. Although efforts have been made to align these new curricula with CanMEDS, we don't yet know to what extent these competencies are meaningfully integrated. METHODS: A content analysis approach was used to systematically evaluate national Canadian curricula for 18 residency-training programs and determine the number of times each enabling CanMEDS competency was represented. RESULTS: Clear trends persisted across all programs. Medical Expert and Collaborator competencies were well integrated into curriculum (81% and 86% mapped to assessment) while competencies related to the Leader, Professional, and Health Advocate roles were less frequently mapped to assessment (41%, 36%, and 40%) and were often absent from the new curricula altogether (59%, 64%, and 60%). CONCLUSION: Deliberate planning in curriculum development affords the early identification of gaps. These gaps can inform current assessment practice and future curricular development by providing direction for innovation. If we are to ensure that any new curricula meaningfully address all CanMEDS roles, we need to think carefully about how to best teach and assess underrepresented competencies.

CONTEXTE: Alors que les instances dirigeantes conçoivent de nouveaux programmes d'études visant une intégration plus poussée des principes de l'éducation médicale fondée sur les compétences, notamment dans des modèles de formation axés sur la durée, la question se pose de savoir si l'on parvient à y préserver le caractère central des compétences CanMEDS actuelles. Malgré les efforts consacrés pour aligner les nouveaux programmes d'études sur CanMEDS, nous ne savons pas encore si l'intégration de ces compétences se fait avec discernement. MÉTHODES: L'approche d'analyse de contenu a été utilisée pour évaluer systématiquement 18 programmes de résidence au Canada et pour déterminer le nombre de fois que chaque compétence habilitante CanMEDS est représentée dans ces programmes. RÉSULTATS: Des tendances claires se dégagent pour l'ensemble des programmes. Tandis que les compétences d'expert médical et de collaborateur sont bien intégrées aux programmes (elles se retrouvent à hauteur de 81 % et 86 % respectivement dans l'évaluation), celles liées aux rôles de leader, de professionnel et de promoteur de la santé se répercutent moins souvent dans l'évaluation (41 %, 36 % et 40 %) et elles sont même souvent absentes des nouveaux programmes (59 %, 64 % et 60 %). CONCLUSION: Une planification rigoureuse dans le cadre du développement de cursuspermettrait de rapidement cibler les lacunes. La mise en lumière de ces lacunes peut éclairer les pratiques d'évaluation actuelles et orienter les programmes d'études futurs vers des pistes d'innovation. Si nous voulons nous assurer que tout nouveau programme d'études aborde de manière efficace l'ensemble des rôles CanMEDS, nous devons porter attention à la meilleure façon d'enseigner et d'évaluer les compétences sous-représentées.

Voices from the Front Lines: An Analysis of Physicians' Reflective Narratives about Flaws with the 'System'.

Physicians often express frustration with the 'system' in which they work. Over time, this frustration may put them at risk of burnout and disengagement, which may impact patient care. In this study, we aimed to understand the nature of the system flaws that physicians identified in their published narratives and to explore their self-representation as agents of change. We reviewed all reflective narratives published in four medical journals (NEJM, JAMA, CMAJ, Annals IM) between January 2015 and December 2017 (n = 282). By consensus, we identified those that addressed system flaws (n = 87). Using content and narrative analysis, we analyzed the types of flaws and the physicians' orientation to the flawed system. We identified seven recurring system flaws-five related to medical culture: failures of communication, erosive impact of the hidden curriculum, inadequate health advocacy, frenzied pace of work, and experience of stigma. Less frequently, physicians' narratives also exposed limited and disparate healthcare resources and restrictive institutional practices as impeding patient-centered care. Physicians expressed agency to create change foremost when writing about flaws related to medical culture. While physicians are challenged by system flaws, they strive to practice in ways that do not succumb to them. We saw tension between the elements outside the physician's control and those within it. This tension becomes a source of distress when the compromises that emerge from system flaws move physicians away from the values that define their professional identity.

Bringing narratives from physicians, patients and caregivers together: a scoping review of published research.

Patients and family caregivers tell different stories about their illness and care experiences than their physicians do. Better understanding of the relationships among these narratives could offer insight into intersections and disconnections in patient, caregiver and physician perceptions of illness and care. Such understanding could support enhanced patient-centred care in medical education and practice. Narrative writing is increasingly common among physicians, patients and caregivers and uniquely positioned to reveal matters of concern to these groups. We conducted a scoping review to identify literature in which first-person narratives from more than one group (physicians, patients and/or caregivers) were considered as 'data'. A search strategy involving nine databases located 6337 citations. Two reviewers independently screened titles and abstracts. Full-text screening followed (n=82), along with handsearching of grey literature and bibliographies. Of these, 22 met inclusion criteria. Most pieces analysed narratives by patients and caregivers (n=13), followed by patients, caregivers and physicians (n=7) and patients and physicians (n=2). Only nine pieces compared perspectives among any of these groups. The rest combined narratives for analysis, largely patient and caregiver stories (n=12). Most of the 22 papers used descriptive content analysis to derive themes. Themes of humanity, identity, agency and communication intersect between groups but often manifest in unique ways. What is absent, however, is a more interpretive narrative analysis of structure, orientation and characterisation within these narratives, which may reveal even more than their content. This scoping review offers a cautionary tale of lost potential. Many narratives are gathered and analysed but usually only thematically and rarely comparatively. We call for researchers to explore the potential of comparative analysis and the power of narrative inquiry in the field. Comparative narrative analysis may enrich understanding of how differences between perspectives come to be and what they mean for the experience of illness and care.

Feedback from health professionals in postgraduate medical education: Influence of interprofessional relationship, identity and power.

INTRODUCTION: Capitalising on direct workplace observations of residents by interprofessional team members might be an effective strategy to promote formative feedback in postgraduate medical education. To better understand how interprofessional feedback is conceived, delivered, received and used, we explored both feedback provider and receiver perceptions of workplace feedback. METHODS: We conducted 17 individual interviews with residents and eight focus groups with health professionals (HPs) (two nurses, two rehabilitation therapists, two pharmacists and two social workers), for a total of 61 participants. Using a constructivist grounded theory approach, data collection and analysis proceeded as an iterative process using constant comparison to identify and explore themes. RESULTS: Conceptualisations and content of feedback were dependent on whether the resident was perceived as a learner or a peer within the interprofessional relationship. Residents relied on interprofessional role understanding to determine how physician competencies align with HP roles. The perceived alignment was unique to each profession and influenced feedback credibility judgements. Residents prioritised feedback from physicians or within the Medical Expertise domain-a role that HPs felt was over-valued. Despite ideal opportunities for direct observation, operational enactment of feedback was influenced by power differentials between the professions. DISCUSSION: Our results illuminate HPs' conceptualisation of feedback for residents and the social constructs influencing how their feedback is disseminated. Professional identity and social categorisation added complexity to feedback acceptance and incorporation. To ensure that interprofessional feedback can achieve desired outcomes, education programmes should implement strategies to help mitigate intergroup bias and power imbalance.

Implicit Stigma Recognition and Management for Health Professionals.

OBJECTIVE: Stigma against individuals with mental illness has disastrous consequences for patient outcomes. Better approaches to reducing stigma in health care professionals are required. Implicit stigma education is an emerging area of research that may inform the design and implementation of stigma reduction programs. In this "in brief report," the authors describe the evaluation of a novel implicit stigma reduction workshop for health professionals. METHODS: The authors conducted a realist evaluation using a longitudinal multiple case study approach. Once a conceptual model was established, three case studies were conducted on physicians and nurses (n = 69) at an academic health sciences center. Within each case, pre- and post-attitudinal scales and qualitative data from semi-structured interviews were used. Consistent with realist evaluation principles, context-mechanism-outcome configuration patterns were analyzed. RESULTS: An implicit stigma recognition and management workshop produced statistically significant changes in participant attitudes in two out of three contexts. The qualitative evaluation described the perceptions of sustainable changes in perspective and practice. The degree to which individual participants learned with and worked among inter-professional teams influenced outcomes. CONCLUSIONS: Implicit stigma recognition and management is a useful educational strategy for reducing stigma among health professionals. Once stigma is recognized, curricular interventions may promote behavioral change by encouraging explicit alternative behaviors that are sustained through social reinforcement within inter-professional teams.

Implicit Bias and the Feedback Paradox: Exploring How Health Professionals Engage With Feedback While Questioning Its Credibility.

PURPOSE: Learners and practicing health professionals may dismiss emotionally charged feedback related to self, yet little research has examined how to address feedback that threatens an individual's identity. The implicit association test (IAT) provides feedback to individuals regarding their implicit biases. Anticipating feedback about implicit bias might be emotionally charged for mental health professionals, this study explored their experience of taking the IAT and receiving their results, to better understand the challenges of identity-threatening feedback. METHOD: The researchers sampled 32 psychiatry nurses, psychiatrists, and psychiatric residents at Western University in Ontario, Canada, after they completed the mental illness IAT and received their results. Using constructivist grounded theory, semistructured interviews were conducted from April to October 2017 regarding participants' experience of taking the IAT. Using constant comparative analysis, transcripts were iteratively coded and analyzed for results. RESULTS: While most participants critiqued the IAT and questioned its credibility, many also described the experience of receiving feedback about their implicit biases as positive or neutral. Most justified their implicit biases while acknowledging the need to better manage them. CONCLUSIONS: These findings highlight a feedback paradox, calling into question assumptions regarding self-related feedback. Participants' reactions to the IAT suggest that potentially threatening self-related feedback may still be useful to participants who question its credibility. Further exploration of how the feedback conversation influences engagement with self-related feedback is needed.

Striving While Accepting: Exploring the Relationship Between Identity and Implicit Bias Recognition and Management.

PURPOSE: Implicit biases worsen outcomes for underserved and marginalized populations. Once health professionals are made aware of their implicit biases, a process ensues where they must reconcile this information with their personal and professional identities. The authors sought to explore how identity influences the process of implicit bias recognition and management. METHOD: Using constructivist grounded theory, the authors recruited 11 faculty and 10 resident participants working at an academic health science center in Canada. Interviews took place from June to October 2017. Participants took an online version of the mental illness implicit association test (IAT) which provides users with their degree of implicit dangerousness bias toward individuals with either physical or mental illness. Once they completed the IAT, participants were invited to draw a rich picture and interviewed about their picture and experience of taking their IAT. Data were analyzed using constant comparative procedures to develop focused codes and work toward the development of a deeper understanding of relationships among themes. RESULTS: Once implicit biases were brought into conscious awareness, participants acknowledged vulnerabilities which provoked tension between their personal and professional identities. Participants suggested that they reconcile these tensions through a process described as striving for the ideal while accepting the actual. Relationships were central to the process; however, residents and faculty viewed the role of relationships differently. CONCLUSIONS: Striving for self-improvement while accepting individual shortcomings may provide a model for addressing implicit bias among health professionals, and relational dynamics appear to influence the process of recognizing and managing biases.

Adaptive reinventing: implicit bias and the co-construction of social change.

Emerging research on implicit bias recognition and management within health professions describes individually focused educational interventions without considering workplace influences. Workplace learning theories highlight how individual agency and workplace structures dynamically interact to produce change within individuals and learning environments. Promoting awareness of individual biases shaped by clinical learning environments may therefore represent a unique type of workplace learning. We sought to explore how individuals and the workplace learning environment interact once awareness of implicit biases are triggered within learners. In accordance with longitudinal case study methodology and informed by constructivist grounded theory, we conducted multiple longitudinal interviews with physician and nurse participants over 12 months. Our results suggest that implicit bias recognition provokes dissonance among participants leading to frustration, and critical questioning of workplace constraints. Once awareness is triggered, participants began reflecting on their biases and engaging in explicit behavioural changes that influenced the perception of structural changes within the learning environment itself. Collaboration, communication and role modeling within teams appeared to facilitate the process as individual and workplace affordances were gradually transformed. Our findings suggest a potential model for understanding how individual learners adaptively reinvent their role in response to disruptions in their learning environment.

A Framework for Integrating Implicit Bias Recognition Into Health Professions Education.

Existing literature on implicit bias is fragmented and comes from a variety of fields like cognitive psychology, business ethics, and higher education, but implicit-bias-informed educational approaches have been underexplored in health professions education and are difficult to evaluate using existing tools. Despite increasing attention to implicit bias recognition and management in health professions education, many programs struggle to meaningfully integrate these topics into curricula. The authors propose a six-point actionable framework for integrating implicit bias recognition and management into health professions education that draws on the work of previous researchers and includes practical tools to guide curriculum developers. The six key features of this framework are creating a safe and nonthreatening learning context, increasing knowledge about the science of implicit bias, emphasizing how implicit bias influences behaviors and patient outcomes, increasing self-awareness of existing implicit biases, improving conscious efforts to overcome implicit bias, and enhancing awareness of how implicit bias influences others. Important considerations for designing implicit-bias-informed curricula-such as individual and contextual variables, as well as formal and informal cultural influences-are discussed. The authors also outline assessment and evaluation approaches that consider outcomes at individual, organizational, community, and societal levels. The proposed framework may facilitate future research and exploration regarding the use of implicit bias in health professions education.